Every finding on record at Aviata at St Cloud

Based on observation, interview, and record review, the facility failed to maintain the only Americans with Disabilities Act (ADA)-accessible public entrance in operable condition. As a result, residents using wheelchairs were unable to independently enter the facility and were required to wait outside until staff or others opened the door for them for 3 of 3 resident reviewed for preferences of a total sample of 10 residents, (#5, #6, and #7).Findings: On 6/30/26 at 9:16 AM, as the surveyor was about to enter the facility, the handicapped-accessible button located to the right of the outside entrance door was pressed; however, it did not open the doors. The second set of interior doors was opened by the receptionist. On 6/30/26 at 9:18 AM, when asked about the handicapped-accessible button outside not working, the receptionist stated it did not work and it had not worked for a while. She explained she could open the inside doors with a control button at her desk; however, to open the outside doors, she had to manually press a button located just inside the entrance, and only the right door would open. On 6/30/26 at 9:42 AM, resident #6 was sitting in his wheelchair in his room and stated he obtained a daily leave of absence (LOA) pass because he liked to sit outside. He pointed to an outside area that could be seen through the window and back door. He showed the LOA pass he obtained that day and stated he would soon be leaving. He said he looked forward to spending time outside each day because he previously worked at a local home improvement store and received visits from former coworkers or friends while outside. He shared when he reached the main entrance, the receptionist opened the interior entrance doors using the button at her desk, and he pressed the other button to exit. He stated once he was ready to return inside, he had to call the facility or wait for someone to enter the building and assist him by opening the door. He indicated the handicapped-accessible button outside had not worked for at least 5 months and said he always mentioned it during the town hall meetings he attended regularly. He said he was always told they are waiting for corporate to approve it. On 6/30/26 at 9:52 AM, resident #5 was sitting in his wheelchair outside the facility to the right of the main entrance, within view of the entrance doors. He stated he had lived in the facility approximately 8 years. He confirmed the handicapped-accessible button at front entrance was not working and said it was one of the things he had gotten used to. He indicated electricians had worked on the door but could not get it working properly. He said the receptionist had to get up and push the buttons throughout the day. He stated the issue had existed for more than 6 months and he had never seen anything like it. He said he was astonished the problem had not been fixed despite experts having worked on it and commented it was unusual they could not determine the cause. On 6/30/26 at 11:38 AM, resident #7, who was sitting in a wheelchair by the door of his room, stated the handicapped-accessible button at the main entrance had not worked for months. He indicated the facility administration was aware of the problem and nothing had been done to correct it. He shared he once observed a resident waiting until someone opened the door to assist him back inside. He added there was not even a buzzer to alert someone inside to open the door. He stated his sister held the door open for him whenever they went outside. On 6/30/26 at 4:33 PM, resident #1's family member stated the entrance door needed repair and had been broken for over a year. She explained the door had to be opened manually. She stated this was very difficult for someone using a wheelchair. She shared when she arrived to visit her family member, residents were sometimes waiting outside and had said, Oh good, please let me in. She stated residents who enjoyed going outside through the main entrance required assistance to enter and exit the building. She explained she frequently brought supplies for her family member, including water, juice, and clean laundry in a cart, and it was difficult to enter because the handicapped-accessible button was not functioning and she had to manually open the door. She stated she did not always receive assistance from the front desk staff. She further stated she had personally helped residents re-enter the building because no one had been available to assist them. She concluded, This would all be solved if they would just fix the handicap button. The facility is cutting corners at the expense of the residents. On 6/30/26 at 10:07 AM, the Activities Coordinator stated the handicapped-accessible button at the main entrance had not been operational for over a year but should be repaired. She explained when exiting, the button worked but only opened the right door. She indicated the inside doors could be opened by the receptionist using a control button. She mentioned it made it difficult when bringing supplies into the building. She stated she participated in resident council meetings and only one resident brought up the issue because he went outside often. She mentioned both the Director of Maintenance and the Administrator (NHA) were aware of the problem. She added the facility had someone attempt to repair it, but it continued not to work, and the repair was very expensive. On 6/30/26 at 1:12 PM, the Director of Maintenance stated he was responsible for the general building, including repairs and maintenance. When asked about the issue with the main entrance door and handicapped-accessible button, he produced a quotation dated 4/20/26 to correct the problem. He stated he had forwarded the quotation by email to the [NAME] President (VP) of Plant Operations. He mentioned he could not locate another vendor to provide an additional quotation. He explained the door had been repaired in April; however, the system was so old it required a complete upgrade. He stated he had done everything within his control, but the matter was beyond his authority. He indicated the NHA was aware of the situation. He explained the door worked only from the inside and that pressing the interior button caused only one door to open outward. He stated it was the facility's ADA-accessible entrance and acknowledged it should be operational. He confirmed family members and a resident had raised concerns about the door during resident council meetings. He stated he informed them the facility was aware of the issue and was working on it. Later, at 1:12 PM, the Director of Maintenance indicated he reviewed his maintenance logs from September 2025 through June 2026 at the surveyor's request but found no documentation of the issue and could not determine how long it had existed. On 6/30/26 at 2:16 PM, the NHA stated she was responsible for ensuring the day-to-day operations of the facility ran smoothly and the residents were safe and received appropriate care. She stated she first became aware of the main entrance door issue at the beginning of the year when the Director of Maintenance informed her of the problem. She explained the Director of Maintenance had contacted several companies, obtained multiple quotations, and was awaiting approval from the VP of Plant Operations. She stated the matter was something a little higher than her and would need to be approved by the VP of Plant Operations. When asked how long the approval process took, she stated it depended on different factors. She confirmed this was the facility's only ADA-accessible public entrance. She acknowledged it was important for the issue to be corrected so residents and visitors with disabilities had unrestricted access into and out of the facility. When asked about the facility's policy regarding the physical environment, she stated the facility did not have one. Review of the email communication between the prospective vendor and the Director of Maintenance dated 4/20/26 included a description of the work and a price quotation for the door access system. The email message was forwarded to the Regional Plants Operations (RPO) on 4/21/26. Review of the email message dated 4/22/26 between the vendor and Director of Maintenance read, If you want we can look at just fixing what you have, your set up right now is with the RF (radio frequency) wireless push to open units that connect to the mechanical door opener above the doors, the one set of doors that only one door opens is most likely a connection issue or malfunction in the door opener above the door. The push to open units are like a garage door opener so most can just have a new push button and sync it to the existing RF receiver. The Director of Maintenance forwarded the response message to the RPO on 4/27/26. Review of the email dated 5/14/26 from the RPO to the Director of Maintenance, with copy to the VP of Plant Operations, included a message addressed to the VP of Plant Operations which read, . attached is the door opener quote from a local vendor for (name of the facility). (Company name) stated they do not provide this service, and the local company quoted a system that requires a cloud system to operate with a subscription. They stated they could attempt to repair the system that has been worked on by multiple companies, but it is unlikely they can get system to work with its age and availability of parts. Review of the response from VP of Plant Operations dated 5/15/26 read, Why can't the push buttons be replaced with the same RF set up. The controllers are only $200 on Amazon. Review of the vendor's quotation document dated 4/20/26 indicated the total cost to correct the main entrance door issue would be $6,177.92. The description read, Customer has stand alone 2 door access with RF push to release needing new set up. The quotation stated the price was valid for 30 days and did not include any applicable state tax. Review of the Director of Maintenance/Maintenance Supervisor job description, signed by the Director of Maintenance and the NHA on 6/02/25, revealed he was responsible for planning, organizing, developing, and directing the overall operation of the Maintenance Department in accordance with federal, state and local standards, guidelines, and regulations governing the facility, ensuring the facility was maintained in a safe and comfortable manner. The job description further indicated he was responsible for the upkeep pf the facility, including the building, building systems, and grounds, and played a key role in the facility's safety program. Review of the Facility assessment dated [DATE] revealed an assessment of the physical environment, equipment, services, and other physical plant considerations necessary to care for residents. The assessment included a table listing categories, resources, and processes to ensure adequate supply, appropriate maintenance, and replacement. Under Other physical plant needs, it included, sliding doors, ADA-compliant entry/exit ways, and ingress/egress doors were evaluated daily by the Director of Maintenance for proper functioning.

Based on observation, interview, and record review, the facility failed to complete a comprehensive significant change in status assessment for 1 of 1 resident review for Activities of Daily Living (ADLs) in a total sample of 10 residents, (#1).Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including unstageable sacral pressure injury, functional quadriplegia, type 2 diabetes, and chronic obstructive pulmonary disease. Review of resident #1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/28/26 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS assessment showed resident #1 required substantial/maximal assistance from staff for eating, oral hygiene, upper body dressing and personal hygiene. Resident #1 was dependent for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off footwear. The MDS assessment also showed resident #1 required substantial/maximal assistance with bed mobility, including rolling left and right, sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, chair/bed-to-chair transfers, and toilet transfers. Review of resident #1's quarterly MDS assessment with an ARD of 5/31/26 revealed a BIMS score of 13 out of 15, indicating intact cognition. The MDS assessment showed resident #1 was now dependent on staff for all ADLs, including eating, oral hygiene, upper body dressing, personal hygiene, toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off footwear. The MDS assessment also showed resident #1 was now dependent for rolling left and right in bed and chair/bed-to-chair transfers. Sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, and toilet transfers were documented as not attempted due to the resident's medical condition or safety concerns. Review resident #1's care plan, initiated on 5/12/26, revealed the resident had a decrease in ADL function related to physical limitations and decreased motivation. On 6/30/26 at 11:12 AM, resident #1 stated he needed assistance with everything because he could no longer move his hands or arms. He stated he required assistance with meals because he was unable to manage a spoon independently. He indicated when he was admitted , he was able to do certain things independently; however, he had experienced a decline in his ability to perform those activities. On 6/30/26 at 12:35 PM, Certified Nursing Assistant A stated resident #1 was totally dependent on staff for all ADLs. She indicated he could not move his arms or legs and required staff assistance with meals, drinks, and using the telephone. On 6/30/26 at approximately 5:35 PM, the Director of Nursing and the Regional Nurse Consultant reviewed resident #1's medical records and acknowledged a significant change in status assessment had not been completed despite the decline in ADLs identified in the quarterly MDS assessment with an ARD of 5/31/26. On 6/30/26 at 5:56 PM, resident #1's MDS assessments and ADLs were reviewed with the MDS Lead and MDS Coordinator. The MDS Lead confirmed the findings documented on each MDS assessment and acknowledged resident #1 had declined in more than two ADLs from the admission assessment to the quarterly assessment. She confirmed resident #1 met the criteria for a significant change in status assessment; however, one had not been completed and did not provide an explanation for why it had not been performed.

Based on interview and record review, the facility failed to implement the resident's care plan for toileting for 1 of 1 resident reviewed for Activities for Daily Living (ADLs) in a total sample of 10 residents, (#1).Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including unstageable sacral pressure injury, functional quadriplegia, type 2 diabetes, and chronic obstructive pulmonary disease. Review of resident #1's quarterly Minimum Data Set assessment with an Assessment Reference Date of 5/31/26 revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. The MDS assessment showed resident #1 was dependent on staff for all ADLs, including toileting hygiene. The MDS assessment also showed resident #1 was dependent for rolling left and right in bed and chair/bed-to-chair transfers. Sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, and toilet transfers were documented as not attempted due to the resident's medical condition or safety concerns. Review of resident #1's care plan, initiated on 5/12/26, revealed the resident had a decrease in ADLs related to physical limitations and decreased motivation. Interventions included developing and implementing a personalized care routine that promoted independence while ensuring safety. Review of another care plan, dated 3/25/26, revealed an alteration in unusual functional performance in self-care related to a recent hospitalization and impaired mobility. Interventions revised on 5/28/26 included toileting and bed mobility, including rolling from side to side and side to back, and indicated resident #1 was dependent and required the assistance of two staff members for toileting and bed mobility. On 6/30/26 at 11:12 AM, resident #1 stated he needed assistance with everything because he could not move his hands or arms. He stated he required assistance with meals because he was unable to manage a spoon independently. Later, at 4:03 PM, resident #1 stated the majority of time, the Certified Nursing Assistant (CNA) assigned to him that day came with another staff member to change him; however, if she could not find someone to assist, she changed him by herself. He further stated she was very efficient but explained he was dead weight. He stated he could no longer move his hands and had gradually declined since his admission. He indicated only two CNAs who were very tall were able to provide his care independently. On 6/30/26 at 12:35 PM, CNA A stated resident #1 was totally dependent on staff for all ADLs . She indicated he could not move his arms or legs and required assistance with meals, drinks, and using the telephone. She stated she overheard another CNA say she could no longer change resident #1 by herself and was waiting for someone to assist her; however, the larger CNAs were able to provide his care independently. She confirmed resident #1 could not roll to his left or right side without assistance and said he could not do anything. She stated when resident #1 was admitted to her unit, staff were told two staff could assist him, but it was not mandatory. She confirmed staff could ask another employee for assistance if needed; however, she reiterated it was not required and stated she provided toileting care by herself. She stated she reviewed residents' care plans when she was unfamiliar with a resident but also learned residents' care needs through verbal communication with nurses or other CNAs. On 6/30/26 at 6:00 PM, the Director of Rehabilitation stated Occupational Therapy (OT) discharged resident #1 on 6/25/26 after determining he had plateaued . She confirmed the OT Discharge Summary documented resident #1 was dependent for all ADLs and required the assistance of two staff members for all care except eating, oral hygiene, putting on and taking off footwear, and personal hygiene. On 6/30/26 at 6:08 PM, the Director of Nursing reviewed resident #1's medical record and confirmed the resident required the assistance of two staff members during toileting. Review of the facility's policy titled Plans of Care, revised 9/25/17, revealed an individualized person-centered plan of care would be developed for each resident based on the comprehensive assessment to address the resident's identified medical, nursing, mental, and psychosocial needs.

Based on interview, and record review, the facility failed to ensure staff reported allegations of abuse timely and thoroughly investigate an alleged incident of sexual abuse by a cognitively impaired male resident, (#2), resulting in a delay of implementation of appropriate corrective actions, based on the result of the investigation findings.Findings:Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, schizoaffective disorder bipolar type, mood disorder, disorder of psychological development, and attention-deficit hyperactivity disorder.Review of resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had clear speech, was able to be understood, and could understand others. Her Brief Interview of Mental Status (BIMS) score was 10 out of 15, which indicated moderate cognitive impairment.Resident #2's record revealed he was admitted to the facility on [DATE] with diagnoses that included dementia, alcohol abuse with alcohol-induced psychotic disorder, and primary insomnia.The quarterly MDS assessment for resident #2 dated 7/29/25 revealed he had clear speech, was able to be understood, and was able to understand others. His BIMS score was 6 out of 15, which indicated severe cognitive impairment.Review of resident #2's medical record revealed he had a care plan initiated on 6/02/14 for the use of psychotropic medications related to behavior management. The care plan was initiated on 6/01/24 and was revised on 10/17/24.On 10/09/25 at 1:40 PM, resident #1 was in her room sitting in a chair by the window next to her bed. She expressed she was fearful but was willing to speak about the incident on 10/06/25. The resident explained that night around 9:00 PM, she was asleep in her bed when she was awakened by resident #2 touching her back, arm, and stomach. She recalled she immediately screamed and resident #2 exited the room. Resident #1 said she walked out of her room and saw resident #3 in the hallway who told her he heard her scream. She asked resident #3 to tell the nurse. Resident #1 conveyed the nurse came to see her and asked her what happened but did nothing else in regard to ensuring resident #2 did not repeat his actions. Resident #1 reported she could not sleep well that night because she was scared that resident #2 would come back to the room. She said she called her sister that night and told her what had happened, and, in the morning, she saw resident #2 still wandering in the hallway.On 10/09/25 at 1:29 PM, resident #3 stated that on 10/06/25 at approximately 9:00 PM, he was in his room, sitting in his wheelchair and had a clear view of the hallway. He recalled he saw resident #2 walking down the hallway towards resident #1's room and moments later heard her scream. He went towards resident #1's room and she was coming out of the room. She seemed scared and told him that resident #2 had come into the room and touched her while she was asleep. Resident #3 said she asked him to tell the nurse because she was scared to do it herself. Resident #3 said he spoke with Licensed Practical Nurse (LPN) B at the nurses' station and told him what he had witnessed. He remembered resident #1 joined them a few moments later at the nurses' station and told LPN B what happened. Resident #3 said LPN B took resident #1 back to her room and attempted to calm her down but he did not recall anything was done to keep resident #2 from returning to resident #1's room. He said he had witnessed at other times, resident #2 entering other resident rooms uninvited and touching their belongings. He explained that resident #2 used to be his roommate and he requested to change rooms because he used to touch his things without permission. He said he felt resident #1 was affected by the incident because she was scared to sleep that night and was crying.On 10/09/25 at 1:29 PM, resident #3 was sitting in the common area of the facility. He could not recall the event nor any details of what happened.On 10/10/25 at 12:14 PM, LPN B confirmed he had worked on 10/06/25 during the overnight 7:00 PM to 7:00 AM shift. He said that between the hours of 11:00 PM and 11:30 PM he was in the 100-hallway where residents #1, #2, and #3 lived, passing medications alongside LPN A. The LPN recalled that residents #1 and #3 walked casually down the hallway to LPN A and reported that resident #2 had entered resident #1's room to touch her but they did not say where she was touched. LPN A told resident #1 to go back to her room and she would come see her. LPN B said he did not see resident #2 in the hallway at that time, which he indicated was rare because he usually paced the hallways at night. LPN B said he was not resident #1 or #2's nurse, so he was not involved and did not report the incident to the on-call Supervisor. The nurse said he was not asked to write a statement by anyone at the facility.On 10/10/25 at 11:52 AM, LPN A confirmed she was the assigned nurse for residents #1 and #2 on 10/06/25. She said that between the hours of 10:30 PM and 11:00 PM, she passed medications in the 100-hallway when resident #1 walked up to her cart and was visibly shaking. LPN A recalled resident #1 told her that resident #2 had been in her room and touched her hand and back. The nurse explained she told resident #1 to return to her room and she would come to see her. LPN A said she saw resident #2 standing near the doorway of his room and she asked him what happened. The nurse said resident #2 was unable to remember anything. The LPN recalled that resident #2 told her if he had done something to resident #1, he wanted to apologize but she told him to stay in his room. LPN A said she shut resident #1's room door and positioned herself where she could watch resident #2 in case he came out of his room. The nurse said she sent the Director of Nursing (DON) a text message, but it never went through until the morning. She did not say why she did not attempt to call the DON or the Administrator who was the Abuse Coordinator, when she did not get a reply. LPN A said she received a message from the DON at approximately 6:00 AM, directing her to write a statement of what happened and to get statements from the residents. The DON told her that resident #2 would be put on one-to-one supervision that morning. She said she did not perform a skin check on resident #1 because when she spoke to her, she told her she was fine, so she did not think a skin check was needed. LPN A said she returned to work on 10/08/25 at 7:00 PM and saw resident #2 was on one-to-one supervision.On 10/10/25 at 11:21 AM, the Assistant Director of Nursing (ADON) said that on 10/07/25 at approximately 10:00 AM, she heard resident #1 talking about the incident in the hallway to another staff member so she approached her. Resident #1 told her resident #2 had come to her room and touched her shoulder. The ADON reported the incident to the Administrator and DON so that an investigation could be started. She said that the psychiatric provider was consulted to evaluate both residents on 10/08/25. Resident #1 spoke with the psychiatric provider via telehealth and told her that she was scared to sleep at night and could not eat. The ADON said she did not instruct LPN A to complete an incident report because this incident did not require one. She expressed that the expectation for staff was to call the DON or Administrator to report all incidents and for staff to take any allegations of abuse seriously. She said that on 10/08/25 she passed out a handout to staff instructing them to watch resident #2 closely to ensure he did not enter other resident rooms.On 10/10/25 at 1:22 PM, in a joint interview with the DON and Administrator, the DON said that on 10/07/25 at 6:20 AM, he received a text message from LPN A that resident #1 alleged resident #2 had entered her room to touch her on the shoulder and wake her up. The DON said he instructed LPN A to write a statement but said there were no other instructions given. The Administrator confirmed she received a call from the DON telling her about the incident, and that resident #1 was doing fine. The Administrator said they had a meeting with resident #1's sister on 10/07/25 to discuss the incident with her but confirmed they did not tell the sister what would be done to ensure resident #2 did not get near resident #1 again. They said they spoke with resident #1 who told them she was fine and felt safe at the facility. She said they did not gather statements from staff until 10/08/25 because they felt the event did not rise to the level of harm. The DON confirmed he did not instruct LPN A to conduct a skin assessment on either resident or complete an incident report. He said there was no order to do one-to-one supervision with resident #2 until 10/08/25 after the sister insisted something be done to ensure resident #2 did not repeat his actions as he still wandered the hallways freely at night. The Administrator said LPN A should have continued to reach out to the DON when she did not hear back from him right away. She said she was the Abuse Coordinator, and her number was posted throughout the facility. She confirmed they did not do a full investigation because resident #1 said she was doing fine. She agreed that all allegations of abuse should be investigated thoroughly to ensure proper actions were taken to keep residents safe.Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Policies and Procedures revised 11/16/22, revealed that sexual abuse was defined as non-consensual sexual contact of any type and was not limited to unwanted intimate touching of any kind. Generally, sexual contact was non-consensual if the resident did not want the contact to occur. The procedure for investigation was to immediately upon an allegation of abuse, the suspect should be segregated from residents pending the investigation. The assigned nurse or DON should perform and document a thorough nursing evaluation and notify the attending physician. An incident report should be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The policy indicated the Abuse Coordinator or DON should take statements from the victim, suspects, and all possible witnesses including those within the vicinity of the alleged abuse, and upon completion of the investigation, a detailed report should be prepared.

Based on observation, and interview, the facility failed to provide a homelike dining experience in the day/dining rooms on both nursing units for all residents who ate their breakfast and dinner meals there. This affected 29 residents at the two observed meals with the potential to affect all residents who chose to eat their meals in the unit's day/dining rooms. Findings: The facility's main dining room was noted during the survey dates from 4/08/25 to 4/10/25 not to be open for residents to eat their breakfast or dinner meals. For breakfast and dinner, residents were able to eat in the day/dining room on either of the two nursing units, or in their bedroom. On 4/08/25 at 8:10 AM, six residents were observed as they ate breakfast in the day room on the 100's unit. The meals for each resident were served with their dishes, drinks, and flatware left on the meal trays from which they ate, which created an institutional appearance. There were also no centerpieces or linen on the tables. A few minutes later, at 8:20 AM, twelve residents were observed as they ate breakfast in the 200's unit dayroom which also had no centerpieces or table linens and residents eating from trays at the tables. On 4/10/25 at 8:54 AM, eleven residents were observed as they ate breakfast in the 200's unit day/dining room with their meal dishes on their meal trays. A table with four residents eating their meal from their trays with the lids from the main plates stacked in the center of the table, instead of a centerpiece. The residents at the table stated they usually ate breakfast and sometimes dinner in the unit day rooms. They explained the tables were crowded with their trays and the lids on it. Resident #59 stated it was better at lunch when the trays were removed and the dishes with food were placed on the table. She stated they also used to have flower centerpieces on the table which made it nicer. On 4/10/25 at 8:56 AM, the Activities Director stated she never noticed that meal items were left on the trays during breakfast meal service, but was sure dishes, drinks and flatware were removed and placed on the tables during lunch at the main dining room. She added she would make sure to discuss making the environment more homelike in the unit dayrooms/dining rooms, with the Administrator. At 9:30 AM , the Administrator and Regional [NAME] President of Operations stated they were aware the unit dining areas were not homelike and were going to be ordering linen tablecloths for them. They stated they were also going to spruce up the environment with plants, art, and other decorations so the residents felt like it was their home and not like they were trapped in an institution. They stated they want it to be decorated for the resident's enjoyment. On 4/10/25 at 12:58 PM, Certified Nursing Assistant (CNA) B explained they left the dishes on the trays when the residents ate in the unit day rooms at breakfast and dinner for no specific reason, it was just how they did it. She acknowledged it was important to make the environment homelike for residents as it was their home and made them, especially the more confused residents, feel more like they were at home rather than an institutional facility. On 4/10/25 at 1:05 PM, CNA A stated she had worked there for a long time and they had never been told to remove the dishes from the meal trays when serving meals in the unit dayrooms, only in the main dining room. She added, we always did it this way. The facility's policy entitled, Meal Distribution, dated February 2023, did not include information for providing a homelike dining experience for residents.

Based on observation, and interview, the facility failed to implement hand hygiene protocol for residents to help prevent the development and transmission of communicable diseases and infections for 23 residents who ate meals in the dining room. Findings: On 4/07/25 at 11:49 AM, in the facility main dining room, 23 residents were observed as they were assisted to their tables to dine. Several residents stated they arrived from physical therapy. None of the residents were offered a way to clean their hands before they ate. A short time later at 12:12 PM, staff sat next to and provided meal assistance to four residents without providing hand hygiene for them. On 4/10/25 at 8:58 AM, Certified Nursing Assistant (CNA) D explained that several years ago they used to hand out wipes to residents to clean their hands before they ate but over time that practice stopped. She added, it would be a good thing to do that again because cleaning hands was important to help stop the spread of germs. CNA D said the residents often touched their food while eating and they could have germs on their hands. On 4/10/25 at 9:03 AM, CNA C explained they never reminded residents to wash their hands or offered hand hygiene prior to eating meals during the two years she had worked at the facility. CNA C acknowledged that staff could offer the residents disinfectant gel or wipes to clean any germs or dirt from their hands. On 4/10/25 at 12:58 PM, CNA B stated it was important for people to wash their hands before eating because germs were everywhere. She said there was, .no saying what the residents have touched prior to their eating. CNA B added staff had never been told to clean the resident's hands before meals, and she just hadn't thought about it herself. On 4/10/25 at 1:05 PM, CNA A did not remember ever washing resident's hands prior to eating meals in the past [AGE] years since she had worked there. She stated it was important in order to not spread germs. On 4/10/25 at 3:12 PM, the facility's Infection Preventionist stated it was important for people to wash their hands before they ate and she was sure the facility had provided education on the importance of hand hygiene before meals last year. She added this was common knowledge we all learned as a child and as nursing staff, we know this. The Infection Preventionist said she was disappointed that nursing staff stated they were never educated or did not know to offer to clean residents' hands prior to mealtimes. She added, washcloths, hand wipes and disinfection gel were all available for use. The facility's policy entitled Handwashing/Hand Hygiene, dated 2019, stated the facility considered hand hygiene as the primary means to prevent the spread of infections and staff should make sure to clean their hands before and after assisting a resident with meals. The policy indicated residents would be encouraged to practice hand hygiene, but did not specify staff should offer hand hygiene to residents prior to meals.

Based on interview, and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the complaint survey conducted on 12/10/24 at the facility revealed citations including F609 for concerns related to reporting of abuse allegations. During the course of the current survey, F609 was again identified for concerns of investigating and reporting allegations of abuse and/or neglect. As a result of the repeat citation, it was identified there was insufficient auditing and oversight of the previous mentioned citation. On 2/18/25 at 3:55 PM, the Administrator explained she did not look at the actual grievance forms, just the grievance log brought in monthly to the Quality Assurance and Performance Improvement (QAPI) meeting. She stated the facility's last QAPI meeting was held on 2/13/25 and the focus was the facility's new QAPI plan. The Administrator stated she was not the Administrator during the survey in December 2024 when the facility was previously cited for failure to report allegations of abuse and neglect, and could not say what was done after those concerns were found to prevent repeat deficiencies from occurring. Review of the facility's Complaint/Grievance policy revised on 10/24/22 revealed grievances would be review by the Quality Assurance Performance Improvement Program Committee. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revised on 11/16/22 read, The center will review allegations of Abuse, Neglect, misappropriation of resident property and exploitation during QAPI meetings. QAPI committee will review info including but not limited to: The thoroughness of the investigation, Protection of the resident(s), Risk factors identified, Root-cause analysis of the investigation, Systemic changes that may be required. Review of the facility's Quality Assurance Performance Improvement Program policy revised on 10/24/22 revealed the objective was to focus on indicators of the outcomes of care and quality of life. The document mentioned the review of activities such as resident/family complaints/satisfaction. The policy read, The center will collect and monitor data from different departments reflecting its performance. The center will identify data sources and timeframes for collection. Data sources may include but are not limited to . Grievance logs . Medical record reviews .

Based on interview, and record review, the facility failed to ensure staff were knowledgeable of and followed their grievance process for 1 of 2 residents reviewed for grievances, of a total sample of 8 residents, (#7). Findings: Review of resident #7's medical record revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy (disorder that affects the brain), chronic obstructive pulmonary disease, type 2 diabetes, liver disease, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 1/22/25 revealed resident #7 had a Brief Interview for Mental Status score of 7 out of 15 which indicated she was cognitively impaired. The MDS assessment indicated she had no hearing or vision impairment. She was usually understood by other and she usually understood others. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for her health and well-being. She was dependent on staff for toileting hygiene and needed substantial/maximal assistance for personal hygiene. She was always incontinent of bladder and bowel. Review of the Resident Grievance Log revealed resident #7 filed a concern on 2/05/25. The Complaint/Grievance Report read, resident #7, had to be changed for the second time and the CNA (Certified Nursing Assistant) yelled at her saying I just changed you. [Resident #7] says this is not the first time and does not like being yelled at. Incident occurred at night. The Documentation of Investigation section showed the grievance was assigned to Nursing on 2/07/25. The Findings of investigation section was left blank. The Plan to resolve complaint/grievance, read, corrective action taken w/ (with) management re: (regarding) behavior. The Expected results of actions taken, read, To improve customer service. The NO box was checked for, Reportable to stage agency. The Post-Investigation Follow Up section was left blank. Review of the Reportable Event Log in February 2025 did not include resident #7. There was no report submitted to the State agency. On 2/17/25 at 10:07 AM, the Social Services Director (SSD) explained she was the Grievance Officer and responsible for overseeing the grievances. She stated grievances could be written by anyone and the facility determined if it was, truly a grievance. She indicated the facility had 10 days to resolve the grievance. The Social Services Director said, Depending on the situation, it may become a reportable. She stated grievances were discussed every day during morning meetings. She noted the Administrator (NHA) was the Abuse Coordinator, but anyone of them were mandatory reporters and anyone could report allegations of abuse and neglect. She shared the facility had two hours to report abuse and neglect. On 2/18/25 at 10:22 AM, the Administrator (NHA) stated grievances were discussed in morning meetings but were not read verbatim just discussed as a general concern. She mentioned whoever received a grievance needed to inform her if a reportable was questionable. On 2/18/25 at 3:42 PM, the NHA and SSD reviewed resident #7's grievance form dated 2/05/25. The SSD stated she gave a copy to the Unit Manager (UM) to follow up and she was waiting for disciplinary action and education for the resolution. The NHA stated she had not seen the grievance and was not aware of it. The NHA read the concerns of resident #7 and stated the grievance, sounded as [like] verbal abuse. The NHA confirmed the grievance was not followed up with resident #7 or reported to the State agency. On 2/18/25 at 3:55 PM, the NHA stated the SSD told her she had not seen this grievance, it may have fallen through the cracks, or was probably given to the Unit Manager (UM) directly by the Direct Patient Experience Coordinator. The NHA stated when the form was handed to the SSD by the UM, she did not read it and just filed it. The NHA confirmed this was not investigated as required. Review of the facility's Complaint/Grievance policy revised on 10/24/22 revealed the intent to support each resident's right to voice a complaint/grievance and to make prompt efforts to resolve the complaint/grievance and inform the resident of the progress towards resolution. The document read, Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy.

Based on interview, and record review, the facility failed to prevent further abuse, and timely and accurately report an allegation of abuse to the State Agency for 2 of 4 residents reviewed for abuse, of a total sample of 8 residents, (#1 and #7). Findings: 1. Review of resident #7's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including encephalopathy (disorder that affects the brain), chronic obstructive pulmonary disease, type 2 diabetes, liver disease, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 1/22/25 revealed resident #7 was usually understood by other and she usually understood others. Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated she was cognitively impaired. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for her health and well-being. She was dependent on staff for toileting hygiene and needed substantial/maximal assistance for personal hygiene. She was always incontinent of bladder and bowel. Review of the Resident Grievance Log revealed resident #7 filed a concern on 2/05/25. The Complaint/Grievance Report read, resident #7 had to be changed for the second time and the CNA (Certified Nursing Assistant) yelled at her saying, I just changed you. [Resident #7] says this is not the first time and does not like being yelled at. Incident occurred at night. Review of the Reportable Event Log in February 2025 did not include resident #7. There was no report submitted to the State Agency. On 2/18/25 at 3:42 PM, the Administrator (NHA) stated she had not seen the grievance from resident #7 and was not aware of it. The NHA read the concerns in the grievance form from resident #7 and stated it sounded as verbal abuse and confirmed it was not followed up or reported. Later at 3:55 PM, the NHA stated the Social Service Director told her she had not seen this this grievance, that it may have fallen through the cracks, or was probably given to the Unit Manager (UM) directly by Direct Patient Experience Coordinator. The NHA confirmed this was not investigated as required. 2. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, cellulitis of right lower limb, difficulty walking, orthopedic aftercare, arthritis, and repeated falls. Review of the MDS quarterly assessment with ARD of 12/11/24 revealed resident #1 had a BIMS score of 14 out of 15 which indicated he was cognitively intact. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for his health and well-being. Resident #1 needed substantial assistance from staff for toileting hygiene and personal hygiene. He was always incontinent of bladder and occasionally incontinent of bowel. Review of a State Agency report for physical abuse submitted by the facility on 2/11/25 revealed the NHA learned of resident #1's allegation of abuse at 2:15 PM on 2/11/25. The report included the following description of the allegation/incident: Resident #1 wanted to be changed, CNA C asked him to give her a moment, but he wanted to be changed immediately. CNA C walked up to resident #1 to advise him that she would get to him when she finished the other resident. Resident #1 stated he felt uncomfortable with how close she got to him when she approached him. On 2/17/25 at 8:50 AM, resident #1 stated prior to admission to the facility, he had right hip surgery, fell after surgery at the hospital, and had not been able to walk again or work with therapy. Resident #1 shared he experienced an abuse incident early one morning. He explained a CNA raised her hand to hit him, and he reacted by using foul language towards her. He mentioned that was the first time the CNA had worked with him. He stated the police came to talk to him and he was told she would not care for him again. He explained his nurse told the CNA to change him, but the CNA left him naked then left the room. He mentioned when she returned, she made a gesture to hit him, and he closed his fists and raised his arms to protect himself because he felt like she would hit him. He stated he could not get up to defend himself. He said, She must have been drugged or something because someone who does that to a patient lying in bed cannot be right. He recalled someone else came to get him dressed. He stated a manager later spoke with him about the incident. On 2/17/25 at 5:44 AM, Registered Nurse (RN) A recalled early one Saturday morning resident #1 reported CNA C raised her hand and he perceived it as she was going to hit him. She explained that morning, CNA C called RN A into resident #1's room and the resident told her he was wet and needed to be changed. RN A stated CNA C responded she would return to change him. RN A indicated CNA C stepped out of the room and sat by the nurses' station to document and did not change resident #1 at that time. RN A mentioned she later returned to give resident #1 his medications and he told her CNA C returned to his room later and he had to hold her hand to not get hit. She indicated she reported the incident to the Weekend Supervisor and completed a witness statement. She stated she and the Weekend Supervisor called the Director of Nursing (DON) that same morning and reported the allegation. She stated she did not know what happened after that because she did not work the rest of the weekend. She indicated she did not perform a head-to-toe assessment for resident #1. She stated he was not crying, agitated or upset when he told her about the incident and he did not request a change of assignment. She recalled the oncoming shift CNA B reported what resident #1 told her and she told CNA B she had already reported the incident to the DON. She explained after that day, no one in the facility asked her any questions about that incident. On 2/17/25 at 8:09 AM, the Weekend Supervisor stated the Abuse Coordinator was the NHA. She shared allegations of abuse or neglect were reported immediately because the facility had 2 hours to file a report. When asked about the incident for resident #1, she recalled CNA B told her resident #1 reported a CNA had, smacked him or put her hand towards him. She indicated she was unable to interview resident #1 because he spoke Spanish. She shared she and CNA B went to resident #1's room to interview him. The Weekend Supervisor stated resident #1 said the CNA who had him last night put her hands toward him. She indicated she later asked RN A and she confirmed she was aware of the incident. The Weekend Supervisor shared she then called the DON and reported it. She explained typically we would have the nurse do a skin check but she did not do it. She said, My time in his room was limited because resident #1's roommate did not like anyone in the room who did not speak Spanish. She indicated CNA C was assigned to that room from 11 PM to 7 AM and did not speak Spanish. She said, We do not always have Spanish speaking CNAs at night, but there was a staff member working who could translate if or when needed. She stated she did not recall if she wrote a statement or not that morning but remembered reporting it to Administration. She shared she worked on nursing carts in the South Wing both Saturday and Sunday and did not know what happened after she reported the incident. On 2/17/25 at 9:25 AM, CNA B stated on Saturday 2/08/25, she started her shift at 6:30 AM, and did her rounds as always. She mentioned resident #1 liked his privacy curtain closed and the light off at night. She recalled when she went to resident #1's room, he was crying. She stated she asked him what happened, and he shared an incident that occurred earlier during the night. She stated resident #1 told her he had urinated in his brief and was burning so he pressed his call light and the CNA responded she did not have time to change him, turned the call light off and told him to go to sleep. CNA B indicated he said he turned on the call light for a second time, the same CNA returned and she started yelling at him. He told her the CNA raised her hands like she was going to hit him on his face so he put his hands up and he asked her, Are you going to hit me on my face? then the CNA left the room. She explained he shared the nurse came in and he explained what happened to the nurse but still he was not changed. CNA B indicated she changed resident #1 at that time, and he was soaking wet so she took him to the shower room and gave him a shower. She shared she noticed he had a lot of DermaSepting ointment on. She explained, only a little of that ointment should be used in red areas but not the private areas because it could cause burning sensation. She indicated before she gave resident #1 a shower she spoke with the Weekend Supervisor. She recalled the Weekend Supervisor came to resident #1's room, he was upset and talking in Spanish, so she tried to translate. She mentioned she was present when the Weekend Supervisor and the nurse called the DON. She stated resident #1 was very upset the rest of the day, he called his son, and his son tried to calm him down. CNA B mentioned whenever he remembered the incident, he cried, he was very upset. She stated she, wrote a statement right away. She shared CNA E who was also a witness when resident #1 told her about the incident also wrote a statement. She stated she worked on 2/08/25, 2/09/25 and 2/10/25 and no one from Administration spoke with her or asked her questions about the incident. On 2/17/25 at 10:26 AM, the DON recalled resident #1's incident started on 2/08/25 when he turned his call light on because he needed to be changed. He indicated resident #1 did not speak much English, so CNA C called the nurse, and the nurse explained to the CNA he needed to be changed. He stated CNA C left resident #1's room and returned to change him. The DON said, According to the resident, he saw the CNA was agitated with him, the CNA went to provide the care, the resident told the CNA hey do you want to hit me, hit me. The DON stated he asked resident #1 if CNA C hit him and the answer was no and the CNA provided care, and that was the end. The DON recalled the Weekend Supervisor called him after Licensed Practical Nurse (LPN) D told her about the incident. He indicated he spoke with resident #1 via video call with LPN F who was working in that unit but was not assigned to resident #1. The DON stated he called LPN F because she spoke Spanish. The DON stated he asked resident #1 if he felt intimidated or unsafe and the resident responded he was okay, but he did not want CNA C caring for him. The DON said, On that day there is nothing to report because it was a customer service issue. On 2/17/25 at 10:50 AM, the DON and NHA presented their report to the State Agency dated 2/11/25. The NHA stated the Direct Patient Experience staff was informed by resident #1's CNA about an incident with CNA C. The DON stated on 2/08/25, CNA B mentioned resident #1 was crying about something that happened that morning, and his night shift CNA did not understand him. The DON and NHA did not answer why they did not have witness statements from the staff assigned to resident #1 the day of the allegation. The DON stated the staff did not mention resident #1 thought CNA C was going to hit him. The DON did not answer whether he read the progress note from LPN D in resident #1's medical record. The NHA stated they did not have RN A's or CNA B's statements in their investigation folder. On 2/17/25 at 11:47 AM, the DON and CNA B stated they wanted to clarify that resident #1 did not say he was hit by CNA C. The DON and CNA B validated CNA B's statement was correct. The DON verified he instructed the Weekend Supervisor to collect witness statements, but he did not follow up with her. On 2/17/25 at 11:59 AM, LPN D stated during morning medication pass on 2/08/25, resident #1 told her he did not want the antibiotic he was on because it made him pee too much and turned his urine orange. She shared she could tell he was upset, and he shared, They do not want to take him to the bathroom. She explained he had a Urinary Tract Infection (UTI), and he needed to take his antibiotic. She recalled he shared I go to the bathroom too much and someone tried to hit me. She indicated his main language was Spanish, but he spoke some English. She mentioned she spoke with CNA B and they told the Weekend Supervisor about what resident #1 shared. She recalled the Weekend Supervisor informed the DON who got on the phone with resident #1 but they were talking in Spanish, so she did not understand their conversation. She stated CNA B, the DON and herself were in the room when the DON spoke with resident #1. She recalled when resident #1 told her someone tried to hit him, he was not crying but he was agitated, and I could tell he was upset. She stated she entered a progress note in his medical record but was not asked to write a witness statement. LPN D said, There was no other conversation about this incident until today. Review of resident #1's medical record revealed a Progress Note entered on 2/08/25 at 9:04 AM, by LPN D. The note read, During a.m. (morning) med (medication) pass pt (patient) seem upset, pt didn't want to take ABT for UTI, pt was stating it turns his urine orange and stated that it burns, pt was educated on the importance of taking meds, and that his urine turning orange is a harmless side effect that goes away after completion of taking med, and the medication will help the burning, pt took meds and stated he didn't have a good night because CNA tried to hit him because he turns on light to be changed, stating he urinates too much. Supervisor was notified. On 2/17/25 at 12:17 PM, CNA E shared before 7:00 AM on 2/08/25 CNA B called her to come into resident #1's room. She indicated CNA B told her she wanted a witness to ensure she understood correctly what resident #1 was saying. CNA E stated resident #1 was crying and she asked what happened. She mentioned he stated he was very, very upset because he got into an argument with the night shift CNA because he wanted his brief to be changed and felt a burning sensation, and they were like fighting verbally. CNA E stated resident #1 raised his hands showing them what he did when he thought the CNA was going to slap him. She explained she and CNA B asked resident #1 if the CNA hit him and he responded no, but he raised his hands because he thought she was going to hit him. She stated she reported the incident to the night nurse who told her she had spoken with the resident. She mentioned no one asked her for her witness statement until today. On 2/18/25 at 9:02 AM, CNA C stated resident #1 communicated with her in English. She recalled performing her rounds as usual on that particular night. She mentioned at around 3:00 AM she was collecting cups to get new ones with fresh water for all her assigned residents. She stated she answered a call light in resident #1's room and he said he needed his cup of water and began speaking to her in Spanish. She indicated she asked him what he was saying, but he continued speaking in Spanish, so she left the room to get the nurse because she did not understand Spanish. She stated she returned with RN A and the nurse told her resident #1 said he was wet and needed to be changed. She indicated she changed his brief and accidentally bumped into his bedside table causing some things to fall to the floor. CNA C stated she pulled his pants up, got all the things from the floor and told him to pull his sheet over his head the way he liked and always did. She indicated she made the hand gesture for him to pull the sheet over his head. She stated she left the blanket over his chest, instructed him to pull it over and he told her not to talk to him like that and made a gesture with his finger pointing at her. She indicated she left his room after that, and returned to check on him around 5:00 AM and he was sleeping. She mentioned she did not talk to him again. She recalled she finished her shift and left for the day. No one mentioned anything or asked any questions. She explained when she returned to work on Monday 2/10/25, she noticed her assignment was changed so she wondered why. She shared she spoke to the other CNA who had her assignment, and they discussed changing their assignments. She stated a CNA working on the unit asked her if she had received a call from Human Resources (HR). She shared she was told by that CNA resident #1 made an allegation, apparently on Friday you threw your hands up and that was the rumor she heard. CNA E stated she did not receive a call that weekend from the facility and was shocked about the allegation. She stated she was told by that CNA if I were you, I would leave the assignment the way it was. She indicated she tried to speak with RN A who working that night, but she did not speak much English. She mentioned RN A confirmed she had to stay over on Saturday to write a statement about what happened that morning. CNA E stated she did not go into resident #1's room on 2/10/25 to 2/11/25. She stated she attended a town hall meeting the morning of 2/11/25 and left the facility at approximately 9:00 AM. She indicated she received a call from HR later that day, between 4:00 and 5:00 PM and was informed she was suspended and had to come in to write a statement. She shared she came to the facility on Wednesday 2/12/25, wrote her statement and learned the facility's protocol was to suspend her for three days until they completed an investigation. She stated HR called her yesterday and told her she needed to come in for a class today. On 2/18/25 at 11:54 AM, the Direct Patient Experience explained she visited all residents daily to ensure everything is up to par with them. She explained on 2/11/25, a CNA shared resident #1 had a concern. The Direct Patient Experience staff stated she and the NHA spoke with resident #1. She shared resident #1 explained he had a verbal altercation with CNA C one night, and he felt safe in the facility, but did not want that CNA to care for him any longer. On 2/17/25 at 1:30 PM, the NHA explained HR spoke with CNA C to inform her of the suspension. The NHA stated she felt CNA C's statement was clear and she did not have any follow up questions for her. She shared when the DON called her on 2/08/25, he explained resident #1 was upset at a CNA but the resident was the one yelling to the CNA and it escalated. The NHA indicated she ran it by the Regional Nurse Consultant and was told it sounded more like a grievance. She shared all grievances were discussed during morning meetings but she did not realize the whole situation, and the DON made it seem like the Weekend Supervisor was not making it a severe incident. The NHA stated when she was called, a physical or verbal abuse allegation was not mentioned. She indicated she assumed the DON took it as not an abuse allegation or undermined it. The NHA stated LPN F said she did not get a statement from CNA B, but CNA B confirmed she wrote a statement. The NHA stated she did not review and was not aware of LPN D's progress note in resident #1's medical record and did not think management looked at the note. She confirmed the facility did not interview other residents assigned to CNA C. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revised on 11/16/22 included the steps for investigating allegations of abuse. The form read, Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. The Investigation section included, 'The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Any suspect who is an employee will be suspended when identified. Increased supervision of alleged victim and residents . The Protection section read, Provide the resident with emotional support and counseling during and after the investigation, if needed. The Reporting/Response section revealed reporting should be immediately, but no later than 2 hours after the allegation was made if the events that caused the allegation involved abuse to the Administrator and other officials in accordance with State law. The policy included the DON was the designated abuse coordinator in the absence of the Executive Director.

Based on interview, and record review, the facility failed to ensure staff reported allegations related to an incident of alleged verbal abuse of a resident by a staff member in a timely manner for 1 of 3 residents reviewed for abuse/neglect/exploitation, (#1). Findings: Resident #1 was initially admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) due to embolism of left middle cerebral artery, aphasia (inability to speak), generalized anxiety disorder, and recurring major depression. Resident #1's Quarterly Minimum Data Set assessment dated [DATE] revealed he had a Brief Interview of Mental Status score of 12 out of 15 which indicated moderate cognitive impairment. He presented with depressed moods for several days during the two week look back period and did not exhibit any behaviors of rejection of care or physical and verbal violence towards others. Resident #1 had upper and lower extremity functional limitations in range of motion to the right side of his body. He required setup/clean-up assistance for eating and oral hygiene and supervision/touch assistance for showers, toileting, dressing, and personal hygiene but was independent for mobility. Review of the facility's reportable/adverse incidents from September- November 2024, revealed that on 11/21/24 the facility reported alleged verbal abuse towards resident #1 by Licensed Practical Nurse (LPN) A. The report indicated that on 11/20/24 at around 10:00 PM, LPN A was heard by witnesses yelling in resident #1's room. When they came out of the room the resident was visibly upset and attempting to tell LPN A something regarding his medications. The report detailed LPN A said that resident #1 punched her on the abdomen while they were in the room and then she was overheard telling the resident that if it wasn't for her going to jail, she would punch him in the [expletive] face. The incident report indicated resident #1 was taken to his room by Certified Nursing Assistant (CNA) D and Registered Nurse (RN) C. LPN A continued working with resident #1 and staff failed to report the incident until the end of the shift. The report showed LPN A reported the incident to the Staffing Coordinator prior to leaving the facility, over nine hours later. Review of resident #1's daily progress notes revealed on 11/20/24 at 10:00 PM, LPN A documented that resident #1 punched her in the abdomen and was visibly upset and angry, but it was unclear to her why he had behaved in that manner when she attempted to obtain his vitals. She wrote that prior to obtaining the vitals the resident appeared pleasant and agreeable, but he had difficulty expressing himself and became angry when not understood. She indicated the resident was removed from the area by a CNA and taken to his room. On 12/09/24 at 1:00 PM, resident #1 was interviewed in his room while he was sitting up in his wheelchair. When asked about the incident that occurred on 11/20/24 with LPN A he became very upset and was unable to verbally explain what happened because of his speech impediment but he attempted to act it out. He was sat by the right side of the bed next to the window and then wheeled himself around to the left side of the bed and transferred into his bed to show that he was in bed when LPN A came into his room. He transferred back into his wheelchair and wheeled out of the room to the hallway where there was a nurse at a medication cart next to his room. He started to bang loudly on the medication cart and pointed to the nurse. The nurse asked him if he was attempting to explain what happened with LPN A and he shook his head in agreement. She said he was still very upset about the situation, but she was unsure of the whole story. Resident #1 wheeled himself back into his room and nodded in agreement that LPN A had cursed at him and he hit had her. He had a book with pictures and words next to his bed and he pointed to a page that said that his cognition was intact, but he just could not talk. Then he flipped to another page where he pointed at a sad face. On 12/09/24 at 4:10 PM, in an interview with LPN A via telephone, she confirmed that she was resident #1's assigned nurse on 11/20/24. She said that around 10:00 PM on 11/20/24 resident #1 was due for his blood pressure medication so she entered his room with the medication and a blood pressure machine. His blood pressure was low, so she was going to hold the medication and then the resident got frustrated because she did not have the rest of his medication. Due to his speech impediment, she was unable to understand what he had said but she thought he was asking for the rest of his medications. She said that she administered his other two medications and then attempted to get the blood pressure machine that was left in his room. Resident #1 punched her on the abdomen, and she left the room upset but not seriously injured. She said that she cursed at the resident and told him that she would call the cops on him for hitting her. She explained the resident was out in the hallway when she cursed at him, but said she did not see any staff around. She said that she chose to give the resident his medications last, and she knew that he preferred to have them earlier so that had probably made him upset. She did not immediately report the incident to her Supervisor but instead waited until the end of her shift to report it to the Staffing Coordinator. She said she had received education on reporting abuse/neglect previously on 10/20/24 and was aware that she should have called the On-call Supervisor immediately to report the incident. On 12/09/24 at 4:45 PM, CNA D said that on 11/20/24 at around 10:00 PM, she was at the nurse's station on the North Wing when she saw resident #1 and LPN A coming out of his room. CNA D recalled LPN A was screaming that he had punched her on the abdomen. CNA D said that the resident was pointing at the medication cart that was by his room and putting up three fingers. She expressed that resident #1 looked very upset with LPN A and overheard her say that if it wasn't for her going to jail she would [expletive] punch him in the face. She said that he was probably upset because LPN A gave him his medications later than he preferred, and he could not tell her due to his speech impediment. She said she assisted the resident back to his room and got him to calm down before putting him to bed. CNA D said that the incident could be considered abuse because LPN A cursed at the resident, but she did not immediately report it because she thought it was LPN A's responsibility. On 12/09/24 at 5:53 PM, CNA B said she had worked on the North Unit on 11/20/24 and overheard the commotion with LPN A and resident #1. She explained that she witnessed LPN A cursing at resident #1 and saw that he was very upset. She said she did not report it to a Supervisor because she expected that LPN A would do that. She said she had received abuse/neglect training in the past and was told that she should report suspected abuse/neglect to a Supervisor as soon as possible. On 12/09/24 at 6:30 PM, RN C stated that she had worked on the North Unit on 11/20/24 and was passing medications down the hallway from resident #1's room. She overheard LPN A screaming for help because resident #1 had punched her in the stomach. She said that other CNAs were attempting to take him to his room and LPN A continued to pass medications but did not report the incident. RN C said she did not report the incident to her Supervisor because LPN A should have done it. She confirmed she had received abuse/neglect training in the past and was told that they must report any allegations of abuse/neglect to their Supervisor as soon as possible. On 12/10/24 at 3:52 PM, the Director of Nursing (DON), Administrator, and Regional Nurse Consultant (RNC) were jointly interviewed regarding the incident and abuse/neglect training. The DON stated that during the morning clinical meeting on 11/21/24 she was informed by the Staffing Coordinator of the incident. She confirmed she had not received a call from LPN A or any other staff members on the night of 11/20/24. She spoke to the resident during the investigation, and he was upset because LPN A gave him his medications late and he was also frustrated. The DON said LPN A was suspended pending the investigation because witnesses heard her cursing at the resident. She said that all staff received abuse/neglect training upon hire, annually, and after any allegations of abuse/neglect. She confirmed that all staff were educated on being mandatory reporters and to report any incidents to their immediate Supervisor, DON, or the Administrator within 2 hours per facility policy. The Administrator said that the expectation was for staff to report all incidents to their Supervisor on site or via phone within 2 hours of occurrence. Review of the facility's policies and procedures titled Abuse, Neglect, Exploitation, and Misappropriation, revised 11/16/22, revealed that verbal abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age, ability to comprehend, or disability. Verbal abuse could include mocking, insulting, yelling, or hovering over a resident with intent to intimidate. Employees were trained that if they witnessed or had knowledge of an act of abuse or allegation of abuse, neglect, exploitation, or mistreatment they must report the information immediately, but no later than two hours after the allegation was made. An employee would be deemed to have violated their obligations if they failed to report an incident of abuse that was witnessed or reported to them.

Based on interview, and record review, the facility failed to develop, implement, and revise the person-centered comprehensive care plan to ensure it met their preferences, goals, and addressed their medical, physical, mental and psychosocial needs, for 1 of 2 residents reviewed for changes in behavior, of a total sample of 3 residents, (#3). Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses that included a wedge compression fracture of unspecified lumbar vertebra, Parkinson's Disease, adult failure to thrive, and cognitive communication deficit. He was discharged from the facility on 11/25/24 due to family request to take him to a different state. Resident #3's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. The assessment revealed he did not exhibit any physical or verbal behaviors towards others and did not have any wandering behaviors. Review of the discharge MDS assessment completed on 11/25/24, revealed a different BIMS score of 3 out of 15,and included disorganized thinking continuously without fluctuations, wandering behaviors, and other behaviors such as pacing, rummaging, and disrobing in public. He was independent for all activities of daily living and had no functional limitations. Review of resident #3's medical record revealed he had an order for a electronic wander bracelet placed on 11/01/24 that was to be checked daily. Review of the facility's reportable/adverse incidents from September- November 2024, revealed a report of an alleged resident to resident abuse involving another resident and resident #3. According to the report on 11/18/24 at approximately 1:00 AM a nurse reported to the On-call Supervisor that resident #3 had entered another resident's room and was observed by staff attempting to pull this resident out of bed by her wrist to take her to the shower. According to witness statements resident #3 was not wearing any clothing except for a blanket around him. The staff reported they took resident #3 to his room and then completed an assessment on both residents. The facility's immediate response to the event was to place resident #3 with a one to one sitter, notification to family and physician, and a referral for psychological evaluation. Review of resident #3's care plan initiated 11/01/24 revealed he had wandering behaviors related to entering other residents' rooms naked. Interventions revised 12/10/24, after the resident had been discharged , included monitoring the electronic wander bracelet for placement, and redirecting the resident to other activities. On 12/10/24 at 12:37 PM, the MDS Coordinator said that she was one of the people responsible for creating and updating the care plans. She said that during Inter Disciplinary Team (IDT) meetings she would be informed of any changes with the residents and then she would go to the unit to complete an assessment. The care plan was generated by the resident assessments, physician orders, resident preferences, and any other information received by the staff. She said that she found out that resident #3 wandered into another resident's room during the morning meeting on 11/18/24 and was aware that he had wandered into other resident rooms in the past but had not attempted to get them out of bed. She explained he had a care plan for wandering behaviors that had been initiated after he wandered into a resident's room for the first time after admission. She said that after his second and third incident of wandering into female resident's rooms, no revisions to the care plan interventions had been made in response to the continued behaviors. On 12/10/24 at 12:04 PM, the Director of Nursing (DON) confirmed that resident #3 had wandering behaviors and had been reported by two female residents in the past because he entered their room. She expressed an electronic wander bracelet was ordered after the first incident, and a care plan was initiated. She confirmed after the second instance, the care plan interventions were not revised and after the third instance he was put on a one to one sitter but said the care plan was not updated because the family would be taking the resident home. The DON said the resident was discharged on [DATE]. She said that the expectation was for the IDT team to discuss care plan interventions and determine their effectiveness. Review of the facility's policies and procedures on Plans of Care revised 9/25/17, revealed that an individualized person-centered plan of care would be established by the IDT team with the resident and/or resident representatives to the extent practicable and updated in accordance with state and federal regulatory requirements. The care plan must be reviewed, updated, and revised based on the resident's changing goals, preferences, and needs. The care plan may include services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as well as individualized interventions and alternative services that honor the resident's preferences.

Based on interview, and record review, the facility failed to maintain medical records that were complete and accurately documented related to missing and incomplete documentation of a reportable incident for 2 of 3 sampled residents, (#2, and #3). Findings: Review of the facility's reportable/adverse incidents from September- November 2024, revealed a report of alleged resident to resident abuse involving resident #2 and #3. According to the report on 11/18/24 at approximately 1:00 AM, a nurse reported to the On-call Supervisor that resident #3 had entered resident #2's room and was observed by staff attempting to pull resident #2 out of bed by her wrist to take her to the shower. According to witness statements resident #3 was not wearing any clothing except for a blanket around him. The report indicated staff took resident #3 to his room and then completed an assessment on both residents. Resident #2 was found to have slight redness on her wrist with no other visible injuries and she expressed to the nurse that she was not afraid of resident #3 but was not intending to go with him. The facility's immediate response to the event was to complete a skin assessment on resident #2, place resident #3 with a 1 to 1 sitter, notification of the event to family and physician, and a referral for psychological evaluation. Review of resident #3's medical record revealed that on 11/18/24 a progress note had been entered by the Social Service Director (SSD) that documented that resident #3's wife had been informed about an alleged physical abuse allegation he was involved in with resident #2. There was no documentation detailing the event or the immediate care that was provided to the resident post incident. Resident #2's medical record revealed that there were no progress notes entered on 11/18/24 that detailed the event, any assessments that were done, or any notification to the family and doctor. The record indicated she was seen by the Advanced Practice Registered Nurse related to a fall that she sustained on 11/19/24 but there was no mention of the abuse allegation incident. A psychiatric evaluation was completed on 11/21/24 as part of the new admissions process but there was no mention of the abuse allegation. Review of the assessments that were done on 11/18/24, revealed that a weekly skin assessment was completed on 11/18/24 at 5:37 PM, over 17 hours after the abuse allegation, with no documentation of the redness that had been reported by the nurse who assessed her immediately after the incident. On 12/09/24 the Director of Nursing (DON) provided a paper copy of a skin observation assessment that she completed on resident #2 dated 11/18/24 with no time documented. According to the DON this assessment had been completed as part of the investigation but not immediately after the incident. She confirmed there was no documentation of a skin assessment immediately after the incident. On 12/09/24 at 6:30 PM, Registered Nurse (RN) C said that she was the nurse who responded to resident #2's room during the early morning hours on 11/18/24. She said that she observed resident #3 attempting to pull resident #2 out of bed by her wrist and assisted in getting him out of the room. She said that she completed an assessment of resident #2 and noticed some redness to her wrist but no other injury was noted. She provided the assessment information to the On-call Supervisor but confirmed she did not document in the resident's medical record. On 12/10/24 at 2:51 PM, the SSD stated that she started working at the facility on 10/30/24 and was delayed in receiving access to document in the facility's electronic medical record system. She provided a copy of a note typed in plain white paper that was dated 11/18/24 but had no time. The note regarded a visit to resident #2's room to follow up on the incident that occurred the night prior with another resident. According to the facility, the incident occurred in the early morning hours of 11/18/24. The SSD stated in the note that the resident's daughter was at the bedside, and she informed the daughter of what had happened. The SSD said that during an investigation of alleged abuse, she was responsible for completing an initial psychosocial assessment of the resident and then following up for three days or more as needed. She confirmed that by 11/18/24 she already had access to the electronic medical record but chose to type her notes on a word document. She said that the psychosocial assessment that was completed on 11/18/24 had been started on 11/16/24 as part of the resident new admission assessment and not related to the incident. She was unable to provide documentation of the follow up visits that she completed with resident #2 regarding the incident. On 12/10/24 at 12:04 PM, the DON stated that her expectation was for staff to document any changes in resident condition, interactions with family, or incidents prior to the end of their shift. She said the progress note should have a brief explanation of any incident involving the resident. Review of the facility's policies and procedures regarding clinical/medical records revised on 8/25/17, revealed that the purpose of the clinical record was to document the course of the resident's plan of care and to provide a medium of communication among health care professional involved in their care. The clinical record must contain a record of the resident's assessments, the plan of care and services, and progress notes that indicate changes towards achieving care plan goals.

Based on observation, interview and record review, the facility failed to ensure a safe smoking environment for 10 of 10 residents reviewed for smoking, of a total sample of 17 residents, (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23). Findings: On 9/18/24 at 10:45 AM, resident #11 was observed in his room sitting on the edge of his bed. He was noted with bilateral high above the knee leg amputations. On his night table next to the bed in clear view was a pack of cigarettes and lighter. He was alert and oriented to person, place, and time. He said that some of the residents were allowed to keep their cigarettes and lighters, but staff did hold some of the residents' lighters. On 9/18/24 at 11:20 AM, residents #11, #15, #16 and #17 were observed outside smoking on the patio, with no staff present outside on the patio. None of the residents had on smoking aprons and resident #11 lit resident #15's cigarettes with his own lighter. The four residents present smoking used an ashtray on the patio table that was overflowing with old cigarette butts as well as one butt that was still burning. The Staffing Coordinator was noted standing inside the building watching the residents through a window while residents were outside smoking on the patio approximately 20-30 feet away. The Staffing Coordinator said none of the residents in the building needed an apron to smoke and since resident #15 was blind, resident #11 lit her cigarettes. Resident #11 confirmed he lit resident #15's cigarettes because she was blind. Resident #15 voiced she did have her own lighter and was not going to return it to staff when they were done smoking. The staffing coordinator made no attempt to come out and light residents' cigarettes, to stop resident #11 from lighting other residents' cigarettes, nor to empty the overflowing ashtray. The staffing coordinator did not notice that when resident #16 finished smoking, he re-entered the building via self-propelling in his wheelchair and still had 1/2 pack cigarettes with a lighter in his possession. She did not ask the resident to return his smoking materials to be kept safely by the facility. On 9/18/24 at 11:25 AM, the Central Supply staff said she came to relieve the Staffing Coordinator and supervise the smokers. She explained her role when supervising smoking activity was to ensure the residents were smoking safely. She said the residents were not supposed to keep their own lighters but some of them could hold onto their cigarettes and staff should light their cigarettes for them. The Staffing Coordinator also remained inside while residents #11, #15, and #17 were still outside smoking. The Central Supply staff was unaware residents #11 and #15 both had their own lighters, and she did not go outside to empty the ashtray that was 75% full on the patio table with burning cigarette butts present. On 9/18/24 at 11:27 AM, the Director of Nursing (DON) came outside to the smoking area while residents #11, #15, and #17 were noted outside still smoking and explained the residents were supposed to return their lighters when they were done smoking. The DON was informed that resident #16 had already finished smoking and was observed re-entering the building after smoking with his lighter on his person and staff did not attempt to retrieve his lighter. On 9/18/24 at 12:00 PM, the Nursing Home Administrator (NHA) provided the schedule of various staff that were supposed to supervise the smokers which included: restorative certified nursing assistants (CNA), Activities assistant, Social Service personnel, the Staffing Coordinator, the North Wing Unit Manager, the Wound Nurse, the Manager on duty, the Weekend Supervisor, the Medical Records staff, the Central Supply staff, and the North and South units CNAs with assignments 1 thru 5. The education that staff most recently attended was 3/26/24. The NHA verified they only reviewed the policy with the staff and had no special training or test for the staff who supervised the resident smoking activity. The facility NHA provided a list of 10 residents who participated in the smoking activity. Of the residents on the list, residents #17 and #22 were assessed with severe cognitive impairment and #21 and #15 had moderate cognitive impairment. Resident #15's Smoking Evaluation dated 5/24/24 revealed that her vision is not adequate, and she is not able to safely light her own cigarettes. Under the comments section nurse documented, Resident is legally blind and will need a staff member to light her cigarette and place her hand on the ashtray. Resident #15's care plan dated 5/29/24 for being a smoker had goal that she will not smoke without supervision and interventions included to provide supervision while smoking and requires a smoking apron. Resident #17's Smoking Evaluation dated 7/16/24 showed he had short- and long-term memory impairment and was deemed an unsafe smoker. His smoking care plan revised 8/16/23 with the goal he will not suffer injury due to unsafe smoking included intervention to provide a smoking apron. Resident #21's smoking care plan revised 6/11/24 included intervention that he required supervision while smoking. Resident #22 smoking care plan dated 1/19/24 showed that he required supervision while smoking. Resident #23's smoking care plan revised on 8/16/23 showed that he does require supervision and although he can light his own cigarettes, post activity his lighter is turned into staff and kept in a lock box. He was educated on 8/16/24 regarding relinquishing lighter possession policy. On 9/18/24 at 1:12 PM, again there were 8-10 residents seen smoking on the outside patio. Activities Assistant B was present inside the building but said she could see the smokers outside through the large glass window on the unit. She said she usually provided smoking supervision in the morning and at 3:30 PM. She explained she stayed inside because she could be around smoke due to her medical condition. She did not know what the facility smoking policies and procedures were for residents. The Activities Assistant said most of the residents were high functioning and able to keep their own lighters, but she was not sure of the facility rules. She verified it was difficult for her to properly supervise residents smoking from inside the building while they were outside, and she did not realize she should go outside with them. While interviewing the Activities Assistant there were approximately 4 to 5 residents observed sitting at the patio table passing around a lit cigarette to light their unlit ones. The DON was now present outside with the smokers and did not notice this behavior or stop the residents from lighting their cigarettes from an already lit one. On 9/18/24 at 3:22 PM, the NHA verified the staff should instruct residents participating in the smoking activity to not light each other's cigarettes or use other residents' lit cigarettes to light them. She added that after the activity, staff were to retrieve any lighters and safeguard them until the next scheduled smoke time activity. The NHA explained if the residents were not following the smoking policies staff were to report it to them so that they could re-educate the resident on the policies and they would issue a 30-day notice if they continued to not follow the rules. On 9/18/24 at 4:39 PM, the DON said, the staff who provided smoking supervision for residents should be outside sitting with the residents while they were smoking to ensure they were smoking safely and to intervene if they were not. The DON verified the staff should light residents' cigarettes and not allow them to light each other's cigarettes off already lit ones. The DON added the staff were to report to a supervisor if residents were not following the smoking policies so that they could intervene and give 30-day discharge notices if warranted. Review of the facility's policies and procedures for Smoking-Supervised, revised 2/07/20 read, The Center will provide a safe, designated smoking area for resident. For the safety of all residents the designated smoking will be monitored by staff member during authorized smoking times The center will have safety equipment available in designated smoking area including smoking blankets, smoking aprons, a fire extinguisher and no combustible self-closing ashtrays 4. During designated smoking times staff will be assigned to assist or supervise resident whose care plans indicate assistance or supervision is required while smoking. 5. The Center will retain and store matches, lighters, etc. for all residents. 6. All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 7. Residents will be advised upon admission that violations of the smoking policies may result in revocation of smoking privileges, discharge, and /or report to law enforcement .9. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plans of care for 2 of 2 residents reviewed for IV care, of a total sample of 17 residents, (# 2, and #18). Findings: 1. On 9/18/2024 at 12:14 PM, resident #2 was observed with a midline intravenous (IV) catheter in her right upper arm with a transparent dressing. There was no date on the dressing noted. Resident #2's medical record revealed that on 9/04/24 an Advanced Practice Registered Nurse ordered that due to the results of a Urine Analysis with a Culture and Sensitivity the resident was ordered Imipenem-Cilastatin (an antibiotic) Intravenous Solution Reconstituted 250 milligrams (mg) IV every 6 hours for 7 days. Resident #2's medical record contained a nursing note dated 9/09/24 that indicated the IV on the resident' s left forearm was not functioning for use for medication administration, and the company IV Access was contacted to place a new IV site. Resident #2's medication administration record for September 2024 revealed Imipenem-Cilastatin was administered intravenously from 9/05/24 through 9/11/24. 9/18/24 at 2:15 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) observed resident #2's right upper arm midline IV catheter site. They verified there was no date on the transparent dressing covering the insertion site, and verified there should be a date on the dressing if the dressing had been changed. The DON reviewed the orders section of Resident #2's medical record and noted there was an entry on 9/09/24 that the left arm IV was unable to be flushed, and no right upper arm midline IV catheter site was noted. The Facility's Catheter Insertion and Care policy specific to midline catheter dressings stated such catheter dressings would be changed at intervals and as needed to prevent catheter related infections associated with contaminated, loosened, or soiled catheter site dressings. The General Guidelines of this policy indicated to change a midline catheter dressing 24 hours after catheter insertion, and every 5-7 days, or if it was compromised in any way. On 9/18/24 at 4:30 PM, the DON verified there were no documentation that resident #2's midline IV catheter in her right upper arm dressing had been changed since its placement on 9/09/24. Not 24 hours after insertion nor after 7 days post insertion. She stated she had called resident #2's physician to discontinue the placement of the right upper arm midline IV catheter. She verified that 09/11/24 was the date when the last dose of the IV medication had been administered to resident #2, seven days earlier. 35086 2. Resident # 18 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 9/10/24. His diagnoses included infected surgical wound left foot, orthopedic aftercare of amputation, acute osteomyelitis left ankle/foot, amputation left great toe and diabetes type 2. Review of the AHCA (Agency for Healthcare Administration) Transfer Form 5000-3008 from the hospital dated 9/10/24 revealed he had a peripherally inserted central catheter (PICC) line in his right upper arm. A PICC line is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs, (retrieved on 9/20/24 from www.cancer.gov). On 9/18/24 at 1:45 PM, resident #18 was observed sitting up in his wheelchair outside on patio smoking. He was alert and oriented to person, place, time and situation. He was noted with a PICC line in his right upper arm and the dressing was dated 9/06/24. He said he was getting antibiotics in his IV line three times per day for an infection in his foot. He expressed concerns that no one at the facility has changed the IV dressing or the green cap on the IV tubing since he recently returned from the hospital. On 9/18/24 at 1:40 PM, resident #18's assigned Registered Nurse (RN) A validated the dressing on his right arm was greater than seven days old and should have been changed by 9/13/24, five days previously. RN A admitted she had not cared for him the last couple of days but did over the weekend and should have changed it then. She explained the reason she did not change it was because she did not see it on her schedule to be done. She verified even if not on her schedule it should have been changed every 7 days and as needed. Review of the medical record for resident #18 showed he had an order dated 9/14/24 for nurses to change the IV dressing every week and as needed, PICC line flush with 10 milliliters of normal saline every shift and prn (as needed), and Meropenem (antibiotic) 1 Gram IV every 8 hours for 20 days. Resident #18's comprehensive plan of care was initiated on 9/10/24 for IV medication due to osteomyelitis and included interventions to change the IV dressing and record observation of the site every shift. Review of the Medication Administration Record revealed there were five nurses on two different shifts that gave him IV mediations from 9/14/24 to 9/18/24 and missed the opportunity to change his IV dressing when they accessed the site to give the antibiotics. On 9/18/24 at 4:54 PM, the Director of Nursing (DON) was informed of the concern regarding resident #18's IV dressing not being changed for 13 days. The DON said the nurses were expected to follow standards of nursing practice and change IV dressings every 7 days for a clear dressing or every 2 days if unable to see the site. The DON added she would need to check with the manufacturer or pharmacy for how frequently to change the green cap on the IV tubing and thought nurses should change it at least daily. The DON verified any of the nurses giving his IV medications should have noticed the dressing was out of date and changed it sooner. The DON said she would follow up regarding the green cap and would inform the staff how often and when to change it. The facility policy for Catheter Insertion and Care revised 1/17/19 read, Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter related infections Change transparent semi-permeable membrane [TSM] dressing at least every 5-7 days and prn .If gauze is used, it must be changed every 2 days The following information should be recorded in the resident's medical record: 1. Date and time dressing was changed .

Based on observation, interview, and record review, the facility failed to obtain a physician order for Oxygen (O2) therapy and failed to administer O2 therapy as ordered by the physician for 2 of 2 residents reviewed for O2 therapy, of a total sample of 17 residents, (#2, #13). Findings: 1. On 9/18/24 at 12:14 PM, resident #2 was observed seated in her wheelchair with a nasal cannula in her nose. The O2 tubing connected to an oxygen tank on the back of her wheelchair. The O2 flow rate indicated on tank was 3 liters per minute (L/min). Review of resident #2's medical record revealed she was readmitted to the facility on [DATE] from the hospital. Her diagnoses included: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Cardiomegaly, and unspecified sequelae of unspecified cerebrovascular disease. There was no physician's order for oxygen. On 9/18/24 at 2:07 PM, Licensed Practical Nurse (LPN) E, resident #2's assigned nurse, verified she had seen resident #2 with her O2 nasal cannula in her nose that day attached to the tank at the back of the resident's wheelchair. She said she thought the flow rate for resident #2's oxygen was 3 liters per minute (L/min). LPN E examined resident #2's medical record and verified she could not find a current physician's order for oxygen use in Resident #2's record. On 9/18/24 at 2:15 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) observed resident #2 seated in her wheelchair with nasal cannula in place, oxygen tubing connected to the oxygen tank behind her wheelchair. The DON verified the flow rate indicated on the oxygen tank was 3 L/min. The DON verified the oxygen tank regulator on the back of resident #2's wheelchair indicated an empty tank. On 9/18/24 at 4:30 PM, the DON verified resident #2 did not have a physician's order for oxygen use, to determine the flow rate nor when it should be used. She said she thought resident #2 should have had an order because she had recently used it in the facility. She thought the order might have been mistakenly dropped from resident #2's record when the resident had been readmitted from the hospital. 35086 2. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD) and adult failure to thrive. On 9/18/24 at 10:35 AM, resident #13 was observed lying in bed asleep wearing O2 via nasal cannula (NC) with her O2 concentration set at 4 L/min. On 9/18/24 at 1:08 PM, resident #13 again was observed lying in bed on her right side with her O2 at 4 L/min via NC. She was more alert at this time and pleasantly confused. The O2 concentrator was untouched from earlier and remained on the left side adjacent to her bed and was not within her reach. Review of the medical record revealed resident #13 had physician orders for continuous oxygen at 2 L/min via NC. Review of the comprehensive care plans for COPD and Altered Respiratory status included interventions to give oxygen per physician orders and did not show any behaviors regarding the resident adjusting her own oxygen settings. The goal of the plan of care was that she would have minimal complications related to shortness of breath. On 9/18/24 at 2:00 PM, the assigned Licensed Practical Nurse (LPN) C checked the medical record and confirmed the resident was supposed to get her O2 at 2 L/min. The nurse then went into the resident room where resident was noted still on her right side in bed wearing her oxygen via NC set at 4 L/min and the nurse then adjusted the concentrator knob down to 2 L/min. The resident denied adjusting her oxygen settings and stated, I don't mess with it. On 9/18/24 at 4:50 PM, the DON said the nurse should check the oxygen settings every time they went into a resident's room to ensure they were getting it as ordered by the physician, so they get the proper care. Review of the facility's policy and procedure for Oxygen Therapy dated 11/30/24 read, In the event a resident requires the use of oxygen to manage a medical condition, The Company will offer assistance as ordered by the resident's physician .Procedure: 1. The nurse will organize the oxygen therapy as ordered by the resident's physician Adjust the flow of oxygen as ordered by the physician .

Based on interview and record review; the facility failed to investigate after a resident was found with suspected illicit drugs for 1 of 1 resident reviewed, (#11), of 17 sampled residents. Findings: Resident #11 a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included absence of bilateral legs above the knees, diabetes type 2, peripheral vascular disease, chronic obstructive pulmonary disease, depression, phantom limb pain syndrome, heart failure, repeated falls and nicotine dependence. On 8/11/24 at 1:40 AM, the weekend supervisor nurse documented a behavior note that read, Resident found by this nurse at [1:30 AM] to be sitting in wheelchair on patio area between timeclock and South wing dayroom passed out, slow to arouse. Resident leaning forward towards concrete, eyeglasses on ground in front of him, pack of cigarettes on ground. This nurse assisted CNA [Certified Nursing Assistant] to return resident to room. When pack of cigarettes picked up from concrete there was a small plastic bag with suspected illicit street drug rolled in partially burned paper which was confiscated. MD [Medical Doctor] made aware. Nursing informed to hold all Narcotics at this time and continue to manually check BP/pulse just prior to giving them in the future. Review of the facility incident log showed no incidents investigated regarding nurse finding suspected illicit street drug in resident #11's possession. On 9/19/24 at 10:30 AM, the facility [NAME] President (VP) of Operations read the weekend supervisors' note dated 8/11/24 at 1:40 AM and acknowledged there should have been an incident on their log, police called and note documented to say who disposed of the suspected illicit drugs. On 9/19/24 at 11:00 AM, the North Wing Unit Manager and Director of Nursing (DON) said they had no knowledge of an incident regarding a suspicion by staff that resident #11 had/used illicit street drugs. The Unit Manager said she was on leave at the time of the incident (8/11/24) and the nurse who cared for the resident that night no longer worked here and therefore was not available for interview. The DON and Unit Manager said staff were not suppose to dispose of suspected illicit drugs, law enforcement should have been called to do that. They explained the nurse could have taken a picture of the drugs, we could have checked with the doctor to see if he wanted a drug test done on the resident, then initiated an incident report and investigation. They said their investigation would have included getting statements from the resident and staff, as well as updating his comprehensive care plan to ensure other staff were aware of the incident. The DON and Unit Manager explained the process that the Weekend Supervisor should have called the On-call Supervisor who would have then informed the DON or the Nursing Home Administrator of the incident. They could have then directed the staff as to the appropriate steps to take. They both verbalized the staff were never to dispose of suspected illicit street drugs. On 9/19/24 at 2:00 PM, in a telephone interview with the weekend supervisor she said, she found resident #11 outside, in the enclosed patio area on property after hours and he was asleep and seemed lethargic. She got the CNA to assist him back into the building and to his room. She explained, the small plastic bag fell out of his cigarette pack and had less than inch long of partially burned non-filter paper, and she was not sure if it was marijuana or a cigarette. It was such a small amount that, I flushed it down the toilet because I could not identify it. The Weekend Supervisor added, it was the On-call Supervisor who told her to flush it down the toilet and the physician told me to hold the resident's narcotics and monitor him. The DON who was present during the interview said the On-call Supervisor at that time was the South Wing Unit Manager who no longer worked there. The Weekend Supervisor verified she had not received any education on how to dispose of illegal drugs. She stated she did not have 2nd nurse witness her flush the potential illegal drug down toilet, and she did not know to initiate an incident report. Review of the facility policies and procedures for Accident and Incident Investigation effective 11/30/14 read, Certain accident and incident, including injuries of unknown origin, medication discrepancies and adverse drug reactions will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event .A happening that is not consistent with routine operations of the facility or care of resident will warrant the completion of an incident report .Notification must be made to the following: Resident representative, physician, the Executive Director, Director of Nursing, or their designee, must begin a documented investigation The investigation will include interviews with the resident, all staff involved The investigation must be thoroughly documented using the Investigative Report form The facility must use the Performance Improvement process for problem identification and corrective action when necessary.

Based on interview and record review, the facility failed to update an individualized care plan for potential for adverse drug interactions for 1 of 1 reviewed for opioid and antianxiety medications, of a total sample of 17 residents, (#11). Findings: Resident #11, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included absence of bilateral legs above the knees, diabetes mellitus type 2, peripheral vascular disease, chronic obstructive pulmonary disease, depression, phantom limb pain syndrome, heart failure, repeated falls and nicotine dependence. On 8/11/24 at 1:40 AM, the Weekend Supervisor documented a behavior note that read, Resident found by this nurse at [1:30 AM] to be sitting in wheelchair on patio area between timeclock and South wing dayroom passed out, slow to arouse. Resident leaning forward towards concrete, eyeglasses on ground in front of him, pack of cigarettes on ground. This nurse assisted CNA [Certified Nursing Assistant] to return resident to room. When pack of cigarettes picked up from concrete there was a small plastic bag with suspected illicit street drug rolled in partially burned paper which was confiscated. MD [Medical Doctor] made aware. Nursing informed to hold all Narcotics at this time and continue to manually check BP[blood pressure]/pulse just prior to giving them in the future. On 8/13/24 Advance Practice Registered Nurse (APRN) D documented, CHIEF COMPLAINT: Urgent visit. The pt [patient] had a fall. Received message notable the pt [patient] was lethargic with slurred speech from the lobby by supervisor nurse. He had slight bleed with laceration on the right side of forehead. There was order to send the pt to hospital. Pt refuse .Seeing the pt today he states he fell out of bed because he was having a bad dream. It was reported to me that the pt was doing drugs outside of the building and return as described above. Pt reports cocaine [a few days ago]. His VS [vital signs] are stable. He has small abrasion to the right forehead . On 9/19/24 at 2:00 PM, in a telephone interview the Weekend Supervisor said she found resident #11 outside, in the enclosed patio area on property after hours. She stated he was asleep and seemed lethargic so she got the Certified Nursing Assistant (CNA) to assist him back into the building and to his room. She explained, a small plastic bag fell out of his cigarette pack which had a less than inch long partially burned rolled non-filter paper, and she was not sure if it was marijuana or a cigarette. It was such a small amount that I flushed it down the toilet because I could not identify it. The Weekend Supervisor added, it was the On-call Supervisor who told her to flush it down the toilet and the doctor told me to hold his narcotics and monitor the resident. The Director of Nursing (DON) who was present during the interview said the On-call Supervisor at that time was the South Wing Unit Manager who no longer worked here. The Weekend Supervisor verified she had not received any education on how to dispose of illegal drugs, nor did she have a 2nd nurse witness her flush the potential illegal drug down the toilet. She also stated she did not know to initiate an incident report. The Weekend Supervisor stated she was not aware of any other incidents with resident #11 using any illegal drugs at the facility or off property. Review of current orders for resident #11 included the medication Alprazolam 1 milligram (mg) by mouth at bedtime for anxiety since 10/21/23, Morphine Sulfate ER (extended release) 15 mg, give 2 tablets every 8 hours for pain since 7/22/24 and Morphine Sulfate 15 mg by mouth every 12 hours as needed for moderate to severe pain since 7/30/24. Review of resident #11's comprehensive care plans included use of anti-anxiety medications related to anxiety disorder, use of antidepressant medications related to depression, pain medication therapy related to chronic pain and phantom pain status post amputation. The resident had a total of 25 pages of care plans but they did not contain a plan or intervention related to the incident on 8/11/24 involving possible illicit drug use nor of the note on 8/13/24 when the APRN documented cocaine use by the resident a few days ago. On 9/19/24 at 12:58 PM, the Nursing Home Administrator (NHA) and DON acknowledged the APRN never reported the recent use of cocaine to the, nor were they aware until the time of the survey that nurse found possible illicit drugs on the resident 8/11/24. The DON verified that at that time he did not have a revised plan of care regarding potential for adverse drug interactions since he was on prescription medications that included Alprazolam and Morphine, which could interact with illicit drugs or cocaine. Review of the facility policy and procedure for Plan of Care revised 9/25/24, read, An individualized person centered plan of care will be established by the interdisciplinary team [IDT] with the resident and/or resident representative .Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident .the plan is oriented toward attaining or maintain the highest practicable, physical, mental and psychosocial well-being

Based on record review and interview, the facility neglected to provide appropriate care and services to prevent a pressure injury for a vulnerable and physically impaired resident and failed to complete a thorough investigation for neglect after a worsening pressure injury for 1of 4 residents sampled for pressure ulcers, of a total sample of 17 residents, (#3). The facility's failure to implement preventative interventions, ensure timely and adequate treatments for pressure injuries and complete a thorough investigation for neglect resulted in actual harm, for one dependent resident who was deemed at risk for development of wounds. Resident #3 acquired a pressure injury in the facility that was not treated for 10 days after it was identified which caused the wound to worsen. Resident #3 suffered severe wound infections and sepsis that required hospitalization . He later died on hospice services. Findings: Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included lung abscess with pneumonia, Alzheimer's disease, anxiety, type 2 diabetes, prostate cancer, cognitive communication deficit, and urinary retention. The medical record indicated resident #3's skin was intact when he was admitted to the facility. Resident #3 was discharged to an acute care hospital on [DATE]. Review of the Minimum Data Set (MDS) Discharge, Return Anticipated assessment with assessment reference date of [DATE] revealed resident #3 had severely impaired cognitive skills for daily decision-making. The document indicated he did not exhibit any behavioral symptoms or reject evaluation or care necessary to achieve his goals for health and well-being. The assessment revealed the resident required moderate to maximum assistance with activities of daily living (ADL) and moderate assistance to roll side to side and sit up in bed. Section H of the assessment indicated he was always incontinent of bowel movements. The MDS assessment revealed resident #3 had one unhealed Stage III pressure ulcer not present on admission to the facility. In an interview on [DATE] at 9:05 AM, the MDS Coordinator clarified resident #3 actually had a stage IV pressure ulcer upon his discharge from the facility. A Change in Condition dated [DATE] documented the resident was observed with an open area on the right buttock. The note indicated the physician gave orders for nursing staff to follow up with the wound care team. A progress note dated [DATE] at 7:51 PM, read the resident was observed with an open area on the right buttocks and the wound care team was consulted. The note indicated the primary care physician was notified. Review of the medical record revealed resident #3 did not receive treatment for the open wound for another 10 days, until [DATE]. Additionally, the record reflected resident #3 had no documentation that treatments were completed for 8 of the 18 days in which he had orders for daily treatments to the wound in the Treatment Administration Record. Almost half of his wound treatments were not documented as completed from [DATE] through [DATE]. On [DATE] at 5:44 PM, Certified Nursing Assistant (CNA) B recalled resident #3 as confused but he pleasant and friendly. She remembered she tried to keep him on his side but when she didn't have him on her assignment, he would always be on his back unless he was in the chair. She indicated she even talked to the night shift staff to try to keep him off his back because it went from a tiny little area to a bigger area in three days while she was off. The family spent a long time here and were concerned about his wound. On [DATE] at 12:20 PM, Registered Nurse (RN) E stated CNA B notified her resident #3 had a wound. She recalled she then informed the wound care nurse, and the Advance Practice Registered Nurse (APRN). RN E remembered he had no wounds on his bottom,then she was off a few days and when she came back he had the open wound there. She said, He did not have an air mattress on the bed when the wound was discovered. She stated he had poor nutrition which could affect his skin or a wound. She said his wife was at his bedside when the wound was discovered. On [DATE] at 3:50 PM, the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant (RNC) reviewed notes from the Quality Assurance Performance Improvement (QAPI) meeting held on [DATE]. They indicated the discussion included skin checks and dressing changes. The DON stated a facility wide audit was conducted to ensure all residents had an up-to-date skin assessment and wound dressing changes. The plan was to educate 100% of nurses, educate the Interdisciplinary Team (IDT) and Unit Managers. The DON/designee would complete 5 random audits 5 times a week for 4 weeks, then weekly for 4 weeks, then monthly for 2 months. A Performance Improvement Plan (PIP) was initiated on [DATE] regarding pressure wounds. The DON stated they did additional education regarding documentation and expectations for the nurses. For CNAs the education included the expectation to look at the resident's skin each time care was provided and notify nurses of changes they observed. The DON explained the facility did audits to ensure dressings were changed and documentation supported the change as well. She added an ad hoc QAPI meeting was held and a PIP was developed and implemented for pressure wounds. The DON was unable to say why resident #3 was not included in the PIP or on any audits for pressure wounds. The RNC stated they revised the PIP on [DATE] and were still working on it. The Administrator stated that on [DATE], the facility was informed by the Department of Children and Families (DCF) there was an allegation of neglect. Review of the investigation regarding the neglect complaint for Resident #3 included the following information: On [DATE], the Administrator interviewed the Wound Care nurse. She stated she last saw resident #3 with the wound care physician on [DATE]. She stated he had a stage IV sacral wound and the current treatment in place was a calcium alginate dressing with moistened gauze with Dakins solution. She further stated the treatments were being following according to the physician orders. The wound was determined to be stable at that time. On [DATE], the Rehabilitation Director was interviewed by the Administrator. He stated resident #3 received physical, occupational and speech therapy while in the facility. However, in spite of rehabilitation interventions, he did not demonstrate significant functional progress, attributable to the effect of multiple comorbidities. He stated the resident was not ambulating upon admission to the facility. He further stated that aggressive rehabilitation to achieve ambulation was neither practical, safe or appropriate, so it was not implemented. He said, a head-to-toe skin assessment was completed by the DON on [DATE]. No new skin impairments were identified. The Administrator said the investigation found that review of the medical record revealed resident #3 was evaluated by the wound care physician on [DATE], 13 days after the wound was identified by CNA B and the primary care physician verbally ordered a wound consult. A wound debridement was performed on the sacral wound at that time and new orders were given for a calcium alginate dressing. The next week on [DATE], the resident was again reevaluated by the wound care physician and noted the wound continued to decline. No new treatments were ordered at that time. On [DATE], the resident was seen by the primary care physician and new orders were given for antibiotics for a suspected urinary infection. On [DATE], the resident was seen by the wound care physician and the wound was noted to be stable. The wound care physician discussed hospice services with the family at bedside. On [DATE], the resident was seen by the physician and the daughter was at bedside and requested the resident be transferred to the hospital for urinary catheter exchange and wound care. The physician expressed the resident did not need to be transferred because he was currently being treated but the daughter insisted the patient transfer to the hospital. He said the allegation was refuted by evidence collected during the investigation. Based on interviews from facility staff members and residents, it was unable to be determined that the allegation of neglect occurred the Administrator said. On [DATE] at 3:50 PM, the DON stated the revised PIP included looking at physician orders for treatment, review of the care plan, physically checking the resident, and documentation to support that everything was done. The investigation read that no new orders were given but review of resident #3's medical record revealed new orders for treatment were given every week when the wound care physician saw him. The investigation revealed only the wound nurse and Director of Rehabilitation were interviewed as to the neglect concerns. There were no interviews with the assigned nurses or CNAs who took care of the resident regarding his wound or the care given. The DON stated the wound nurse did not attend the ad hoc meeting on [DATE]. She was not able to explain why the wound nurse was not in attendance. On [DATE] at approximately 4:15 PM, the NHA acknowledged not providing wound care for resident #3 was neglect. She also acknowledged a thorough investigation and review of resident #3's chart was not conducted.

Based on observation, interview, and record review, the facility failed to provide care and services, according to professional standards of practice, to promote skin integrity and prevent the development and worsening of pressure injuries for 1 of 4 residents reviewed for pressure injuries, of a total sample of 17 residents, (#3). The facility's failure to implement preventative interventions and ensure timely and adequate care and treatments for pressure injuries resulted in actual harm, for one dependent resident who was deemed at risk for development of wounds. Resident #3 acquired a pressure injury that was not treated for 10 days after it was identified which caused the wound to worsen. Resident #3 suffered severe wound infections and sepsis that required hospitalization , and he subsequently died on hospice services. Findings: Review of the medical record revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include lung abscess with pneumonia, Alzheimer's disease, anxiety, type 2 diabetes, difficulty walking, cognitive communication deficit, urinary retention. The medical record indicated resident #3's skin was intact when he was admitted to the facility. The record indicated resident #3 was discharged to an acute care hospital on [DATE]. John Hopkins Medicine defines pressure injuries, also called bed sores or pressure sores as follows: Pressure injuries are most likely to occur in older adults, particularly those who live in nursing homes. Studies show more than 1 in 10 nursing home residents have suffered from a bedsore. Those with chronic illnesses like diabetes and those who are under nourished are at greater risk . If found and treated quickly, pressure injures should heal within a matter of weeks. But if left untreated, they can quickly worsen. Pressure injuries start as red, blue, or purplish patches on the body. The don't blanch, or turn white, when touched and they get worse over time. These patches can quickly develop into blisters and open sores. The sores can then become infected and grow deeper until they reach muscle, bone or joints. Pressure injuries have 4 stages, ranging from an early warning signal to the most severe: Stage I. Red, blue or purplish area first appears on the skin like a bruise. It may feel warm to the touch and burn or itch. Stage II. The bruise becomes an open sore that looks like an abrasion or blister. The skin around the wound can be discolored and the area is painful. Stage III. The sore deepens and looks like a crater, often with dark patches of skin around the edges. Stage IV. The damage extends to the muscle, bone, joints and can cause a serious infection of the bone, known as osteomyelitis. It can also lead to a potentially life-threatening infection of the blood called sepsis, (retrieved on [DATE] from www.hopkins medicine.org). Review of the Minimum Data Set (MDS) Discharge Return Anticipated assessment with assessment reference date of [DATE] revealed resident #3 had severely impaired cognitive skills for daily decision-making. The assessment indicated he did not exhibit any behavioral symptoms or reject evaluation or care necessary to achieve his goals for health and well-being. The assessment also revealed the resident required moderate to maximum assistance with activities of daily living (ADL), moderate assistance to roll side to side and sit up in bed and maximum assistance to sit up to stand and transfer to a chair. Section H of the assessment indicated he was always incontinent of bowel movements. The MDS assessment revealed resident #3 had one unhealed Stage III pressure ulcer not present on admission to the facility. In an interview on [DATE] at 9:05 AM, the MDS Coordinator clarified resident #3 actually had a stage IV pressure ulcer upon his discharge from the facility. On [DATE] at 9:12 AM, resident #3's daughter stated when she saw how bad the pressure sore looked, she talked to everyone at the facility. She said, They were supposed to change him and reposition him every few hours, but I was there for over 7 hours, and no one changed him or repositioned him the whole time. She explained he had a urinary catheter, and it was never changed at the nursing home although it was supposed to be changed every month. She stated the resident was discharged from the hospital on [DATE] to short-term rehabilitation to complete intravenous antibiotic therapy. She said her father was put in hospice two weeks after entering the nursing home and passed away two weeks later. Review of the medical record revealed a care plan dated [DATE], for bowel incontinence related to immobility. The goal was for the resident not to have skin breakdown related to incontinence. Interventions included staff to provide incontinence care after each incontinent episode. Another care plan dated [DATE], revealed the resident had potential for pressure injury development related to decreased mobility and incontinence. The goal was for the resident to have intact skin, free of redness, blisters or discoloration by/through the review date. Interventions included staff to follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, serve diet as ordered, and monitor/ document/report any changes in skin status. An additional care plan also dated [DATE] revealed the resident had an ADL self-care performance deficit. The goal was the resident would improve his current level of function through the review date. Interventions included the resident required substantial assistance with bed mobility, eating, and with personal hygiene/oral care; and resident was totally dependent on staff for bathing, and toileting. Review of the medical record revealed no care plan was ever initiated for resident #3's actual pressure wound. Review of the Braden Score for Predicting Pressure Ulcer Skin Risk completed on admission [DATE] reflected the resident was at moderate risk for a pressure ulcer. Subsequent Braden scales completed on [DATE] and again on [DATE] scored resident #3 as low risk for developing a pressure sore, even after he was found to have developed one. A progress note dated [DATE] at 8:00 PM, by Registered Nurse (RN) D revealed an open area on the right buttock was discovered and the family, primary physician and the wound care team were notified. On [DATE] at 5:44 PM, CNA B said, I do remember resident #3, he was confused but he would smile and try to talk to us. I tried to keep him on his side because he ended up with a pressure ulcer. I even talked to the night shift to try to keep him off his back it went from a tiny little area to a bigger area in three days while I was off. CNA B stated she recalled when resident #3 was not on her assignment, he would be lying on his back or in a chair. The CNA said the family visited him often and expressed concern about his wound. Review of the medical record revealed no documentation by Certified Nursing Assistants (CNAs) after [DATE] regarding resident #3's pressure wound, except on shower sheets dated [DATE] which indicated redness in the sacral area. On [DATE] and [DATE] the CNA documented on the shower sheet there was no indication of a skin condition in conflict with other documentation in the medical record. All 4 sheets were signed by the Charge nurse as having being reviewed. The CNA Kardex dated as of [DATE] also had no documentation which indicated resident #3 had a pressure wound. Review of the Weekly Skin Integrity Review sheets, completed by nurses, revealed a skin sheet dated [DATE] was the first time resident #3's skin was noted as not intact. The skin sheet did not have documentation of the location or a description of the wound. There was no documentation of skin sheets again for over 3 weeks until [DATE]. Review of a progress note dated [DATE], Advance Practice Registered Nurse (APRN) A documented, Deconditioning/ Gait instability- Patient is high risk for functional impairment without therapy and adequate pain control. Patient has high risk for developing contractures, pressure ulcers, poor healing, or fall if not receiving adequate therapy and pain control. Review of the Pressure Ulcer Wound Round sheets completed by the wound nurse initially on [DATE] revealed resident #3 had a stage III pressure ulcer to his sacrum which measured 5 centimeters (cm) by 5.5 cm by 0.3 cm with 30 percent slough (dead tissue within a wound) and 20 percent necrosis. The treatment was documented as silver alginate. A week later on [DATE] the Pressure Ulcer Wound Round sheets showed resident #3's wound had deteriorated to a stage IV with 70 percent necrosis and a wound bed which had turned black. The size of the wound also increased to 9 cm by 7 cm by an unable to determine measurement. The treatment was documented as Medical grade honey. On [DATE], a month after the wound was initially found, the Pressure Ulcer Wound Round sheets showed resident #3's sacral pressure wound was still a stage IV that now measured 12 cm by 7 cm with a depth that was still unable to be determined. The treatment was now documented as silver alginate and moistened gauze. On [DATE] at 9:20 AM, the Wound Care RN confirmed resident #3 had a facility acquired pressure ulcer that declined rapidly in the month after it was found. She said when the assigned nurse notifies her of a resident's wound she would enter the orders for what the resident needed for wound healing such as wound care or an air mattress, and complete a weekly skin note. The Wound Care RN said she did not usually measure the wounds, unless the physician did not come to see the resident. She explained she would classify the stage of the wound at that time and document her assessment of the wound. The Wound Care RN stated she had put orders in for resident #3 but said they were, missing from his medical record. She confirmed resident #3's facility acquired wound was not discussed in the clinical meeting and explained nurses did not always tell them when they found a skin impairment or wound. The Wound RN recalled sometimes nurses would sign off orders in the Treatment Administration Record (TAR) when they did not complete them themselves. She explained she had been told previously that it was okay for the floor nurses to document the treatments even if they were not the ones doing them. Although the wound was discovered on [DATE], the first visit by the wound physician did not take place until [DATE] per the consult note which revealed the wound was a stage III unhealed pressure ulcer. Per the physician's note the wound was debrided that day to remove devitalized tissue, biofilm, eschar and slough. The consult note listed wound orders which included, cleanse/irrigate with normal saline/water, keep the area dry and clean, apply calcium alginate with silver, and cover with foam dressing. Additional orders included for nursing to change dressing every day and as needed, implement pressure relieving measures and offloading as tolerated and a consult from the Registered Dietician to implement a nutritional plan, protein supplements, and daily multivitamins. Review of additional wound physician notes indicated the total surface area of resident #3's wound increased from 27.5 cm squared on the first visit of [DATE] to 84 cm squared a month later on [DATE]. On [DATE] at 11:23 AM, the wound physician stated he came to the facility weekly, but no longer worked at the facility. He explained when a new wound was identified at the facility, nursing staff would notify him, and he would see that resident on his next visit to the facility where he would update them with any orders he wanted to implement. The wound physician clarified he would also add interventions in his notes if he saw they were not already in place, as he did on [DATE]. He recalled resident #3 and explained his wound deteriorated over the three weeks until [DATE] when he was transferred to the hospital upon his family's request. The wound physician stated the facility implemented floor nurses to perform wound care instead of the wound nurse. He said, I cannot attest that if the nurses were busy, the [resident's] wound care was done. He explained he didn't anticipate how quickly resident #3's wound would deteriorate. Review of the TAR for [DATE] revealed no orders for wound treatments were initiated until [DATE], nine days after the wound was first noted by the CNA. The Medication Administration Record for April and [DATE] revealed supplements for wounds were not ordered until [DATE], 13 days after the Dietary consult was ordered by the wound physician. Review of the TAR reflected during the 19 days from [DATE]-[DATE] nursing staff documented the resident received a total of ,d+[DATE] dressing changes as ordered by the physician for his pressure wound. On [DATE] at 3:50 PM, the Regional Nurse confirmed wound care was not done as ordered for resident #3. She stated education for the expectation of accurate documentation was implemented and two staff were terminated after the concern about wound care not being done was found by the Interdisciplinary team on [DATE]. She explained this was an ongoing Performance Improvement Project with active audits but confirmed resident #3 was not included in their audits and the concerns found during the survey were not discovered by the facility until brought to their attention by the survey team. A progress note on [DATE] at 12:48 PM, by the indicated, Resident's family requested that he be transferred to the Emergency Department (ED) due to his sacrum wound not healing and his urinary catheter needing to be changed. APRN C was notified of the request and went to assess the resident and determined that the concerns brought up by the family could be treated at our facility. Family continued to insist that we send him to the ED. 911 was called and the resident was sent to the ED . Hospital records dated [DATE] to [DATE] revealed the resident had severe sepsis from an unstageable sacral wound when he arrived at the ED. Cultures were taken from the wound and the resident was given intravenous (IV) antibiotics. Results of the wound cultures revealed the wound was growing extended-spectrum-beta-lactamase (ESBL), Klebsiella pneumonia and methicillin resistant staphylococcus aures (MRSA). The hospital record revealed resident #3 had another bed side debridement in the hospital by the surgeon. The surgical note indicated infected, necrotic, gangrenous tissue was excised from the sacral wound which extended to the bone. The hospital record indicated the resident died approximately a month later on hospice. ESBL which are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics (retrieved on [DATE] from www.webmd.com.) MRSA is a staphylococcus germ (bacteria) that does not get better with the type of antibiotics that usually cure staphylococcus infections (retrieved on [DATE] from www.ncbi.[NAME].nih.gov). The job description, Wound Care Nurse dated [DATE] detailed the job function of being delegated the administrative authority, responsibility and accountability to carry out assigned duties. Responsibilities included provide direct resident care in assessment, treatment and follow up for wound management as ordered by the physician; complete required documentation in an accurate and timely manner; and collaborate with the Interdisciplinary Team to encompass all aspects of care to promote wound healing. Review of the Clinical Guideline Skin & Wound policy and procedure effective date [DATE] revealed the purpose to provide a system to identify at risk skin, implement individual interventions including evaluation and monitoring, healing and to decrease worsening of and the prevention of pressure injuries. The procedure indicated the licensed nurse was to complete the skin evaluation weekly and document in the medical record, develop individualized goals and interventions and document on the care plan and CNA Kardex.

Based on observation, interview and record review, the facility failed to treat residents who required assistance with meals in a dignified and respectful manner for 4 of 4 residents reviewed for dining, of a total sample of 17 residents, (#4, #15, #16, and #17). Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and aphasia. Review of resident #4's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 6/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severely impaired cognition. She was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. On 6/19/24 at 8:25 AM, resident #4 sat in bed while Certified Nursing Assistant (CNA) H assisted her with breakfast. CNA H fed resident #4 while standing next to her bed. CNA H then sat down and stated someone else was coming to feed resident #4's roommate. CNA H said, We have a lot of feeders. 2. Review of resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, congestive health failure, type 2 diabetes and glaucoma. Review of resident #15's quarterly MDS assessment with ARD of 3/25/24 revealed a BIMS score of 10 out of 15, indicating moderately impaired cognition. He required substantial assistance with Activities of Daily Living (ADLs), including eating. On 6/18/24 at 12:30 PM, CNA G was observed feeding resident #15 while standing. 3. Review of resident #16's medical record revealed he was readmitted to the facility on [DATE] with diagnoses of stroke and dementia. Review of the quarterly MDS assessment with ARD of 6/04/24 revealed a BIMS score of 0 out of 15, indicating severely impaired cognition. He was totally dependent on staff for eating. On 6/18/24 at 12:35 PM, resident #16 was lying in bed with his lunch tray at the bedside table. CNA F entered his room a couple of minutes later, elevated the head of the bed and began to feed resident #16 while standing next to him. At 12:40 PM, CNA F assisted resident #16 with a drink while still standing by his bed. 4. Review of resident #17's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, Parkinsonism, and type 2 diabetes. Review of resident #17's annual MDS assessment with ARD of 5/11/24 revealed a BIMS score of 0 out of 15, indicating severely impaired cognition. She was totally dependent on staff for all ADLs, including eating. On 6/18/24 at approximately 12:40 PM, CNA G was observed feeding resident #17 while standing next to her and not talking to the resident. On 6/18/24 at 12:50 PM, CNA F acknowledged she had stood while feeding resident #16. She indicated even if his bed was in the lowest position she was unable to reach him. She indicated she knew she was not supposed to stand when feeding the resident because it could give the impression she was rushing him. She mentioned when he was in bed, she remained standing to feed him. She stated she had not mentioned to the nurse or the Unit Manager (UM) she stood to feed him because she was too short. She then stated on CNA G's assignment there were, 3 feeders. On 6/18/24 at 1:24 PM, CNA G stated her assignment included 5 residents who required assistance with meals. She indicated she sometimes sat but usually stood up when feeding residents. She said, I know I am supposed to sit. She acknowledged there was a chair in resident #15's room. She validated she stood when feeding resident #17. She mentioned she was supposed to be at eye level, make the resident comfortable, and talk to the resident while feeding him or her. On 6/19/24 at 11:49 AM, CNA H stated resident #4's bed did not go all the way down for her to be in a comfortable position to feed the resident. She stated she had not told the UM or anyone about it. She indicated she sat down after giving resident #4 the first bite. She validated she referred to residents as feeders earlier but should have not used that word in reference to them. On 6/20/24 at 4:27 PM, the Administrator and Director of Nursing validated the CNAs were expected to sit while feeding residents and should not refer to residents as feeders. The Regional Nurse Consultant stated CNAs had been educated many times about this. She said it was a matter of, diligently micromanaging the full house. Review of the Skills Competency Assessment: Eating Support required for all CNA staff revealed the employee was evaluated to perform tasks listed independently and without supervision. The skills and competency included, Never make the resident feel that the meal must be hurried but the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident. Review of the facility policy and procedure titled Resident Rights dated 11/30/14 read, It is the policy of The Company to . Ensure that residents' rights are known to staff.

Based on interview, and record review, the facility failed to ensure a resident who was actively dying received necessary medication for pain and comfort based on the comprehensive assessment and in accordance with professional standards of practice for 1 of 3 residents reviewed for hospice care out of 8 sampled residents, (#1). The facility's failure to ensure the assigned nurse gave necessary medication to a terminally ill, actively dying resident resulted in psychosocial harm to resident #1. Based on the resident's severe cognitive impairment and inability to express her response and using the reasonable person concept, the resident would have experienced pain, anxiety, agitation, distress, and depressed mood due to not receiving necessary narcotic analgesic medication for 10 ,d+[DATE] hours that was ordered to be given every 4 hours by the physician. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] under the care of hospice. Her diagnoses included Alzheimer's disease, cerebral ischemia, cardiac arrhythmia, spinal stenosis, lower back pain, protein calorie malnutrition, altered mental status, pelvic and perineal pain, pain in right foot, anxiety, insomnia, history of falls, cerebral atherosclerosis, atrial fibrillation, and muscle weakness. The resident's hospice initial certification of terminal illness began on [DATE] with terminal diagnosis of end stage cerebral atherosclerosis and secondary diagnosis of vascular dementia. Cerebral atherosclerosis is a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain. (https://www.ninds.nih.gov/health-information/disorders/cerebral-arteriosclerosis). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 5 out of 10 which indicated severe cognitive impairment. She had disorganized thinking and altered level of consciousness. The assessment noted the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of resident #1's individualized plan of care documented the resident was dependent on staff to meet emotional, intellectual, physical, and social needs. The care plan noted the resident had mood/behavior problems related to anxiety, impaired cognitive function related to dementia and memory recall. The care plan for pain related to decreased mobility and chronic back pain included interventions to administer analgesic medications as ordered by the physician with the goal that she will have adequate pain relief. The care plan for terminal prognosis related to cerebral atherosclerosis had the goal to maintain her comfort and interventions included admitted to hospice service, observe resident closely for signs of pain and administer pain medications as ordered. The physician orders for Morphine dated [DATE] to [DATE] read 100 milligrams (mg) per 5 milliliters (ml) solution give 0.25 ml every 4 hours for pain and increase on [DATE] to 0.5 ml every 4 hours for pain. Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath. Successfully reducing pain and addressing concerns about breathing can provide needed comfort to someone who is close to dying (https://www.nia.nih.gov/health/providing-comfort-end-life). On [DATE] 2:06 PM, in a telephone interview, resident #1's daughter stated her mother did not receive her scheduled dose of Morphine at 8 AM or 12 PM on [DATE] when she was dying. She said she and her family were in the resident's room the entire time and the nurse, Registered Nurse (RN) A did not come into the room to administer the Morphine. Review of the facility AHCA (Agency for Healthcare Administration) Immediate Report #181527 read, On [DATE] .resident representative .complained to .Unit Manager that the resident did not receive her scheduled morphine at 12 noon .nurse was suspended pending investigation .Resident is under crisis care due to imminent death Review of the Controlled Medication Utilization Record for resident #1's Morphine 100 mg/5 ml showed the nurses signed for 0.25 ml on [DATE] at 2 PM and 8 PM and on [DATE] at 12 AM, 4 AM, 8 AM, and 12 PM. The doses in question were documented by RN A as given on [DATE] at 8 AM and 12 PM. The Medication Administration Record showed that on [DATE] At 8 AM and 12 PM, RN A signed for giving Morphine Sulfate 100 mg/5 ml 0.5 ml by mouth for pain. Review of the Administration History report dated [DATE] showed a time stamp by RN A that he administered 0.5 ml of Morphine at 9:27 AM and 11 AM. This conflicted with what he logged on the Controlled Medication Record of only 0.25 ml of morphine at 8 AM and 12 PM. On [DATE] at 10:16 AM, the Director of Nursing (DON) said according to the Medication Administration Record (MAR), RN A gave Morphine to resident #1 on [DATE] at exactly 9:27 AM and 11 AM. Review of facility's investigation for misappropriation and RN A's statement dated [DATE] read, Give medication morphine ,d+[DATE] and ,d+[DATE] the room empty at the moment. The time stamp of 9:27 AM was contrary to RN A's time of giving medication between ,d+[DATE] AM. The statements/interviews obtained from nurses Hospice Licensed Practical Nurse (LPN) C, Hospice LPN D, Hospice RN Case Manager, and family of resident #1 noted they did not see RN A in the resident's room except for Hospice LPN D who indicated he only saw him after 7 AM to do an assessment and not give Morphine. During their investigation, the facility obtained a witness statement dated [DATE] by the crisis care Hospice LPN C. The statement revealed she arrived at the bedside at 8 AM and the Hospice Night LPN D was still present and remained in the room with her until 8:30 AM. Hospice LPN C documented I was with patient continuously never left bedside .facility unit manager asked about the morphine dose from 8 AM and 12 PM she asked [nurse A] he stated he gave it, which he did not .the Director of Nursing states she spoke with [nurse A] .counted the medications to discover the two doses were not there so the count reflected he gave the morphine but I know the patient in my care and she did not get any and I had never left her bedside .(Advanced Practice Registered Nurse [APRN] G) from facility came to patient and assessed her to report she reacted to testing thought she had not received any medications and will get her morphine now 2:30 PM Director of Nursing gave morphine 1 ml as ordered. The patient rested quietly after that dose and (APRN G) returned in 45 minutes to reassess her. Family remains with patient . On [DATE] at 11:50 AM, the Unit Manager (UM) said resident #1 received crisis care from hospice who was providing around the clock nurse at the bedside. The UM explained crisis care was for pain or symptom management. She stated resident #1 was moaning, grimacing, and tensing up when staff tried to reposition her or provide care. The UM verified the hospice nurses did not administer the medications, it was the responsibility of the facility nurses. The hospice nurses provided repositioning and incontinence care but relied on the facility nurse to administer medications. The UM recalled that on [DATE] at about 1 PM to 2 PM, the Hospice Case Manager reported to her that resident #1's family was concerned as the resident was in pain and looked uncomfortable. The family did not believe the nurse had administered her Morphine. The UM said she spoke to the resident's daughter who told her she did not believe her mother was given Morphine. The daughter's husband and brother were in the room at the time along with Hospice LPN C. The daughter conveyed she had been in the resident's room since 10:00 AM and the assigned nurse, RN A had not been in the room. The daughter explained she had not stepped out of the room or used the restroom and had remained at her mother's bedside the entire time. She added that her brother arrived at 12:00 PM. Hospice LPN C verified the daughter's statement and reported she had been in the room since 8:00 AM and had never left the resident's bedside. The UM said she then spoke to the assigned nurse, RN A and he reported that he gave the resident Morphine twice on his shift. The UM noted she verified the narcotic sign out count was correct. The UM explained she then informed the family and Hospice LPN C that the Morphine narcotic count was correct. She said the Hospice LPN C and the resident's daughter stated, RN A did not give medication, and something has to be done. The UM reported her concerns to the DON. The DON then re-checked the Morphine bottle to ensure the count was correct and sent RN A home. The UM noted the family and Hospice LPN C reported to the DON that the resident looked uncomfortable and was in pain if they moved her. She validated the importance of keeping someone on hospice comfortable when providing end of life care. The UM added the daughter was furious and stated, he [RN A] absolutely did not go in the room since she had been at beside since 10 AM. Hospice LPN C also stated that she had not seen RN A since she had been at bedside since 8 AM. The UM said the daughter was very upset and did not deserve to go through that when her mom was dying and the Certified Nursing Assistants (CNAs) on the unit did not see RN A go into the room either. The UM indicated that it was not possible for someone to go into the resident's room and not been seen. She noted she could not understand how RN A could say he went in the resident's room and nobody saw him. On [DATE] at 12:44 PM, during a telephone interview, Hospice LPN C said she provided bedside hospice care to patients who were dying and in need of symptom/pain management at end of life. She verified she worked at the facility on [DATE] and cared for resident #1 from 7:50 AM to 7 PM. She recalled when she arrived at the facility, resident #1 was not agitated or fidgeting and she was informed by the Hospice Night LPN D that the last dose of Morphine was given at 4 AM. She noted that when she and LPN D repositioned the resident close to 8:20 AM, the resident was not comfortable, was fidgeting, moaning and moving her legs. She remembered Hospice Night LPN D stayed in the room until 8:20 AM and reiterated that resident #1 received Morphine last at 4 AM by the facility nurse. She said the resident seemed more uncomfortable at 10 AM and was moving around more. She recalled the resident's daughter spoke to RN A who told her he gave Morphine to her mother at 8 AM. Hospice LPN C said the resident did not receive Morphine at 8 AM as she and Night LPN D were in the room and did not see RN A come in the room. When we asked RN A to give the Morphine at 12 PM he said to me and the family that he could not give it again until 4 PM as he already gave the 12 PM dose. He swore up/down he gave it, and the facility said the counts were correct, but nobody saw him. She said the daughter was very upset and APRN G got involved. She recalled APRN G assessed the resident and indicated the resident had not had any medication. She noted the APRN made sure the DON administered medication to make the resident comfortable. Hospice LPN C said the resident was more comfortable after the DON gave Morphine. She recalled APRN G also came back after Morphine was given and noted the resident was more comfortable. Hospice LPN C verified the daughter arrived in the resident's room a little after 10 AM and the rest of the family arrived after 12 PM. She noted the daughter did not leave the bedside except to talk with the DON in the hall and then left around 5:30 PM. Hospice LPN C verified she never left the room except to use the bathroom in the resident's room when the family were present. She verbalized that she and the family were very upset as RN A was adamant that he gave the resident's Morphine but they were always in the room and never saw him. During a telephone interview on [DATE] at 1:45 PM, Hospice Night LPN D stated he was assigned to resident #1 on the night shift from 7 PM to 8 AM on [DATE]-[DATE]. He said the resident was comfortable during his shift and the last time he saw the facility nurse give Morphine was at 4 AM. She was declining and her breathing was shallow. He explained that he stayed in the room until approximately 8:30 AM with Hospice LPN C and the Hospice Case Manager arrived at approximately 7:45 AM. He said he only saw facility RN A once after 7 AM when he assessed the resident but he did not administer any Morphine. A telephone interview was conducted on [DATE] at 1:30 PM, with Hospice Case Manager who verified she saw resident #1 on [DATE] from 7:45 AM to 8:10 AM. She said the resident was imminent which indicated she was close to death. She was moaning a little at that time and the Hospice Night LPN D said she received her last dose of Morphine at 4 AM from the facility nurse. At that time, she was getting Morphine routinely every 4 hours and could have breakthrough medication every 2 hours if needed. She recalled she came back around 11:45 AM and wrote more orders to increase the Morphine dose because the resident showed signs of increased pain. She recalled the UM had reported RN A gave her the Morphine at 8 AM so she did a virtual call to the hospice physician so he could visualize resident #1. She said the hospice physician gave orders to increase her Morphine dose from 0.5 ml to 1.0 ml. I reported the dosage change to RN A and gave him the new order to update the facility orders. She said RN A told her he would and she left to visit another resident in the facility. The Hospice Case Manager stated she then received a text at about 12:45 PM that RN A had not given the Morphine yet. I came over and she was still uncomfortable and ready for a dose. I went to the UM and told her the Hospice LPN C reported that (resident #1) .missed a 2nd dose and the family at beside are very upset. She recalled the DON intervened, and she was not aware of what transpired. She said she informed the Hospice Physician and documented an incident report. She added that the resident's family at bedside were visibly upset. On [DATE] at 1:55 PM, during a telephone interview, the Hospice Physician said he did a virtual visit and resident #1 looked very agitated and in pain but died in peace after we adjusted her medications. He added, the facility is not consistent when giving medications and I did not realize at the time when I ordered to increase her Morphine that the nurse may not have given the 8 AM and 12 PM doses. On [DATE] at 4:38 PM, APRN G remembered he assessed resident #1 on [DATE] around ,d+[DATE] PM per the family's request. He recalled there were 2 family members and a Hospice Nurse present at the bedside. He said the resident was uncomfortable and restless probably due to not getting her prescribed Morphine. He said he heart rate was irregular at 110 beats per minute and blood pressure was okay. When he assessed her for pain, he did a mild chest rub and she really grimaced and that was enough to tell that she did not have pain medication in her system. He explained he also did [NAME] test where the heel was rubbed from the foot up the toes and she withdrew and kicked her legs up immediately and I could tell there was no pain medication in her. He stated he told the nurse to change the pain medication schedule and to give a dose now and continue the same schedule. He noted when he came back 45 minutes later after she received Morphine, she was calmer, and the [NAME] response was very soft. He reported the family members at the bedside were upset as they were confident the nurse did not give the medication. He said he was familiar with the family as they recently had 2 other family members that died in the facility under hospice care. He said they should not have had the added stress regarding mom not getting needed medications prior to her death. On [DATE] at 12:10 PM, a telephone interview was conducted with RN A and the Business Office Manager (BOM) assisted with translation as per RN A's request who spoke Spanish. RN A said he had been a nurse for [AGE] years and worked for the facility initially as an agency nurse and then was hired by the facility last year. He verified he was the assigned nurse for resident #1 on [DATE] from 7 AM to 7 PM. He recalled he went to the resident's room to assess her prior to 8 AM and there was a nurse from hospice in the room. He then immediately went back to give the Morphine and the hospice nurse was in the hall at approximately 8 AM and resident #1 was alone. He said he went back to give a second dose of Morphine between ,d+[DATE]:30 AM and there was no one in the room. He then went on break at 11:45 AM. RN A was persistent that he gave Morphine to resident #1 and said he gave the drops under the tongue. When asked why he did not return the facility phone calls, he stated he did not call them back because he was upset. He said,I never took drugs before and it is just ridiculous. On [DATE] at 8:25 AM, during a telephone interview, the resident's daughter said she went to the facility on [DATE] because the Hospice Nurse called her and said her mom was close to passing. She recalled she arrived at the facility between 9 -9:30 AM and found her mom in bed moaning, grimacing and raising her legs due to spasms. She explained her mom never complained of pain and was very stoic. She stated she did not leave the room until approximately 1:30 PM to inform the DON that no one had come in the room to give her Morphine. She indicated the facility staff did not believe her and the DON and UM both said the narcotic counts were correct. They did not believe us that RN A never came into the room. I asked him (RN A) while he was out at the medication cart around 2 PM if he was going to give mom her medications and he said that he already gave Morphine and then left to speak to a supervisor. She said the experience added to her family's stress and if they had known this was going to happen, they would have kept her at home. The Hospice Services Agreement dated [DATE] read, Facility Interdisciplinary Group means a team of Facility employees will monitor the deliver of the Hospice Services to a Hospice Patient in order to assure that professional standards and principles are followed in the provision of the Hospice Services within the Facility Hospice Plan of Care means with respect to each Hospice Patient, a written care plan .including management of discomfort and symptom relief, appropriate to meet the Hospice Patient's needs and the related needs of the Hospice Patient's family Responsibilities and Services To Be Furnished By Facility. Facility Plan of Care and Facility services .Facility will furnish Facility Services to each Hospice Patient in accordance with the Hospice Patient Facility Plan of Care .must receive all nursing services as prescribe and must be kept comfortable .shall provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and Facility Plan of Care .

Based on interview, and record review, the facility neglected to implement a system to identify and instruct staff in the required level of transfer assistance needed, and the specific mechanical lift required for residents that required assistance with transfers for 1 resident of a total sample of 12 residents, (#1). This failure contributed to the use of an inappropriate mechanical device, and resulted in a left humeral fracture for the resident. On 2/16/23 at 10:30 AM, Certified Nursing Assistant (CNA) A transferred resident #1 from her bed to her wheelchair using a pivot to stand transfer technique and transported her to the shower room. After her shower, CNA A used a sit to stand mechanical lift to transfer the resident from the shower chair to her wheelchair. Resident #1 slipped from the lift, and the lift's sling slid down her left arm. The resident was suspended in the lift with her left arm in the air. CNA A called for help, and CNA B, and Registered Nurse (RN) C assisted the resident to her wheelchair. The resident sustained a skin tear to her left hand and complained of pain to her left shoulder. The resident was transferred to the hospital following the incident where it was identified the resident sustained a left humeral neck fracture. The facility's failure to identify the type of lift and provide the required level of assistance for transfers placed all residents requiring mechanical lifts at risk for serious harm or serious injury and resulted in Immediate Jeopardy starting on 02/16/2023. The Immediate Jeopardy was removed on 02/24/2023. Findings: Cross Reference F689 Resident #1 an [AGE] year-old female was admitted to facility on 8/30/21. Her diagnoses included, epilepsy, pain in the left ankle and joints of the left foot, pain in the left knee, difficulty in walking, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, dementia, and generalized muscle weakness. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/08/22 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10 out of 115. Review of the resident's annual MDS assessment with ARD of 9/07/22 revealed the resident required extensive assistance with two-person physical assist for transfers. Review of the resident's care plan for Activities of Daily living (ADL) self-care performance deficit related to hemiplegia and hemiparesis, and generalized muscle weakness, initiated on 9/17/21 and revised on 12/03/21 revealed, the resident is totally dependent on 2 staff for transfers. Review of a Change in condition form and progress note dated 2/16/23, revealed the resident fell from the mechanical lift while being transferred to her wheelchair. She sustained a laceration to her left hand, and complained of pain to her left shoulder. The resident was transferred to the hospital on 2/16/23 and x-rays showed the resident sustained a left humeral neck fracture. On 2/21/23 at 10:56 AM, the Director of Clinical Services (DCS), and the Assistant DCS explained that on 2/16/23 at 10:30 AM, resident #1 was transferred by CNA A with a sit to stand mechanical lift from the shower chair to her wheelchair in the shower room. The CNA told them, that she had completed the resident's shower, and was placing an incontinent brief on the resident while the resident was in the sit to stand lift, when the resident slipped out of the lift. The lift's sling slid down her left arm, and the resident was suspended from the lift. The DCS stated the resident complained of left shoulder pain and was transferred to the ER, where x-ray showed a left humerus neck fracture. They indicated the resident was a 2 person transfer and CNA A did not seek assistance when transferring her. They acknowledged the resident's care plan did not specify the type of lift to be used, until it was updated on 2/17/23, after the incident. On 2/21/23 at 12:25 PM, in a telephone interview, CNA A, recalled she lifted the resident from her bed and pivoted her to her wheelchair and took the resident to the shower room in a shower chair. She stated that after the shower, she removed the resident from the shower in the shower chair, then placed the sit to stand lift sling around the resident's waist and put the lift up. CNA A said the resident was standing and held on to the lift with her right hand. She explained that she moved the shower chair back, and placed the resident's wheelchair behind her, and attempted to put an incontinent brief on the resident to complete pulling up her pants. The CNA said the resident let go of the lift, took her hand out of the sling, and slipped down, with her left arm suspended in the air. CNA A said when the resident pulled her hand from the sling, there was a bruise to her left hand, due to being suspended in the lift. When asked the how the resident should have been transferred, CNA A explained that she was supposed to review the resident's Kardex to find out how the resident should be transferred. She said she did not check the resident's Kardex, but asked another CNA how the resident was transferred, and was told she could stand and pivot. She stated she knew better and should not have transferred the resident by herself and should not have used the sit to stand lift. On 2/21/23 at 4:50 PM, in an interview with the Interim Executive Director, the Divisional Nurse Consultant, and the DCS, the Divisional Nurse Consultant recalled the facility interviewed CNA A who said she was sorry, and that she knew resident#1 required assist of two persons. The CNA reported she did not review the resident's Kardex, but asked another CNA how the resident was transferred. The Divisional Nurse Consultant stated the facility verified neglect based on the evidence obtained during the investigation, and the Root Cause Analysis (RCA) was, A single appropriately trained CNA with documented competency dated 5/25/2020, and 4/28/22 made the decision on her own not to follow facility standard of practice . The single CNA did not seek assistance from nurse or other trained direct care staff when transferring resident via mechanical lift. However, the RCA did not identify the omission on the resident's care plan, and Kardex of the type of mechanical lift required for the resident's transfer as a contributing factor to the incident which resulted in the fall with major injury for resident #1. On 2/22/23 at 3:52 PM, the Divisional Consultant Nurse stated that prior to the incident on 2/16/23 with resident #1, care plans and Kardex never identified the type of mechanical lift to be used for transfer. She verbalized that on 2/17/23 the resident's care plan and Kardex was updated to include the type of mechanical lift required for resident transfers. On 2/23/23 at 10:53 AM, the DCS stated that prior to the incident on 2/16/23, the plan of care did not identify the type of mechanical lift required for transfer. However, after the incident the care plan and Kardex was updated to specify whether a sit to stand or a total mechanical lift was required. The facility's policy Abuse, Neglect, Exploitation & Misappropriation with effective date of 11/30/2014, and revision date of 11/16/2022 described neglect as the failure of the center, its employees .to provide goods and services to a resident that are necessary to avoid physical harm. Review of the job description for CNA, created September 2018 revealed the job duties and responsibilities included providing direct care in accordance with treatment plans, and to follow established safety precautions in the performance of all duties. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On 2/16/23 at 2:00 PM, resident #1 was transferred to the hospital. *On 2/16/23 at 7:00 PM, the facility made aware that resident #1 sustained a left humeral fracture. *On 2/16/23 CNA A was suspended pending investigation. The Immediate report was submitted to the Agency For Health Care Administration, and to the Department of Family and Children. *On 2/17/23 the Interim Executive Director (ED) conducted investigation to include re-enactment of the event. Statements were obtained from nurses and CNAs who worked on the South Unit on 2/16/23. The DCS in collaboration with the therapy department established a list of residents requiring mechanical lifts for transfers. Residents were rescreened by the Therapy Director between 2/17/23 to 2/22/23 to ensure appropriate transfer procedure was in place. Care plans were updated by the MDS Coordinator to include which mechanical lift is to be used during transfers. On 2/23/23, and 2/24/23 interviews were conducted with three RNs, one LPN, and 12 CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include seven additional residents who were identified as requiring a sit to stand mechanical lift for transfer, and two residents at risk for falls/actual falls. Observations, interviews, and record reviews revealed no concerns, and as of 2/23/23 following rescreen by therapy, only resident #2 and #5 now required a sit to stand lift for transfers. Review of the in-service attendance sheets validated mechanical lift education accompanied by competencies and posttest were completed using the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift for facility and Agency staff, with 91% completion as of 2/23/23. New hires will receive education in orientation, and certified letters were mailed to staff members who were unable to attend the training, to set up appointment for the in-service. Interviews conducted from 2/23/23 to 2/24/23 with 15 facility staff including 2 RNs, 1 LPNs, and 12 CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and type of mechanical lift required for resident transfers.

Based on observation, interview and record review, the facility failed to prevent an avoidable accident with major injury for a vulnerable, physically, and cognitively impaired resident, and failed to identify and provide the required level of transfer assistance required for 1 of 12 residents sampled for accidents, (#1). This failure contributed to the use of an inappropriate mechanical device, and resulted in the resident sustaining a left humeral neck fracture. On 2/16/23 at 10:30 AM, Certified Nursing Assistant (CNA) A transferred resident #1 from her bed to her wheelchair using a pivot to stand transfer technique and transported her to the shower room. After her shower, CNA A used a sit to stand mechanical lift to transfer the resident from the shower chair to her wheelchair. Resident #1 slipped from the lift, and the lift's sling slid down her left arm. The resident was suspended in the lift with her left arm in the air. CNA A called for help, and CNA B, and Registered Nurse (RN) C assisted the resident to her wheelchair. The resident sustained a skin tear to her left hand and complained of pain to her left shoulder. The resident was transferred to the hospital following the incident where it was identified the resident sustained a left humeral neck fracture. The facility's failure to identify the type of lift and provide the required level of assistance for transfers placed all residents requiring mechanical lifts at risk for serious harm or serious injury and resulted in Immediate Jeopardy starting on 02/16/2023. The Immediate Jeopardy was removed on 02/24/2023. Findings: Cross Reference F600, F656 Resident #1, an [AGE] year-old was admitted to the facility on [DATE]. Her diagnoses included, epilepsy, pain in the left ankle and joints of the left foot, pain in the left knee, difficulty in walking, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, dementia, and generalized muscle weakness. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/08/22 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10/15. The assessment indicated transfers occurred only once or twice during the review period, and resident #1 was totally dependent on one staff person for personal hygiene. The resident's balance during transition and walking was assessed as being not steady, and she was only able to stabilize with staff assistance when moving from seated to standing position, and surface-to-surface transfers. She had impairment in functional limitation in range of motion on one side of her upper and lower extremities. Review of the resident's annual MDS assessment with ARD of 9/07/22 revealed the resident required extensive assistance with two-person physical assist for transfers. Review of the medical record revealed the resident received Physical Therapy (PT) from 1/22/22 to 2/18/22. On discharge from PT on 2/18/22, the resident required maximum assistance with transfers. The note identified the resident was dependent on staff for transfers and was not ambulatory. There was no indication from therapy that a mechanical lift was to be used to transfer resident #1. A Change in Condition form and nursing progress noted both dated 2/16/23, revealed the resident fell from the mechanical lift while being transferred to her wheelchair. The resident sustained a laceration to her left hand, and complained of pain to her left shoulder which was scored as 6 on a 0-10 numerical scale. Physician orders were received to transfer the resident to the emergency room (ER). The Hospital Emergency Report dated 2/16/22 at 4:39 PM, revealed x-ray of the humerus done in the ER showed the resident sustained a left humeral neck fracture. On 2/21/23 at 10:56 AM, the incident was discussed with the Director of Clinical Services (DCS), and the Assistant DCS. They explained that on 2/16/23 at 10:30 AM, resident #1 was being transferred by CNA A using a sit to stand mechanical lift from the shower chair to her wheelchair in the shower room. CNA A reported she had completed the resident's shower and was trying to put an incontinence brief on the resident while the resident was in the sit to stand lift. The CNA transferred the resident by herself, the resident slipped out of the lift, the sling pad slid down her left arm, and the resident was suspended from the lift. CNA A called for assistance and CNA B responded. Both CNAs attempted to transfer the resident from the lift to her wheelchair, but could not, and they called for Registered Nurse (RN) C to assist. The three staff then transferred the resident to her wheelchair. RN C notified the ADCS and the physician was contacted. the resident was transferred to the ER. The ADCS stated she called the ER later to ascertain the resident's status and was informed that the x-ray showed a left humerus neck head fracture. Review of the resident's care plan with the DCS, and the Divisional Consultant Nurse for Activities of Daily living (ADL) revised on 12/03/21 included, the resident is totally dependent on 2 staff for transfers. The care plan did not specify the type of lift to be used, until it was updated on 2/17/23 after the incident on 2/16/23 to include the specific mechanical lift. On 2/21/23 at 11:45 AM, resident #1 was lying in bed. She pointed to her left arm which had a sling in place and a dressing was noted to the top of her left hand. The resident nodded yes when asked in Spanish if she had pain but was not able to answer additional questions. On 2/21/23 at 11:47 AM, Licensed Practical Nurse (LPN) D, stated she was aware of the incident with resident #1. She stated the resident was a 2 person assist for transfers and the CNA did not use the appropriate transfer. LPN D verbalized the resident's left arm was contracted and a sit to stand lift should not have been used. On 2/21/23 at 11:55 AM, RN C recalled she was in the South Wing on 2/16/23, when CNA B told her she had to go to the shower room to assist another CNA. RN C stated when she went into the shower room, resident#1 was in the sit to stand lift with her right arm down by her side, and her left arm up in the air. RN C reported a laceration was noted to her left hand, and CNA A, was holding on to the resident. She verbalized the three of them transferred the resident into her wheelchair and returned her to her bed. She noted the resident complained of left arm pain and the physician was notified. She said the physician gave orders to send the resident to the hospital due to the left-hand laceration and pain to her left shoulder. RN C recalled when she returned to work the next day, she found out the resident sustained a fracture. RN C stated she did not know why CNA A used the sit to stand lift as the resident had a contracted left hand and would not have been able to hold on to the bar of the lift. She added the resident was skinny,and the sling used was probably too big. The sit to stand lift was observed with the RN C. She acknowledged there was no individual sling for each resident to be used with the lift. On 2/21/23 at 12:25 PM, in a telephone interview, CNA A confirmed she was assigned to resident #1 for the 7:00 AM to 3:00 PM shift on 2/16/23. She verbalized the resident was quiet, spoke Spanish, but was able to point and make her needs known. She verified the resident had a contracted left hand. She stated that on 2/16/23, she lifted the resident from her bed and pivoted her to her wheelchair and transported the resident to the shower room onto a shower chair. She recalled she showered the resident and placed her pants partially on while she was sitting in the shower chair. She stated she then placed the sit to stand lift sling around the resident's waist, and moved the lift up which placed the resident in a standing position. CNA A said the resident stood and held on to the lift with her right hand. She explained she then moved the shower chair back, and placed the resident's wheelchair behind her, and attempted to put an incontinence brief on the resident to complete pulling up her pants. The CNA said the resident let go of the lift, took her hand out of the sling and slipped down, with her left arm suspended. She indicated the resident did not fall on the floor. She said she reached over, moved the wheelchair, and pulled the emergency light for help. CNA A recalled CNA B responded and helped her to lower the lift. She said RN C came to assist and the three of them transferred the resident into the wheelchair and back into bed. She noted the resident sustained a bruise and cut to her left hand and RN C assessed her for any further injuries. CNA A reported she was supposed to review the resident's chart to know how the resident should be transferred. She said she did not check the resident's Kardex but was told the resident could stand and pivot. She said she knew better, and should not have transferred the resident by herself. She verbalized when the resident was sitting in the shower chair, she looked uncomfortable, and at the time she could not find anyone to help her, so she took the chance of doing the transfer by herself. She did not explain why she used a sit to stand lift to transfer the resident. On 2/21/23 at 1:10 PM, the Director of Rehab stated that part of therapy assessment included functional mobility, and the therapist determined how much assistance the residents required based on their initial evaluation. He explained mechanical lift use was determined by the nursing department and therapy determined the resident's required level of assistance. He indicated the sit to stand mechanical lift had certain requirements for use, and included the resident's ability to bear weight, and if the resident had enough upper extremity strength to grip the handles of the lift. He said that as a rule therapy did not make the determination of whether residents required mechanical lifts for transfers. He noted that therapy staff determined the level of assistance a resident required for transfers and then nursing would decide which lift device to use. He recalled resident #1 was on Occupational Therapy (OT) from 10/09/22 to 10/31/22, for spasticity of her left hand and wrist, and a splint for her left wrist and hand was addressed. He stated the resident received Physical Therapy (PT) from 1/22/22 to 2/18/22 and required maximum assist for transfer, requiring at least 75% help. The Director of Rehab verbalized that if the resident was assessed as requiring maximum assist with PT, for safety, a mechanical lift would be fine for the resident. He explained that based on requirements of the sit to stand lift, and due to the spasticity of the resident's left hand, the resident would not be able to hold the bar of the sit to stand lift and a total mechanical lift would be appropriate for her. He stated he heard about the incident with the resident in the shower room on 2/16/23, and said it was a wrong decision by CNA A to use the sit to stand lift, especially when staff was using the total mechanical lift before, and clearly the resident could not have been able to grasp the handlebars of the sit to stand lift. On 2/21/23 at 2:38 PM, in a telephone interview, resident #1's Power of Attorney (POA) stated the facility called him on 2/16/23, and he spoke to the supervisor. He said a nurse called and told him that there was an incident in the shower when they tried to lift the resident with a lift. He stated the resident had a stroke, and had weakness to her left side, her left hand was contracted, and she was not able to hold anything with her left hand. He said she did not have a strong left arm. On 2/21/23 at 4:50 PM, in an interview with the Executive Director (ED), the Divisional Nurse Consultant, and the DCS, the Divisional Nurse Consultant recalled the facility interviewed CNA A who said she knew resident #1 required assist of two persons for transfers. The CNA reported she did not review the resident's Kardex, but asked another CNA how the resident was transferred. The Divisional Nurse Consultant stated the facility verified there was neglect based on the evidence obtained during the investigation, and the root cause analysis was that, an appropriately trained CNA with documented competencies dated 5/25/2020, and 4/28/22 made the decision on her own not to follow facility standard of practice with regard to utilization of a fully and functioning mechanical lift. She added the CNA did not seek assistance from a nurse or other trained direct care staff when transferring resident #1 with an inappropriate mechanical lift. On 2/22/23 at 10:57 AM, CNA B recalled on 2/16/23, CNA A called for help from the shower room. She went to help and found resident #1 in the sit to stand lift with her knees touching the footpad of the lift, and her left arm was extended behind her. She remembered she and CNA A tried to sit the resident in her wheelchair from the lift, but could not, so she called RN C, and they all helped to transfer the resident to her wheelchair. CNA B stated the resident was transferred back to her bed and RN C assessed the resident. She indicated the resident had injuries to her left hand and complained of pain to her left shoulder. CNA B stated she had been assigned to resident #1 before and since the resident was very light weight, two persons would transfer her from bed to chair without a lift, but when taking a shower, they would use the total mechanical lift to transfer her to the shower bed. She stated the resident's left hand was contracted, and she could not use her left hand to hold the grab bars on the lift. She said the resident could not stand, because she did not have strength in her legs, so the sit to stand lift was not appropriate for the resident. CNA B stated CNA A did not ask her for help prior to the incident in the shower room. On 2/24/23 at 11:30 AM, the Advanced Practice Registered Nurse (APRN) stated the facility notified him that resident #1 fell from the lift and that her left arm was hurting. The APRN recalled he was not in the facility, so he directed staff to transfer the resident to the hospital. He said he saw the resident when she returned to the facility but she was not able to give him any details of what happened. He verbalized he gave orders for pain medication and noted the resident was at her baseline, did not appear distraught or anxious, so there was no need for a psychiatric evaluation. On 2/24/23 at 11:36 AM, in a telephone interview, the Medical Director (MD) stated she was the resident's Primary Care Physician. She was aware the resident was transferred with a mechanical lift by one CNA and sustained a fracture. She said she was involved in the AdHoc Quality Assurance Performance Improvement (QAPI), meeting. She indicated staff knew that 2 staff were required to transfer residents with a mechanical lift. She explained the resident could not be transferred with a sit to stand lift as her hand was contracted. Review of the job description for CNA, created September 2018 revealed her job duties and responsibilities included providing direct care in accordance with treatment plans, and to follow established safety precautions in the performance of all duties. The facility's policy Transfer/Mobility Evaluation Low Lift with effective date 11/30/2014, and revision date of 11/01/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs .Two staff members are required when using a mechanical lift. Lift status will be indicated on the resident's care plan and Kardex. Review of the Facility Assessment Tool dated 2/13/2023 revealed that services and care offered was based on resident needs and included mobility and fall/fall with injury prevention. The assessment showed the facility would provide person-centered care, and would use the facility's resources to provide competent care for residents including staff, staff training/education and competencies. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On 2/16/23 at 2:00 PM, resident #1 was transferred to the hospital. *On 2/16/23 at 7:00 PM, the facility made aware that resident #1 sustained a left humeral fracture. *On 2/16/23 CNA A was suspended pending investigation. The Immediate report was submitted to the Agency For Health Care Administration, and to the Department of Family and Children. *On 2/17/23 the Interim Executive Director (ED) conducted investigation to include re-enactment of the event. Statements were obtained from nurses and CNAs who worked on the South Unit on 2/16/23. The DCS in collaboration with the therapy department established a list of residents requiring mechanical lifts for transfers. Residents were rescreened by the Therapy Director between 2/17/23 to 2/22/23 to ensure appropriate transfer procedure was in place. Care plans were updated by the MDS Coordinator to include which mechanical lift is to be used during transfers. On 2/23/23, and 2/24/23 interviews were conducted with three RNs, one LPN, and 12 CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include seven additional residents who were identified as requiring a sit to stand mechanical lift for transfer, and two residents at risk for falls/actual falls. Observations, interviews, and record reviews revealed no concerns, and as of 2/23/23 following rescreen by therapy, only resident #2 and #5 now required a sit to stand lift for transfers. Review of the in-service attendance sheets validated mechanical lift education accompanied by competencies and posttest were completed using the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift for facility and Agency staff, with 91% completion as of 2/23/23. New hires will receive education in orientation, and certified letters were mailed to staff members who were unable to attend the training, to set up appointment for the in-service. Interviews conducted from 2/23/23 to 2/24/23 with 15 facility staff including 2 RNs, 1 LPNs, and 12 CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and type of mechanical lift required for resident transfers.

Based on interview and record review, the facility neglected to develop and/or implement procedures to identify, communicate, and provide necessary care and services to ensure the safety of a resident who was at high risk for falls; and neglected to follow standards of practice related to post-fall response, for 1 of 6 residents reviewed for falls, out of a total sample of 8 residents, (#1). These failures contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered severe pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had a swelling on the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department (ED) staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to implement policies and procedures to prevent neglect and effectively respond to fall incidents placed all residents who were at risk for falls at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F655, F689, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was confusion, and she was alert and disoriented but could follow simple instructions. She had a risk alert for falls and was incontinent of bowel and bladder. The form showed resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. Review of resident #1's Admission / Readmission Data Collection form dated [DATE] at 6:00 PM, revealed she required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The admission assessment described the resident as independent with ambulation but requiring wheelchair only. The document included a Fall Risk Evaluation with scored responses to determine if the resident was at risk for falls was incomplete as some sections were left blank and inaccurate responses were selected in other sections. There was no total score for determination of the resident's level of risk for falls. On [DATE] at 12:53 PM, Registered Nurse (RN) A confirmed he was the assigned nurse on the day resident #1 was admitted . He recalled the facility's electronic medical record (EMR) system was down that day and he was accustomed to completing new admission documentation in the computer. RN A explained the resident arrived late in his shift, almost at 7:00 PM as he was getting ready to go home. He stated he started the required paperwork but did not complete it. On review of the resident's chart, he confirmed he did not initiate a baseline care plan and the fall risk evaluation and other sections of the assessment form were not done. RN A said, If we do not do it, the Unit Manager checks all the paperwork when he comes in. He acknowledged he assessed the resident's ability to transfer, stand, and ambulate, and noted she was unable to walk due to significant weakness in her legs. RN A confirmed resident #1 required a wheelchair for safety but she did not have one. He stated to his knowledge, a Physical Therapist had to evaluate her before she received a wheelchair. RN A acknowledged the resident was very confused and at risk for falls but he did not initiate any fall prevention interventions before he completed his shift and left the facility. When asked what could have been done to ensure the resident's safety, RN A stated it would have been possible to increase supervision by Certified Nursing Assistants (CNAs) if he had been able to enter it as a task or care directive in the EMR. On [DATE] at 2:20 PM, Physical Therapist I stated he evaluated resident #1 on Saturday, [DATE], and deemed her to be at high risk for falls. He explained the resident required a walker and support with a gait belt to ambulate a distance of five feet. Physical Therapist I stated the resident required a wheelchair to get to the bathroom and CNAs would have to use a gait belt to support her during transfers from the wheelchair to the toilet. He verified resident #1 did not have a wheelchair in her room and explained it was the responsibility of nursing staff to obtain one from Central Supply. Physical Therapist I said, My evaluation is the basis for care. However, he did not recall if he communicated his recommendations regarding resident #1's care and safety needs with nursing staff. Physical Therapist I stated there was no facility protocol to guide communication between the therapy and nursing departments. He explained other facilities utilized communication forms to ensure important information regarding safety alerts and therapy recommendations was available. Physical Therapist I stated if he had significant concerns he would relay them to the Rehab Director who would in turn communicate with nursing management. On [DATE] at 4:40 PM, the Director of Rehab stated he would expect therapists to communicate necessary interventions to the Weekend Nursing Supervisor, especially if there was a safety issue. He reviewed resident #1's Physical and Occupational Therapy notes and confirmed there was no documentation that nursing staff were notified of the resident's fall risk or provided with recommendations for assistance with mobility and toileting. When asked why therapists did not provide resident #1 with a wheelchair, the Director of Rehab stated therapy staff did not provide wheelchairs. He explained he attended interdepartmental meetings during which clinical team members including either the Director of Nursing (DON) or the Assistant DON (ADON) collaboratively reviewed all residents on therapy caseload. The Director of Rehab stated all residents who were admitted on weekends were discussed during the team meeting on Mondays, but he did not recall discussion of resident #1's therapy evaluations and recommendations, her fall risk, or need for a wheelchair on Monday, [DATE] On [DATE] at 10:43 AM, the North Wing Unit Manager (UM) explained he attended clinical management team meetings and participated in chart reviews on Monday mornings for residents who were admitted over the weekend. He did not recall participating in the review of resident #1's chart and said, Somebody else did it. The UM was asked to review the resident's medical record and acknowledged the fall risk evaluation was inaccurate, incomplete, and did not identify risk for falls. He confirmed he completed the baseline care plan on Monday [DATE] based on information he obtained from the inaccurate, incomplete admission assessment done by RN A. The UM validated RN A had not completed the continence tracking form either. He explained both forms were usually done in the EMR which had not been available to staff for approximately two weeks. The UM acknowledged there needed to be effective communication within the nursing department and between nursing and other departments to facilitate good care. He confirmed any safety issue such as escalating confusion and high fall risk needed immediate interventions which should be noted in the chart. The UM verified nursing staff did not appropriately determine resident #1's risk for falls, implement fall prevention approaches or notify the physician as her likelihood for falls increased over the weekend. He stated no member of his staff informed him of resident #1's behavioral or safety concerns on Monday when he returned to work. He confirmed nurses could have initiated one-to-one supervision, called the attending physician, or reported their concerns to a supervisor. The UM stated he expressed concerns to facility administration in the past regarding weekend admissions as there were no clinical managers except the weekend supervisor onsite to thoroughly review all assessments and ensure paperwork was completed. Review of the facility's policy and procedure Fall Management revised on [DATE], revealed residents would be evaluated for fall risk, and patient-centered interventions would be initiated as indicated. The purpose was . to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Post-fall strategies directed staff to first evaluate the resident and provide post-fall care, then initiate neurological checks according to the facility policy. Next, the nurse was to notify the physician and family and re-evaluate the resident utilizing a Post Fall Evaluation tool. The interdisciplinary team would review fall documentation, complete a root cause analysis, and develop new care plan interventions to prevent additional falls. On [DATE] at 3:22 PM, resident #8 informed the Divisional Nurse Consultant and the DON that over the weekend resident #1 had been her roommate and fell at least four times. Resident #8 informed them nursing staff were aware as they picked resident #1 up off the floor and returned her to bed each time. On [DATE] at 3:57 PM, the DON stated nursing staff neither documented nor reported that resident #1 fell over the weekend. The DON stated her expectation was nurses would take appropriate post-fall actions such as thorough assessments, neurological checks, notification of the physician and family, and complete a fall investigation packet for each incident. The DON said, In this situation, if the interdisciplinary team had been aware the resident fell on ce or more on the weekend, other interventions would have been put in place. On [DATE] at 6:55 PM, in a telephone interview with RN B (who worked for a staffing agency), she confirmed she was assigned to resident #1 during the 7:00 PM to 7:00 AM shift on [DATE]. RN B recalled the off going nurse informed her the resident was admitted two days prior and was a fall risk and required constant redirection during the day shift as she kept attempting to ambulate without assistance. RN B stated she worked for a staffing agency and was not knowledgeable about the facility's fall prevention protocols and initiating interventions such as increased supervision. RN B described her assignment as overwhelming that evening and change of shift report lasted from 6:45 PM to almost 7:30 PM. She said, I had maybe 30 plus patients and my first admission came in at 7:45 PM, so before I could do rounds on the unit I had to handle that. She recalled at approximately 8:00 PM, a CNA informed her a resident was on the floor. RN B confirmed she responded and found resident #1 lying on the floor in a mixture of urine and feces and she noted a bump on the left side of her forehead. She said, I asked the CNAs if she was alert at baseline and they said they had been talking to her before. When I tried to speak to her she had no clear words, just low sounds. RN B stated the resident's eyes were closed and when she tried to open her eyelids, she squinted. RN B explained she checked resident #1's vital signs and blood glucose level and noted they were normal. When asked if she initiated neurological checks, she stated she did not as she realized the resident would have to go to the hospital. RN B then left the resident with a CNA and returned to the nurses' station. She said, I'm going to be honest with you. I didn't have a computer system, so it took time to get the DON's phone number, find the chart and locate the [History and Physical] to answer questions for EMS. RN B explained only facility nurses had access to the EMR and the other nurse on the unit with her was also from a staffing agency. RN B explained she was hindered by lack of basic information such as a demographic sheet, in the paper chart. In addition, the copier on the unit did not work so she had to ask a CNA to copy paperwork required for the hospital transfer on the other unit. RN B stated she called the DON twice, did not get a response, and then decided to call 911. She estimated approximately 30 minutes elapsed between the discovery of the resident on the floor and the call to 911. RN B stated she notified the resident's daughter after EMS arrived, but she could not recall when she notified the attending physician. On [DATE] at 3:23 PM, in a telephone interview, the facility's Medical Director was informed of the sequence of events after resident #1's last fall. She said, If [resident #1] was obtunded, they should have called 911 first, then let the physician know. She explained her expectation was nurses would notify the physician first as medical providers should be the ones to determine necessary interventions to diagnose or treat a resident after a fall. She explained the standard of practice for an unwitnessed fall was to send the resident to the hospital for testing due to the risk of head injury. Review of a Fire Department Event Report dated [DATE] revealed a 911 call was received from the facility at 8:21 PM. EMS personnel were dispatched at 8:22 PM and they arrived at the facility in five minutes, at 8:27 PM. EMS departed the facility with resident #1 at 8:48 PM and arrived at the hospital ED at 9:01 PM. The Event Notes Addendum indicated resident #1 had a chief complaint of falls. The document showed she had a head injury and she is not responding normally (not completely alert). Caller Statement: PT FOUND ON FLOOR IN BATHROOM UNABLE TO COMMUNICATE NOW POSSIBLY HIT HEAD. On [DATE] at 5:45 PM, an interview was conducted with the Administrator and DON. The DON stated post-fall interviews with staff showed CNAs and nurses were aware of resident #1's fall risk. The Administrator verified that a few hours before the resident fell on Monday, [DATE], the assigned CNA observed the resident ambulating while leaning on and rolling the overbed table. He provided a written statement that showed the assigned day shift nurse informed the night nurse the resident continuously tried to get up from her chair and walk throughout the day. The DON said, They knew they had to keep an eye on her. She was checked approximately every 30 minutes. She had confusion. When asked about appropriate nursing interventions for a confused resident at risk for falls, the DON said, I would expect more frequent supervision. The DON acknowledged neither staff statements nor the plan of care reflected a specific frequency of monitoring, level of supervision, or defined fall prevention approaches. The DON explained admission nurses would identify residents' needs during the initial assessment and create a baseline care plan which could be updated by any nurse as needed. She reviewed resident #1's medical record and validated the admission assessment was incomplete, the fall risk evaluation was inaccurate, and the documentation in the progress notes did not reflect the extent of the resident's behavior and confusion or include fall prevention interventions. The DON confirmed resident #1's admission assessment and hospital transfer form indicated she required a wheelchair. The DON was informed the resident was never provided with a wheelchair during her three-day stay in the facility. The Administrator stated staff statements indicated resident #1 was last seen by her assigned CNA, seated in a chair at bedside, at 7:40 PM and was found on the floor at approximately 8:00 PM. The DON stated the assigned nurse attempted to contact her and left a voicemail regarding the resident's fall with head injury at 8:14 PM. On [DATE] at 3:57 PM, the DON explained the facility's EMR system was hacked (unauthorized entry into a computer system) on [DATE], and although facility staff gained access to the EMR after a couple weeks, agency nurses only received access within the past 24 hours. The DON stated there were challenges in keeping paper records current and accurate and not all nurses documented as required. She confirmed the sequence of RN B's actions after resident #1's fall was wrong. The DON said, In my experience, the call to 911 should have been first, then the physician should have been told. She explained preparation of paperwork, and notification of the DON and the family should have occurred afterward. The DON confirmed a CNA corroborated resident #8's description of resident #1's fall during the weekend. On [DATE] at 5:04 PM, CNA D stated she worked for a staffing agency and was assigned to resident #1 on Monday, [DATE], during the 3:00 PM to 11:00 PM shift. She explained she relied on verbal report from other staff to get information on how to care for her assigned residents. CNA D stated that evening was her first shift with resident #1 and since there was no wheelchair provided, she assumed the resident could walk. CNA D said, It's hard to get report. The only thing I was told was to keep an eye on her. There is no [CNA care plan] here, and no written instructions on what the residents need. On [DATE] at 3:40 PM, in a telephone interview, Licensed Practical Nurse (LPN) C stated she worked for a staffing agency and was assigned to resident #1 on Monday, [DATE], during the 7:00 AM to 7:00 PM shift. She did not recall passing on any information regarding resident #1's fall risk in change of shift report. LPN C explained only staff with access to the EMR would have accurate information on residents' plans of care. She explained the facility did not have paper care plans so she would need to ask other nurses for information on care needs and safety concerns. On [DATE] at 3:33 PM, in a telephone interview, the Weekend Nursing Supervisor stated she usually tried to see all newly admitted residents on the weekends, and she checked to ensure all assessments were done. She recalled she put resident #1's paperwork together and built her chart on Saturday, [DATE], the day after admission. The Weekend Nursing Supervisor was informed resident #1 fell on Monday, [DATE] and the assigned nurse was hindered by lack of a face sheet with important demographic information. She said, Typically, I do put a face sheet, but that weekend I did not have access to the electronic chart so I couldn't print one. The Weekend Nursing Supervisor did not recall if she checked the nursing admission assessments for accuracy, and to verify if the the plan of care was appropriate. She was not aware a baseline care plan was not initiated. She explained, Care plans should have been done by the admission nurse, so we know what their needs might be. The Weekend Nursing Supervisor stated she thought the facility's policy was that wheelchairs required approval by the therapy department. Review of the facility's policy and procedure Abuse, Neglect, Exploitation & Misappropriation revised on [DATE], revealed the facility recognized each resident had the right to be free from Neglect. The document included the definition, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy indicated an example of Neglect was failure to take precautionary measures to protect the health and safety of the resident. The Facility Assessment Tool dated [DATE] revealed the facility could meet the needs of residents with impaired cognition, behavior that needed interventions, and cirrhosis. The document indicated facility staff would be trained and demonstrate competence in .rights of the resident and the responsibilities of a facility to properly care for its residents. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #1 was discharged from the facility to the hospital. *On [DATE], the Divisional Nurse Consultant educated the Administrator, DON, ADON, and the Social Services Director (SSD) regarding Abuse, neglect, and Exploitation. *On [DATE], the SSD initiated education of all current facility staff to include all departments regarding Abuse, Neglect, and Exploitation. The facility educated 95 of 135 staff members as of [DATE]. Certified letters were sent out to those staff members who were unable to attend the education. Any facility or contracted staff who did not receive education will not be permitted to work until education is completed and validated by the DON or designee. *On [DATE], the DON and ADON initiated education with all licensed nurses including agency nurses regarding assessment of residents post fall to include policy and procedures for neurological evaluation for any unwitnessed falls, notification of change in condition, code of ethics rule to ensure falls are reported with emphasis on no retaliation policy, fall management policy and procedure, baseline care plan policy, and to notify DON of all resident falls once physician and/or emergency services have been notified. Education was accompanied by post-testing. As of [DATE], the facility educated 10 of 22 licensed nursing staff. Certified letters were sent out to those staff members who were unable to attend the education. Any facility or contracted staff who did not receive education will not be permitted to work until education is completed and validated by the DON or designee. *On [DATE], the facility submitted the Agency for Health Care Administration (Florida state survey agency) Federal Report regarding a Neglect allegation. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at risk with current interventions. *On [DATE], the Divisional Nurse Consultant educated the DON, ADON, UM, and Weekend Nursing Supervisor regarding the process for morning clinical meeting, clinical stand down process, and expectations for the Weekend Nursing Supervisor to review new admission charts and charts for residents with recent falls to ensure policy and procedures are implemented. The Divisional Nurse Consultant will attend at least one clinical meeting each week to validate the process is being followed. *On [DATE], the Divisional Nurse Consultant educated the Medical Records Coordinator regarding the requirement to ensure nursing staff has access to the resident EMR or a complete paper chart to include a resident facesheet. *On [DATE], the Divisional Nurse Consultant educated the Administrator, DON, and ADON regarding how to complete a thorough investigation following an event. *On [DATE], the Rehabilitation Program Manager educated therapy staff regarding timely communication between therapy and nursing departments regarding resident mobility, care needs, and assistive devices for transfers. *As of [DATE], all nursing staff to include agency nurses had access to the EMR. *As of [DATE], the interdisciplinary team including the Administrator, DON, ADON, Unit Manager, Minimum Data Set Coordinator, and SSD will review all residents who have fallen during the morning clinical meeting and follow up during clinical stand down. The nursing house supervisor will review new admission charts for residents who fell during the weekend to ensure fall evaluations were complete and accurate, appropriate interventions were implemented to include increased supervision as necessary, care plan updated with appropriate interventions and provides written report to DON. *As of [DATE], the DON or designee will review clinical records of all residents who fell on a weekly basis to validate documentation is in place to include appropriate resident-centered fall prevention interventions, appropriate supervision, and that baseline and/or comprehensive care plans were updated. The Divisional Nurse Consultant will be provided a copy of the weekly audit to provide additional oversight. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, the DON , and the Medical Director. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Preventing Abuse/Neglect/Exploitation/Misappropriation, Falls / Change in Condition / Baseline CP / Neuro checks, Fall Management/Incident Management, Complete Medical Record, Effective Investigation of Falls, Education/Communication Between Therapy and Nursing Regarding Assistive Devices, and Code of Conduct. On [DATE], interviews were conducted with three RNs, one LPN, six CNAs, one Activity staff, one Maintenance staff, and one Dietary staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for falls. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #7, and #8 related to neglect, to include provision of appropriate care and services to prevent falls.

Based on interview and record review, the facility failed to develop a person-centered baseline care plan with appropriate interventions within 48 hours of admission, and failed to involve the resident representative to promote collaborative care and ensure the immediate health and safety needs were met for 1 of 6 residents reviewed for falls of a total sample of 8 residents, (#1). These failures contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had swelling to the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to initiate a baseline care plan placed all newly admitted residents who were at risk for falls at likelihood for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F689, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. On [DATE] at 12:27 PM, in a telephone interview with resident #1's daughter, she explained her mother required long-term care in a skilled nursing facility due to her diagnosis of cirrhosis of the liver and associated medical issues such as increased ammonia levels and altered mental status. The daughter stated her mother was at risk for falls due to physical and cognitive issues, often overestimated her abilities, and therefore required close supervision. She recalled conversations with Admission Department staff prior to her mother's admission, and a lengthy telephone call with the Social Services Director after admission. Resident #1's daughter stated she did not speak to anyone else during her mother's three-day stay in the facility, until a nurse called her on the night of [DATE] to inform her that her mother fell , hit her head, and would be transferred to the hospital. When asked if she spoke with nursing staff regarding her mother's baseline care plan, the daughter reiterated that she had not been contacted by anyone else from the facility. Resident #1's daughter explained her mother suffered a severe head injury that required emergency surgery, and she died the following day. The daughter said, Communication with the facility was an issue. I am disgusted and hurt. I feel like it could have been avoided. Review of the daughter's cell phone call log from [DATE] to [DATE] revealed a 28-minute incoming call from the facility on [DATE] at 1:03 PM, confirmed to be from the SSD. On [DATE] at 8:41 PM, the daughter's call log showed an incoming call from a personal cell phone. The call was confirmed to be from resident #1's assigned nurse, RN B, regarding notification of the fall. The call log did not include any incoming calls from the facility or any unknown numbers. Review of resident #1's medical record revealed the Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE], which showed her primary diagnosis was confusion. The document indicated she was alert and disoriented but could follow simple instructions and was at risk for falls. Resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. The Admission / Readmission Data Collection packet dated [DATE] at 6:00 PM, revealed the resident's admission diagnoses included confusion. The document indicated resident #1 required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The sections of the admission packet related to fall risk evaluation, pain evaluation, mood and behavior, and review of medications were either blank, incomplete, and/or inaccurate. On [DATE] at 12:53 PM, Registered Nurse (RN) A stated he received resident #1 when she arrived at the facility on [DATE] and started the admission paperwork. RN A confirmed he did not initiate a baseline care plan on admission to address the issues he identified during his assessment of the resident. Resident #1's Physical Therapy evaluation dated [DATE] revealed she required moderate assistance to change positions. The document read, Patient presents with strength impairments, balance deficits, and decreased safety awareness. The Occupational Therapy evaluation dated [DATE] indicated resident #1 required maximum assistance for toileting tasks including transfers and hygiene. The document indicated she had impaired strength in both arms, could not stand for ten seconds without upper extremity support. On [DATE] at 2:20 PM, Physical Therapist I stated he evaluated resident #1 on [DATE] and determined she was at high risk for falls. He explained the resident would need a wheelchair to get to the bathroom safely, and then should use grab bars while a CNA held a gait belt to assist and support her as she transferred to the toilet. Review of the facility's policy and procedure Plans of Care revised [DATE] revealed the interdisciplinary team would develop a person-centered care plan in conjunction with the resident and/or the representative. The procedure directed staff to develop and implement an individualized Person-Centered baseline care plan within 48 hours of admission that includes. areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Review of the resident's medical record revealed a Baseline Care Plan and Summary dated [DATE], signed by the North Wing Unit Manager (UM). The designated signature lines for resident #1 and/or her representative were blank. The form showed the resident was admitted on [DATE] at 6:00 PM, therefore the baseline care plan should have been created and reviewed with the resident's daughter by [DATE] at 6:00 PM. The baseline care plan did not reflect information noted on the hospital transfer form and the admission assessment. The UM noted resident #1 would be discharged to the community rather than remain in the facility. The baseline care plan for falls and safety had a goal that resident #1 would remain free from injury. However, the interventions did not appropriately address the resident's high risk for falls and significant confusion. The UM noted resident #1 had self-care deficits and required the assistance of only one person for all activities of daily living (ADLs). The document did not include use of a wheelchair, walker, or gait belt, and any other recommendations for transfers based on Physical and Occupational therapy evaluations. On [DATE] at 10:43 AM, the North Wing UM acknowledged RN A was responsible for initiating resident #1's baseline care plan and confirmed the results of therapy evaluations should have been utilized to revise the document. The UM verified the resident's baseline care plan was completed on Monday [DATE], based on review of the medical record including the incomplete and inaccurate admission assessment. He acknowledged the importance of the baseline care plan as a communication tool to facilitate good care. The UM confirmed safety issues such as confusion and fall risk required immediate interventions which should be documented in the chart. On [DATE] at 7:50 PM, the Director of Nursing (DON) stated the facility's process for care of a newly admitted resident involved a chart audit in the daily clinical meeting. She explained that for residents admitted on the weekend, the audit was done on Monday morning. The DON stated the clinical management team would ensure all assessments and documents were completed properly, including the baseline care plan. She did not recall discussions regarding resident #1's incomplete admission assessment or lack of a baseline care plan. On [DATE] at 3:57 PM, the DON stated the admission nurse was expected to document assessments, resident/ family education, and basic safety and comfort interventions. She explained the facility could not schedule or assign a specific nurse to complete admission documentation including baseline care plans as the exact time of arrival was never known. She added the Weekend Nursing Supervisor should have reviewed resident #1's chart on Saturday, [DATE], to verify all documentation was complete for the newly admitted resident. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #1 was discharged from the facility to the hospital. *On [DATE], the DON or other nursing management team members initiated education with all licensed nurses including agency nurses regarding provision of supervision of residents to reduce risk of falls. The education included notification of the DON or designee when residents are exhibiting increased behaviors that may lead to falls, initiation or provision of increased supervision if needed, and notification of the DON of all unwitnessed falls once physician and/or emergency services have been notified. Education was accompanied by post-testing. The facility educated 10 of 22 licensed nursing staff. Those nurses who did not receive education will receive education prior to their next scheduled shift. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at high risk. *As of [DATE], nursing leadership will develop and implement plans to stagger hours to provide support and assistance for afterhours admissions to the facility. *On [DATE], the interdisciplinary team to include the Administrator, DON, ADON, UM, Social Services Director, and Minimum Data Set Coordinator will review newly admitted residents during morning clinical meeting to identify fall risk and review baseline care plans to ensure appropriate interventions are in place, to include appropriate amount of supervision based on resident assessment and behaviors. *As of [DATE], nurse leadership will implement baseline care plan binders to be placed at each nursing station. Baseline care plans will be reviewed by the Weekend Nursing Supervisor for new admissions and residents with recent falls. Nurse leadership will bring binders to morning clinical meetings for review. *As of [DATE], the DON or designee will review clinical records of all residents who fell on a weekly basis to validate documentation is in place to include appropriate resident-centered fall prevention interventions, appropriate supervision, and that baseline and/or comprehensive care plans were updated. The Divisional Nurse Consultant will be provided a copy of the weekly audit to provide additional oversight. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, the DON , and the Medical Director. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Preventing Abuse/Neglect/Exploitation/Misappropriation, Falls / Change in Condition / Baseline CP / Neuro checks, Fall Management/Incident Management, Complete Medical Record, Effective Investigation of Falls, Education/Communication Between Therapy and Nursing Regarding Assistive Devices, and Code of Conduct. On [DATE], interviews were conducted with three RNs, one LPN, six CNAs, one Activity staff, one Maintenance staff, and one Dietary staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for falls. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #7, and #8 related to baseline care plans, to include fall prevention and behavioral interventions.

Based on interview and record review, the facility failed to provide adequate supervision and monitoring for a vulnerable, physically and cognitively impaired resident to prevent falls for 1 of 6 residents reviewed for falls, of a total sample of 8 residents, (#1). This failure contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had a swelling to the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM, and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department (ED) staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to identify and provide the appropriate level of supervision and frequency of monitoring for a resident with a known high risk for falls contributed to resident #1's fall(s) with head injury and placed all residents who were at risk for falls at likelihood for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F655, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was confusion, and she had impaired sight and hearing. The document indicated she was alert and disoriented but could follow simple instructions. She had a risk alert for falls and was incontinent of bowel and bladder. The form showed resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. Resident #1 was to be evaluated and treated by Physical, Occupational and Speech Therapists as indicated, but her rehabilitation potential was deemed to be poor. Resident #1's Admission / Readmission Data Collection form dated [DATE] at 6:00 PM, was completed by Registered Nurse (RN) A. The document revealed the resident's admission diagnoses included confusion. RN A noted resident #1 was alert and oriented to person and place, had long term memory problems, and modified independence in cognitive skills for decision-making. RN A noted resident #1 required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The admission assessment described the resident as independent with ambulation but requiring wheelchair only. The document included a Fall Risk Evaluation with scored responses to determine if the resident was at risk for falls. RN A noted resident #1's mental status was alert and oriented instead of intermittent confusion to reflect her primary diagnosis of confusion. The resident's ambulation and continence status was noted as chairbound although RN A had assessed her as ambulatory and incontinent. The document revealed the resident's vision was adequate rather than impaired, and the section related to gait and balance noted only that resident #1 required an assistive device but failed to include the resident's gait and balance problems. RN A did not select any responses regarding medications and predisposing diseases that contributed to the resident's risk for falls. The fall risk evaluation form was incomplete, inaccurate, and did not provide a total score for determination of the resident's level of risk for falls. Review of resident #1's medical record revealed an additional fall risk evaluation tool, the Morse Fall Scale. The responses were inaccurate and/or incomplete regarding resident #1's secondary diagnoses, ambulatory aids, and gait. The evaluation tool was not scored to designate resident #1 as low, medium, or high risk for falls. Resident #1's Medication Administration Record revealed she received medication that could increase her risk for falls. She had physician orders for Amlodipine 5 milligrams (mg) once daily for hypertension, Mirtazapine 7.5 mg at bedtime for depression, Spironolactone 50 mg once daily for fluid retention, and Lactulose 15 milliliters three times daily for liver cirrhosis. Spironolactone is a diuretic or water pill that prevents the body from absorbing too much salt by increasing urine output. Lactulose is a medication used to decrease blood ammonia levels that cause confusion in patients with liver cirrhosis. This medication pulls water into the colon and causes excretion of ammonia in soft or liquid stools (retrieved on [DATE] from www.drugs.com). On [DATE] at 12:53 PM, RN A stated he received resident #1 when she arrived at the facility on [DATE] and started the admission paperwork. He recalled the resident was very confused. RN A said, I evaluated her for ambulation. She was very combative, and I had to sit and talk to her to get her to cooperate. She had weakness in her legs. I held her hands and she could only make one step before she had to sit down. RN A stated resident #1 was not admitted with a wheelchair, but she needed one. He explained he thought the therapy department would provide a wheelchair. RN A reviewed the fall risk evaluation form, acknowledged it was incomplete, and stated he did not initiate baseline care plans to address the issues he identified. He verified if residents were at high risk for falls or exhibited behavioral symptoms, nurses should implement increased supervision. On [DATE] at 12:27 PM, in a telephone interview with resident #1's family, the daughter explained her mother was previously a resident of an Assisted Living Facility, but due to her diagnosis of cirrhosis of the liver and associated medical issues such as increased ammonia levels and altered mental status, she required a skilled nursing facility for a higher level of clinical monitoring and closer supervision as her disease worsened. The daughter recalled she and her husband told several facility staff including admissions staff, the Social Services Director, and nurses about her mother's confusion and risk for falls. Resident #1's son-in-law stated he visited the facility at lunch time on Saturday [DATE], the day after admission, and found his mother-in-law seated on the edge of her bed and he was concerned she was left in the room unsupervised. The son-in-law stated he approached the assigned male nurse and requested that someone assist his mother-in-law to a supervised group activity. The son-in-law said, I explained to [the male nurse] she was a fall risk. He stated there was no wheelchair at her bedside at the time of his visit. Resident #1's daughter described her mother as quite confused and stated she often overestimated her abilities. She recalled on the evening of [DATE], a nurse notified her that her mother had fallen. The daughter said, She minimized her condition and made it sound like it was precautionary to send her to the hospital. However, by the time the family got to the hospital, they were told her mother was unresponsive and needed surgery. The daughter stated her mother died soon after surgery and the family was told her death was due to brain injury from the fall. She said, I am disgusted and hurt. I feel like it could have been avoided. On [DATE] at 6:36 PM, the facility's Admission Department Care Liaison confirmed she spoke with resident #1's daughter prior to admission to obtain as much information as possible. The Care Liaison confirmed her pre-admission notes read, fall precautions and indicated the resident could be stubborn and was confused at times, more so at night. On [DATE] at 4:40 PM, the Director of Rehab provided resident #1's therapy evaluations and explained the documents showed she required staff to support her by holding a gait belt around her waist, with additional support of a walker if she walked. He stated without these interventions, resident #1 would lose her balance and fall. The Director of Rehab stated based on the Occupational and Physical Therapy evaluations, resident #1 would need to be transferred from her bed or a regular chair to a wheelchair in order to go to the bathroom or anywhere else as she would not be able to walk safely. He said, Especially during the early stages of therapy, I would not recommend walking to the bathroom until she had more gait training. The Director of Rehab stated he would expect therapists to communicate necessary interventions to the nursing supervisor, especially if there was a safety issue. He confirmed the therapists' documentation did not show notifications were made to the nursing staff regarding the resident's fall risk or their recommendations for assistance with mobility and toileting. When asked why therapists did not provide resident #1 with a wheelchair, the Director of Rehab stated therapy staff did not provide wheelchairs. On [DATE] at 2:20 PM, Physical Therapist I recalled resident #1 was seated in a chair beside her bed when he arrived to evaluate her on the morning of [DATE]. He described the resident as confused, but lucid at some points. Physical Therapist I explained he brought a walker and gait belt to conduct the evaluation and confirmed the resident did not have a wheelchair. He stated the common practice in the facility was that every resident should be given a wheelchair on admission. He explained nursing staff had access to wheelchairs as they were kept in Central Supply, not in the Therapy Department. He stated his fall risk assessment resulted in a score of greater than 78% which indicated a high risk for falls. He recalled resident #1 could not initiate and complete the motion to stand from the chair without assistance and was only able to ambulate about five feet with a walker and his support. Physical Therapist I stated the resident would have needed a wheelchair to get to the bathroom safely, and she would need to use grab bars while a CNA held a gait belt to assist and support her as she transferred to the toilet. Physical Therapist I stated the assigned nurse was busy with medication administration that morning and he did not recall whether he gave a verbal report with recommendations to nursing staff. Resident #1's Physical Therapy evaluation dated [DATE] revealed she required moderate assistance to change positions from lying to sitting and sitting to standing. She also needed moderate assistance to ambulate five feet with a two-wheeled walker. The document read, Patient presents with strength impairments, balance deficits, and decreased safety awareness. and required skilled Physical Therapy service to minimize falls and decrease dependence on staff. The document indicated the resident did not use a wheelchair and was unable to complete a 30-second chair rise without physical assistance. The Occupational Therapy evaluation dated [DATE] indicated resident #1 required maximum assistance for toileting tasks including transfers and hygiene. The document indicated she had impaired strength in both arms, could not stand for ten seconds without upper extremity support, and had impaired safety awareness. Review of resident #1's electronic and paper charts revealed therapy notes with evaluation findings and fall prevention recommendations were not included in her medical record. The resident's charts showed no nursing care plans were initiated on admission to ensure appropriate fall prevention and behavioral management approaches were in place to ensure her safety. Review of Interdisciplinary Progress Notes revealed on [DATE] during the 7:00 AM to 7:00 PM shift, resident #1 was seated in a chair at bedside and was seen by rehab staff. The note indicated she was confused, required redirection and was .closely supervised for safety. The progress note confirmed the resident's family visited but did not address the son-in-law's concerns regarding her being left unsupervised in the room. The nursing note did not reflect any discussion with the Physical Therapist regarding the resident's fall risk, required mobility device, and the level of assistance necessary for transfers and ambulation. A note dated [DATE] at 12:00 AM, written by Licensed Practical Nurse (LPN) J, read, Resident reminded not to use bedside table to ambulate in room. Alert [with] confusion. The note did not indicate approaches were initiated to ensure the resident's safety or that a supervisor was notified. A progress note dated [DATE] at 2:00 PM, revealed resident #1 remained a fall risk and staff continued to check on her. The note did not describe the level of supervision or frequency of monitoring required. Later that afternoon at 4:00 PM, the nurse wrote, New orders for psych consult due to confusion & increased agitation per Administrator. Left voicemail for [name of practitioner]. Awaiting call back. The progress note did not show the attending physician and the resident's emergency contact were notified of concerns related to resident #1's behavior and safety. The nursing note did not include any fall prevention interventions initiated despite documentation of the resident's confusion, behavioral symptoms, and attempts to ambulate without assistance. The Hospital Transfer Form dated [DATE] revealed resident #1 was transferred to the hospital after a fall. Review of resident #1's hospital record revealed a Hospitalist Discharge Summary dated [DATE] at 11:51 AM. The note indicated resident #1 was brought to the ED due to altered mental status after being found on the bathroom floor of a nursing home. A computerized tomography or CT scan of her brain showed an acute subdural hematoma (SDH) with midline shift. Resident #1 was intubated, placed on mechanical ventilation, and had an emergency craniotomy with evacuation of the bleed. The note read, Patient clinically deteriorated, no brain stem reflexes. Repeat CT showed a large right SDH with worsening midline shift and transtentorial herniation. The resident was discharged to hospice services with a diagnosis of subdural hematoma. A subdural hematoma is a collection of blood between the covering of the brain and the surface of the brain. It is often caused by a severe head injury which results in bleeding that fills the brain area and compresses brain tissue (retrieved on [DATE] from www.medlineplus.gov). Midline shift refers to a displacement of brain tissue across the center line of the brain. It may occur after a traumatic brain injury which pushes the brain towards one side. Herniation occurs when parts of the brain are squeezed through structures within the cranium. Midline shift and herniation are a medical emergency and can be fatal (retrieved on [DATE] from www.acquiredbraininjury-education.[NAME].nhs.uk). Review of a Certification Of Death form revealed resident #1's date of death was [DATE] at 2:23 PM and her manner of death was an accident. The document indicated her cause of death was a subdural hematoma due to blunt head trauma on [DATE] in an unwitnessed fall in nursing home. On [DATE] at 7:55 PM, in a telephone interview, Certified Nursing Assistant (CNA) E stated she was assigned to resident #1 on Friday, [DATE], the evening she was admitted to the facility. CNA E recalled the resident wore a bracelet that indicated she was a fall risk. She described the resident as alert, but very confused. CNA E stated she was again assigned to care for resident #1 on Monday, [DATE], from 3:00 PM to 4:00 PM. She explained resident #1 had diarrhea and soiled her brief. CNA E said, I think the nurse walked her to the bathroom and I came in and took over. She explained after she provided the resident with incontinence care in the bathroom, she walked her back to a chair. She said, I wouldn't trust her walking by herself. CNA E stated resident #1 would not use the call light and she once even caught her walking around the room pushing the over bed table. She confirmed the resident did not have a wheelchair. CNA E stated she did not inform the nurse about the resident walking with the table, and she was never told by the nurse to remain in the room with the resident or bring her out to the common area. CNA E explained there were other residents on the unit who were at risk for falls and she did not think the facility had enough staff to provide them with one-to-one supervision. On [DATE] at 7:22 PM, in a telephone interview, CNA D, stated she assumed care of resident #1 from CNA E on [DATE] at 4:00 PM when the North Wing staffing assignments were adjusted. CNA D stated she had never cared for the resident before, and CNA E told her resident #1 did not have a wheelchair and tried to walk around by grabbing walls and using the rolling overbed table. CNA D recalled resident #1 asked to be taken outside. She said, I told her since she could not walk and did not have a wheelchair I could not take her out. She tried to get me to take the other resident's wheelchair. CNA D stated CNA E also informed her that resident #1 was able to walk to the bathroom with help but should be encouraged to use her brief instead. CNA D stated she tried to check on the resident every 30 to 60 minutes between caring for her assignment of ten to twelve other residents. She stated at one point she discovered resident #1 walking as she pushed the rolling table towards the door. CNA D stated she asked CNA E to assist her as it was difficult to redirect the resident. She said, We did not tell the nurse. I try to handle that, not report to the nurse. I tried to distract her and change the subject. I was afraid she would fall. CNA D acknowledged resident #1 was at high risk for falls. She explained she got verbal report on how to care for resident #1, but there was no CNA care plan or other written instructions. CNA D stated she last saw resident #1 at about 7:40 PM as she passed by her room on the way to take care of another resident. She recalled she was in the hallway at approximately 8:00 PM when another resident alerted staff that resident #1 was on the floor. CNA D stated she rushed to the room and found the resident on the floor, partially in the bathroom, with a large swelling on the side of her forehead. She stated there was feces in a chair, and feces and urine on the floor. CNA D explained she tapped the resident's shoulder and called her name, but the resident was non-verbal and only moaned softly. On [DATE] at 6:55 PM, in a telephone interview with RN B, she confirmed she was assigned to resident #1 for the 7:00 PM to 7:00 AM shift on [DATE]. RN B recalled the off going nurse informed her the resident was admitted two days prior and was a fall risk. RN B said, She told me she had to remind the patient constantly to sit down because she was confused and trying to walk on her own. RN B stated she was told resident #1 displayed that behavior throughout the day shift and the day nurse and the CNA had to redirect the resident frequently while they cared for other residents. RN B was asked if either she or the off going nurse implemented any fall prevention interventions to address the safety issue. She said, I am not their employee, so I do not know what their protocol is for fall risks. RN B stated she did not know if she could have initiated one-to-one supervision, scheduled monitoring with increased frequency, or any other intervention, and she was unsure of the facility's process for updating care plans. When asked about possible interventions to prevent falls, she said, If I were concerned about fall risk, I would make sure she had correct footwear and put her at the nurses' station for increased monitoring. She stated at approximately 8:00 PM, a CNA informed her a resident was on the floor. RN B confirmed she responded and found resident #1 lying in a mixture of urine and feces and there was no wheelchair in the room, neither by her bed nor in the bathroom. RN B explained she did not receive any information on the resident's mobility status or activities of daily living (ADL) needs in report, and there were no Physical Therapy notes in the chart. On [DATE] at 2:53 PM, resident #8 recalled her roommate, resident #1, was admitted on a Friday night and said, It was quite a weekend! Resident #8 stated during the few days they shared a room, resident #1 argued, yelled, screamed, and fell at least four times. Resident #8 said, She was very, I mean extremely, confused . She kept coming over to my side of the room to ask for and search through my things. She was using her rolling table to walk around the room, and she also wanted to use my wheelchair. Resident #8 stated over the weekend, resident #1 walked across to her side of the room and fell at the foot of her bed. She said, It had to have been between 10:00 PM and midnight. I'm not sure if she hit her head. She was on the floor, and she couldn't get up by herself. I used my call light to call someone, but at the same time I yelled for help for her. Two staffers, a CNA and a med nurse, came in and they helped her up. Resident #8 stated on another occasion that weekend her roommate also fell near the bathroom as she walked while pushing the over bed table. Resident #8 recalled her roommate fell twice on her last day in the facility, Monday [DATE]. She stated the first time was after dinner. It was not the big fall. They, some staff, got her up and put her back in the chair. Resident #8 stated later that evening she heard resident #7 yell, Patient down! She explained, If it wasn't for [name of resident #7], I don't think anyone would have known for a while because I didn't see that one. On [DATE] at 3:00 PM, in a telephone interview, LPN J confirmed she was assigned to resident #1 for the night shifts on Saturday [DATE] and Sunday [DATE]. She recalled during shift change report she was told to keep an eye out for her. LPN J said, I wound up going into the room with her several times that shift, and she kept trying to get up and walk. I would keep going back and she was trying to walk, and her legs were swollen. I told the CNA to keep an eye on her. I did not stay with her as I had a lot of residents. At one point, she was pushing her overbed table down the hallway. I yelled to the CNA, and we ran down the hallway to get her. She must have gotten halfway down the hallway, between her room and the nurses' station. LPN J explained she asked the CNA to monitor the resident, but never specified a frequency or tried to arrange one-to-one supervision. She stated it was not possible to offer closer monitoring as the CNA had other residents who were at risk for falls who also had to be watched. LPN J denied any knowledge of resident #1 falling during the night shift as reported by the resident's roommate. She acknowledged she did not report the safety concerns to the physician or a supervisor. On [DATE] at 3:12 PM, in a telephone interview, CNA K stated she was assigned to care for resident #1 on one night shift, but she could not recall the date. CNA K stated she was not sure of the time, but she remembered the call light sounded and resident #8 shouted for help. CNA K stated when she arrived in the room she saw resident #1 seated on the floor by her roommate's bed. She explained she ran to notify LPN J who was the assigned nurse and they both returned to the room. CNA K stated resident #1 denied hitting her head when questioned by LPN J, and they both lifted her to a standing position and carried her back to bed. The CNA explained resident #1 was not able to stand on her own and could not really walk because her legs were so swollen. She stated she assumed the nurse would complete the necessary paperwork, so she did not report the fall to anyone else. CNA K stated resident #1 was not placed on frequent or continuous monitoring after the fall. On [DATE] at 3:33 PM, in a telephone interview, the Weekend Nursing Supervisor stated she was informed resident #1 was confused. She said, If a resident is confused or if there is a safety issue, nurses could ask if they felt they needed more staff. She explained the admission nurse was responsible for creating a baseline care plan to inform nursing staff of care needs. She said, Normally they would not be allowed to ambulate without assistance until assessed by physical therapy. The Weekend Nursing Supervisor stated no staff told her resident #1 fell on the weekend. On [DATE] at 10:43 AM, the North Wing Unit Manager (UM) reviewed resident #1's medical record and acknowledged the fall risk evaluation was inaccurate, incomplete, and did not clearly deem her at risk for falls. The UM explained the admission nurse did not initiate a required continence tracking form for evaluation of resident #1's elimination patterns to determine an appropriate toileting schedule. The UM denied receiving any reports from nursing staff regarding the resident's constant attempts to ambulate without assistance or absence of a wheelchair. He confirmed any safety issue such as escalating confusion and high fall risk needed immediate interventions which should be noted in the chart. The UM verified nursing staff did not appropriately determine resident #1's risk for falls, implement fall prevention approaches or notify the physician as her likelihood for falls increased over the weekend. On [DATE] at 7:50 PM, the Director of Nursing (DON) recalled on [DATE] at approximately 1:00 PM, as she rounded on the North Wing, resident #1's assigned nurse asked her if the resident always stood up and asked to leave the building. The DON stated she told the nurse resident #1 was newly admitted and staff had to continue evaluating her. The DON stated during her final rounds at approximately 4:00 PM, she was informed the assigned nurse had initiated a psychiatric consult and CNAs were checking on resident #1 every 20 to 30 minutes. On [DATE] at 3:23 PM, in a telephone interview, the facility's Medical Director confirmed resident #1's falls should have been reported according to protocol. She explained her expectation was nurses would notify the physician first as medical providers should be the ones to determine necessary interventions to diagnose or treat a resident after a fall. When informed resident #1 possibly had multiple unwitnessed falls over the weekend, the Medical Director stated the standard of practice was to send residents out to the hospital after unwitnessed falls due to the possibility of head injuries. On [DATE] at 3:57 PM, the DON confirmed every fall should have been reported. She said, In this situation, if the interdisciplinary team had been aware the resident fell on ce or more on the weekend, other interventions would have been put in place. Review of the facility's policy and procedure Fall Management revised on [DATE], revealed residents would be evaluated for fall risk, and patient-centered interventions would be initiated as indicated. The purpose was . to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. The document indicated a resident's fall risk was based on results of the Fall Risk Evaluation and contributing factors including medications, diagnoses, and the environment. The process involved development of interventions based on risk factors and updating nurse and CNA care plans. The policy directed staff to notify the physician and family after a fall and re-evaluate the resident utilizing a Post Fall Evaluation tool. The interdisciplinary team was expected to review fall documentation, complete a root cause analysis, and develop new care plan interventions to prevent additional falls. Review of the Facility Assessment Tool dated [DATE] revealed the facility could meet the needs of residents with impaired cognition, behavior that needed interventions, and cirrhosis. The document indicated the facility offered services including assistance with activities of daily living, mobility, prevention of falls and falls with injury, mental health and behaviors, and therapy. The assessment showed the facility would provide person-centered care, ensure direct-care staff had relevant information to provide that care, and identify hazards and risks for residents. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #1 was discharged from the facility to the hospital. *On [DATE], the facility initiated education of all licensed nursing staff including agency nurses. The DON or other nurse management team members provided education on provision of supervision of residents to reduce risk of falls. Topics included notification of the DON or designee when residents exhibited increased behaviors that may lead to falls, provision or initiation of increased supervision if needed, notification of DON of all unwitnessed falls once the physician and/or EMS was notified. Education was accompanied by post testing. The facility educated 10 of 22 licensed nursing staff as of [DATE]. Those nurses not educated will receive education prior to the next scheduled shift. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at risk. *As of [DATE], Code of Ethics training was completed by the Administrator and department heads to include the responsibility to report all resident falls to ensure fall prevention measures are implemented for resident safety. Training included a No Retaliation rule for staff and/or residents who make such reports. The Administrator will add Code of Ethics training to monthly [NAME] Hall Agenda for all facility staff. The facility educated 52 of 135 staff on Code of Ethics. *On [DATE], the facility sent certified letters to those staff members who were unable to attend education. Any facility or contracted staff who did not receive education will not be permitted to work until education is completed and validated by the DON or designee. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, the DON , and the Medical Director. *As of [DATE], the Interdisciplinary Team to include the Administrator, DON, Assistant [TRUNCATED]

Based on interview and record review, the facility failed to honor advance directives for a Do Not Resuscitate Order (DNRO) for 1 of 8 residents with DNROs, of a total sample of 15 residents reviewed for advanced directives, (#1). This failure resulted in resident #1 enduring chest compressions, intubation, defibrillation, and mechanical life support despite her wishes for a natural, dignified death. These actions placed her at risk for severe pain, organ damage and resulted in a prolonged dying process. As resident #1 could not express her reaction to this event, applying the reasonable person concept, she would likely have experienced serious psychosocial harm by being resuscitated against her wishes and put on life support. On [DATE] at approximately 5:30 PM, resident #1 became unresponsive in her room while her assigned nurse, Registered Nurse (RN) A was at her bedside. The nurse Unit Manager (UM), the resident's assigned nurse and two other nurses performed cardiopulmonary resuscitation (CPR) without verifying resident #1's code status. The nurses did not follow the facility's policy and procedure which directed two licensed nurses to confirm the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services (EMS) personnel were notified and resident #1 was transported to the hospital where she was placed on life support. Soon after the resident #1 was taken to the hospital, RN A reviewed her medical record and discovered the resident had a an active DNRO and should not have received any resuscitative measures. The facility's failure to honor advance directives put all residents with a DNRO at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy after verification of the facility's immediate actions. Findings: Resident #1, a [AGE] year-old female, was originally admitted to the facility from the hospital on [DATE], and recently readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 15, which indicated she was cognitively intact. The assessment revealed resident #1 required extensive assistance for bed mobility and transfers, had shortness of breath with exertion and received [CONDITION(S)]. She did not have a prognosis of life expectancy of less than 6 months, and she was able to provide data for the assessment. Review of resident #1's electronic medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read, Do not resuscitate current and verified, and prescriber written. Resident #1 had a care plan initiated on [DATE] for advance directives related to a discussion with the resident and evidenced by a dated DNRO. The goal was for her advance directives to be followed. Care plan interventions directed staff to discuss advance directives with resident #1 and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident #1's paper chart revealed a State of Florida DO NOT RESUSCITATE ORDER signed by resident #1 on [DATE]. The patient's statement read, Based upon informed consent, I the undersigned, hereby direct that CPR be withheld or withdrawn. The physician's statement directed the withholding of CPR including artificial ventilation, cardiac compressions, and defibrillation in the event of resident #1's cardiac or respiratory arrest. Resident #1's physician co-signed the form on the same date, printed her name, and included her medical license number in the designated section in the center of the form. A Change in Condition (SBAR) form dated [DATE] read, Patient was smoking outside, she started vomiting, patient taken to her room and placed in bed. She started vomiting again and not responding. CPR started, ambulance was called in and patient taken to (name of) Hospital. The advance care planning section of the form with options for Full Code or DNRO was left blank. The form was completed by RN A who documented 911 was called and she notified the attending physician and family. In telephone interviews on [DATE] at 9:53 AM and at 5:19 PM, RN A recalled on Thursday [DATE] at approximately 5:15 PM, she was notified by resident #1's assigned Certified Nursing Assistant (CNA) G that the resident was outside smoking and had vomited. RN A stated she went outside to check on resident #1, who was alert and oriented. RN A directed CNA G to bring resident #1 back to her room so she could assess her more thoroughly. RN A recalled when she arrived in the resident's room a few minutes later, she was seated on the side of her bed, and she assisted CNA G to place resident #1 in a lying position. RN A stated resident #1 suddenly vomited again and started to lose consciousness. RN A recalled she told CNA G to get help, but CNA G stood there in shock and did not move. RN A stated she ran into the hall and yelled, I need help. We have a code here. RN A stated she then went to the computer to check if resident #1 had Full Code or DNRO. She stated the computer home page showed resident #1's photograph with the letters DNR near it. RN A recalled when she returned to the resident's bedside, other nurses, including the UM and a few CNAs arrived with the code cart which contained resuscitation equipment. RN A stated she told the staff who were present that resident #1 had a DNRO, and said, We can't perform CPR. RN A stated she applied oxygen and attempted to obtain resident #1's vital signs while another nurse suctioned the food she had vomited from her mouth. RN A recounted a few minutes later, a CNA entered the room with resident #1's chart and stated there was a DNRO that was not signed by the physician. RN A explained the South Wing UM glanced at the chart from across the room and said, Oh, the DNR is not signed, we have to perform CPR. RN A stated the UM started chest compressions. On [DATE] at 3:57 PM, in a telephone interview, Licensed Practical Nurse (LPN) D stated she was working on the nursing unit when she heard RN A yell out for help with a code and asked for someone to call 911. LPN D stated she went to get the code cart, when she noted CNAs E and F at the nurses' station unsuccessfully attempting to use the overhead intercom to page the code. LPN D stated she stopped to make the overhead page and directed the CNAs to take the code cart to resident #1's room and then she called 911. LPN D recalled she overheard someone say they were going to start CPR, so she pulled resident #1's chart off the rack to look for the gold colored DNRO form [the State of Florida requires the DNRO DH Form be printed on some shade of yellow-colored paper for EMS, https://www.floridahealth.gov/about/patient-rights-and-safety/do-not-resuscitate/faq-page.html#white%20paper]. She stated she found the form in front of the chart and directed CNA F to take the chart to resident #1's room so the nurses could see it. LPN D stated it was only a few minutes later that EMS personnel arrived. On [DATE] at 1:03 PM and on [DATE] at 4:38 PM, in telephone interviews, the UM stated she responded to an overhead page for a Code Blue on the afternoon of [DATE]. She stated when she arrived at resident #1's room, she observed RN A and several CNAs in the room. The UM stated she was the only nurse manager on duty at that time and she quickly took responsibility of the situation. She stated she asked if anyone knew resident #1's code status, and RN A replied she thought resident #1 had a DNR but she was not sure. She recalled CNA E offered to get resident #1's chart, and when she returned with it, she told them that resident #1 had a DNRO but it was not signed by the physician. The UM stated she was leaning over resident #1 at that moment, ready to initiate CPR, when she glanced at the chart. She recalled CNA E stood near the doorway and held the chart towards her. She stated she quickly looked at the form, decided it was not signed by the physician and started chest compressions. She acknowledged resident #1's chart with the DNRO form never arrived near resident #1's bed where the nurses stood ready to start resuscitation attempts. The UM confirmed RN A did not look at the chart as she was occupied using the bag-valve mask to push oxygen into resident #1's lungs. She stated two other nurses entered the room to assist with the resuscitation efforts and none of them looked at the gold colored DNRO in the resident's chart. The UM stated she did a few rounds of chest compressions and became winded with her efforts and asked for relief from another nurse. She explained three different nurses performed several rounds of chest compressions before EMS personnel arrived and took over. She validated that none of the nurses examined resident #1's DNRO form to verify the required signatures were in place before they resuscitated her. The UM recalled EMS quickly took over chest compressions, put a tube into resident #1's airway, and shocked her heart before they transported her to the hospital. On [DATE] at approximately 10:00 AM in a telephone interview, RN A recalled she was seated at the nurses' station to review the chart shortly after resident #1 was transported to the hospital. She stated she noted the gold colored DNRO form in the front of resident #1's chart and realized the physician's signature was present in the middle of the form. RN A stated she immediately showed the signed DNRO form to the UM who exclaimed, Oh my God! We coded a patient with a DNR! RN A explained the error occurred because nurses, including herself did not double check the chart to confirm the DNRO before commencing CPR. RN A stated nurses at resident #1's bedside chose to follow the UM's directions instead, since she was the nurse manager on duty. Review of the hospital's Emergency Provider Report dated [DATE], revealed EMS personnel performed one electrical shock to resident #1's heart, intubated her for mechanical ventilation and inserted a large needle into the bone of her leg to administer medications before she arrived at the hospital. The emergency room physician noted resident #1 responded to pain but otherwise had no response. Review of the hospital's Critical Care Progress Note dated [DATE] revealed resident #1 had medical interventions performed on her in the hospital including a tube placed to drain her urinary bladder, a catheter inserted into her neck for medication administration and she was placed on a machine that breathed for her. The critical care physician noted resident #1 was critically ill with imminent or threatening deterioration in the patient's condition. The physician also noted in her plan, Daughter requests DNR as patient never wanted to be intubated. Review of the facility's investigative findings revealed resident #1's family decided to remove her from life support, and the resident died at the hospital on [DATE], two days after she was resuscitated. In a telephone interview on [DATE] at approximately 1:10 PM, the UM stated nurses were instructed to check the code status of unresponsive residents before attempting resuscitation. She explained the gold colored DNRO forms were kept in the front of residents' charts and nurses were expected to validate this form in the chart to verify code status before performing CPR. She confirmed she did not verify the physician's and resident's signature on resident #1's DNRO form with another nurse per policy and procedure. She recalled that none of the four nurses who helped to resuscitate resident #1 verified the signatures on resident #1's DNRO form beforehand. On [DATE] at 1:47 PM, the Director of Nursing (DON) stated a CNA notified her by phone that resident #1 was unresponsive and staff were attempting to resuscitate her. The DON recalled she was returning to the facility when the UM called and informed her staff performed CPR on resident #1 who they later discovered had a DNRO. The DON confirmed all nurses who participated in resident #1's resuscitation failed to follow policies and procedures to verify her code status before performing CPR. She stated every nurse involved in that situation should have looked at the DNRO form. She explained that although RN A noted the DNR status on the computer home page, all nurses who resuscitated resident #1 should have checked the signed gold DNRO form that was in the room. She acknowledged staff should not have simply followed directions from the UM regarding initiating CPR on resident #1. Review of the Orientation Checklist: Agency Staff and Full or Part Time Contractors revealed topics included review of resident rights policy, tour to include location of emergency carts, review of emergency codes, and policies on advance directives and CPR. On [DATE] at approximately 12:25 PM, the DON confirmed the facility was unable to provide signed documentation for completion of orientation material for agency nurses, LPNs A and B. On [DATE] at 11:05 AM, the Medical Director stated she was informed resident #1 received CPR against her wishes as she had a DNRO. She explained the cause was none of the nurses looked closely at the gold DNRO form. She stated nurses should be educated to look at the form to confirm its validity. The facility's policy and procedure, Florida Cardiopulmonary Resuscitation with revision date of [DATE] revealed CPR would be provided to all residents identified to be in [CONDITION(S)] unless the resident had a fully executed Florida DNRO. The document directed staff to call for assistance and required two licensed nurses to verify the resident's identification. The document indicated the fully executed Florida DNRO should be maintained in the medical record. Review of the facility's policy and procedure, Advanced Directives with revision date of [DATE] revealed the facility would honor all properly executed advance directives provided by the resident and/or resident representative. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] the DON provided individualized training for the four licensed nurses regarding determination of resident code status. *On [DATE] the Registered Nurses were suspended pending an investigation and were terminated on [DATE] and [DATE]. *On [DATE] an ADHOC Quality Improvement Performance (QAPI) Committee meeting reviewed the recommendations made from the root cause analysis (RCA). The RCA identified as failure to accurately verify DNR status. Participants included the Medical Director, Executive Director, Director of Clinical Services, MDS coordinator, Case Manager, Human Resource Coordinator, Business development Coordinator, Central Supply, Business Office Manager, Medical Records, Maintenance Director, Activities Director, Housekeeping Supervisor and Director of Rehab Services. *On [DATE], a Performance Improvement Plan was developed and initiated based on the RCA. The ADHOC QAPI Committee approved the recommendations. *Five code drills were completed to include all shifts from [DATE] to [DATE]. A total of 44 staff participated in the drills. *On [DATE], 22 of 24 licensed nurses and 11 agency nurses received education which included the topics: CPR policy and procedure, advance directives policy and procedure, Nurse Practice Act, Resident rights, Following Physician orders, and Abuse/Neglect/ Exploitation/Misappropriation. Education accompanied by post testing to validate understanding and competency. All nurses obtained a passing score. Certified letters were sent to the two additional licensed nurses who had not completed education regarding completing the education and post test prior to working the next shift. *Newly hired licensed nurses and any agency nurses will receive the above education upon hire and prior to starting work. Interviews were conducted from [DATE] to [DATE] with 15 staff members including 3 RNs, 7 LPNs, 4 CNAs and 1 Social worker. All staff were knowledgeable of CPR and advance directive policies and procedures. The sample was expanded to include 14 additional residents for review of advance directives. Residents #2, #3, #4, #5, #6, #7, and #8 were Full Code status. Residents #9, #10, #11, #12, #13, #14, and #15 had DNROs. Interviews and/or record reviews revealed no concerns regarding adherence to advance directives including DNROs.

Based on record review and interview, the facility failed to honor a resident's advance directives and did not follow physician's order to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 3 sampled residents, (#1) in a total sample of 8 residents reviewed for code status. Resident #1 had advance directives and physician's order that did not include withholding of cardiopulmonary resuscitation (CPR). On [DATE], at approximately 7:10 AM, resident #1 was found unresponsive in bed with absence of vital signs. Two facility nurses, Licensed Practical Nurse, (LPN) B & Registered Nurse (RN) A failed to verify the resident's code status which included Cardiopulmonary Resuscitation to be initiated. They did not initiate CPR as per the resident's wishes or call 911 per facility policy after finding the resident unresponsive. The resident died . The facility's failure to provide CPR per the resident's advance directives, and physician orders, resulted in Isolated Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was determined to be Past Noncompliance. The facility administrator was notified of the Immediate Jeopardy on [DATE] at 3:45 PM. The Immediate Jeopardy was removed on [DATE]. The facility's non-compliance was corrected on [DATE] when the facility had fully implemented corrective actions. Findings: Resident #1 was a long-term care resident and had been initially admitted to the facility on [DATE] for non-Alzheimer's dementia, [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. On [DATE], resident #1 was hospitalized and returned to the facility on [DATE]. His readmission [DIAGNOSES REDACTED]. On [DATE], he was again hospitalized and returned to the facility on [DATE]. The readmission [DIAGNOSES REDACTED]. The facility's policies and procedure for Cardiopulmonary Resuscitation, dated [DATE], included the following: Cardiopulmonary Resuscitation will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a fully executed Do Not Resuscitate order (DNRO) order. The procedure included, In the event of [MEDICAL CONDITION], immediately call for assistance . Two licensed nurses are to verify resident identification and fully executed Do Not Resuscitate order . Use the paging system and call Code Blue to Room Number or location of the event three times.In the absence of a fully executed Do Not Resuscitate order the facility will immediately begin CPR. Center staff 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 representative . Document in the medical record. Resident #1's physician orders revealed that he had been a full code status since his admission on [DATE]. The most recent full code status order was dated [DATE]. The full code status order was continued at that time. LPN B's progress note dated [DATE] at 12:43 PM read, Resident found in room absent of breath, pulse, Dr (Doctor) . and family notified . funeral home here at 11:05 AM to receive the body. There was no documented evidence that a Code Blue had been called when the resident was found unresponsive. There was no documented evidence that CPR had been initiated or that 911 had been called. On [DATE] at 1:12 PM, Certified Nursing Assistant (CNA) C said that she was resident #1's assigned CNA on the 7 AM-3 PM shift on the day he died , [DATE]. She stated that when she entered resident 1's room on [DATE] at approximately 7:10 AM, she noted that he did not look right. I looked at him . his eyes were wide open and his mouth was open. She said he did not respond to her verbal stimulus and when she touched him, he was still warm. CNA C said that she called out to CNA D, who was coming out from the room across the hallway, to come into the room and help her check the resident. CNA C said that she checked for a pulse on his wrist and CNA D checked for a pulse on his neck, but that neither could find one. She said they immediately went to the door and called out for help from Registered Nurse (RN) A in the hallway. RN A came into the room first and then resident #1's assigned nurse, LPN B, was seen coming down the hallway. RN A told LPN B to disconnect the feeding machine and the oxygen, and told her to go check the chart. CNA C said RN A then told the CNAs to clean up the resident. She said LPN B, who was new to the facility, had asked RN A for help in what to do. According to CNA C, RN A had responded by saying You've been a nurse long enough, you should know what to do. CNA C said that she was not aware at that time whether the resident was a full code or DNR. She said that she did not actually see if the nurses checked the resident's medical record. She said she noted there was no Code Blue paged on the overhead speaker and no CPR initiated for resident #1. A telephone interview was conducted on [DATE] at 5:22 PM with CNA D. She said that it was just shortly after 7 AM when CNA C called her into resident #1's room. She said the resident was unresponsive and they checked for pulses. She said that he was warm to touch, but had no vital signs. They called the nurses to come into the room. She said that no Code Blue was called and no CPR was given. She was asked by RN A and LPN B to help CNA C clean up the resident. CNA D said that she found out at the end of her shift on [DATE] about the resident's code status and that CPR should have been started. She could not explain why resident #1 did not receive CPR. She said, The CNAs were looking toward the nurse for direction and the nurses acted like he was a DNR. She said she thought the nurses had checked his code status, . and they did not instruct anyone to do CPR. She stated, They (the nurses) were superiors and we were looking to them for instruction. The facility's Advanced Directive policy and procedure, revised [DATE], included the following: The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative . Social Services and/or Business Development Coordinator/designee will assist the resident/resident representative to complete the Advance Directives Discussion Document. If an advance directive exists the Social Services . designee will obtain a copy and place it in the resident's medical record . Advanced Directives will be reviewed: Quarterly, Hospice Admission, and additional times as need or requested by the resident/resident representative On [DATE] at 12:04 PM, the Social Services Director (SSD) said that she was the manager on duty (MOD) on Sunday [DATE]. She said she arrived at the facility at 8:30 AM. At 9 AM she was rounding on the North Wing where resident #1 resided. She saw that resident #1's daughter was crying in the hallway. She said the daughter informed her that her father had passed away earlier in morning. The SSD stated that she verified with LPN B that the resident had passed. She then reviewed resident #1's medical record at about 3:00 PM. She read the nurse's note and saw no documentation that a Code Blue had been called or that CPR had been initiated. She reviewed the Advanced Directives tab in the paper copy chart and found that his Advance Directives Discussion Document, dated [DATE], indicated he was a full code indicating that CPR should have been initiated. The SSD said she immediately spoke to LPN B and asked her if CPR had been performed. She said LPN B was surprised and stated, He was a full code? The SSD said that LPN B reported to her that she had not looked in the medical record for the code status as he was already deceased when she entered his room. The SSD added that when she asked LPN B if she had checked his code status, LPN B reported to her, . I didn't think to check on that (code status) because he was already gone. The SSD said that she quickly reported this to the director of clinical services (DCS) who immediately came to the facility and started an investigation. At this time, review of resident #1's medical record with the SSD validated that resident #1 was a full code. She also validated that resident #1's Advance Directives Discussion forms, dated [DATE] indicated the resident and resident representative's wishes were for full code and CPR to be provided. The SSD said resident #1's daughter was his health care proxy and was very involved with her father's care. She visited him daily. She said the daughter did not want hospice for him and had hoped that he would get better. On [DATE] at 3:19 PM, a telephone interview was conducted with resident #1's assigned nurse on the day of his death, LPN B. She said that she was a relatively new hire and had started working in the facility the beginning of [DATE]. She said that she worked at the facility on a part-time as needed basis. She said that she was a floating nurse, did not have a permanent assignment, and worked on both nursing units as needed. LPN B said that on [DATE], she worked the 6:30 AM-3 PM shift and was resident #1's assigned nurse. LPN B said that during her shift to shift report, the off going nurse said that resident #1 was fine. She said that at approximately 7:10 AM, she heard CNA C and CNA D call out for her to come into the resident's room. She said RN A was already in the room checking the resident. LPN B stated that she then checked for breathing and a heartbeat with her stethoscope. The resident did not have any vital signs. Contrary to CNA C and D's statement, LPN B said his skin was cool to touch. LPN B stated that RN A had instructed her to turn off the feeding tube, take off his oxygen tubing, and then instructed the two CNAs to clean him up. LPN B said that she and RN A then went to the nurses' station to review his medical record. She said that RN A asked her if he was hospice and then asked to see his paper copy chart. LPN B said RN A reviewed resident #1's paper copy medical record and electronic medical record (EMR). She said, I thought she (RN A) looked through the medical record She said that RN A then called the daughter and the physician. The daughter arrived at the facility about 8 AM. LPN B said that it was not until the SSD approached her later in the afternoon about the resident's passing that she realized he was a full code and that CPR should have been initiated. LPN B stated, I was so overwhelmed by the situation and didn't check for the DNR status because he had already passed. She added that everything was happening so fast that when she asked for help from RN A, she thought RN A had taken charge. LPN B said that she thought RN A had checked for the code status. LPN B said that she had never been involved in a Code Blue at this facility. She said she had been a nurse for about [AGE] years. LPN B stated that she should have checked for the resident #1's code status. On [DATE] at 3:45 PM, a telephone interview was conducted with RN A. She said that on [DATE] at about 7:10 AM, she went into resident #1's room after CNA C and CNA D called out to her. Contrary to CNA C, D and LPN's statements that indicated RN A was first to arrive in the room, RN A said LPN B was already in the room assessing the resident. RN A stated, Looking at him he appeared to be dead. She said that his mouth was open and his eyes were opened and fixed. RN A said that she checked for a pulse and it was absent. She said the resident's arm was cool to touch. This is a discrepancy from CNA C and D's interviews who said that his arm was warm to the touch. RN A said normally, the aides helped and reviewed the chart for code status, but these aides just gathered around. She told them to stop the tube feeding and clean him up. RN A said that she and LPN B went to the nurse's station and that she told LPN B to look in the medical record for his code status. RN A said she began making phone calls to the daughter and physician. She stated that LPN B reviewed the chart and reported to her that the code status was not in the medical chart. RN A said that she found the resident was full code status in the electronic medical record, (EMR) and called the DCS to report this. This contradicted a later interview with the DCS who said that RN A had not informed about the event. RN A then changed her statement and said that she had discovered resident #1 was a full code after the SSD informed her later in the day. RN A said she thought LPN B had already looked at the code status when this all started. She said when a resident has a full code status, that a Code Blue is called, CPR is initiated and 911 is called. RN A said that it was her opinion that the assigned nurse (LPN B) should be responsible for identifying the resident's code status and initiating CPR. She added that she had never performed CPR in this facility, but had practiced with the facility's code blue drills. On [DATE] at 11:42 AM, a telephone interview was conducted with resident #1' daughter. She validated that she was her father's healthcare proxy. She said that on the day that he passed, a nurse at the facility, name unknown, had called her saying that his blood pressure was dropping very low and that she needed to come to the facility right away. She said when she arrived at the facility, he had already passed. She stated the next day, on [DATE], she received a call from the DCS, South wing unit manager, SSD, and the administrator. They informed her that CPR was not performed on her father and that 911 had not been called. The daughter said that she had visited her father on the day before he died , and had spoken to him through his bedroom window due to Coronavirus Disease ,[DATE] (COVID-19) visitation restrictions. She said her father had a hard time talking, but smiled at her. She then asked, Why did the facility not do CPR after they called me and told me his blood pressure was dropping? He was having trouble breathing and they told me to come. She stated, Maybe he could have been brought back if CPR was done. She added, My father was a fighter and wanted CPR. He and I both wanted everything possible to be done. On [DATE] at 1:10 PM, a telephone interview was conducted with the facility's Medical Director who was also resident #1's physician. She said that she was aware that resident #1 had deceased and that CPR had not been initiated as per her orders and the resident's wishes. She said that she thought the nursing staff assumed he was a DNR due to all his comorbidities and a recent decline that required a feeding tube placement. She said that he had recently had a [MEDICAL CONDITION] and stroke. On [DATE] at 9:45 AM and on [DATE] at 3:47 PM, interviews with the administrator and DCS were conducted. During both interviews, the DCS validated that resident #1 was a full code and that CPR should have been initiated when the resident was found unresponsive. She validated the resident had advance directives that indicated he and his daughter wanted CPR to be performed. The DCS stated that RN A and LPN B did not follow facility policies and procedures to call a Code Blue when they found the resident unresponsive. They failed to immediately check for his code status in the medical record, and failed to initiate CPR. She said that after speaking to both nurses, there was confusion over where to find the code status and who was responsible to check the code status. She noted that both nurses claimed that they could not find the code status or an advanced directive indicating he was a full code. She added that the code status of all the residents at that time was located in the front of the paper copy medical record under the Advanced Directives tab. The code status was also noted in the EMR under the resident's profile, and on the resident's Medication Administration Record [REDACTED]#1 not receiving CPR. She said there was a discrepancy as to which nurse first arrived on the scene and would be responsible to take charge. She said there had been confusion and a lack of communication between the nurses and who would take charge of the situation. She said that there was no indication that the nurses had a valid reason for not initiating CPR. Review of the facility's corrective measures implemented by the facility revealed the following: *Chart audits of all current residents was completed by [DATE]. The chart audits comprised of a review of Physician Orders, Medication Administration Record [REDACTED]. Chart audits, by the SSD will continue on daily basis for 1 week, then weekly for 4 weeks. The daily chart audits until [DATE] were verified by the surveyors. *Nursing administration team initiated staff education on the Red Light/Green Light process for validating resident code status. The staff were educated on Abuse, Neglect, Exploitation, Misappropriation and Injuries of Unknown Origin, Resident Rights and the Nurse Practice Act. Additional education was done with the licensed nurses on the Shift Report process regarding physician orders and resident code status. The education included where to find resident code status in the Electronic Health Record (EHR) and in the Medical Record (Hard Chart). As of [DATE], twenty-seven of thirty-five licensed nurse had been educated and post tests conducted. Certified letters were sent to the remaining eight nurses about Code Status verification and these eight nurses will not be permitted to work until all in-service education on resident code status was completed. *The facility initiated mock, Code Blue Drills on [DATE] on all shifts. Previously, the drills were monthly. The PRN (as needed) and nurses on leave will participate in mock, Code Blue Drills, prior to working their next shift. *An ad-hoc Quality Assurance Performance Improvement meeting was held on [DATE] with the participation of the Medical Director, Administrator, DON, SSD, ADON. The Medical Director approved the root caused analysis and correction plan. *On [DATE] at 4:51 PM, the SSD verified that the facility currently had 39 residents with a DNR and 70 residents that were Full Code. *On [DATE] at 2:05 PM a mock Code Blue Drill was observed in room [ROOM NUMBER]. Staff had retrieved the resident's paper chart and brought it to the room. The staff determined that the DNRO was incomplete and not signed and CPR was initiated. After the drill the DCS and ADON were interviewed. They stated that they used several scenarios for the mock Code Blue Drills including incomplete DNRO. They stated that this drill was to test for incorrect DNR status. They stated that this drill was a success and there was a written evaluation done after each drill which were verified. *On [DATE] at 3:47 PM, a meeting held with the Administrator, DCS and Regional Nurse Consultant provided a timeline of events. They stated that their root cause analysis was that the nurses did not verify and locate the resident's code status. The DCS added there was an assumption, due to the resident decline, that the staff assumed the resident was on hospice. The DCS provided clarification that a hospice resident does not mean the resident has an automatic DNRO. She stated this was incorporated in the in-service education. The DCS stated the facility had ensured that the code status was on the 'profile ribbon' on the EHR and the 'profile ribbon' remains at the top of each section of the EHR. The DCS stated that resident code status was the first page on the paper medical chart. Lastly, the DCS stated there was a lack of leadership during the Code Status event on [DATE]. She stated not one of the two nurses that responded took an active leadership role to ensure CPR was initiated. She added as part of their education, the first licensed nurse to arrive/respond was in charge of the Code, regardless of credentials (LPN vs RN). This nurse will delegate tasks and give direction to the staff that respond to the code. This was verified by interviews and during mock Code Blue drills. *Staff interviews with (3 RNs, 3 LPNs and 2 CNAs) revealed the facility had provided education on CPR/Code status and that mock Code Blue Drills were being conducted. The nurses confirmed that the code status of each resident was on the profile section of the EHR and the first page of the paper medical chart. The staff also acknowledged the changes at shift change. Walking rounds with the off going nurse and the on-coming nurse must be done. In addition, at shift change, the off going nurse/on coming nurse must verify each of the resident's code status for that particular assignment. The nurses all stated that they had received CPR/DNRO/Code status training upon hire and re-education since [DATE]. The nurses stated that they had participated in the mock Code Blue Drills. They acknowledged that the first nurse to arrive on the scene during a Code Blue leads the code. They added that 2 licensed nurses must verify code status before the initiation of CPR. The CNAs confirmed that they had received CPR/DNR/Code training upon hire. The CNAs stated that recent education had clarified their responsibilities during a Code Blue. The aides noted that the nurses must verify the resident's code status prior to the initiation of CPR. The CNAs stated the nurse would oversee the Code and they could assist with retrieving the chart, the crash cart, call 911, and other tasks as directed by the charge nurse. All staff confirmed that CPR would continue until relieved by the emergency services personnel or until the resident responded. *Medical record reviews were conducted for 5 current residents. All the residents' code status was quickly found in the EHR and was the first page of the paper medical record.

Based on observation, interview and record review, the facility failed to complete a review and revision of care plan to include individualized approaches to prevent development of a recurrent pressure ulcer for 1 of 5 residents reviewed with pressure ulcers (#148). As a result of the facility's non-compliance, the resident sustained [REDACTED]. Findings: Cross Reference to F314 & F520. 1.Resident #148 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] indicated that she was rarely/never understood, totally dependent on 1-2 persons for all of her needs, always incontinent of urinary and bowel, requires a feeding tube for nutrition, is at risk for developing pressure ulcers, has 1 stage-2 pressure ulcer that was not present upon re-entry or admit to the facility. The date of the oldest stage 2 pressure ulcer was 2/02/17, and it was not present or a lesser stage on the prior assessment. Skin and Ulcer Treatments were pressure-reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, and pressure ulcer care. Review of the wound care physician notes indicated the resident was seen on 2/08/17 for an initial evaluation of a [MEDICATION NAME] spine wound. The physician notes indicated the wound was a stage 2 pressure ulcer that gradually appeared and was present for one week prior to 2/08/17. According to the International National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel Pressure Ulcer Classification System, there are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury. Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough The physician documented that the resident grimaced when touched in the wound area. The wound did not have any necrotic tissue and the size of the wound was 0.3 centimeters (cm) in length, 0.2 cm in width, and 0.1 cm in depth. A treatment of [REDACTED]. The wound care physician notes dated 2/15/17 indicated the [MEDICATION NAME] spine pressure ulcer healed. The physician noted that the location of the newly healed area and the bony [MEDICATION NAME] deformity required [MEDICATION NAME] for additional protection for additional skin breakdown and repositioning as tolerated. Resident #148 had a significant change MDS assessment completed with the assessment reference date of 5/08/17. The assessment was essentially the same as prior assessment except for decrease in function bilateral upper extremities, and she did not have a stage 1 or higher pressure ulcer at the time this assessment was completed. The skin and ulcer treatments that applied were pressure-reducing device for bed and application of non-surgical dressings other than to feet. The care areas assessment (CAA) summary indicated she triggered for pressure ulcer to be addressed in care planning. The medical record contained a care plan for the potential for impaired skin integrity initiated on 2/16/17, related to a history of pressure ulcers, immobility, fragile skin, incontinence, and external forces listed the goal of care was that the resident will be free from impaired skin integrity and interventions will remain in place the prevent further impaired skin integrity through the next review, target date 5/15/17. The interventions included: follow facility policies/protocols for the prevention/treatment of [REDACTED]. On 7/21/17 at 5:53 PM, interview and concurrent record review was conducted with MDS registered nurses (RN) F and & G. They confirmed that resident #148 was at high risk for pressure ulcers due to being bedbound and chairfast, advanced age, history of recurrent pressure ulcers to her back/spine in February 2017. She has kyphosis/curvature of her spine that contributes to skin break down around the bony prominences of her upper/mid spine area. She has poor nutritional status and receives tube feeding for her nutrition, and has contractures to her lower extremities and decreased in range of motion in her left arm. When asked about the history of the pressure ulcers to her back/spinal area and lower extremities, MDS nurse F said that the pressure wound on her back was identified initially on 2/09/17 and then resolved on 2/16/17. She said the same pressure wound recurred on 5/18/17 and resolved again on 6/09/17. The MDS nurses confirmed the resident had a care plan for the potential for impaired skin integrity initiated on 2/16/17, related to a history of pressure ulcers, immobility, fragile skin, incontinence, and external forces listed the goal of care was that the resident will be free from impaired skin integrity and interventions will remain in place to prevent further impaired skin integrity through the next review, target date 5/15/17. The interventions included: follow facility policies/protocols for the prevention/treatment of [REDACTED]. The care plan was not reviewed after the 5/15/17 target date. The care plan did not address the resident's abnormal posture and kyphosis of the back. It did not include the history of recurrent pressure ulcers to the [MEDICATION NAME] spine area and how it contributed to the increased risk for further breakdown to her back/spinal area The MDS nurses confirmed that the care plans were not individualized to accurately describe resident #148's medical condition and comorbidities. They said they used preprinted forms. They failed to individualize the plan of care to reflect that the resident has kyphosis/curvature of the spine, which would make her back more susceptible to breaking down, her history of skin breakdown back/spinal area in February and May 2017, the location of her contractures or her decreased range of motion in her bilateral upper extremities. The MDS nurses also confirmed that no new interventions were added to address the residents skin or pressure wounds from 2/17/17 through 5/17/17, then from 5/19/17 through 7/20/17, and that the care plans were not individualized, revised timely, and no new interventions were considered to prevent recurrent breakdown to her [MEDICATION NAME] spine. On 7/20/17 at 3:30 PM, an observation was conducted with the Director of Nursing (DON) in the resident's room. The DON confirmed the presence of skin breakdown on the resident's upper back measuring approximately ½ to 1 cm. round. The DON stated, since the wound base has yellow slough, she would classify the wound as an unstageable pressure ulcer. When asked about their policies and procedures for reporting new skin breakdown when CNAs are giving care, the DON stated, the CNA should have reported this new area to the nurse right away when she saw it this morning. This pressure ulcer to the [MEDICATION NAME] spine was not identified until it was an unstageable wound. She sustained a pressure ulcer to the same area on her [MEDICATION NAME] spine 3 times within 5 months. During an interview on 7/21/17 at 10:30 AM, the DON confirmed the weekly skin assessments were not completed and the resident did have any changes to the care plan to address an effective pressure distribution surface. An unstageable pressure wound is defined as Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (npuap.org). The facility Clinical Guideline-Skin & Wound. dated 4/01/17, read, Overview: to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The process listed, develop individualized goals and interventions and document on the care plan and the CNA Kardex, Monitor residents' response to treatment and modify treatment as indicated, Evaluate the effectiveness of the interventions and progress towards goals during the care management meeting and as needed.

Based on observations, interviews, and record review, the facility failed to failed to prevent the development of avoidable, recurrent pressure ulcers (#148) and failed to ensure residents received weekly skin checks consistently per the plan of care for 5 of 9 residents with pressure ulcers (#148, 95, 125, 104, & 189).The facility's failure to prevent an avoidable pressure ulcer resulted in actual harm as evidenced by formation of an unstageable pressure wound. Findings: Cross Reference to F280 and F 520 1.Resident # 148 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Her most recent minimum data set (MDS) assessment included a significant change with the assessment reference date of 5/08/17. An interview with the MDS nurse on 7/21/17 at 5:53 PM indicated the resident had a decline in range of motion of her upper extremities to contribute to the significant change. She is rarely/never understood, totally dependent on 1-2 persons for all her activities of daily living, is bedbound, unable to turn herself in bed and is always incontinent of urine and bowel. The resident is at risk of developing pressure ulcers and had no stage 1 or higher pressure ulcers at the time this assessment was completed. The assessment indicated the skin and ulcer treatments that applied were pressure-reducing device for bed and application of nonsurgical dressings other than to feet. The care areas assessment (CAA) summary indicated she triggered for pressure ulcer to be addressed in care planning. Review of the wound care physician notes indicated the resident was seen 3 months earlier, on 2/08/17, for an initial evaluation of a [MEDICATION NAME] spine wound. The physician notes indicated the wound was a stage 2 pressure ulcer that gradually appeared and was present for one week prior to 2/08/17. According to the International National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel Pressure Ulcer Classification System, there are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury. Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough The physician documented that the resident grimaced when touched in the wound area. The wound did not have any necrotic tissue and the size of the wound was 0.3 centimeters (cm) in length, 0.2 cm in width, and 0.1 cm in depth. A treatment of [REDACTED]. The wound care physician notes dated 2/15/17 indicated the [MEDICATION NAME] spine pressure ulcer healed. The physician noted that the location of the newly healed area and the bony [MEDICATION NAME] deformity required [MEDICATION NAME] for additional protection for additional skin breakdown and repositioning as tolerated. The medical record contained a care plan for the potential for impaired skin integrity initiated on 2/16/17, related to a history of pressure ulcers, immobility, fragile skin, incontinence, and external forces listed the goal of care was that the resident will be free from impaired skin integrity and interventions will remain in place to prevent further impaired skin integrity through the next review, target date 5/15/17. The interventions included: follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the treatment administration records for June and July 2017 revealed no evidence of application of [MEDICATION NAME] every 5 days and as needed for protection. On 7/21/17 at 5:53 PM interview and concurrent record review was conducted with MDS Registered Nurses (RN) F & G. They confirmed that Resident #148 was at high risk for pressure ulcers due to being bed and chairfast, advanced age, history of recurrent pressure ulcers to her back/spine in February 2017. She has kyphosis/curvature of her spine that contributes to her skin breaking down around the bony prominences of her upper/mid back region. She has poor nutritional status and is on tube feeding for her nutrition, has contractures to her lower extremities, pressure ulcers to bilateral feet, and decreased in range of motion in her left arm. When asked about the history of the pressure ulcers to her back/spinal area and lower extremities, MDS nurse F said that the pressure wound on her back was identified initially on 2/09/17 and then resolved on 2/16/17. She said the same pressure wound recurred on 5/18/17 and resolved again on 6/09/17. On 7/17/17 at 4:20 PM, the resident was in bed. Her eye contact was poor and she was nonverbal. On 7/18/17 at 11:37 AM, the resident was in bed with the head of bed elevated 45 degrees and she was nonverbal. On 7/19/17 at 3:54 PM, the resident was lying in bed. The resident did not have a specialty support surface during those times. On 7/20/17 at 10:10 AM an observation and interview was conducted with Certified Nursing Assistant (CNA) C who was in the process of giving care to the resident in her room. The resident was observed lying on her right side in bed. Her midline spine upper/mid back curved and rounded and the resident had an open wound on her midline spine-upper back that was approximately 0.5 cm to 1.0 cm round. The wound was moist with yellow slough so that the base of the wound was not visible. The edges were pink. The resident did not have any protective [MEDICATION NAME] dressing on at this time. The CNA said that she would report change in skin condition to the nurse and that she had not noticed any other changes in the resident's skin while doing care. The resident was totally dependent with care and had contractures to her bilateral lower extremities. On 7/20/17 at 2:25 PM Licensed Practical Nurse (LPN) B was asked if the CNA had reported any alterations or changes in the resident's skin integrity and she stated, no the CNA did not report any changes in the resident's skin condition. If there were any changes, she should report to the nurse right away. On 7/20/17 at 2:30 PM CNA C was asked if she had reported the new area of skin breakdown on the resident's back area to the nurse yet. She stated, I have not had a chance to tell the nurse yet. The CNA was asked, what is the facility policy for reporting new skin breakdown, the CNA stated, I should have reported immediately to the nurse the new open area on the resident's back. A total of 4 hours and 20 minutes elapsed from when the CNA first identified a change in skin condition on the resident's spine. She failed to report the change to the nurse immediately. The facility Clinical Guideline-Skin & Wound, dated 4/01/17, read Overview: to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The process listed, CNA to complete skin observations and report changes to Licensed Nurse and licensed nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved. On 7/20/17 at 2:46 PM an observation and interview was conducted with LPN D who was the resident's nurse on the 3-11 shift and LPN C who is was the resident's nurse on the 7-3 shift. They both confirmed that CNA C did not report the new wound to the residents' upper spine until approximately 2:30 PM, approximately 4 hours and 20 minutes after it was identified as an open wound. Both nurses said, CNAs are to report new breakdown immediately to the nurse. They both said that they went to check the resident's upper back skin just prior to the interview and they confirmed the presence of the new pressure wound on the spine. On 7/20/17 at 3:30 PM, an observation was conducted with the Director of Nursing (DON) in the resident's room. The DON said that the resident was on regular mattress that was not a specialty type of alternating air mattress or any specialty surface to prevent breakdown to her spine. The DON confirmed the presence of skin breakdown on the resident's upper back measuring approximately ½ to 1 cm. round. The DON stated, since the wound base has yellow slough she would classify the wound as an unstageable pressure ulcer. When asked about their policies and procedures for reporting new skin breakdown when CNAs are giving care, the DON stated, the CNA should have reported this new area to the nurse right away when she saw it this morning. The DON was asked about pressure reduction surfaces to prevent recurrent breakdown to the resident's spine and she said that because the pressure wounds were only on the lower extremities, it would not warrant specialty mattress. She said now that she has been identified with an unstageable pressure ulcer on her back area it would be appropriate. An unstageable pressure wound is defined as Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (npuap.org). On 7/20/17 at 4:55 PM, the DON was asked in the presence of the Administrator why she provided one skin assessment dated [DATE] for Resident #148, instead of 2 months that were requested. The DON said the facility had not done weekly skin assessments in 41 days and the last one was done on 6/09/17. When asked why the nurses had not followed the physician order [REDACTED]. Review of the facility policies and procedures for Skin Evaluation revised 4/01/17, read, A Licensed Nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesion, abrasions, reddened areas and skin problems. On 7/21/17 at 10:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON) in the presence of the DON. The ADON said she completed a skin assessment on resident #148 the night of 7/19/17 as part of another investigation. This information was not provided until after the unstageable pressure wound was identified on 7/20/17. She said she did not document the skin assessment in the electronic medical record as part of the weekly skin integrity review, but had documented it on a different piece of paper. The ADON said she did not see observe any skin breakdown, redness, or blister on the resident's spine. The DON said resident #148 could have progressed from intact skin to an unstageable pressure wound from the night of 7/19/17 to the morning of 7/20/17 due to her comorbid condition, kyphosis of spine, and failure to thrive. The DON confirmed the resident did not have any other new unstageable pressure ulcers that developed in less than 12 hours. On 7/21/17 at 10:30 AM, the DON was asked to provide any policies and procedures for treatment or prevention of pressure wounds and she provided a 1-page policy titled Clinical Guideline-Skin & Wound, dated 4/01/17. She confirmed that this was the facility's only policy for skin and wounds. The guideline overview read, to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. She said she did not have any written guidance as to when it would be appropriate to initiate a specialty mattress for residents' with pressure wounds or at risk for recurrent pressure ulcers. The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED]. Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction, and microclimate control for the individual if fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care and is at high risk for additional pressure ulcers. On 7/21/17 at 11:04 AM an interview was conducted over the phone with Resident #148's Wound Care Physician E. Physician E said that she has been treating the resident for several pressure wounds on and off for approximately the past 6 months and she does have a history of lumbar pressure wounds to her back in February of this year that resolved on 2/15/17. She has lower extremity contractures, is immobile and requires constant repositioning and turning. The resident also has kyphosis of her back that would contribute to her developing pressure wounds in that area. When asked if the resident could have developed a new unstageable wound to her back/spinal area from the night of 7/19/17 to the morning of 7/20/17, the physician stated, her condition has been stable from a medical point of view and I would have expected the nurse doing the skin assessment of her back to have noted redness or blister on 7/19/17 prior to the development of an unstageable wound on 7/20/17. According to NPUAP, there are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury. Stage 1 ulcer has intact skin with non-blanchable (persistent redness) of a localized area usually over a bony prominence .Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough Stage 3 presents with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Stage 4 presents as full thickness tissue loss with exposed bone, tendon or muscle .Unstageable presents with full thickness tissue loss in which the base of the ulcer is covered by slough .and Suspected Deep Tissue Injury presents as purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.: 2.On 7/21/17 at 5:40 PM the DON and Regional Registered Nurse (RN) H confirmed that the following residents who had pressure wounds did not have weekly skin assessments completed as ordered by the physician and per the plan of care: Resident # 95 on 6/14/17 & 6/22/17, Resident #125 not done from 5/20/17 to 6/21/17, Resident # 148 from 6/10/17 thru 7/18/17, Resident #104 on 7/18/17, and Resident #189 on 6/19/17 and 6/26/17. On 7/21/17 at 12:25 PM the DON said that although the residents had orders for weekly skin checks, she thinks it was deactivated in the electronic record system. She said she was still currently investigating why and how the assessments were not done and did not know how many were not completed.

Based on observation, interview, and record review, the facility failed to ensure quality assessment and assurance program/monitoring was effective to meet the needs of residents related to prevention and treatment of [REDACTED].#148, 95, 125, 104, & 189). The failure to identify, develop, and implement, actions plans to correct quality deficiencies and the failure to monitor the plan of correction for deficiencies regarding the prevention of pressure ulcers resulted in actual harm for resident #148 who sustained recurrent avoidable pressure ulcers to her [MEDICATION NAME] spine. Findings: Cross refer to F314: Based on observations, interviews, and record review, the facility failed to failed to prevent the development of avoidable, recurrent pressure ulcers (#148) and failed to ensure residents received weekly skin checks consistently per the plan of care for 5 of 9 residents with pressure ulcers (#148, 95, 125, 104, & 189).The facility's failure to prevent an avoidable pressure ulcer resulted in actual harm as evidenced by formation of an unstageable pressure wound. The facility's Clinical Guideline-Skin & Wound, policy dated 4/01/17, read, Overview: to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The Quality Assurance performance Improvement (QAPI) portion of the Clinical Guideline read, Patterns and trends of newly developed and/or worsening skin conditions will be reviewed by the QAPI team. In an interview conducted on 7/21/17 from 6:53 PM to 7:40 PM with the Administrator, Director of Nursing (DON), and Regional Registered Nurse (RN) H about the Quality Assurance (QA) Committee, the DON said that she was new at the facility and so was the Regional RN as of January of 2017. The Administrator indicated that their focus has been on stabilization of their staff and after the staff were stabilized, they planned to be able to start working on other quality areas in the facility. The Quality Assurance Committee was ineffective as evidenced by recurrent deficiency for Code of Federal Regulation 483.25(b) Skin Integrity, F314. They failed to develop and implement corrective action for pressure ulcer care and prevention that resulted in actual harm to resident #148. When asked what type of monitoring the facility was conducting for continued compliance and for how long monitoring was conducted, Regional Nurse H said that they do not know where their Plan of Correction (POC) book is from last year regarding F 314, so they have not been continuing to monitor compliance in that area. On 7/21/17 at 6:53 PM the Administrator confirmed the team did not review and QAPI for pressure ulcer care or prevention.