Every finding on record at Aviata at the Gardens - Tallahassee

Based on observations, record review, resident interview and staff interview, the facility failed to develop a comprehensive care plan to address refusal of care for 1 of 26 sampled residents. (Resident #138) The findings include:Observations of Resident #138 were conducted on 4/13/26 at 1:22 PM, 4/14/26 at 12:48 PM, 4/14/26 at 4:38 PM, 4/15/26 at 9:18 AM, 4/15/26 at 12:49 PM, and 4/16/26 at 9:25 AM. During all of these observations, the resident was observed to have oily appearing, uncombed hair and some of her fingernails were about 1/2 centimeter past the nail bed. On 4/16/26, the resident was noted to have an odor. An interview was conducted with Resident #138 on 4/16/26 at 9:25 AM. She stated her last bath or shower was Saturday 4/4/26 and the staff have not offered to brush her hair or trim her fingernails at all this week. A review of Resident #138's medical record revealed she was admitted to the facility on [DATE]. A care plan was initiated on 2/10/26 for alteration in usual functional performance in self-care related to decreased mobility, cerebral palsy, flaccid paralysis with an intervention of partial/moderate assist with 1 staff assist for bathing/showering. The current care plans did not indicate the resident would refuse showers/bathing and ADL (activities of daily living) care.An interview was conducted with Employee C (Subacute Unit Manager) on 4/16/26 at 9:34 AM. She stated the resident would refuse showers/bathing at times and has since admission. An interview was then conducted with Employee D (Minimum Data Set Coordinator) on 4/16/26 at 10:33 AM. Employee D reviewed Resident #138's care plans and confirmed the resident did not have a care plan for refusal of bathing or ADL care. She stated the facility usually discussed these things during clinical meetings. Employee D confirmed the resident's refusal of ADL care and bathing should have been care planned. The facility policy Plans of Care (N-1015 revised 9/25/17) states, An individualized person-centered plan of care will be established by the interdisciplinary team with the resident and/or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirements.

Based on staff interviews, observations, and photographic evidence, the facility failed to maintain an effective pest control program to ensure a clean, safe, and homelike environment in 1 of 2 nutritional pantries reviewed.The findings include:Observation of the nutritional pantries in the general and restorative care sides of the building was conducted on 04/15/2026 at 2:22 PM with the dietary manager. Small, dark, cylindrical pellets within the pantry cabinets were observed. In addition, upon observation, live, brown, fast-moving insects about half an inch long were observed within the nutritional pantry cabinets and at the baseboard of the wall below the cabinets. The Dietary Manager stated, yes, that is a roach. Photographic evidence was obtained of the small dark cylindrical pellets and roaches within these cabinets.An additional observation and interview were conducted on 04/15/2026 at 2:40PM with the Maintenance Director in the nutritional pantry in the general and restorative care side of the facility. When shown the small, dark, cylindrical pellets, the Maintenance Director confirmed that those were from a cockroach. Additional photographic evidence was obtained. An interview with the Facility Administrator was conducted on 04/16/2026 at 10:50 AM. The Facility Administrator stated that the Dietary Manager is responsible for keeping the pantry clean and stocked.An interview with the Dietary Manager was conducted on 04/16/2026 at 11:00 AM. The Dietary Manager stated that the pantry is stocked and cleaned by their staff. She acknowledged the cabinets were not cleaned properly.

Based on observations, resident and family interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 10 residents reviewed. The findings include: On 12/2/25 at approximately 12:00 pm, tour of the facility was conducted on the 100/200/300 halls. Upon entry to the unit, by the nurse station, a strong odor of urine permeated throughout the hallways. Again, on the same day at approximately 3:00 pm, the strong odor continued throughout the halls. On 12/3/25 at approximately 10:00 am, a second tour of the 100/200/300 halls revealed the strong odor of urine still existed. On 12-3-25 at 11:06 am, an interview with Resident #9's family member revealed Last week at 10:30 am, the hall was a mess I found him filthy, dirty, and soaking wet. She stated hospice is now coming for him 3 times a week. When hospice aides come and bathe him, they call and say they found him in a mess. The family member stated she is at the facility at least 4 times per week and there is always a bad smell of urine on the halls. She stated , That smell is probably because the staff strip the beds and leave all the sheets/linens at the foot of the bed, then they come back after doing all the other beds and pick/bag up the clothes, leaving them there stinking for an extended period of time. Resident #6 On 12-2-25 at 12:07 pm an interview with Resident #6 revealed she has had cockroaches in her room. She stated her daughter purchased a glue pad because the facility is not doing anything about the problem. An observation of the floor under the air conditioner (AC) revealed a glue pad that had several cockroaches and a very small roach running on the floor along side the glue pad. (Photographic evidence obtained) A second observation of the resident's room was conducted on 12-3-25 at 10:00 am and revealed the glue pad contained more roaches. On 12-5-25 at 11:19 am an interview with the Maintenance Director revealed that he recently had the pest control change from spray to dust in order to address the roach problem. He also stated they bought the glue strips and placed them in resident rooms under the AC unit. When asked why there are so many live roaches, he really did not have an explanation. At this time, he confirmed the pest control has not been effective. Review of the pest control invoices revealed monthly services on site 2x per month for resident rooms per request/pest sighting logbook. Monthly service also performed for common areas, kitchens/dining areas, housekeeping/laundry, activity/therapy rooms, dry food storage, courtyard, dumpster area, EXT perimeter. Wasp up to 15'. Applied to patients rooms to target nuisance ants, roaches, silverfish and spiders.Review of Pest Sighting Logs for the 400/500/600 halls revealed numerous recent sightings of roaches on 400, 500 and 600 halls between 7-15-25 and 11-21-25. Review of the Pest Sighting Logs for 100/200/300 halls revealed numerous sightings of roaches as recently as 12-2-25 on the 200 and 300 halls. room [ROOM NUMBER] On 12/02/2025, an observation of room [ROOM NUMBER]'s privacy curtain divider showed it was visibly soiled with unknown substances and that Bed B had no pillowcases on pillows and that the pillow is dirty with unknown substance. On 12/02/25 interview room [ROOM NUMBER]B's resident revealed she has been here a week with no linen changes or housekeeping services. The resident stated she has asked repeatedly with no assistance from staff or housekeeping. On 12/02/25 at 2:54 PM, an interview with the Housekeeping Director revealed that the December schedule is not up yet and each month we have a project schedule that is a different task staff focus on besides the daily cleaning. Staff deep clean when a resident moves out of the room, disinfect mattress, pull trash, wipe horizontal down of surfaces, dusting top to bottom, dividing curtains, but there are regular room cleans.

Based upon observations, policy review, and interviews the facility failed to maintain proper labeling of medications with dates of when medication was opened, correctly label multi-use vial medications of when it was first accessed, follow label instructions for expiration dates, and provide safe storage of controlled drugs.The findings include: An observation of medication carts was conducted on [DATE] at approximately 3:15 pm. Medication cart 1 on the 400 unit had loose tablets in the drawers, a medicine cup of a clear gel like substances with the name [NAME] written on it in the top drawer, and an expired insulin pen dated [DATE] with a label that states to throw away any remaining medicine that remains 28 days after the first use. (Photographic evidence obtained)The medication cart on the 500 unit reveals had loose pills in the top drawer, a medication cup with unknown tablets placed in the medication drawer with no label or identification of what the medication is. When asked, Nurse E stated she does not know what the medication the cup is. Expired insulin pens were observed on the medication cart. A vial of opened Haldol injection was in the top drawer that had been used but withno date on it. Multiple narcotic medication cards of residents who has been discharged from facility still on the medication cart.(Photographic evidence obtained)An observation was conducted of the medication cart on the 600 unit. This revealed a narcotic medication drawer was noted with approximately 92 cards with narcotic medications. When asked why there were so many, Nurse A responded that the cards on the right side of the drawer are for residents still in the facility. The cards on the left side and a few in the back of the right-hand side are narcotic cards of residents that were discharged over a month or two months ago. She stated they are not allowed to remove the cards from the medication cart per the directions of the Director of Nursing (DON). Loose tablets were noted in the top drawer of the cart. It was unknown what medications they were. The DON was asked to explain her process of removing medications from the medications carts once a resident is discharged from the facility and she states. She stated that she goes to each unit every other week and checks the narcotics, removes the narcotic count sheet for that medication, and the narcotic medication, reviews it with the nurse assigned to the cart that day and ensures the count is correct. They sign it off, then the narcotic medication is removed from that cart. She then scans the medication to pharmacy. When the consulted comes into visit, we destroyer the medication per protocol. She further states the nurses on the units are not allowed to remove any empty cards or discharged or discontinued medications from the medication carts due to a drug diversion that took place last year. When asked if she does this on a weekly basis she stated yes. When asked to explain why there was 92 medications cards on the carts on the 600 units with 50-60 of those medications belonging to residents who have been discharged from the facility over the last two months, she stated that she has been out a few days. Review of pharmacy consultant reports for the last 3 months on [DATE] shows no issues related to the medication carts upon inspection and no issues with controlled substances logs.

Based on observation and interviews, the facility failed to maintain all the areas in the kitchen in safe and functional condition. The findings include: On 12/02/2025 at 2:43PM, observation of the kitchen food cart storage area showed walls were damaged with scuffed marks, deep scratches, deep scrapes, and broken sheetrock. The east wall has a hole above the wood bumper about the size of a fist and above the base board approximately 3 feet long. The sheetrock has broken off, exposing sheetrock metal grate. The bottom of the main door appears to be damaged, causing the wood to split. Door frames were dirty with paint chipping off. The floor appears to be dirty, floor material chipping, exposing the concrete. The mop area floor tiles were missing and the drain is missing the floor drain cover. (Photographic evidence obtained) On 12/03/25, an interview with the Regional Dietary Manager revealed two forms were completed and given to administration for repairs. An evaluation was completed in October 31,2025 from the Registered Dietician stating that all floors and walls are not in good condition repairs is listed as pending. A quality assurance evaluation form completed on 11/13/25 by the Regional Dietary Manager was marked as unsatisfactory for floors, walls, and missing floor tiles in all food storage areas. On 12/03/2025 at 1:30PM, an interview with the Maintenance Director stated he was aware of the kitchen repairs and it has been approved and they have all the materials.

Based on observations, staff and resident interviews, and record reviews, the facility failed to maintain an effective pest control program to ensure the facility is free of pests, specifically cockroaches.The findings include:Resident #6On 12-2-25 at 12:07 pm, Resident #6 stated she has had cockroaches in her room. She stated her family purchased a glue pad because the facility is not doing anything about the problem. An observation of the floor under the air-conditioner (AC) revealed a glue pad that had several cockroaches and a very small roach running on the floor along side the glue pad. (Photographic evidence obtained)A second observation of the resident's room was conducted on 12-3-25 at 10:00 am and revealed the glue pad contained many more dead roaches and some still alive attempting to free themselves. On 12-5-25 at 11:19 am interview was conducted with the Maintenance Director, who stated he recently had the pest control change from spray to dust in order to address the ongoing roach problem. He also stated they bought the glue strips and placed them in resident rooms under the AC unit. When asked why there are so many live roaches, he did not have an explanation. At this time, he confirmed the pest control has not been effective.The pest control invoices revealed monthly services occurred on site two times per month for resident rooms. Monthly service was performed for common areas, kitchens/dining areas, housekeeping/laundry, activity/therapy rooms, dry food storage, courtyard, dumpster area, and the perimeter. Review of Pest Sighting Logs for the 400/500/600 halls revealed numerous recent sightings of roaches on 400, 500 and 600 halls between 7-15-25 and 11-21-25. Review of the Pest Sighting Logs for the 100/200/300 halls revealed numerous sightings of roaches as recently as 12-2-25 on the 200 and 300 halls.

Based upon record reviews and interview, the facility failed to provide care and services to prevent worsening of wounds for 1 of 1 residents reviewed for pressure ulcers. (Resident #7)The findings include:Upon record review Resident #7 was admitted to facility initially on 5/1/25, was discharged to hospital and re-admitted to the facility on [DATE] with the diagnosis of Peripheral Autonomic Neuropathy, COPD, Rheumatoid Disease, AFIB, and Chronic Respiratory Failure. A Minimum Data Set (MDS) assessment with a date of 5/7/25 revealed that skin conditions is not coded for any pressure areas or ulcers but states she is at risk for pressure ulcers.On 5/16/25 a wound assessment was completed post re-admission from hospital that reveals wound #1 right inner thigh, measuring 4cm x 0.3 cm x 0.1 cm, etiology: pressure ulcer / injury at a stage 2 and not acquired in house. Wound #2 on the left buttocks measured 1.0 cm x 1.0 cm x 0.1 cm, etiology was incontinence associated dermatitis with stage partial thickness and not acquired in house. Daily wound care treatments were initiated. A wound care assessment was completed on 5/28/25 indicating that wound 1 and wound 2 were resolved and healed.A wound assessment was performed on 6/6/25 that reveals a Wound #3 on the Left Heel measuring 3.5 cm x 3.5 cm x 0.0 cm etiology pressure ulcer / injury, unstageable and states that wound was present on admission with the date of 5/15/25. Wound #4 on the right heel measured 0.6 cm x 1.5 cm x 0.0 cm etiology pressure ulcer / injury, unstageable and states that wound was present on admission with the date of 5/15/25.A change of condition nursing assessment was completed on 7/30/25 at 07:20 AM, revealing Resident #7 was sent to an acute care hospital for altered level of consciousness status and an apparent minor wound now developing redness, swelling or pain for right ankle wound.A vascular consult was conducted while Resident #7 was at the hospital dated 08/01/25 revealing she has been generally weak and groggier than usual over the past day or so. She has chronic wounds on her feet, and the facility was concerned they were getting worse and unsure how long the wounds have been present. Left heel wound measured 4.0 cm x 3.0 cm x 0.1 cm unstageable pressure injury with tan / black necrotic tissue, right posterior lower leg with two full thickness wounds measures 20 cm x 7 cm area. These wounds are with black boggy eschar, foul smelling, the eschar is lifting and soft brown moist necrosis. There are areas on sacrum, hips, and posterior thighs and lateral right lower extremity consisting of dark purple hue color and irregular shape. Areas on sacrum and buttocks is beginning to demarcate revealing partial-thickness tissue loss. A weekly skin assessment was conducted by nursing staff on 7/16/25 reveals treatment to bilateral heel in progress with skin intact, weekly skin assessment dated [DATE] reveals treatment in progress skin intact, and on 7/30/25 at 07:43 am reveals right ankle wound treatment in progress, left ankle wound treatment in progress, bilateral buttocks noted with discoloration.Wounds #3 and #4 were not identified on re-admission on [DATE] and was not assessed by wound care until 6/6/25. The wound to right posterior lower extremity was not identified on weekly skin checks and was assessed during facility wound care rounds. Resident 7 was transferred to acute care hospital where she presented with worsening of wounds and right posterior lower leg wounds were identified and treated per hospital documentation on 7/30/25.On 12/5/25 at 12:30 pm, an interview was conducted with the Wound Care Nurse that reveals staff nurses and CNAs will notify her of any skin changes that may occur in residents at the facility. She then reviews and / or assesses the resident with skin issues, perform a second skin assessment, and if needed will add the resident to the wound care rounds for the physician to see. She stated that when Resident #7 was admitted to facility, she had a wound to her bottom and to her heel. She further stated Resident #7 was sent out to the hospital several times and when she returned to the facility, she had bilateral ulcers to her heels and behind her calves. When asked to explain why the wounds to Resident 7 heels were not assessed until 6/6/25 and the wounds to the back of her calves were not identified or assessed on the weekly wound rounds, she did not respond. Upon asking the wound care nurse if she was the only nurse to provide wound care to the residents in the facility she stated that she is unless she is off or has been called off due to overstaffing, then the nurses assigned to the residents will perform dressing changes.

Based upon Interviews, observations, and facility policy review the facility failed to ensure and provide routine medications to residents in a timely manner. The facility failed to ensure the controlled drug records are in order, signed out appropriately by administering staff nurses and that all controlled medications are accounted for. While conducting observations of medication carts on 12/2/25 at approximately 3:15 pm, Nurse E opened up the narcotic medication drawer and removed 5-7 narcotic cards. A small white tablet was noted in the bottom of the drawer. She then stated the medication count sheet was blank. But she signed it out because she was told to do that today for the other nurse. On 12/2/25 an interview was conducted with Resident 12 at 08:00 pm, she stated that over the weekend she had to go without her pain medication. She stated was told by a nurse that she forgot to send in a script to the pharmacy for her pain medication. she said, This morning, I asked for a pain pill at 5:00 am and I didn't get it until 6:30 am.Upon review of Resident #12's medication administration record on 12/3/25, it revealed that she only received Tylenol for pain medication from 11/30/25 through 12/1/25. The facility medication administration policystates, .medications are administered in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and the need for additional training. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.An interview with the Director of Nursing (DON) was conducted on 12/3/25 at 10:00 am. The DON stated she started a program improvement plan for narcotic controlled substances due to a residents' medication card prescription label was marked out and someone wrote in 10 mg. She stated it was brought to her attention that one the medication cards was labeled wrong, so I initiated a plan of correction for it. She stated a medication prescription label on a narcotic card for Resident #11 regarding her oxycontin 5 mg was marked out / crossed out and someone wrote above 10 mg. She started education with all nurses on the controlled substance process. When asked DON to explain the process for removing controlled substance / narcotic medication from the medication carts once a resident was discharged from the facility, she explained that she goes to each unit every other week and checks the narcotics, removes the narcotic count sheet for that medication and the narcotic medication, reviews it with the nurse assigned to the cart that day and ensures the count is correct, her and the nurse sign off, then the narcotic medication is removed from that cart. She then scans the medication to the pharmacy. When the consultant comes into visit, we destroy the medication per protocol. She further stated that the nurses on the units are not allowed to remove any empty cards or discharged , discontinued medications from the medication carts due to a drug diversion that took place last year. When asked if she does this on a weekly basis, she stated she did. When asked explain why there was 92 medications cards on the carts on the 600 units with 50-60 of those medications belonging to residents who have been discharged from the facility over the last two months, she stated she had been out a few days. When asked to explain the process for when a narcotic count is not correct, she stated the nurse is to notify her immediately any time a count is not correct. Then she goes to that medication cart along with the nurses and attempts to figure out the discrepancy. She was not aware of any issues. She continues to state that nurses are not allowed to sign off narcotics for another nurse, that is against policy and regulations. When presented with an incorrect medication narcotic count sheet, she could not explain what happened. An interview with Staff Nurse B on 12/3/25 at 10:40 am was performed. She stated the facility process for administering narcotic medication: when you remove a narcotic medication to administer, you sign off on the narcotic medication count sheet and the administration record. When asked if she would ask a nurse to sign off a medication that was given and that she forgot to sign off, she replied that it is not allowed. Upon showing Nurse B a copy of the narcotic count sheet for Resident #11 and asked if she was familiar with Resident #11 and if she administered medications to Resident 11 on 12/1/25, she replied yes. Staff Nurse B looked at the narcotic sheet for Resident 11 and stated she gave her a pill at 09:00 am and stated, This is my signature here and points to the entry on 12/1/25 at 09:00 am. She further stated, I don't know whose signature that is below it. I know I gave her another pill that afternoon, but that is not my signature. Staff Nurse B then stated she did get a phone call yesterday from Staff Nurse C about a medication not being signed off. I told her to sign it off and I would come over the unit later on to sign and verify that I gave the medication. When asked if she went to the unit to verify later in the shift, she replied, no.An interview was conducted with Staff Nurse C on 12/3/25 at 4:00 pm. When asked if she recalls an issue with the medication count that occurred on 12/1/25, she stated yes, I got to work and went over to my assigned unit and counted my cart, but the other nurse hadn't made it in to work yet. A little while later Staff Nurse E came to me and said the count was off on the cart. I went over to the cart and looked at what she was telling me. I called Nurse B who was working and asked if she had given a pill to resident and forgot to sign it out. She said yes, I probably did and asked me to sign the medication out for her and she would come over later to sign it. I signed out that the medication was given on 12/1/25 at 3:00 pm. Review of pharmacy consultant reports for the last 3 months on 12/4/25 shows no issues related to the medication carts upon inspection and no issues with controlled substances logs.

Based on interviews, record review and facility policy review, the facility failed to invite resident to care plan meetings for 1 of 3 residents sampled. (Resident #2)The findings include:On 7/14/25 at 5:02 PM, an interview was conducted with Resident #2. She stated she had not participated in any care plan meeting since she arrived at the facility. She further stated she had not been invited to any care plan meeting. A review of Resident #2's medical record was conducted with Staff A, the MDS coordinator. Resident #2 was admitted on [DATE]. A record of the most recent care plan meetings indicated they were conducted on 5/2/25, 2/27/25 and 11/29/24. Care plan meeting forms were signed and dated by Staff A and the Social Services Director. There was no indication that Resident #2 was in attendance. On 7/15/25 at 9:27 AM, an interview was conducted with Staff A. She stated that Resident #2 did not participate in the care plan meetings. She was unsure of the reason Resident #2 did not attend. A review of the facility's policy and procedure was conducted. The facility policy titled, Care Plan Invitation, dated 11/30/2014, revised 9/25/2017, stated The resident and/or the resident representative shall be invited to attend each of the interdisciplinary Care Planning Conferences for the specific resident. Deliver a Care Planning invitation to the resident 7-14 days prior to the date of the conference Place a copy of the invitation in the medical record. Request that the resident and/or resident representative contact the facility designee to confirm or reschedule the date/time for the resident's conference. Have all attended to the Care Planning Conference, including resident and resident representative sign the Care Plan Conference Record to verify their attendance.

Based upon interview, observation, and record review, the facility failed to maintain a clean environment in 2 out of 4 halls observed.The findings include:On 7/14/25 at 10:02 AM, during the initial tour, hallway 300 was noted with has a very strong urine-like smell.On 7/14/25 at 10:04 AM, Staff C, a housekeeper, was interviewed. She stated she works three days a week from 8:00 am to 2:00 pm. She will have two hallways assigned for cleaning duties. She steted she does not work on weekends. She stated sometimes she would have two extra hallways assigned when someone did not come to work. Upon asking if she was able to finish her assignments, she stated she does what she could. She stated her assignments were to clean surfaces and sweep and mop floors.On 7/14/25 at 10:17 AM, an interview was conducted with Resident # 7. She stated sometimes on the weekends she did not see housekeeping personnel. She further stated staff would sometimes come in and pick up the trash, but they would not mop or wipe the tables.On 7/14/25 at 10:27 AM, an interview was conducted with Resident #8. She stated the last time she saw housekeeping was on Saturday (7/12/25) when they came in and picked up the trash. She further stated that housekeeping doesn't clean on the weekends.On 7/14/25 at 10:43 AM, hallway 100 also had a very strong urine smell.On 7/14/25 at 10:47 AM, Resident #5 was interviewed. She stated housekeeping came in her room every 2 to 3 days. She stated they clean the floors and the table. She further stated she does not recall staff ever coming on a Sunday but they did come in the room on Saturday 7/12/25. It was noted during the interview with Resident #5 that the floor is sticky. Upon inspection of her bathroom, there was a very strong urine-like smell.On 7/14/25 at 5:02 PM, an interview was conducted with Resident #2. She stated housekeeping did not come on weekends and that they did not clean enough. On 7/14/25 at 5:12 PM, a second tour of the facility was performed and hallways 100 and 300 still had a very strong urine-like smell. On 7/14/25 at 5:43 PM, the Director of Nursing (DON) was made aware of the strong urine odor in 100 and 300 hallways. She stated there were no housekeeping staff available at this time at the facility as they had all gone home. On 7/15/25 at 11:15 AM an interview was conducted with Staff B, the Manager of Housekeeping/Laundry. He stated the expectation for housekeeping staff was to clean the rooms every day, which includes sweeping, mopping, and wiping surfaces. Upon request, he was unable to provide documentation of staff daily workload verification.

Based on observation, resident and staff interviews, and record review, the facility failed to develop a comprehensive person-centered care plan to maintain the resident's highest practicable level of physical functioning for 1 of 28 sampled residents. (Resident #88) The findings include: On 02/10/25 at 01:56 PM during an interview with Resident # 88, the resident was asked if they are ever gotten out of bed. The resident replied that their wheelchair is too large and they cannot maneuver it because of the size. She stated she cannot sit up straight due to right-sided weakness and because it is very painful. The resident stated that they have not gotten out of bed but would like to if they had a more comfortable wheelchair. Resident #88 states that they have told staff but nothing has been done. On 02/12/25 at 12:10 PM, an interview was conducted with Staff H (Unit Manager for the 100, 200, and 300 halls). She stated she is new to the position since December and is still learning her role and that she was unaware of any requested equipment needs. She stated that this resident does refuse to get out of bed but could not identify any documentation of refusal and had no answer as to why the resident might be refusing. A review of medical record reveals an order dated 5/25/2024 stating May have restorative/maintenance programs as indicated. The discharge notes from therapy services indicated that the resident had received services from 5/27/2024 to 7/18/2024. The resident was discharged from therapy at that time due to achieving maximum potential. There was recommendations for a Restorative Splint and Brace program with splint to Left Upper Extremity (LUE) and Left lower extremity (LLE) knee for contracture prevention and Bed Mobility Program. Prognosis was noted as Good with consistent staff follow-through. A review of the Care Plan for Resident #88 reveals that she is care planned for an Alteration in Usual Functional Performance in Mobility/Transfer status related to weakness, impaired mobility, balance and gait with reference to Independent resident performance of wheelchair use in room and hall. However, there is no care plan referencing Restorative Nursing or Splint and Brace Program recommended for prevention of contractures.

Based on observation, staff interviews, and record review, the facility failed to provide equipment and restorative services to prevent a further decrease in range of motion for 1 of 3 residents sampled for limited range of motion. (Resident #88). The findings include: On 02/10/25 at 02:47 PM, Resident #88 was observed to have contractures of the left arm/wrist/hand. No supportive devices were noted in the room. On 02/11/25 at 02:10 PM, Resident #88 was observed to be receiving personal care in bed from the nursing aide. Resident #88's left arm and leg were noted to be severely contracted, affecting the resident's ability to change positions. On 02/12/25 at 09:45 AM, the Director of Physical Therapy stated that he has not received any requests for equipment needs for this resident. He verified that, unless consulted, a resident that is not receiving therapy services would not be evaluated for equipment needs. On 02/12/25 at 11:55 AM, an interview was conducted with Staff G, a Licensed Practical Nurse (LPN). She confirmed that equipment needs are provided through PT/OT but the nurse has to let them know if the resident is not receiving therapy. On 02/13/25 at 10:25 AM, a second interview was conducted with the Director of Therapy services regarding Resident #88's current mobility status. He stated that since the resident was not currently receiving services. He confirmed that he had not received any requests for re-evaluation of this resident until this morning. He stated that he was not aware of the extent of resident's contractures as he had not assessed them yesterday. No orders for therapy have been written. He concurred that the resident's condition may have deteriorated due to lack of staffing and a breakdown in communication between Nursing Services and Therapy. On 02/13/2025 at approximately 12:00 PM, Resident #88 verified that she has never been offered, received, or refused splints for her wrist or legs. In reviewing Resident #88's medical record, orders were noted on admitted d 5/25/2024 for physcial therapy to eval and treat as indicated. Rehab potential was defined as Good. In reviewing the discharge notes from Therapy Services, the notes indicated that the resident had received services from 5/27/2024 to 7/18/2024. The resident was discharged from therapy at that time due to achieving maximum potentia,l with recommendations for Restorative Splint and Brace program with splint to Left Upper Extremity (LUE) and Left lower extremity (LLE) knee for contracture prevention and Bed Mobility Program. Prognosis was noted as Good with consistent staff follow-through. Review of Medication / Task Administration records reveals no order or task identified for Restorative services or to apply wrist/leg splints.

Based on observation, interview, and policy review, the facility failed to provide appropriate urinary catheter care for 1 of 1 resident reviewed for catheter care. (Resident #97) The findings included: During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter. When asked how often the staff clean his catheter, Resident #97 stated the staff did not clean his catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #97 had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infections. A review of Resident #97's Admission Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview of Mental Status Score of 11, which indicates he had moderate cognitive impairment. This MDS documented the presence of the urinary catheter. Resident #97's physician orders revealed there were orders written on 01/11/25 regarding Catheter care every shift and as needed. An interview was conducted with Staff A, a Certified Nursing Assistant (CNA), on 02/13/25 at 9:30 AM. Staff A was assigned to care for Resident #97 that day. When asked about Staff A performing catheter and perineal care on Resident #97, Staff A stated she was unaware of how to perform catheter care. Staff A further stated she did not typically work on Resident #97's hallway. When asked if she had cared for other residents with catheters on the other hallways at the facility, Staff A she stated she had. A urinary catheter care observation was conducted with Staff A, CNA and Staff B, CNA on 02/13/25 at 10:33 AM. They gathered towels, washcloths, disposable chux, and an incontinence brief. Staff A and Staff B washed their hands and donned gloves. Staff A had a handful of gloves in her scrub top pocket that she used throughout the catheter care observation. Staff A filled two bath basins with warm water in Resident #97's bathroom while Staff B removed Resident #97's sheets and incontinence brief. Staff A washed her hands and donned a new pair of gloves from her pocket prior to beginning the catheter care. At Staff B's recommendation, Staff A picked the catheter bag up off the bed frame and, raising it above the level of the bladder, moved it onto the bed. There was no catheter securement device present. Staff A placed multiple washcloths in both bath basins and a bar of soap in one bath basin. Staff A then removed a washcloth from the water bin containing the bar of soap, applied soap onto the washcloth, and proceeded to clean Resident #97's penis, from the head back up the shaft. Staff A then verbalized she did not know how to pull back Resident #97's foreskin, so Staff B assisted her in this task, revealing Resident #97's glans penis. The glans penis had a large buildup of white smegma present. Staff A used a new washcloth with soap to clean the glans penis. She continued using the same area of the washcloth while applying new soap to the washcloth for the whole glans penis, removing the smegma until it appeared clean. She then used a new washcloth with soap to clean Resident #97's catheter tubing and scrotum. Staff A then used a new washcloth with clean water to wipe clean the resident's glans penis, catheter tubing, and scrotum. She then dried the area with a clean towel. After changing Resident #97's incontinence brief, Staff A and Staff B sat Resident #97 upright in the bed and covered him with his sheets, again, raising the catheter bag above the level of the bladder to hang the bag back on the bed frame. Neither Staff A nor Staff B replaced Resident #97's foreskin until after being reminded to do so by Resident #97 himself. An interview was conducted with the facility's Director of Nursing (DON) on 02/13/25 at 12:45 PM. The DON was told about the above concern with the catheter care, including the gloves in the pocket, unawareness of how to perform catheter care, and the lack of catheter securement device. The DON stated she planned to perform competencies on the staff as she also had concerns about staff members not understanding how to perform catheter care on uncircumcised residents. During the Quality Assurance and Performance Improvement meeting conducted on 02/13/25 at 1:00 PM, it was mentioned that, on 01/20/25, the facility administration had identified that nursing competencies regarding urinary catheter care were not up to date. Review of the facility's polity titled Catheter Care, Urinary, revision date 09/05/17 revealed the proper procedure for performing catheter care involved the following: Remove catheter securement device Wash perineal area with soap and water Rinse well and dry Clean catheter tubing with soap and water, starting at the meatus, cleaning in circular motion along its length, moving away from the body. Rinse well using the same motion Reattach catheter securement device

Based on observation, interview, and record review, the facility failed to ensure medical records contained complete and accurate information for 3 of 28 residents reviewed for medical records. (Residents #92, #5, #105) The findings include: Resident #92 During a tour of the facility conducted on 02/10/25 at 12:33 PM, Resident #92 was noted receiving oxygen via a nasal cannula. Closer observation revealed the oxygen tubing was dated 01/26/25 (photographic evidence obtained). A review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. Resident #92 had a medical history significant for Acute and Chronic Respiratory Failure, Apnea, Bipolar, Depression, and Dependence on Supplemental Oxygen. A review of Resident #92's Quarterly Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview of Mental Status (BIMS) score of 15, which indicates she was cognitively intact. A review of Resident #92's Care Plan revealed a care plan was written on 10/01/24 regarding altered respiratory status, history of respiratory failure-oxygen via nasal cannula, change tubing . as ordered. A review of Resident #92's physician's orders revealed an order was written on 09/20/24 for Respiratory: Oxygen 2 liters nasal cannula Continuous every shift. Further order reviews revealed an order was written on 01/17/25 for Change oxygen tubing, mask and/or nasal cannula weekly. May change sooner as needed. Every night shift every Friday. A review of Resident #92's Treatment Administration Record (TAR) revealed a staff member documented the oxygen tubing was changed on 02/07/25 (photographic evidence obtained). Resident #5 During a tour of the facility conducted on 02/10/25 at 12:40 PM, Resident #5 was observed receiving oxygen via a nasal cannula. Closer observation revealed the oxygen tubing was dated 01/26/25 (photographic evidence obtained). A review of Resident #5's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #5 had a medical history significant for Paralysis, Chronic Obstructive Pulmonary Disease, Heart Failure, and Traumatic Brain Injury. A review of Resident #5's Quarterly MDS, dated [DATE] revealed he had a BIMS score of 8, which indicates he had moderate cognitive impairment. A review of Resident #5's Care Plan revealed there was no care plan written regarding oxygen use. A review of Resident #5's physician orders revealed orders were written on 09/11/24 for Oxygen 2 liters per minute via nasal cannula as needed and Change tubing, mask and/or nasal cannula weekly. May change sooner as needed for hygiene AND every night shift every Friday. A review of Resident #5's TAR revealed a staff member documented the oxygen tubing was changed on 02/07/25 (photographic evidence obtained). An interview was conducted with Staff M, a Licensed Practical Nurse (LPN), on 02/12/25 at 2:50 PM. Staff M stated the night shift nurses were responsible for changing resident's oxygen tubing, but she could not confirm how often it was changed. She stated, to my knowledge, they are supposed to label it when it's changed. An interview was conducted with the facility's Director of Nursing (DON) on 02/12/25 at 4:05 PM. She stated the expectation would be for whoever performed care, such as changing oxygen tubing, would sign it off in the resident's medical record. In this instance, the night shift nurse should not have signed off that the oxygen tubing was changed. The DON further stated the expectation was that oxygen tubing would be changed weekly and labeled with the date of the change. Resident #105 During a tour of the facility conducted on 02/10/25 at 12:45 PM, Resident #105 stated he had a peripherally-inserted central catheter (PICC) line in place for antibiotic use. Closer observation revealed the PICC dressing was dated 02/01/25. An interview was conducted with Resident #105 during this observation. He stated he did not know when the PICC dressing was changed last by the facility staff (photographic evidence obtained). A review of Resident #105's medical record revealed he was admitted to the facility on [DATE]. Resident #105 had a medical history significant for Cellulitis of the Right Upper Limb, Acute Osteomyelitis Right Hand, and Deep Vein Thrombosis. A review of Resident #105's Admission MDS, dated [DATE], revealed he had a BIMS score of 13, which indicates he was cognitively intact. A review of Resident #105's Care Plan revealed a care plan was written on 01/10/25 regarding he was on IV medications related to right 3rd finger Osteomyelitis and right-hand Cellulitis. A review of Resident #105's physician orders revealed an order was written on 01/15/25 for Change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Every day shift every Wednesday. A review of Resident #105's Medication Administration Record (MAR) revealed a staff member documented the PICC line dressing was changed on 02/05/25 (photographic evidence obtained). Additional observations were conducted on 02/11/25 at 12:20 PM and 1:45 PM of Resident #105's PICC line dressing, which remained dated 02/01/25. An interview was conducted with Resident #105 on 02/12/25 at 3:06 PM, in which he stated his PICC line had been removed the evening of 02/11/25. An interview was conducted with Staff M, LPN on 02/12/25 at 2:45 PM. Staff M stated the PICC line dressings were changed every three to five days. She said the staff should be assessing the PICC line dressings every time they go into the resident's room. She further stated the LPNs could assess the dressings, but a registered nurse had to perform the dressing changes. Staff M continued to explain that there was one nurse who performed the dressing changes on night shift and either the DON or Assistant DON who performed the dressing changes on day shift. Staff M confirmed that her initials were on the MAR as having signed off the PICC dressing change on 02/05/25. When asked why she signed off that the dressing change was completed on 02/05/25, she stated she would have told one of the nurses that Resident #105's PICC line was due for a dressing change and assumed the nurse had changed it. An interview was conducted with the facility's DON on 02/12/25 at 4:05 PM. She stated the expectation would be for whoever performed care, such as changing a dressing change, would sign off the resident's medical record. In this instance, the LPN should not have signed off that the PICC line dressing was changed. The DON further stated the LPN should have looked at the dressing to see if it had been changed and had the registered nurse sign off that the dressing change was completed. Review of the facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection, date revised November 2011 revealed the staff should mark . with date and initials and change the oxygen cannula and tubing every seven days, or as needed. Review of the facility policy titled Guidelines for Preventing Intravenous Catheter-Related Infections, date revised August 2014 revealed the staff should change transparent semi-permeable membrane (TSM) dressings on central venous access devices every 5-7 days or as needed if damp, loosened, or visibly soiled and gauze dressing covered with TSM dressing should be considered a gauze dressing and changed at least every 48-hours.

Based on observations, interview, and record review, the facility failed to maintain proper isolation precautions for 2 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident #97 and #67), and the facility failed to ensure proper handwashing practices during medication administration opportunities for 2 of 20 observations (Resident #71 and #563). The findings include: Resident #97 During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter present. Resident #97 stated the staff did not clean the catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. He had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infection. A review of Resident #97's Admission Minimum Data Set (MDS), dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) Score of 11, which indicates he had moderate cognitive impairment. This MDS documented the presence of the urinary catheter. A review of Resident #97's physician orders revealed there were orders written on 01/11/25 regarding Catheter care every shift and as needed and Enhanced Barrier Precautions. A urinary catheter care observation was conducted with Staff A, Certified Nursing Assistant (CNA), and Staff B, another CNA, on 02/13/25 at 10:33 AM. They gathered their needed supplies from a linen cart and entered Resident #97's room. Staff A and Staff B washed their hands and donned gloves. Staff A had a handful of gloves in her scrub top pocket that she used throughout the catheter care observation. Neither Staff A nor Staff B donned an isolation gown for performing the catheter care. Resident #67 During the initial record review conducted on 02/10/25 at 3:34 PM, Resident #67 was noted with pressure injuries present on his left heel, left groin, right ischium, and sacrum. A review of Resident #67's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. He had a medical history significant for Paraplegia, Malnutrition, Osteomyelitis, Colostomy, Depression, Atrophy, and Muscle Weakness. A review of Resident #67's Annual MDS, dated [DATE] revealed he had a BIMS score of 15, which indicates he was cognitively intact. This MDS documented the presence of pressure injuries. A review of Resident #67's physician orders revealed there were orders written on 11/08/24 regarding wound care procedures for each of his wounds. A wound care observation was conducted with Staff C, Licensed Practical Nurse, and Staff D, Nurse Practitioner. Staff C gathered supplies from the wound care cart prior to entering Resident #67's room. Staff C and Staff D washed their hands and donned gloves. Neither Staff C nor Staff D donned an isolation gown for performing the wound care. 48580 Resident #71 On 02/13/25 at approximately 08:19 AM during Med Pass observations for Resident # 71, Nurse J was observed to dispense medications to Resident #71 without washing her hands or using hand sanitizer. Hand sanitizer was readily available on top of the medication cart and a sink and soap was available in the resident's room. She then proceeded to prepare medications for the next resident without sanitizing her hands between residents. On 02/13/25 at approximately 09:00 AM, Nurse K donned gloves to hang the IV antibiotic for Resident # 563 and was observed to use a gloved hand to place the used bag into a trash can aand then used the same hand to flip hair out of her face, but she did not change gloves. She proceeded to use contaminated gloves to wipe the hub of a medication vial with alcohol and the insert spike of IV tubing. Nurse K then proceded to continue medication pass to Resident # 84. She removed her gloves but did not use hand sanitizer or wash hands between residents. Nurse K was also observed to place her finger inside a medication cup while opening medication cart to obtain ordered medications. A review of the facility policy titled Enhanced Barrier Precautions, dated August 2022 revealed the following: Gloves and gowns are applied prior to performing high contact resident care activity Examples: providing hygiene, device care or use (including urinary catheters), wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk Signs are posted in the door or wall outside the resident's room indicating the type of precautions and personal protective equipment (PPE) required PPE is available outside of the resident's rooms.

Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 4 of 5 residents reviewed for Influenza and Pneumococcal Vaccinations (Resident #101, #51, #105, and #96). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the Pneumococcal vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the Influenza vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the Influenza vaccine. A review of Resident #105's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #105's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #105 was missing a consent form for the Pneumococcal vaccine. A review of Resident #96's medical record for vaccinations revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE] after an extended hospitalization which lasted approximately 3 weeks. A review of the Immunization section of Resident #96's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #96 was missing a consent form for the Pneumococcal vaccine from his initial admission in October 2024. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 02/13/25 at 11:10 AM regarding the missing Influenza and Pneumococcal vaccination consent forms. The ADON stated she would work with the Medical Records Department to find the missing consent forms. The ADON returned at 12:15 PM and confirmed she and the Medical Records personnel were unable to find the missing consents. The ADON then showed the surveyor a check list that the staff follow for each new resident admission, which contained directions that the staff are to obtain consents for Influenza and Pneumococcal vaccines. She stated in speaking with the Medical Records personnel that she was told, after things are scanned into residents' charts, the forms are then disposed of and not kept. Review of the facility's policy titled Influenza Vaccine, revised date March 2022 revealed the influenza vaccine shall be offered to residents, and a resident's refusal of the vaccine shall be documented on the informal consent for influenza vaccine and placed in the resident's medical record. Review of the facility's policy titled Pneumococcal Vaccine, revised date March 2022 revealed residents are offered the vaccination within 30 days of admission to the facility, vaccines are administered to residents per our facility's protocol, and if refused, appropriate information is documented in the resident's medical record indicating the date of the refusal.

Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 3 of 5 residents reviewed for COVID-19 Vaccinations (Resident #101, #51, and #105). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the COVID-19 vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the COVID-19 vaccine. A review of Resident #105's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #105's electronic medical record revealed he had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #105 was missing a consent form for the COVID-19 vaccine. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 02/13/25 at 11:10 AM about the missing COVID-19 vaccination consent forms. The ADON stated she would work with the Medical Records Department to find the missing consent forms. The ADON returned at 12:15 PM and confirmed she and the Medical Records personnel were unable to find the missing consents. The ADON then showed a check list that the staff follow for each new resident admission, which contained directions that the staff are to obtain consents for COVID-19 vaccines. She stated in speaking with the Medical Records personnel that she was told, after things are scanned into residents' charts, the forms are then disposed of and not kept. She said the Medical Records personnel also told her, Sometimes things get stuck together and that may have been why the consents were missing from the charts. A review of the facility's policy titled COVID-19 Vaccine-Resident, revised date 11/17/21 revealed the staff should review the COVID-19 consent with the resident/resident representative, obtain signature indicating acceptance or declination, and file the consent form in resident electronic health record.

Based on observations, staff and resident interviews, record review, and policy review the facility failed to take precautions to ensure safety of residents during smoking times for 6 of 10 residents reviewed. (Residents #4, #5, #6, #7, #8, and #10) The findings include: On 12/10/24 at approximately 9:00 AM an interview was conducted with Staff Member B, a Certified Nursing Assistant (CNA). She indicated that the CNA's escort the residents outside for smoking in addition to their daily assignments. She said there are quite a few smokers at the facility and no dedicated staff assigned to supervise smoking. She explained that residents get impatient waiting to go out and some of the higher functioning residents occasionally go outside to smoke without supervision. She also said that several residents in the facility have their own lighters and cigarettes that they keep in their rooms. She said Resident #4 goes out and needs close supervision because she is blind. She indicated that Resident #8 keeps a lighter in her purse and is always wanting to go outside to smoke. On 12/10/24 at approximately 9:00 AM, Staff Member A, another CNA, was interviewed. She indicated agreement with what Staff B and reiterated concerns with the supervision of the residents during smoking. She said sometimes they have 20 residents smoking at a time. They have to stop what they are doing to take residents out who smoke outside. Residents who smoke often get agitated while waiting to go outside. They have to stop resident care to take the smokers outside. On 12/10/24 at approximately 9:04 AM, Resident #4 was observed seated in a wheelchair in a common area asking several staff members if it was time to go outside to smoke yet. She told staff members that normally she goes out to smoke by now. It appeared that she had trouble with her vision and could not clearly see or identify staff members. Staff members in the area did not respond to the residents' requests. On 12/10/24 at approximately 9:08 AM, there were several residents in wheelchairs observed waiting at the door to the smoking area. Resident #5 was seated in his wheelchair next to the exit to the smoking area. He had a lighter and cigarettes in his pocket. Resident #6 was also seated in the next to the exit door. An interview was conducted with Resident #5. Resident #5 said, I have my lighter with on me all the time. Resident #6 was also observed with a lighter in his hand. On 12/10/24 at approximately 9:30 AM, smoking time was observed. Staff Member S, another CNA, was present with residents at the time. There were no smoking safety aprons present in the area. Resident #5 and #6 lit cigarettes and began smoking. A few minutes later, Resident #7 pulled a lighter out from his pocket. Resident #8 removed a lighter from her purse and began to smoke. Staff Member S was asked to point out the safety aprons. Staff Member S indicated that he did not know where the smoking aprons were. The staff member was asked to see the area where smoking supplies are kept for the residents. Staff Member S stated that several of the residents normally keep their cigarettes and lighters with them. He explained that Resident #9 was not allowed to keep his lighter with him but many of the other residents keep their smoking supplies with them. He explained that he did not know where the box of smoking supplies or the aprons were kept. He indicated that he was a temporary staff member who came up after the hurricane. He indicated that he worked for a sister facility and has received training regarding safety in resident smoking areas. After the interview, Staff Member S stepped inside and left the residents smoking in the smoking area without supervision for approximately 1 minute. At approximately 9:34 AM, Staff Member B came out to assist. On 12/10/24 at approximately 9:40 AM, the Assistant Director of Nursing (ADON) came out to the smoking area. She was asked if the residents should have their lighters in their possession at all times. The ADON explained that residents should not have lighters with them. She explained that the facility has a smoking box that is supposed to come out with the aprons at smoking time. Resident #10 had a lighter in her hand at the time. The ADON collected the lighters from Resident #5, #6, #7, #8 and #10. At approximately 9:50 AM, a staff member brought Resident #4 outside to the smoking area. Resident #4 said, I can't see. Where is my cigarette? The staff member told her they are getting her an apron to wear for smoking. Resident #4 shifted impatiently raised her voice slightly as she said, I don't wear no apron. Where is my cigarette? Resident #4 was asked if she normally wears an apron when she smokes. She replied: No, No, No Ma'am. I don't know what they are giving an apron for. I have never worn an apron. As the staff member applied the apron, the resident said, What is this apron for? I have never used an apron. This is the first time they ever done this. On 12/10/24 at approximately 10:00 AM, a review of the record of Resident #4 revealed that she was admitted on [DATE]. Resident #4's care plan indicted that she had impaired vision and loss of vision in both eyes. The surveyor was unable to locate a smoking evaluation in the electronic record for Resident #4. Additionally, there was no mention that the resident smokes in the care plan. There was no indication she ever received any smoking related injuries or mishaps. On 12/10/24 at approximately 11:00 AM the ADON provided copies of two smoking evaluations for Resident #4, one dated 11/27/24 at 5:33 PM and the other dated 12/10/24 at 10:12 AM and the facility smoking policy. A review of the smoking evaluation dated 11/27/24 was conducted. The evaluation indicated that Resident #4 does not smoke. A smoking evaluation was not completed on that date. A review of the evaluation completed on 12/10/24 at 10:12 AM indicated that Resident #4 smoked. The assessment indicated that her vision was inadequate. She was determined to be a safe smoker. The assessment indicated that Resident #4 requires constant supervision while smoking. There was no mention of use of the smoking apron in the evaluation. Page 7 of the updated care plan indicated that Resident #4 was a smoker. Date initiated 12/10/24. Goals: The resident will not smoke without supervision through the review date. Date initiated 12/10/24. Interventions included the resident was instructed about the facility smoking policy on 12/10/24. The resident requires a smoking apron while smoking. Date initiated 12/10/24. The resident requires SUPERVISION while smoking. Date initiated 12/10/24. The resident's smoking supplies are to be stored at the nursing station. Date initiated 12/10/24. On 12/10/24 at approximately 12:00 PM, a review of the facility smoking policy dated 11/30/2014 was conducted. The policy stated, Residents that wish to smoke will be evaluated on admission/readmission, quarterly, and with change of condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking the center will include the appropriate information on the care plan. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. The policy also stated that the center will retain and store matches, lighters etc . for all residents, which was not the case for Residents #5, #6, #7, #8 and #10.

Based on resident and staff interviews, review of the facility grievance log, and policy and procedures, the facility failed to make prompt efforts to resolve grievances for 2 of 3 residents reviewed. (Residents #2 and #3) The findings include: On August 14, 2024 at 2:07 pm, a telephone interview was conducted with the husband of Resident #2. He stated he has filed two grievances with the previous administrator, one in August 2024 and another in July 2024. He stated they had voiced numerous complaints to the previous Nursing Home Administrator (NHA) and nothing was ever done about it. On August 14, 2024 at 2:20 pm, an interview was conducted with Resident #3. She stated that several grievances have been filed with the previous NHA about two Certified Nursing Aides (CNAs) that speak disrespectfully to the residents and failed to render assistance when needed, but nothing ever gets done about it. The same staff who disrespect and ignore the call lights continue to work on this hallway according to the resident. She also stated that, after she had lodged complaints against this CNA, the CNA was serving meal trays on the hall but skipped over their room. She stated to the CNA that We never received our trays. The CNA stated, I don't want to walk in that room, because she knew we had previously complained about her behavior. Review of the medical record for Resident #2 revealed a Brief Inventory for Mental Status (BIMS) listed as 15 (no impairment of cognition) and the resident's diagnose include hemiplegia/hemiparesis post stroke affect left dominant side; and difficulty walking, among others. Review of the medical record for Resident #3 revealed also revealed a BIMS score of 15 (no impairment of cognition) and a below the knee amputation left side. A review of the Grievance Logs since March 2024 through present revealed there were no complaints or grievances for Resident #2 or Resident 3 during the month of August or July, even though both residents expressly stated they filed a grievance. The Regional Director was interviewed concerning these grievances. He stated that these were grievances were submitted to the previous Administrator, who claimed they had followed up on these issues. They did not discover the failure of the previous administration to follow up on these grievances until after the previous administrator had left. Review of Policy and Procedures Subject Complaint/Grievance Document Name N-1042 Effective Date 11/30/14 and Revision Date 10/24/22 revealed the Procedure as follows: 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. -Complaint/Grievance forms will be available 24 hours per day 7 days a week in an unsecured common area. -Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the Grievance Officer /designee for further action. 3. The Grievance Officer /designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on observations and interviews, the facility failed to provide a clean, safe and home-like environment for 11 of 94 occupied areas. The findings include: On 2/28/24 at 10:34, during the initial tour of the facility, the following environmental concerns were observed: Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-B had an overhead table with exposed edges. Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-A had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-B had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-A had wall paper peeling off the wall and a patched up white substance on the wall. Occupied room [ROOM NUMBER] had overhead tables with the plastic rim detached, exposing particle wood. Occupied room [ROOM NUMBER]-A had an overhead table with edges that are chipped. Additionally, the bed's frame is rusted. Occupied room [ROOM NUMBER]-A had an overhead table with the plastic rim detached, exposing particle wood. Occupied room [ROOM NUMBER]-B had an overhead table with the plastic rim detached exposing particle wood, and dresser also had particle wood exposed on the edges. In the public 200 Hallway, there was an approximately 6 foot long baseboard that was detached from the wall. (Photographic evidence was obtained) On 2/29/24 at 12:50, a follow-up tour was conducted with the Administrator, DON and Regional Consultant. The Administrator stated all the overhead tables and the fall mat would be replaced for new ones. The DON stated the wall paper in room [ROOM NUMBER] would be replaced immediately. The Administrator further stated the bed in room [ROOM NUMBER]-A would be fixed by a new one once the impending shipment arrived. Invoices showing this bed was ordered was requested but were not provided.

Based on staff and family interviews, medical record reviews, policy reviews, and police report review, the facility failed to establish and follow an effective resident identification process for 1 of 3 residents sampled for admission/discharge (Resident #1). The failure to ensure that residents admitted to the facility were correctly entered into the electronic medical record system resulted in Resident #1 being admitted under the name of a resident (Resident #3) who had been discharged from the facility over 5 years ago. Interviews with the resident's spouse revealed the resident was transferred within 24 hours of admission. Resident #1 was admitted under the wrong name and with an incorrect medication list and demographic sheet (containing emergency contact information). The spouse had to file a missing person's report with the local police department to locate her husband. The facility's staff were not aware of the error until law enforcement arrived to investigate the missing person concern. The facility did not ensure that the resident's identity was correctly entered into the electronic medical record (EMR), did not follow patient identification to ensure the 5 rights of medication administration were followed (right patient, right medication, right route, right time, and right dose) which resulted in the resident receiving eye drops for [CONDITION(S)] and an antibiotic prescribed to another patient. He also did not receive his own routine heart, blood pressure and respiratory medications. This failure places all residents who are admitted to the facility at risk for serious injury/impairment/death from inaccurate medical records and physician orders. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J isolated. The facility Administrator was notified of the Immediate Jeopardy finding on 8/03/2022 at 6:25 PM. The Immediate Jeopardy was determined to have begun on 7/08/2022, the day that Resident #1 was admitted to the facility under the wrong name. The Immediate Jeopardy was found removed on 8/04/2022 at 4:06 PM when the facility provided evidence of immediate actions to remove the serious threat. The deficient practice was reduced to a scope and severity level of an D. The findings include: On 8/01/2022 at approximately 9:15 AM, a telephone interview was conducted with the spouse of Resident #1. She stated that her husband was admitted to the facility on [DATE] for short term rehabilitation and was there less than 24 hours before being transferred out to a local hospital. She stated she had spent several hours at the facility with her husband on 7/09/2022 and noticed he was not doing well and was in a bad mood. After leaving her husband at the facility, at approximately 8:00 PM, she received a call from an unknown cell phone number advising her they were calling from the facility and that her husband was being sent out to a local hospital due to elevated blood pressure and difficulty breathing. The spouse reported that she decided to wait until the next morning (7/10/2022) to go to visit him at the hospital. She stated that on the morning of 7/10/2022, she went to the hospital and was told that her husband was not there. She then attempted to call the facility again to clarify exactly where they sent her husband. She stated the staff member who answered the call told her they would not provide her with information about her husband because she did not have Power of Attorney (POA) over him (according to the medical record). At this time, she stated she started to panic and was not sure what to do because no one at the facility would provide her with information or assist her with locating her husband. She stated she returned to the facility to collect her husband's belongings, and again attempted to speak to staff about where they had sent her husband, explaining she was unable to locate him at either of the local hospitals, but they still insisted she could not be given that information because she was not his POA. She stated that as she was leaving, the receptionist working at the time, told her she was sorry about this and advised that she might want to check the morgue. She stated this caused her to run out of the facility and go straight to the police department to report her husband as a missing person. The spouse stated that the police officer contacted the facility and then met her at the hospital. She overheard the hospital nurse on the line speaking to the officer who stated, Oh my gosh! He does have a wife? He's been calling/yelling out for his wife all night long and we thought he just had dementia, because his medical records stated he was not married. Then the officer told her she would need to identify her husband to determine who he actually was, because he was listed under a patient with the same last name but with a different first name, date of birth, and social security number. She went with the officer to the patient's room to peer through a window and was able to identify the patient as her husband. She stated the facility sent her husband to the hospital under another patient's name. She stated the facility's Administrator called her to apologize and said they fixed the situation, so this will never happen again. She stated that she was very worried about what medications her husband had been given, since a nurse advised her that he had been administered eye drops when he does not use eye drops. She stated she is very worried that he may have received medications belonging to the resident under which her husband was erroneously entered as and NOT received the medications he really needs. She stated her husband stayed in the hospital for about two weeks and has since been discharged home to her care on hospice. She stated she is terrified to place him anywhere since this incident occurred. A review was conducted of a police report dated 7/10/2022, which reported that an officer was dispatched [to a local hospital] to make contact with a subject who advised [the hospital] would not let her see family. The officer documented I made contact with the Complainant [Resident #1's wife] in the atrium. Wife advised the following: Husband had been admitted to a rehabilitation facility [address]. At approximately 1830 hours (6:30 PM), on July 9th, she received a missed call from the facility. At approximately 1900 hours (7:00 PM), she called back to the facility and learned her husband was having breathing problems and they were going to call EMS (Emergency Medical Services) to transport him to the hospital. Husband had COVID previously as well. Wife came to [the facility] and was allowed to collect his belongings but stated they would not give her an update as she did not have power of attorney over husband. She responded to [the police department] duty office, who instructed to go in person to [the hospital] to attempt to locate husband. Officer learned there was another patient with the same last name admitted to [hospital room number], who had been brought in from [the long-term care facility]. Looked into the room to see if we could identify him. The patient in the room was COVID positive and we did not enter. We were unable to positively identify him. I then responded to [the long-term care facility] and made contact with a staff member. We were finally able to ascertain husband had been admitted to [the long-term care facility] under another person's identity with the same last name and that information was given to EMS, who then gave it to [the local hospital]. Wife met with staff at [hospital room number] and was able to positively identify him as her husband. The nursing staff was made aware, and they were in the process of correcting the information. The [long term care facility] staff member affirmed the error, and it was captured on my body worn camera for documentation. Although we determined husband was not missing and this is a result of a clerical error from [long term care facility], this report was completed to document the error. Wife also advised husband was possibly given the wrong medication. On 8/01/2022 at approximately 10:35 AM, an interview was conducted with the Administrator and Acting Director of Nursing (Acting DON) who both acknowledged an incident occurred and explained that the resident was admitted to the facility on the evening of 7/08/2022 (Friday) with his correct medical records, but the wrong patient's name was activated in the electronic medical record (EMR). They confirmed that Resident #3, who was activated in error, had not been in the facility since April 2017, and this was Resident #1's first admission to the facility. The Acting DON stated she was at the facility when Resident #1 was sent out to the emergency room (ER) on 7/09/2022. She stated, I put his orders in from [the hospital] paperwork that arrived with the resident upon admission that Friday afternoon. She stated she saw [Resident #1's last name] and clicked on that name because that was the name activated in the EMR. She stated she worked that Saturday on the unit as floor nurse. She stated that a Registered Nurse (RN) told her that Resident #1 had labored breathing and they could not get his oxygen saturation above 86% or 87%. She stated when she asked Resident #1 about going to the ER and he responded yes. She explained that when a resident is transferred out to the ER, they make copies of their orders, and face sheet from the EMR, and these documents are sent with the resident. She stated the medication orders were for Resident #1 and those were the orders she received from [the hospital] upon admission and were the orders she entered into the EMR. She stated she was not at the facility on 7/10/2022 (Sunday) when the police showed up to try to find out where this gentleman was sent. When asked why the wife was not provided with any assistance in locating her husband, or answering specific questions the wife had about her husband's medications and transfer, the Acting DON stated the wife was told she could not have his information because of the clerical error of the resident being entered under another a previous resident's (Resident #3) record, who did not have a wife. She confirmed the face sheet provided to [the local hospital] was for Resident #3 but continued to insist the medication orders were for Resident #1. She stated when the police department showed up, they double checked the paperwork and realized that Resident #3 was at our facility back in 2017, and this resident was actually Resident #1. At this time, the Acting DON stated, We did verify that what medication orders Resident #1 came in with was what was sent out with him, right orders, wrong name only. A review of the Electronic Medical Record (EMR) for Resident #1 revealed no physician orders, no medication/treatment administration records, no care plans, no progress notes, no vital signs, or assessments recorded. However, under the miscellaneous tab there was an attachment that was identified as Resident #1's admission paperwork which had been uploaded into the EMR on 7/08/2022. The attachment contained copies of records from [a local hospital] and contained the resident's discharge orders, diagnoses, medications, and labs from most recent hospital admission. Continued review of the admission paperwork revealed a history and physical dated 6/16/2022 which listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also included in this history and physical was a list of Resident #1's home medication which consisted of Aspirin 81 mg (milligrams) every day; [MEDICATION(S)] 40 mg (high cholesterol medication) every day; [MEDICATION(S)] 6. 25mg (blood pressure and heart failure medication) twice a day; [MEDICATION(S)] 5 mg twice a day (agitation medication); [MEDICATION(S)] 2 puffs, inhalation every 4 hours (respiratory medication); [MEDICATION(S)]/[MEDICATION(S)]/methylsulfonylmethane 750 mg-400 mg-375 mg (arthritis supplement) 2 tabs every day; [MEDICATION(S)] 25mg, 50mg = 2 tabs (tablets) (High blood pressure medication) twice a day; [MEDICATION(S)] 720mg (heart failure medication) twice a day; [MEDICATION(S)] 40 mg (cholesterol medication) every evening; [MEDICATION(S)] 40 mg (High blood pressure medication) every day; Omeprazole 720mg (antacid) every morning; [MEDICATION(S)] 1 mg = 2 cap (capsules) (high blood pressure and urinary retention medication) every evening; [MEDICATION(S)] 20 mg (diuretic) Mon/Wed/Fr/Su (Monday, Wednesday, Friday and Sunday) and 40 mg T/Th/Sat (Tuesday, Thursday and Saturday). None of this information was put into the orders section of the EMR and there was no evidence that Resident #1 had received any of his home medications during his stay at the facility. A review of the EMR for Resident #3, whose EMR was erroneously activated for Resident #1, revealed that Resident #3 was re-activated (readmitted ) on 7/08/2022 and also contained the same attached admission paperwork as Resident #1 uploaded into the miscellaneous tab. The EMR included physician orders for medications and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/08/2022 at 2100 (9:00 PM) [MEDICATION(S)] Calcium Oral Tablet 40 MG (for high cholesterol), on 7/09/2022 at 9:00 AM, [MEDICATION(S)] Ophthalmic Solution 0.005 % (an eye drop to treat [CONDITION(S)]), [MEDICATION(S)] (an antibiotic), [MEDICATION(S)] Ophthalmic Suspension 1 % (an eye drop used to treat [CONDITION(S)]) and [MEDICATION(S)] Ophthalmic Solution 0.5 % (an eye drop used to treat [CONDITION(S)]). It is noted that Resident #3 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of progress notes for Resident #3, erroneously entered as Resident #1, revealed that on 7/9/2022 at 15:46 (3:46 PM), a skilled nursing note documented that Resident #3 (actually Resident #1) was admitted on [DATE] with the nurse documenting that the resident was oriented to person, his skin was warm and dry, no swallowing problems were noted. Mood was pleasant smiling. The note also stated that the resident was pleasantly confused and was receiving an antibiotic for [CONDITION(S)]. At 2300 (11:00 PM) the nurse documented conducting a skin assessment and noted a dressing to his right groin area and Refused to let writer removed dressing to assess. At 20:51 (8:51 PM) the nurse documented speaking with the resident's wife to obtain a Verbal consent give for DNR (Do Not Resuscitate). Upon review of the paper copy of the medications entered into the EMR for Resident #3 it was revealed that the medication list submitted with the hospital's discharge paperwork had a different FIN# (hospital Patient Identifier Number) at the bottom of the page of the medications than the FIN on all the other pages and was actually for a different hospital patient (a third individual) and was not for either Resident #1 or Resident #3, but had been entered into the EMR for Resident #3. These medications included 3 eye drops for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/2022 at approximately 12:35 PM, a follow-up interview was conducted with the Acting DON. She stated the nurse on duty at the time the officer contacted the facility advised her that the police were calling and looking for Resident #1. Staff D, Registered Nurse (RN), advised the Acting DON that she had checked the paperwork, realized the mistake, and advised the officer of the correct resident name (Resident #1). When the surveyor pointed out that the medication list included in the admission packet for Resident #1 had a different FIN number at the bottom of the page of the medications than the FIN on all the other pages, she stated she was unaware that the FIN number displayed on every page from the hospital records was a patient identifier and had not followed up with the hospital as to whom this FIN belonged to. When asked why all of Resident #1's progress notes, assessment for change in condition and medications were still listed under Resident #3 in the EMR, she stated that she had to get with her corporate staff so they could correct the records. On 8/02/2022 at approximately 9:58 AM, an interview was conducted with the Administrator and Acting DON, during which the Acting DON stated it was the Admissions Coordinator who accidentally activated the wrong resident in the EMR. The Acting DON stated she just put the medication orders into the computer. The Acting DON again stated this medication list was in the hard copy paper packet that came with the resident from the hospital. On 8/02/2022 at 1:45 PM, a follow-up interview was conducted with the Admissions Coordinator in the presence of the Corporate Registered Nurse, Administrator, and Acting DON. The Admissions Coordinator stated that the original referral packet from the hospital came through the electronic referral system and demonstrated this by pulling up the records for Resident #1. When the admission referral for Resident #1 loaded into the referral system, this surveyor began to scroll down through all pages of the packet and immediately noticed there was paperwork for a different hospital patient altogether included in the paperwork for Resident #1 that was sent from the hospital. Further review determined the FIN number located at the bottom of the medication list entered for Resident #3 (who was erroneously entered as Resident #1) matched the FIN for the different hospital Patient, not Resident #1 or Resident #3. At this time, the Acting DON, Administrator, and Admissions Coordinator confirmed the medication orders entered for Resident #1 (under the EMR for Resident #3) belonged to another hospital patient. The Admissions Coordinator confirmed that she was the one who activated the wrong resident (Resident #3). At this time, the Acting DON acknowledged that the hospital sent Resident #1 to the facility with a hard paper copy of the admission packet, which included the wrong medication list. The Admissions Coordinator accidentally activated the wrong resident who had the same last name as Resident #1. Residents are activated in the EMR once they are assigned to a room. If the admission happens after hours the Admissions Coordinator can activate offsite (remotely). On 8/03/2022 at approximately 1:22 PM, a telephone interview was conducted with the Consultant Pharmacist. The Pharmacist was provided a list of the medications erroneously given to Resident #1 and a list of the medications the resident should have received. The pharmacist stated that it was very possible that his blood pressure and heart rate would have increased since he missed two of his blood pressure medications. If the resident would have had an allergy to one of the eye drops or the [MEDICATION(S)], he was given in error, there could have been a bad outcome. However, without an allergy to [MEDICATION(S)] he may have had some upset stomach. The pharmacist went on to state that the [MEDICATION(S)] ophthalmic eye drops were a steroid which may or may not result in side effects and the [MEDICATION(S)] could have caused a decrease intraocular pressure since it begins to work within 4 hours but reported he did not know if there would be another side effect. The facility submitted an acceptable IJ Removal Plan. The survey team verified the following facility's immediate actions to remove the likely serious harm: The Admissions Coordinator was educated on ensuring the correct name is entered into the Electronic Medical Record (EMR) for residents being admitted to the facility. One of the administrative staff which includes the Administrator, Business Office Manager, Assistant Business Office Manager and the Receptionist will conduct a second review of the new admissions at the time resident is activated into the EMR by the admission coordinator to ensure resident name is entered into the system correctly. Administrative staff listed above were trained on 8/02/2022 to verify in the EMR along with the admission coordinator at the time the resident is activated into EMR that the correct resident identifying information including name, date of birth and social security number match the paperwork from the discharging hospital. The Acting DON who entered medications into the EMR for the admission, utilizing the medication reconciliation from the hospital, was educated on 8/02/2022 verifying medications are correct and name in the EMR matches name on hospital paperwork. Current facility charge nurses, RNs, and Licensed Practical Nurses (LPNs) were educated starting on 8/02/2022 on the new process for ensuring the name in the EMR matches the hospital paperwork and hospital medication reconciliation is correct. The new process is that 2 charge nurses, RNs or LPNs will review paperwork from the hospital at the same time to confirm the resident's name on the hospital paperwork matches the name in the electronic medical record. The 2 charge nurses, RNs or LPNs will review the medication reconciliation list from the hospital at the same time to confirm the name matches on all pages of the medication reconciliation. These 2 nurses will also during this time verify page number sequence and identification numbers on medication reconciliation to ensure all pages match. The 2 charge nurses, RNs, or LPNs will also review medications in the hospital history and physical and compare to the hospital medication reconciliation list, if any discrepancy is identified, during medication review, the nurse will call the case manager at the hospital or facility physician for clarification. A review of the new admission charts will be conducted by the DON, ADON and Unit Mangers, the next morning to ensure resident name is correct and medication list is accurate. An Ad Hoc Quality Assurance/Performance Improvement meeting was held 8/02/2022 with the Executive Director, Interim Director of Nursing, MDS Coordinator, Dietary Manger, Activities Director, Maintenance Supervisor, Human Resources Director and Medical Director to discuss the opportunity for improvement, assess the current situation, root cause analysis, and plan of correction to include education with licensed nurses and admission team. The Executive Director received education 8/03/2022 by the Chief Operations Officer on the 5 elements of Quality Assurance/Process Improvement. The IDT (interdisciplinary team) was educated on 8/03/2022 on the QAPI process. Important functional areas may include but are not limited to admissions, the admission process, quality of care, staff education and developing and implementing appropriate plans of action to correct identified quality deficiencies related to admitting and transferring a resident using a similar but different name. Education was initiated by the Administrator on 8/03/2022 for all staff to include, staff notification, to the Administrator or DON, if a responsible party or family member of a resident expresses a concern that cannot be resolved by staff on duty, to include the location of a resident. A self-imposed moratorium on new admissions was implemented until the interdisciplinary QAPI team reviews and determines that compliance has been sustained with these processes. A request has been made to the Administrator of the EMR to correct the Medical Record for the affected resident. The Administrator notified the hospital Risk Manager of on 8/03/2022 concerning the issue related to the wrong medication reconciliation list being sent to the facility in the hospital paperwork. The FIN number on the medication reconciliation list and the paperwork for Resident #1 were sent to the Risk Manager on 8/04/2022. She also requested a copy of the hospital paperwork the facility received to be taken to her Friday 8/05/2022.

Based on medical record review, police report review, and staff and family interviews, the facility's Quality Assurance Performance Improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to admitting and transferring a resident using the wrong resident name. This resulted in law enforcement investigating a missing person, the resident receiving the wrong medications, and being transferred to another facility with the wrong history and physical, incorrect medication list, and an incorrect marital status for 1 of 3 residents reviewed for admission/transfer (Resident #1). The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility Administrator was notified of Immediate Jeopardy finding on 8/03/2022 at 6:25 PM. The Immediate Jeopardy was determined to have begun on 7/08/2022, the day that Resident #1 was admitted to the facility under the wrong name. The Immediate Jeopardy was found removed on 8/04/2022 at 4:06 PM when the facility provided evidence of immediate actions taken to remove the serious threat. The deficient practice was reduced to a scope and severity level of a D. The findings include: On 8/01/2022 at approximately 9:15 AM, a telephone interview was conducted with the spouse of Resident #1, who had been admitted to the facility on [DATE] for short term rehabilitation. The spouse reported that on 7/09/2022 at approximately 8:00 PM, she received a call from an unknown cell phone number advising her they were calling from the facility and that her husband was being sent out to a local hospital due to elevated blood pressure and difficulty breathing. The spouse arrived at the hospital the following morning where she was told that her husband was not there. She then called the facility and was told she was not the resident's Power of Attorney (POA) and therefore could not be given information related to the resident. She contacted the local police department who met her at the hospital and after the officer spoke with hospital staff was able to determine the resident had been admitted to the hospital under a patient with the same last name but with a different first name, date of birth, and social security number. Cross Reference F684. A review of the law enforcement report dated 7/10/2022, revealed the officer arrived on site and was able to assist the wife with positively identifying her husband [Resident #1] as the patient admitted in the hospital under the name of Resident #3. A review of the Electronic Medical Record (EMR) for Resident #1 revealed no physician orders, no medication/treatment administration records, no care plans, no progress notes, no vital signs, or assessments recorded. However, under the miscellaneous tab there was an attachment that was identified as Resident #1's admission paperwork which had been uploaded into the EMR on 7/08/2022. The attachment contained copies of records from [a local hospital] and contained the resident's discharge orders, diagnoses, medications, and labs from most recent hospital admission. A review of the EMR for Resident #3 revealed that Resident #3 was re-activated (readmitted ) on 7/08/2022 and also contained all the same admission paperwork for Resident #1 uploaded into the miscellaneous tab in the EMR but also included physician orders, medication administration records (MAR), vital signs and progress notes. Review of the MAR for Resident #3 (erroneously entered as Resident #1) for the dates of July 8 and 9, 2022 revealed that Resident #1 received the following medications that had been entered into Resident #3's EMR: on 7/08/2022 at 2100 (9:00 PM) [MEDICATION(S)] Oral Tablet 40 MG (for high cholesterol), on 7/09/2022 at 9:00 AM, [MEDICATION(S)] Ophthalmic Solution 0.005 % (an eye drop to treat [CONDITION(S)]), [MEDICATION(S)] 500 MG (an antibiotic), [MEDICATION(S)] Ophthalmic Suspension 1 % (an eye drop used to treat [CONDITION(S)]) and [MEDICATION(S)] Ophthalmic Solution 0.5 % (an eye drop used to treat [CONDITION(S)]). None of these medications were listed on the home medication list included in the discharge paperwork that had been uploaded in the EMR under the miscellaneous tab for Resident #1. Upon review of the paper copy of the medications entered into the EMR for Resident #3 it was revealed that the medication list submitted with the hospital's discharge paperwork had a different FIN# (hospital Patient Identifier Number) at the bottom of the page of the medications than the FIN on all the other pages and was actually for a different hospital patient and was not for either resident #1 or Resident #3. These medications included 3 eye drops for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/01/2022 at approximately 10:35 AM, an interview was conducted with the Administrator and Acting Director of Nursing (Acting DON) who both acknowledged an incident occurred and explained that the resident was admitted to the facility on the evening of 7/08/2022 (Friday) with his correct medical records, but the wrong patient's name was activated. They confirmed that Resident #3 had not been in the facility since April 2017 and this was Resident #1's first admission to the facility. When asked why the wife was not provided with any assistance in locating her husband or answering specific questions the wife had about her husband's medications and transfer, the Acting DON stated the wife was told she could not have his information because of the clerical error of the resident being entered under a previous resident's (Resident #3) record, who did not have a wife. At this time, the Administrator stated they completed a Quality Assurance Performance Improvement (QAPI) on this incident on 7/11/2022 (Monday) which requires the Admissions Coordinator to double check the name from [the local hospital] is the same as the one entered in to the EMR. She stated the Unit Managers have to double check what is in the EMR matches the resident's name on the paperwork received from the hospital at the time of admission to the facility. She confirmed the face sheet provided to [the local hospital] was for Resident #3 but continued to insist the medication orders were for Resident #1. She stated when the police department showed up, they double checked the paperwork and realized that Resident #3 was at the facility back in 2017 and this resident was actually Resident #1. At this time, the Acting DON stated, We did verify that what medication orders [Resident #1] came in with as being what was sent out with him, right orders, wrong name only. On 8/02/2022 at approximately 12:35 PM, a follow-up interview was conducted with the Acting DON. She stated she just verified Resident #1's medication orders and also checked the other two admissions that came in on 7/08/2022 to ensure their orders were correct and listed under the correct residents. She stated, We did a QAPI and the root cause was erroneously entering the wrong resident into the EMR on our end. When asked what the admission process was since the new process had been put in to place on 7/10/2022, she stated the nurses do admissions and we take orders, review them, and will be reviewing all hospital paperwork to ensure they are all together. When the surveyor pointed out that the medication list included in the admission packet for Resident #1 had a different FIN# (hospital Patient Identifier Number) at the bottom of the page of the medications than the FIN on all the other pages, she stated she was unaware that the FIN number displayed on every page from the hospital records was a patient identifier and had not inquired with the hospital as to whom this FIN belonged to. At this time, she admitted this new process of matching patient identification numbers on all pages of the record was not included in the QAPI process for the facility and did not correct the problem. Additionally, the Acting DON had not yet informed the hospital of the error they made by including paperwork for a different hospital patient altogether in the admission packet for Resident #1. When asked why all of Resident #1's progress notes, assessment for change in condition and medications were still listed under Resident #3 in the EMR, she stated that she had to get with her corporate staff so they can correct the records. On 8/02/2022 at 1:45 PM, a follow-up interview was conducted with the Admissions Coordinator in the presence of the Corporate Registered Nurse, Administrator, and Acting DON. The Admissions Coordinator stated that the original referral packet from the hospital came through the electronic referral system and demonstrated this by pulling up the records for Resident #1. When the admission referral for Resident #1 loaded into the referral system, this surveyor began to scroll down through all pages of the packet and immediately noticed there was paperwork for a different hospital patient altogether included in the paperwork for Resident #1 that was sent from the hospital. Further review determined the FIN number located at the bottom of the medication list entered for Resident #1 was entered under Resident #3's EMR actually matched the FIN for a different hospital patient, not Resident #1 or Resident #3. At this time, the Acting DON, Administrator, and Admissions Coordinator confirmed the medication orders entered for Resident #1 (under the EMR for Resident #3) belonged to another hospital patient. At this time, the Administrator and Acting DON confirmed the QAPI process they implemented was not adequate and did not include ensuring each FIN number was consistent throughout the packet received from the hospital. They also confirmed that a more thorough investigation on their part would have revealed the real root cause of this error prior to surveyors discovering it. The facility submitted an acceptable IJ Removal Plan. The survey team verified the following facility's immediate actions to remove the likely serious harm: An Ad Hoc Quality Assurance/Performance Improvement meeting was held 8/02/2022 with the Executive Director, Interim Director of Nursing, MDS Coordinator, Dietary Manger, Activities Director, Maintenance Supervisor, Human Resources Director and Medical Director to discuss the opportunity for improvement, assess the current situation, root cause analysis, and plan of correction to include education with licensed nurses and admissions team. The Executive Director received education 8/03/2022 by the Chief Operations Officer on the 5 elements of Quality Assurance/Process Improvement. The IDT (interdisciplinary team) was educated on 8/03/2022 on the QAPI process. Important functional areas may include but are not limited to admissions, the admission process, quality of care, staff education and developing and implementing appropriate plans of action to correct identified quality deficiencies related to admitting and transferring a resident using a similar but different name. Education was initiated by the Administrator on 8/03/2022 for all staff to include, staff notification, to the Administrator or DON, if a responsible party or family member of a resident expresses a concern that cannot be resolved by staff on duty, to include the location of a resident. A self-imposed moratorium on new resident admissions was implemented until the interdisciplinary QAPI team reviews and determines that compliance has been sustained with these processes. The Administrator notified the hospital Risk Manager of on 8/03/2022 concerning the issue related to the wrong medication reconciliation list being sent to the facility in the hospital paperwork. The FIN number on the medication reconciliation list and the paperwork for Resident #1 were sent to the Risk Manager on 8/04/2022. She also requested a copy of the hospital paperwork the facility received to be taken to her Friday 8/05/2022.

Based on observation, staff interview and resident record review, the facility failed to implement a comprehensive care plan to meet the needs of a resident for 1 of 4 residents sampled for pressure ulcers and failed to develop a comprehensive care plan for 1 of 5 residents requiring assistance with Activities of Daily Living (ADL) oral care. (Resident #4) The findings include: Pressure Ulcer On 02/12/2021 an electronic medical record review was conducted for Resident #4, a [AGE] year-old admitted into the facility on [DATE] of post-surgical rehabilitation. The resident's Care Plan which was initiated on 01/26/2021 and revised on 02/10/2021 identified a risk for pressure injury and potential for further pressure injury development related to disease process; immobility - left heel pressure injury. Interventions included: Encourage resident to float heel as she will allow; Administer treatments as ordered and monitor for effectiveness. A Vascular Progress Note dated 01/26/2021 stated Left heel with unstageable ulcer that measures 3.5 x 4.7 cm (centimeters). 100% eschar (dead dark tissue that sheds or falls off from the skin). Mild odor. The Advanced Practice Registered Nurse (APRN) ordered the left heel to be clean with quarter strength Dakin's solution, apply nickel thick of Santyl, pack with Dakin's gauze. Cover with dry dressing. Change daily and prn (as needed) drainage. She needs to offload her heels at all times while in bed. She would benefit from a heel manager in her bed to assist with floating of her heels. A review of Resident #4 Treatment Administration Record (TAR) failed to identify the order for wound care from 1/26/2021 and failed to document the provision of care to the resident's left heel. On 02/03/2021, the Wound Care Progress Note by the APRN identified the left heel ulcer as unstageable. Measurements 5 cm x 5 cm. 100% necrotic slough (dead skin tissue). Odor noted. Wound base is boggy. Wound Care orders: Clean area with quarter strength Dakin solution, apply Dakin's moist gauze and cover and ABD pad (abdominal gauze used to prevent moisture seepage). Wrap with Kerlix (gauze dressing). Change daily and prn drainage. The note goes on to state, The area has not improved, and the wrong dressing was noted on the wound during today's visit. Reiterated the importance of performing daily dressing changes as ordered. The APRN also notes, The heel needs to be floating at all times especially while in bed. She needs to have a heel relief boot on. The wedge shoe is not offloading the heel adequately. On 02/09/2021 the Wound Care Progress Note by the APRN identified the left heel as unstageable. There is a significant amount of non-viable tissue. Bone not exposed but close to the wound bed. Odor noted. Today her heels are floating on the heel manage however there is still significant pressure related changes noted to the peri-wound. Her ulcer continues to decline. Her nutritional status is most likely not adequate. Wound measurements 5.7 cm x 7.0 cm. On 02/18/2021 at 11:30 AM, an interview was conducted with Staff Member F, the Wound Care Nurse. Staff Member F stated she tries to round with the Nurse Practitioner on Tuesdays, when wounds are evaluated and measured. She stated that when recommendations are made by the Wound Care Practitioner, the order or progress note is uploaded into the electronic record and she receives a copy/original. She stated she would be the one responsible for ensuring that the wound care orders were updated, entered into the electronic record and implemented. Staff Member F stated she was assigned to work a medication cart on 01/26/2021 and may be the reason why Resident #4 did not get wound care orders implemented. Oral Care On 02/10/2021 at approximately 10:40AM, an observation was made of Resident #4, during which debris was noted in her teeth. On 2/10/2021 at approximately 2:45 PM, during which the resident was observed with the debris in her teeth. On 02/11/2021 at approximately 11:00AM, Resident #4 was observed with debris in her teeth. On 02/10/2021 an electronic medical record review for Resident #4's revealed the resident was admitted into the facility on [DATE]. The resident's admission MDS (minimum data set) assessment, completed on 1/12/2021, identified the resident required limited to extensive assistance with 1 person assist with personal hygiene to include brushing teeth. The resident's electronic medical record failed to identify the development of a care plan to address the resident's needs for ADL care to include oral care.

Based on observation, staff interview and resident record review, the facility failed to prevent the development and worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #4). The findings include: On 02/12/2021 an electronic medical record review was conducted for Resident #4, a [AGE] year-old admitted into the facility on [DATE] for post-surgery rehabilitation. The nursing assessment completed on admission included a skin assessment which identified scabbing and flaking skin on her lower extremities, no other skin concerns were identified. A review of the Weekly Skin Integrity Review reports failed to reveal skin assessments for the week of 01/10/2021 to 01/17/21. On 01/26/2021, a Vascular Progress Note stated Left heel with unstageable ulcer that measures 3.5 cm (centimeters) x 4.7 cm. 100% eschar (dead dark tissue that sheds or falls off from the skin). Mild odor. The Advanced Practice Registered Nurse (APRN) ordered for the left heel to be clean with quarter strength Dakin's solution, apply nickel thick of Santyl, pack with Dakin's gauze. Cover with dry dressing. Change daily and prn (as needed) drainage. She needs to offload her heels at all times while in bed. She would benefit from a heel manager in her bed to assist with floating of her heels. A review of Resident #4 Treatment Administration Record (TAR) failed to identify the order for wound care per Vascular 01/26/2021. A review of the record failed to reveal documentation that wound care was provided to the resident's left heel. On 02/03/2021 the Wound Care Progress Note by the APRN identified the left heel ulcer as unstageable. Measurements 5 cm x 5 cm. 100% necrotic slough. Odor noted. Wound base is boggy. Wound Care orders: Clean area with quarter strength Dakin solution, apply Dakin's moist gauze and cover and ABD pad (abdominal gauze used to prevent moisture seepage). Wrap with Kerlix (gauze dressing wrap). Change daily and prn drainage. The note goes on to state, The area has not improved, and the wrong dressing was noted on the wound during today's visit. Reiterated the importance of performing daily dressing changes as ordered. The APRN also notes, The heel needs to be floating at all times especially while in bed. She needs to have a heel relief boot on. The wedge shoe is not offloading the heel adequately. The resident's Care Plan which was initiated on 01/26/2021 and revised on 02/10/2021 identified a risk for pressure injury and potential for further pressure injury development related to disease process; immobility - left heel pressure injury. Interventions included: Encourage resident to float heel as she will allow; Administer treatments as ordered and monitor for effectiveness; Monitor nutritional status. Serve diet as ordered, monitor intake and record; report results to MD and follow up as indicated. On 02/09/2021 the Wound Care Progress Note by the APRN identified the left heel as unstageable. There is a significant amount of nonviable tissue. Bone not exposed but close to the wound bed. Odor noted. Today her heels are floating on the heel manage however there is still significant pressure related changes noted to the peri-wound. Her ulcer continues to decline. Her nutritional status is most likely not adequate. Wound measurements 5.7cm x 7.0cm. On 02/12/2021 at approximately 1:45PM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing staff are expected to perform weekly skin sweeps on each resident. If anything is identified then that nurse should report it to the Wound Care Nurse (WCN) and if the WCN is not available, then they should notify the physician and get an order put in place. That order would then get reported to the WCN for her to see if the Wound Care doctor suggests something different. She stated if a nurse was to find an open area on a resident, she would expect it to be reported, an order obtained and the WCN notified. She stated she gets notified of wounds after the Wound Care Practitioner has rounded. On 02/18/2021 at 11:30 AM, an interview was conducted with Staff Member F, the WCN. Staff Member F stated she tries to round with the Nurse Practitioner on Tuesdays, when wounds are evaluated and measured. She stated that when recommendations are made by the Wound Care Practitioner, the order or progress note is uploaded into the electronic record and she receives a copy/original. She stated she would be the one responsible for ensuring that the wound care orders were updated, entered into the electronic record and implemented. Staff Member F stated she was assigned to work a medication cart on 01/26/2021 and may be the reason why Resident #4 did not get wound care orders implemented. A review of the facility's policy and procedure entitled Clinical Guideline Skin & Wound, WC-100, effective 04/01/2017 revealed Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record.; CNA to complete skin observations and report changes to Licensed Nurse. ; Licensed Nurse to document presence of skin impairment /new skin impairment when observed and weekly until resolved; Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/ responsible party and document in the medical record. Monitor resident's response, to treatment and modify treatment as indicated; evaluate the effectiveness of interventions and progress towards goals during the care management meeting and as needed.

Based on staff interview, observation and resident record review, the facility failed to implement dietary recommendations to ensure that residents received sufficient fluid and nutritional intake to prevent weight loss for residents identified at risk of malnutrition for 1 of 4 residents reviewed for hydration/nutrition (Resident #3) The findings include: Review of the record was conducted for Resident #3 which revealed that the Registered Dietitian (RD) had completed a Nutritional Evaluation on 01/19/2021. The evaluation revealed that the resident receives all nutrition and hydration via GT (gastrostomy tube - which is a tube inserted through the abdomen that brings nutrition directly into the stomach) and documented her current body weight was 175 pounds (lbs) with a BMI (body mass index) of 29.2. RD recommendations included bolus feedings via the stomach tube of Glucerna 1.5 one can (237 ml) 6 times daily with a 30 ml (milliliters) water flush before and after the bolus feeding. The recommendations also included a 240 ml water flush every 6 hours not to be given within one hour of boluses feedings. A record review was conducted for resident #3 during which revealed the resident was to have nothing by mouth (NPO) and to have Glucerna 1.5 1 can every 4 hours. A review of the Medication Administration Record [REDACTED]. Missed feedings were as follows: January 10 at 8:00 AM and 1200 PM; January 13 at 4:00 AM; January 17 at 2000 (8:00 PM); January 21 at 2000; January 23 0800, 1200, 1600 (4:00 PM) and 2000; January 24 0000 (Midnight), 0400, 0800, 1200, 1600 and 2000; January 26 0000, 0400, 0800, and 1200 On January 22, 2021 a new order was added for Flush with 240 ml of water every 6 hours, not to be given within 1 hour of boluses. A review of the MAR indicated [REDACTED]. The order was discontinued on January 25th. On February 11, 2021 there was a new order for Enteral Feed Order every 6 hours for hydration 240 ml water via GT. Review of the MAR for February identified the resident did not receive the water bolus on the following times: February 11 at 1800 (6:00 PM) February 12 at 0000, 0600, 1800; February 12 at 0000, 0600, 1200, 1800; February 14 at 0000, 0600. On 02/12/2021 a review of Resident #3's medical record revealed a nutritional evaluation was noted on 02/11/2021. The RD identified the resident's body weight as 175 lbs, as identified on admission over a month prior (01/07/2021.) The admission weight of 175-lbs with a BMI of 29.2 was within desirable range. No new recommendations were made by the RD at that time. On 02/12/21, staff member L, a CNA presented a list of weights for resident #3, which were handwritten on a white sheet of paper. At the top of the page was the resident's name and room number with the dates and weights noted as follows 1/7 175; 2/1 170; 2/12 160.2. Per Staff Member L, Resident #3 was re-weighed today, and her weight was now 160.2-lbs. The resident had lost 14.8 lbs (8.5%) in 34 days since admission. On 02/19/2021 at 10:45AM, a telephone interview was conducted with the Registered Dietitian (RD). She stated she comes to the facility twice a week and gets informed of residents needing nutritional evaluations when she arrives at the facility and goes through all the admissions. The RD stated she was aware that Resident #3 was NP (nothing by mouth) and confirmed she receives all nutritional support via enteral feedings/[DEVICE]. The RD was asked about the resident's weight loss. The RD responded she did a nutritional assessment on the resident on 02/11/2021 and didn't remember the resident having any weight loss and that her nutritional needs were being met. She was not aware of the resident's weight on 02/12/2021 of 160.2 lbs resulting in a 14.8-lbs weight loss since admission (01/07/2021). She stated she would look at that today and would probably change her tube feeding. The RD was asked about the fluid needs of the resident. The enteral orders were reviewed with the dietitian, along with the discontinuation of fluid boluses on 01/25/2021. The RD stated she noticed that on 02/11, when she did her assessment, and re-implemented fluid boluses every 6 hours. The resident was without fluid boluses from 01/25/2021 to 02/11/2021. The RD stated that in her professional opinion, the resident's hydration needs were not being met during that time.

Based on clinical and administrative record reviews, staff interview, physician interview and policy review, the facility failed to ensure a resident was free from neglect by failing to initiate Cardiopulmonary Resuscitation promptly for a resident with a full code status for 1 of 3 closed death records reviewed (resident #1). Per the facility's documentation, CPR was begun 24 to 34 minutes after the resident was found absent of pulse and respirations. This situation resulted in a finding of isolated Immediate Jeopardy at a scope and severity of J beginning on the date Resident #1 died , [DATE]. At the time of the survey 84 of the 99 residents at the facility were found to have a full code status. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:40 PM. The Immediate Jeopardy was removed on [DATE] at 3:41 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference F678 and F867. The findings include: On [DATE], the facility submitted a Nursing Homes Federal Reporting Immediate Report to the State Licensing Agency. The report was submitted subsequent to a neglect allegation that on [DATE] resident #1 expired during the evening shift (3:00 PM to 11:00 PM) as a result of the resident not receiving his morning medications that day. The facility investigated the incident, and on [DATE], submitted the results of the investigation, Nursing Homes Federal Reporting Five Day Report to the State Licensing Agency. Review of the facility's five-day report identified that the day shift nurse (7:00 AM to 3:00 PM) on [DATE] failed to identify that resident #1 was on her assignment and therefore failed to provide nursing services to resident #1 including medication administration. The report concluded that after investigation of the incident by the facility, review by the Medical Director and root cause analysis performed by the Quality Assurance and Performance Improvement (QAPI) committee, the resident's death had no correlation to the missed medications on the day shift. As part of the investigation, the facility documented a detailed timeline of events on [DATE] that transpired prior to the death of Resident #1: At 08:30 AM Resident #1 was assisted with breakfast by his assigned CNA (Certified Nursing Assistant). He ate very little. At 09:00 AM Resident #1 was assisted with a bed bath by his assigned CNA. At 09:15 AM vitals were taken by the assigned CNA. At 10:00 AM the resident was checked by the assigned CNA. At 12:00 PM the resident was checked by the assigned CNA. At 12:10 PM the Charge Nurse checked Resident #1. A friend called to ask how he was doing. Resident #1 was resting with eyes closed, no distress noted. Fluids were noted to be infusing via an intravenous line. At 12:15 PM therapy entered the room to provide therapy Services. Resident #1 was noted with increased confusion, and therapy was withheld for the day. At 12:30 PM Resident #1 was fed lunch by the assigned CNA. He consumed 25%. At 2:00 PM the resident was checked and changed by the assigned CNA. Resident #1 was quiet but responded. At 2:40 PM the assigned 3:00 PM -11:00 PM (,[DATE]) nurse came on shift. Resident #1 was checked by the oncoming Nurse. She asked him how he was doing. He moaned. At 3:20 PM Resident #1 was checked by the oncoming ,[DATE] CNA (CNA B). She noted he didn't look well. The ,[DATE] (7:00 AM to 3:00 PM) CNA (CNA A) was also in the room. The two (2) CNAs discussed Resident #1. The ,[DATE] CNA (CNA B) reported findings to the ,[DATE] Nurse (Licensed Practical Nurse C (LPN C)). At approximately 3:30 PM, the ,[DATE] nurse (LPN C) assessed Resident #1 and identified no vitals and initiated the Code Blue process, which included an overhead page. A review of the Code Blue Documentation form found in the resident's medical record identified that on [DATE] at 3:54 PM a Code Blue was called for resident #1 and also at 3:54 PM Cardiopulmonary Resuscitation (CPR) began. There was a 24 minute discrepancy between the time on the Code Blue form (3:54 PM) and the time the Code Blue process was initiated per the investigation report (approximately 3:30 PM). Staff listed as participating in the resuscitation effort beginning at 3:54 PM included LPN C and Registered Nurse D (RN D). The form was completed by the Director of Nursing (DON). Review of the Physician's Orders revealed an order dated [DATE] which stated, Code status - Full Code (meaning the individual allowed and wished to have all interventions necessary for resuscitation in the event that the individual's heart stopped working). Review of the resident's Death Record dated [DATE] identified that resident #1's cause of death was [MEDICAL CONDITION]. A review of the EMS transport records dated [DATE] in response to resident #1 showed that dispatch was notified of a [MEDICAL CONDITION] at 3:59 PM. Under the Narrative section of the report it identified that facility staff reported that they began CPR compressions at 3:54 PM. The EMS arrived at 4:04 PM and their assessment at 4:06 PM identified the resident in [MEDICAL CONDITION] with non-reactive pupils, cyanotic (blue) skin color, a cold skin temperature, and absent lung sounds. The facility provided a witness statement dated [DATE] from the ,[DATE] CNA, CNA B, who wrote, around 3:20 (PM) I was assigned to do vitals, I went into (resident #1's room) and (resident #1) did not look right to me. There was another CNA from the ,[DATE] shift (CNA A) and I asked her how long (resident #1) looked like that, and she said it was her first time working with him. I tried to do vitals and couldn't get it and called my nurse and told her he (resident #1) did not look right and something was wrong. On [DATE] at approximately 12:30 PM, CNA A (the ,[DATE] PM CNA for resident #1 on [DATE]) was interviewed. CNA A described that throughout her shift on [DATE] resident #1 was not very alert, did not eat very much for breakfast or lunch, and that on that morning the resident had requested his medications and CNA A reported that to the nurse. CNA A, expressed that she did not report any of the changes she saw in the resident because she felt that he was having a bad day and did not think he was declining in condition. CNA A reported that on [DATE] at approximately 3:20 PM the ,[DATE] CNA, CNA B, were both in the resident's room and that CNA B attempted to get the resident's vital signs but the blood pressure machine was reading error and the resident was not responsive. CNA A then stated that she walked out of the room for linens and upon her return to the room, CNA B told her she believed the resident was expiring or not breathing. CNA A reported they got the nurse on duty, LPN C, at approximately 3:30 PM to 3:35 PM. CNA A expressed that she was trained on CPR and stated that CPR should start within a matter of seconds once a person was identified without a pulse or breathing. Staff A additionally expressed she understood neglect to be failing to provide care of services to a resident and that not providing CPR in a timely manner would be considered neglectful. CNA A was not sure of the remainder of the timeline of events as other staff and nurses took over the situation. On [DATE] at approximately 12:48 PM during interview with LPN C she confirmed that she was Resident #1's nurse [DATE] on the 3:00 PM to 11:00 PM shift and that she had initiated the Code Blue process. LPN C expressed that she arrived at work at about 2:30 PM and conducted rounds on her residents where she identified that resident #1, at that time, did not look well and expressed that he was alert to person only and had a lot of confusion. From that point, she expressed she went on to her normal duties and that at some time between 3:00 PM and 3:30 PM CNA B informed her that she was unable to get vital signs and that the resident did not look well. LPN C then stated she went in to assess him and found him without a pulse and not breathing. LPN C stated that she then initiated a Code Blue over the overhead speaker and went to the nurse's station to verify the resident's code status. LPN C stated she knew he was a full code but wanted to check the chart to make sure. After she verified the resident's code status as a full code she went back to the room and initiated CPR while another staff person contacted local Emergency Medical Services (EMS) and brought the crash cart to the room. LPN C stated that she did not recall the exact time CPR started but when showed the Code Blue Documentation form in the medical record she stated that the time of 3:54 PM looked correct. LPN C expressed that she was CPR certified and that she was familiar with the facility's Policy and Procedure for the initiation of CPR and stated that the residents code status should be verified and CPR should start immediately. Staff C additionally stated that she understood neglect to be not providing care to someone who is not able to perform care for themselves and expressed that not initiating CPR or failing to do so in a timely manner would be neglectful. On [DATE] at approximately 2:00 PM during interview with the facility's Medical Director, he expressed that his expectation for the facility was that they were to initiate CPR to a resident who was a full code and found unresponsive without vital signs within a couple of minutes and stated that the amount of time it takes to initiate CPR has a great impact on the effectiveness it has. He also expressed that any direct care staff should be able to recognize and identify when a resident may need CPR and that failing to initiate CPR for a resident with a full code status in a timely manner would be neglectful. The Medical Director expressed he was not aware of the amount of time it took for the facility to provide CPR to resident #1 and when shown the approximate time it took according to the facility investigation he stated that was not a quick enough response and not within the facility's expectations. On [DATE] at approximately 3:30 PM during interview with the facility Administrator, Director of Nursing, and Regional Director of Clinical Services, the Administrator defined neglect as not providing services or care, or not performing necessary duties to help a resident. The Regional Director of Clinical Services expressed that staff were expected to initiate CPR within ,[DATE] minutes at a maximum after identifying that a resident does not have vital signs and that the quicker the better. All three confirmed that CNAs receive training on CPR but are not to initiate CPR, the facility policy was for CNAs to identify the abnormal or absent vital signs and promptly notify the nurse so that the nurse could verify condition and verify code status before initiating CPR. When the surveyor asked how long it took for CPR to be initiated for resident #1 on [DATE], the regional Director of Clinical Services stated approximately 10 minutes and stated when Staff B was obtaining vital signs at approximately 3:20 PM the resident was still breathing, and CPR was not warranted. On [DATE] at approximately 4:05 PM during interview with CNA B, she expressed that on [DATE] at approximately 3:15 PM- 3:20 PM she went into resident #1's room to obtain vital signs. She expressed that at the time that she walked into the room the resident was breathing very shallowly and, shortly after, she could not see him breathing anymore and stated, I felt like I saw him take his last breath and was unable to obtain other vital signs. She stated that she talked with CNA A about the resident's condition and she felt like something was wrong and then they alerted LPN C. CNA B expressed she was unsure of what time CPR started because she left the area to perform other duties. On [DATE] at approximately 4:30 PM during follow-up interview with LPN C to confirm the timeline, LPN C reiterated that between 3:15 PM and 3:20 PM on [DATE] she was alerted that the CNAs for resident #1 were unable to obtain vital signs and she went in to assess him and he was not breathing, had no pulse and that CPR was started after that with another nurse, Registered Nurse D (RN D). At the time of interview, a nursing note was reviewed with LPN C and she confirmed it was the only note she had written that day concerning the resident and CPR. The note was dated [DATE] at 10:28 PM and described that the assigned CNA for resident #1 was unable to obtain vital signs so she assessed the resident after which a Code Blue was initiated, CPR began, and 911 was called. The nurse's note did not have times for when the CNA alerted the nurse or when the nurse assessed the resident or began CPR. LPN C confirmed the only place that described when CPR began was on the Code Blue Documentation form. On [DATE] at approximately 12:36 PM during interview with RN D, he expressed that on [DATE] he heard Code Blue over the loudspeaker while in his work office and rushed to resident #1's room. RN D was unsure of the time he heard the Code Blue call but stated that once in the room another staff went to verify the resident's code status and call 911. When they returned, it was announced the resident was a full code and CPR began. Staff D stated that CPR began before 4:00 PM and when showed the Code Blue Documentation stated that the time of 3:54 PM that was documented was the correct time that CPR began. On [DATE] at 1:41 PM, the DON requested an interview with the surveyor stating that she wrote the times wrong on the Code Blue form. A telephone call interrupted the interview. At 2:19 PM, the DON returned to discuss the recorded times. At that time, the DON was informed that the EMS report matches exactly with the times written on Code Blue form, and the DON stated, never mind and concluded the interview. A review of the facility policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation with a revision date of [DATE], defined neglect as the failure of the center, its employees or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. According to the American Heart Association, FACTS, A Race Against the Clock, Out-of-Hospital [MEDICAL CONDITION], dated [DATE], which is currently posted to their website, [MEDICAL CONDITION] occurs when the heart's electrical system abruptly malfunctions and the heart suddenly stops beating normally .to survive [MEDICAL CONDITION], they must receive immediate cardiopulmonary resuscitation (CPR) to increase blood flow to the heart and brain . for every minute without lifesaving CPR and defibrillation, chances of survival decrease 7%-10%. The Immediate Jeopardy was removed onsite on [DATE] after receipt of an acceptable removal plan and verification of corrective actions. On [DATE] at approximately 3:41 PM the removal plan was verified after staff interviews to determine knowledge on neglect, CPR, the facility policy on CPR, and participation in mock drills. A record review was conducted of training in-service records for 48 of 99 nursing staff on neglect, mock drills for CPR. -The Director of Nursing/Designee re-educated current facility licensed nursing and certified nursing staff in the facility on [DATE] and will continue education through [DATE] at the beginning of each shift before staff work their assignments, regarding the facility's policy and procedures regarding medical neglect which 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. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. All staff were able to define neglect and reported that they had recently been retrained on neglect. A record review of training documentation showed education on resident rights. Education was ongoing for all topics and being implemented as staff arrived at work. Training had been implemented for approximately 48 of 99 CNA and nurse staff at the time of review. -The Director of Nursing/Designee re-educated current facility licensed nursing and certified nursing staff in the facility on [DATE] and will continue education through [DATE] at the beginning of each shift before staff work their assignments, regarding the facility's policy and procedures regarding: 1. Honoring resident's Advanced Directives 2. DNR orders 3. Change of condition, 4. Code Blue Process 5. CPR 6. Resident Rights 7. Accurate and complete documentation in the medical record The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported recent retraining, and were able to express what a resident's code status meant, where to locate it in the medical record, and the facility's procedure for initiating CPR. A record review of training documentation showed education on CPR, advanced directives, code blue process, signs and symptoms of respiratory distress and what should be reported to the nurse immediately by CNA's, vital signs and when to report them, code blue documentation accuracy, CPR policy and procedure, and resident rights. Education was ongoing for all topics and being implemented as staff arrived at work. Training had been implemented for approximately 48 of 99 CNA and nurse staff at the time of review. -On ,[DATE] - ,[DATE] Mock Code Drills were completed each shift by the Director of Nursing/Designee to ensure compliance of facility policy and procedures regarding advanced directives. Mock drills have been completed on [DATE] at 2:37 PM with training of 15 CNAs and 9 licensed nurses, [DATE] at 7:04 PM with training of 10 CNAs and 5 licensed nurses and [DATE] at 10:52 PM with training of 7 CNAs and 4 licensed nurses. Mock code drills will continue daily. The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported participation in mock Code Blue drills in the past 24 hours. -On [DATE], the Social Services Director completed an additional audit of the current facility residents to verify the residents advanced directives/code status, physician's orders and DNR or code documentation correctly reflected the resident's wishes in the medical records per the facility policy and procedures. The surveyor reviewed documentation of code status audits with no concerns.

Based on clinical and administrative record reviews, staff interview, physician interview, policy review and review of the American Heart Association Cardiopulmonary Resuscitation (CPR) guidance, the facility failed to initiate CPR promptly for a resident whose advance directives desired CPR (full code status) in the event of [MEDICAL CONDITION] for 1 of 3 closed death records reviewed (resident #1). Per the facility's documentation, CPR was begun 24 to 34 minutes after the resident was found absent of pulse and respirations. This situation resulted in a finding of isolated Immediate Jeopardy at a scope and severity of J beginning on the date Resident #1 died , [DATE]. At the time of the survey 84 of the 99 residents at the facility were found to have a full code status. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:40 PM. The Immediate Jeopardy was removed on [DATE] at 3:41 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference F600 and F867. The findings include: Review of Resident #1's Florida Death Record dated [DATE] identified that resident #1's cause of death was [MEDICAL CONDITION] with the identified significant conditions of [MEDICAL CONDITION] (disease, damage, or blockage of the hearts major blood vessels), Diabetes Mellitus type 2 (a chronic condition that affects how blood sugar is processed), Chronic Obstructive [MEDICAL CONDITION] Disorder (lung disease that restrict airflow and causes difficulty breathing), [MEDICAL CONDITION] Fibrillation (an irregular heart rate that can cause poor blood flow), and a history of triple Coronary Artery Bypass Graft (a surgical procedure used to restore blood flow to the heart by bypassing three affected arteries). Review of the Physician's Orders revealed an order dated [DATE] which stated, Code status - Full Code (meaning the individual allowed and wished to have all interventions necessary for resuscitation in the event that the individual's heart stopped working). On [DATE], the facility submitted a Nursing Homes Federal Reporting Immediate Report to the State Licensing Agency. The report was submitted subsequent to a neglect allegation that on [DATE] resident #1 expired during the evening shift (3:00 PM to 11:00 PM) as a result of the resident not receiving his morning medications that day. The facility investigated the incident, and on [DATE], submitted the results of the investigation, Nursing Homes Federal Reporting Five Day Report to the State Licensing Agency. Review of the facility's five-day report identified that the day shift nurse (7:00 AM to 3:00 PM) on [DATE] failed to identify that resident #1 was on her assignment and therefore failed to provide nursing services to resident #1 including medication administration. The report concluded that after investigation of the incident by the facility, review by the Medical Director and root cause analysis performed by the Quality Assurance and Performance Improvement (QAPI) committee, the resident's death had no correlation to the missed medications on the day shift. As part of the investigation, the facility documented a detailed timeline of events on [DATE] that transpired prior to the death of Resident #1: At 08:30 AM Resident #1 was assisted with breakfast by his assigned CNA (Certified Nursing Assistant). He ate very little. At 09:00 AM Resident #1 was assisted with a bed bath by his assigned CNA. At 09:15 AM vitals were taken by the assigned CNA. At 10:00 AM the resident was checked by the assigned CNA. At 12:00 PM the resident was checked by the assigned CNA. At 12:10 PM the Charge Nurse checked Resident #1. A friend called to ask how he was doing. Resident #1 was resting with eyes closed, no distress noted. Fluids were noted to be infusing via an intravenous line. At 12:15 PM therapy entered the room to provide therapy Services. Resident #1 was noted with increased confusion, and therapy was withheld for the day. At 12:30 PM Resident #1 was fed lunch by the assigned CNA. He consumed 25%. At 2:00 PM the resident was checked and changed by the assigned CNA. Resident #1 was quiet but responded. At 2:40 PM the assigned 3:00 PM -11:00 PM (,[DATE]) nurse came on shift. Resident #1 was checked by the oncoming Nurse. She asked him how he was doing. He moaned. At 3:20 PM Resident #1 was checked by the oncoming ,[DATE] CNA (CNA B). She noted he didn't look well. The ,[DATE] (7:00 AM to 3:00 PM) CNA (CNA A) was also in the room. The two (2) CNAs discussed Resident #1. The ,[DATE] CNA (CNA B) reported findings to the ,[DATE] Nurse (Licensed Practical Nurse C (LPN C)). At approximately 3:30 PM, the ,[DATE] nurse (LPN C) assessed Resident #1 and identified no vitals and initiated the Code Blue process, which included an overhead page. A review of the Code Blue Documentation form found in the resident's medical record identified that on [DATE] at 3:54 PM a Code Blue was called for resident #1 and also at 3:54 PM CPR began. There was a 24 minute discrepancy between the time on the Code Blue form (3:54 PM) and the time the Code Blue process was initiated per the investigation report (approximately 3:30 PM). Staff listed as participating in the resuscitation effort beginning at 3:54 PM included LPN C and Registered Nurse D (RN D). The form was completed by the Director of Nursing (DON). A review of the EMS transport records dated [DATE] in response to resident #1 showed that dispatch was notified of a [MEDICAL CONDITION] at 3:59 PM. Under the Narrative section of the report it identified that facility staff reported that they began CPR compressions at 3:54 PM. The EMS arrived at 4:04 PM and their assessment at 4:06 PM identified the resident in [MEDICAL CONDITION] with non-reactive pupils, cyanotic (blue) skin color, a cold skin temperature, and absent lung sounds. Additional record reviews and interviews were conducted regarding the timeline discrepancy. The facility provided a witness statement dated [DATE] from the ,[DATE] CNA, CNA B, who wrote, around 3:20 (PM) I was assigned to do vitals, I went into (resident #1's room) and (resident #1) did not look right to me. There was another CNA from the ,[DATE] shift (CNA A) and I asked her how long (resident #1) looked like that, and she said it was her first time working with him. I tried to do vitals and couldn't get it and called my nurse and told her he (resident #1) did not look right and something was wrong. On [DATE] at approximately 12:30 PM, CNA A (the ,[DATE] PM CNA for resident #1 on [DATE]) was interviewed. CNA A described that throughout her shift on [DATE] resident #1 was not very alert, did not eat very much for breakfast or lunch, and that on that morning the resident had requested his medications and CNA A reported that to the nurse. CNA A, expressed that she did not report any of the changes she saw in the resident because she felt that he was having a bad day and did not think he was declining in condition. CNA A reported that on [DATE] at approximately 3:20 PM the ,[DATE] CNA, CNA B, were both in the resident's room and that CNA B attempted to get the resident's vital signs but the blood pressure machine was reading error and the resident was not responsive. CNA A then stated that she walked out of the room for linens and upon her return to the room, CNA B told her she believed the resident was expiring or not breathing. CNA A reported they got the nurse on duty, LPN C, at approximately 3:30 PM to 3:35 PM. CNA A expressed that she was trained on CPR and stated that CPR should start within a matter of seconds once a person was identified without a pulse or breathing. CNA A was not sure of the remainder of the timeline of events as other staff and nurses took over the situation. On [DATE] at approximately 12:48 PM during interview with LPN C she confirmed that she was Resident #1's nurse [DATE] on the 3:00 PM to 11:00 PM shift and that she had initiated the Code Blue process. LPN C expressed that she arrived at work at about 2:30 PM and conducted rounds on her residents where she identified that resident #1, at that time, did not look well and expressed that he was alert to person only and had a lot of confusion. From that point, she expressed she went on to her normal duties and that at some time between 3:00 PM and 3:30 PM CNA B informed her that she was unable to get vital signs and that the resident did not look well. LPN C then stated she went in to assess him and found him without a pulse and not breathing. LPN C stated that she then initiated a Code Blue over the overhead speaker and went to the nurse's station to verify the resident's code status. LPN C stated she knew he was a full code but wanted to check the chart to make sure. After she verified the resident's code status as a full code she went back to the room and initiated CPR while another staff person contacted local Emergency Medical Services (EMS) and brought the crash cart to the room. LPN C stated that she did not recall the exact time CPR started but when showed the Code Blue Documentation form in the medical record she stated that the time of 3:54 PM looked correct. LPN C expressed that she was CPR certified and that she was familiar with the facility's Policy and Procedure for the initiation of CPR and stated that the residents code status should be verified and CPR should start immediately. On [DATE] at approximately 3:30 PM during interview with the facility Administrator, Director of Nursing, and Regional Director of Clinical Services the Regional Director of Clinical Services expressed that staff were expected to initiate CPR within ,[DATE] minutes at a maximum after identifying that a resident does not have vital signs and that the quicker the better. All three confirmed that CNAs receive training on CPR but are not to initiate CPR, the facility policy was for CNAs to identify the abnormal or absent vital signs and promptly notify the nurse so that the nurse could verify condition and verify code status before initiating CPR. When the surveyor asked how long it took for CPR to be initiated for resident #1 on [DATE] the regional Director of Clinical Services stated approximately 10 minutes and stated when Staff B was obtaining vital signs at approximately 3:20 PM the resident was still breathing, and CPR was not warranted. On [DATE] at approximately 4:05 PM during interview with CNA B, she expressed that on [DATE] at approximately 3:15 PM- 3:20 PM she went into resident #1's room to obtain vital signs. She expressed that at the time that she walked into the room the resident was breathing very shallowly and, shortly after, she could not see him breathing anymore and stated, I felt like I saw him take his last breath and was unable to obtain other vital signs. She stated that she talked with CNA A about the resident's condition and she felt like something was wrong and then they alerted LPN C. CNA B expressed she was unsure of what time CPR started because she left the area to perform other duties. On [DATE] at approximately 4:30 PM during follow-up interview with LPN C to confirm the timeline, LPN C reiterated that between 3:15 PM and 3:20 PM on [DATE] she was alerted that the CNAs for resident #1 were unable to obtain vital signs and she went in to assess him and he was not breathing, had no pulse and that CPR was started after that with another nurse, Registered Nurse D (RN D). At the time of interview, a nursing note was reviewed with LPN C and she confirmed it was the only note she had written that day concerning the resident and CPR. The note was dated [DATE] at 10:28 PM and described that the assigned CNA for resident #1 was unable to obtain vital signs so she assessed the resident after which a Code Blue was initiated, CPR began, and 911 was called. The nurse's note did not have times for when the CNA alerted the nurse or when the nurse assessed the resident or began CPR. LPN C confirmed the only place that described when CPR began was on the Code Blue Documentation form. On [DATE] at approximately 12:36 PM during interview with RN D, he expressed that on [DATE] he heard Code Blue over the loudspeaker while in his work office and rushed to resident #1's room. RN D was unsure of the time he heard the Code Blue call but stated that once in the room another staff went to verify the resident's code status and call 911. When they returned, it was announced the resident was a full code and CPR began. Staff D stated that CPR began before 4:00 PM and when showed the Code Blue Documentation stated that the time of 3:54 PM that was documented was the correct time that CPR began. On [DATE] at 1:41 PM, the DON requested an interview with the surveyor stating that she wrote the times wrong on the Code Blue form. A telephone call interrupted the interview. At 2:19 PM, the DON returned to discuss the recorded times. At that time, the DON was informed that the EMS report matches exactly with the times written on Code Blue form, and the DON stated, never mind and concluded the interview. On [DATE] at approximately 2:00 PM during interview with the facility's Medical Director, he expressed that his expectation for the facility was that they were to initiate CPR to a resident who was a full code and found unresponsive without vital signs within a couple of minutes and stated that the amount of time it takes to initiate CPR has a great impact on the effectiveness it has. He also expressed that any direct care staff should be able to recognize and identify when a resident may need CPR. The Medical Director expressed he was not aware of the amount of time it took for the facility to provide CPR to resident #1 and when shown the approximate time it took according to the facility investigation he stated that was not a quick enough response and not within the facility's expectations. A review of the facility policy and procedure, Florida Cardiopulmonary Resuscitation (CPR) dated [DATE], stated that Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such a resident has a fully executed Florida Do Not Resuscitate (DNR) order. The policy and procedure described that in the event of [MEDICAL CONDITION], staff were to immediately call for assistance and two licensed nurses were to verify the resident and whether or not the resident had a DNR order, after which Code Blue was to be called over the paging system and in the absences of a DNR order CPR was to immediately begin. A review of the American Heart Association, FACTS, A Race Against the Clock, Out-of-Hospital [MEDICAL CONDITION], dated [DATE], which is currently posted to their website, [MEDICAL CONDITION] occurs when the heart's electrical system abruptly malfunctions and the heart suddenly stops beating normally .to survive [MEDICAL CONDITION], they must receive immediate cardiopulmonary resuscitation (CPR) to increase blood flow to the heart and brain . for every minute without lifesaving CPR and defibrillation, chances of survival decrease 7%-10%. The Immediate Jeopardy was removed onsite on [DATE] after receipt of an acceptable removal plan and verification of corrective actions. On [DATE] at approximately 3:41 PM the removal plan was verified after staff interviews to determine knowledge on CPR, the facility policy on CPR, and participation in mock drills. A record review of training confirmed in-service records for 48 of 99 Nursing staff, and mock CPR drills. -The Director of Nursing/Designee re-educated current facility licensed nursing and certified nursing staff in the facility on [DATE] and will continue education through [DATE] at the beginning of each shift before staff work their assignments, regarding the facility's policy and procedures regarding: 1. Honoring resident's Advanced Directives 2. DNR orders 3. Change of condition, 4. Code Blue Process 5. CPR 6. Resident Rights 7. Accurate and complete documentation in the medical record The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported recent retraining, and were able to express what a resident's code status meant, where to locate it in the medical record, and the facility's procedure for initiating CPR. A record review of training documentation showed education on CPR, advanced directives, code blue process, signs and symptoms of respiratory distress and what should be reported to the nurse immediately by CNA's, vital signs and when to report them, code blue documentation accuracy, CPR policy and procedure, and resident rights. Education was ongoing for all topics and being implemented as staff arrived at work. Training had been implemented for approximately 48 of 99 CNA and nurse staff at the time of review. -On ,[DATE] - ,[DATE] Mock Code Drills were completed each shift by the Director of Nursing/Designee to ensure compliance of facility policy and procedures regarding advanced directives. Mock drills have been completed on [DATE] at 2:37 PM with training of 15 CNAs and 9 licensed nurses, [DATE] at 7:04 PM with training of 10 CNAs and 5 licensed nurses and [DATE] at 10:52 PM with training of 7 CNAs and 4 licensed nurses. Mock code drills will continue daily. The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported participation in mock Code Blue drills in the past 24 hours. -On [DATE], the Social Services Director completed an additional audit of the current facility residents to verify the residents advanced directives/code status, physician's orders and DNR or code documentation correctly reflected the resident's wishes in the medical records per the facility policy and procedures. The surveyor reviewed documentation of code status audits with no concerns.

Based on clinical and administrative record reviews, staff interview, physician interview, policy review, and review of the American Heart Association Cardiopulmonary Resuscitation (CPR) guidance, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to identify a CPR time delay and develop corrective actions during review of a neglect allegation for 1 of 3 sampled closed death records (resident #1). Per the facility's documentation, CPR was begun 24 to 34 minutes after the resident was found absent of pulse and respirations. This situation resulted in a finding of isolated Immediate Jeopardy at a scope and severity of J beginning on the date Resident #1 died , [DATE]. At the time of the survey 84 of the 99 residents at the facility were found to have a full code status. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:40 PM. The Immediate Jeopardy was removed on [DATE] at 3:41 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference F600 and F678. The findings include: On [DATE], the facility submitted a Nursing Homes Federal Reporting Immediate Report to the State Licensing Agency. The report was submitted subsequent to a neglect allegation that on [DATE] resident #1 expired during the evening shift (3:00 PM to 11:00 PM) as a result of the resident not receiving his morning medications that day. The facility investigated the incident, and on [DATE], submitted the results of the investigation to the State Licensing Agency. Review of the facility's five-day report identified that the day shift nurse (7:00 AM to 3:00 PM) on [DATE] failed to identify that resident #1 was on her assignment and therefore failed to provide nursing services to resident #1 including medication administration. The report concluded that after investigation of the incident by the facility, review by the Medical Director and root cause analysis performed by the QAPI committee, the resident's death had no correlation to the missed medications on the day shift. The report did not identify any concerns with the timeline of the initiation of CPR. As part of the investigation, the report documented a detailed timeline of events on [DATE] that transpired prior to the death of Resident #1 which included: At 2:40 PM the assigned 3:00 PM -11:00 PM (,[DATE]) nurse came on shift. Resident #1 was checked by the oncoming Nurse. She asked him how he was doing. He moaned. At 3:20 PM Resident #1 was checked by the oncoming ,[DATE] CNA (CNA B). She noted he didn't look well. The ,[DATE] (7:00 AM to 3:00 PM) CNA (CNA A) was also in the room. The two (2) CNAs discussed Resident #1. The ,[DATE] CNA (CNA B) reported findings to the ,[DATE] Nurse (Licensed Practical Nurse C (LPN C)). At approximately 3:30 PM, the ,[DATE] nurse (LPN C) assessed Resident #1 and identified no vitals and initiated the Code Blue process, which included an overhead page. A review of the Code Blue Documentation form found in the resident's medical record identified that on [DATE] at 3:54 PM a Code Blue was called for resident #1 and also at 3:54 PM CPR began. There was a 24 minute discrepancy between the time on the Code Blue form (3:54 PM) and the time the Code Blue process was initiated per the investigation report (approximately 3:30 PM). A review of the EMS transport records dated [DATE] in response to resident #1 showed that dispatch was notified of a [MEDICAL CONDITION] at 3:59 PM. Under the Narrative section of the report it identified that facility staff reported that they began CPR compressions at 3:54 PM. The EMS arrived at 4:04 PM and their assessment at 4:06 PM identified the resident in [MEDICAL CONDITION] with non-reactive pupils, cyanotic (blue) skin color, a cold skin temperature, and absent lung sounds. A clinical record review found one nursing note documented by LPN C concerning the resident and CPR. The note was dated [DATE] at 10:28 PM and described that the assigned CNA for resident #1 was unable to obtain vital signs so she assessed the resident after which a Code Blue was initiated, CPR began, and 911 was called. The nurse's note did not have times for when the CNA alerted the nurse or when the nurse assessed the resident or began CPR. A review of the facility investigation was conducted. The investigation included several witness statements, but the witness statements were mainly focused on the resident assignments and missed morning medications, not the delay in CPR. In interview on [DATE] at approximately 12:30 PM, CNA A (the ,[DATE] AM CNA for resident #1 on [DATE]) reported that on [DATE] at approximately 3:20 PM both she and the ,[DATE] CNA, CNA B, were resident#1's room and that CNA B attempted to get the resident's vital signs but the blood pressure machine was reading error and the resident was not responsive. CNA A then stated that she walked out of the room for linens and upon her return to the room, CNA B told her she believed the resident was expiring or not breathing. CNA A reported they got the nurse on duty, LPN C, at approximately 3:30 PM to 3:35 PM. On [DATE] at approximately 12:48 PM during interview with LPN C she confirmed that she was Resident #1's nurse [DATE] on the 3:00 PM to 11:00 PM shift and that she had initiated the Code Blue process. LPN C expressed that at some time between 3:00 PM and 3:30 PM CNA B informed her that she was unable to get vital signs and that the resident did not look well. LPN C then stated she went in to assess him and found him without a pulse and not breathing. LPN C stated that she then initiated a Code Blue over the overhead speaker and went to the nurse's station to verify the resident's code status. LPN C stated she knew he was a full code but wanted to check the chart to make sure. After she verified the resident's code status as a full code she went back to the room and initiated CPR while another staff person contacted local Emergency Medical Services (EMS) and brought the crash cart to the room. LPN C stated that she did not recall the exact time CPR started but when showed the Code Blue Documentation form in the medical record she stated that the time of 3:54 PM looked correct. On [DATE] at approximately 2:00 PM during interview with the facility's Medical Director, he expressed he was not aware of the amount of time it took for the facility to provide CPR to resident #1 and when shown the approximate time it took according to the facility investigation he stated that was not a quick enough response and not within the facility's expectations. On [DATE] at approximately 3:30 PM during interview with the facility Administrator, Director of Nursing, and Regional Director of Clinical Services, the Administrator defined neglect as not providing services or care, or not performing necessary duties to help a resident. The Administrator discussed that when reviewing resident #1's death that the QAPI committee identified issues related to the resident being missed by the nurse's assignment and the fact that the resident missed his medications. The administrator denied the inclusion of CPR response time in their Ad Hoc QAPI meeting held on [DATE] and stated they had not identified any issues with the staff's response time in CPR during the incident. The Regional Director of Clinical Services expressed that staff were expected to initiate CPR within ,[DATE] minutes at a maximum after identifying that a resident does not have vital signs and that the quicker the better. All three confirmed that CNAs receive training on CPR but are not to initiate CPR, the facility policy was for CNAs to identify the abnormal or absent vital signs and promptly notify the nurse so that the nurse could verify condition and verify code status before initiating CPR. When questioned how long it took for CPR to be initiated for resident #1 on [DATE] the regional Director of Clinical Services stated approximately 10 minutes and stated when Staff B was obtaining vital signs at approximately 3:20 PM the resident was still breathing, and CPR was not warranted. The regional Director of Clinical Services further stated that the QAPI committee had identified concerns that the nurse on duty from 7:00 AM to 3:00 PM on [DATE] had failed to identify that resident #1 was on her assignment and the focus of the Ad Hoc QAPI meeting was to address that issue. A record review of the Ad Hoc Quality Assurance and Performance Improvement Meeting notes provided by the facility Administrator found that the meeting notes did not address any concerns related to the time it took staff to identify the need for and initiate CPR for resident #1. The Immediate Jeopardy was removed onsite on [DATE] after receipt of an acceptable removal plan and verification of corrective actions. On [DATE] at approximately 3:41 PM the removal plan was verified after staff interviews to determine knowledge on CPR, the facility policy on CPR, and participation in mock drills. A record review of training confirmed in-service records for 48 of 99 Nursing staff, and mock CPR drills. A QAPI interview and record review confirmed inclusion of CPR initiation and neglect into the facility's QAPI plan. -Ad Hoc QAPI meeting was conducted on [DATE] with the IDT team which included the Medical Director via telephone, Administrator, Director of Nurses, Regional Director of Nurses, Social Services Director, MDS coordinator and Medical Records Director reviewing the regulations for F600, F678 and F867. The corrective plan for the citations were also reviewed along with a review the current CPR policy and policy for Abuse, Neglect, Exploitation and Misappropriation. Ad Hoc QAPI meeting notes were provided to the surveyor and revealed the inclusion of the necessary members of the QAPI committee. The minutes showed a QAPI review of CPR documentation and identification of change of condition as areas of concern with education and mock drills in place to correct. Interview with the administrator and DON at 3:30 PM on [DATE], the Administrator stated We had our QAPI meeting with the Medical Director on the phone and we talked through what we needed to do and education and how to implement that education. We also talked about how to maintain that education and to include it in monthly education. We also talked about and included audits of all residents advanced directives and their flow sheets that are maintained in the front of the medical record. We did a total of three mock drills, so far and those went well. -The Director of Nursing/Designee re-educated current facility licensed nursing and certified nursing staff in the facility on [DATE] and will continue education through [DATE] at the beginning of each shift before staff work their assignments, regarding the facility's policy and procedures regarding: 1. Honoring resident's Advanced Directives 2. DNR orders 3. Change of condition, 4. Code Blue Process 5. CPR 6. Resident Rights 7. Accurate and complete documentation in the medical record The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported recent retraining, and were able to express what a resident's code status meant, where to locate it in the medical record, and the facility's procedure for initiating CPR. A record review of training documentation showed education on CPR, advanced directives, code blue process, signs and symptoms of respiratory distress and what should be reported to the nurse immediately by CNA's, vital signs and when to report them, code blue documentation accuracy, CPR policy and procedure, and resident rights. Education was ongoing for all topics and being implemented as staff arrived at work. Training had been implemented for approximately 48 of 99 CNA and nurse staff at the time of review. -On ,[DATE] - ,[DATE] Mock Code Drills were completed each shift by the Director of Nursing/Designee to ensure compliance of facility policy and procedures regarding advanced directives. Mock drills have been completed on [DATE] at 2:37 PM with training of 15 CNAs and 9 licensed nurses, [DATE] at 7:04 PM with training of 10 CNAs and 5 licensed nurses and [DATE] at 10:52 PM with training of 7 CNAs and 4 licensed nurses. Mock code drills will continue daily. The surveyor verified training documentation. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. The staff all reported participation in mock Code Blue drills in the past 24 hours. -On [DATE], the Social Services Director completed an additional audit of the current facility residents to verify the residents advanced directives/code status, physician's orders [REDACTED]. The surveyor reviewed documentation of code status audits with no concerns. -The Director of Nursing/Designee re-educated current facility licensed nursing and certified nursing staff in the facility on [DATE] and will continue education through [DATE] at the beginning of each shift before staff work their assignments, regarding the facility's policy and procedures regarding medical neglect which 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. On [DATE] between 2:35 PM, and 3:30 PM, the surveyor conducted interviews with CNA E, CNA G, LPN F and LPN H. All staff were able to define neglect and reported that they had recently been retrained on neglect. A record review of training documentation showed education on resident rights. Education was ongoing for all topics and being implemented as staff arrived at work. Training had been implemented for approximately 48 of 99 CNA and nurse staff at the time of review.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to ensure that licensed nurses have the competencies and skill sets necessary to care for residents receiving insulin 1 of 3 residents sampled for insulin review, (#19). A nurse was preparing to administer 55 units of [MEDICATION NAME], a fast-acting insulin, instead of [MEDICATION NAME] N, the ordered intermediate-acting insulin. This type of insulin error could potentially result in dangerously low blood sugar levels ([DIAGNOSES REDACTED]) which can cause unconsciousness, [MEDICAL CONDITION], and death, and had the potential to affect all 31 current residents in the facility receiving insulin injections. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator was notified of the Immediate Jeopardy finding on 10/17/19 at 5:07 PM. Immediate Jeopardy was removed on 10/17/19 at 6:30 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions which included immediate retraining of nursing staff on insulin administration and implementation of a two-step verification process for insulin injections. The deficient practice remains at a scope and severity level of a D. Cross reference to F760, F835 and F867. The findings include: On 10/17/2019 at approximately 8:05 AM, nurse D, a Licensed Practical Nurse (LPN), obtained a vial of [MEDICATION NAME](a fast acting insulin) from the medication drawer to administer ordered 55 units of [MEDICATION NAME] N (an intermediate-acting insulin). The nurse was stopped at that point to review the medication order. The nurse recognized the error, then told the surveyor that she would have to get the [MEDICATION NAME]from the refrigerator. The nurse then returned to the medication cart with a [MEDICATION NAME] flex pen from the EDK (emergency drug kit), and dialed 55 units, and attached the needle. LPN D entered resident #19's room, informed the resident that she was there to administer insulin, and opened an alcohol swab. The surveyor asked LPN D to step out of the room. The nurse confirmed that she was going to administer the medication and did not recognize that she had pulled the wrong medication. The surveyor confirmed with the Director of Nursing (DON) that the order was for 55 units of [MEDICATION NAME] N. Cross Reference F760. On 10/17/2019 at approximately 12:00 PM, an interview was conducted with LPN D. LPN D stated she was a new nurse, and had taken her nursing boards in (MONTH) of 2019 and started working as a nurse on (MONTH) 1, 2019. LPN D stated she only received 5 days of new employee orientation to include medication and insulin administration, and was not comfortable with the training she had received. LPN D stated that some days she feels comfortable giving medications and other days she does not. She stated, for example, she did not receive any training on giving medications during a tube feeding. LPN D stated no one has monitored her during medication pass or evaluated her readiness to administer medications. During an interview with the DON on 10/17/2019 at approximately 10:00 AM, the DON indicated there was no system currently in place for closer managerial oversight for newly graduated nurses. On 10/17/2019 at approximately 10:53 AM, a telephone interview was conducted with the pharmacy consultant for the facility. The pharmacist stated that [MEDICATION NAME] N was a long acting basal insulin and often was given morning and evening. The pharmacist stated that [MEDICATION NAME] was a quick acting insulin and was often used for sliding scale insulin coverage. The surveyor asked the pharmacist what the possible effects were if [MEDICATION NAME]was administered instead of ordered [MEDICATION NAME] N Insulin. The pharmacist indicated that if [MEDICATION NAME]were to be administered at a time when [MEDICATION NAME] N insulin was ordered, the possible effect to the resident could include initial control of blood glucose but that the resident might not be able to maintain the desired blood glucose level control throughout the day. The pharmacist stated that at least 3 types of face-to-face training opportunities regarding insulin and insulin pens were available to the facility. These training options included: 1. Insulin/Insulin Pen Training by the Pharmacist, 2. Insulin/Insulin Pen Training by the Pharmacy Nurse Consultant, 3. Insulin/Insulin Pen Training by a Pharmaceutical Company Representative coordinated through the Consult Pharmacist. The pharmacist stated that hardcopy Insulin/Insulin Pen Training documents can be provided if requested. The pharmacist was not aware of any requested Insulin or Insulin pen training from the facility. During an interview with the DON on 10/17/2019 at approximately 11:00 AM, the DON stated that the facility currently used the pharmacy audit tool for 2 nurse audits per quarter (8 nurses per year). The DON indicated that the facility had not used or needed other pharmaceutical training services. On 10/17/2019 at approximately 11:45 AM, the surveyor requested the facility policies for insulin administration, clinical staff training, any training policies related to nursing medication administration, and the staff record for LPN D. A one page document, Insulin Administration Policies and Procedures, Document Name: N-845, Effective Date: 11/30/2014, Revision Date: 9/5/2017 was provided. A review of the document found the following information: Obtain physician's orders [REDACTED]. A personnel record review was conducted for the training and competency evaluations for LPN D. LPN D was hired on 5/1/2019 and had an Occupational Associate Degree for Practical Nursing dated 2/19/2019. The only documentation of orientation was a form entitled, Facility Blue Ribbon Orientation Checklist which was completed on 5/1/2019. The orientation items included items such as organizational structure, core values, and employment policies. There were no clinical skill evaluations noted. Also found was evidence of previous medication errors to include: On 7/31/2019, a Medication Discrepancy Report for missed antibiotic doses on 7/27 and 7/28/19 of the antibiotic [MEDICATION NAME] and subsequent Employee Corrective Action form dated 8/07/2019. On 7/30/2019, a Medication Discrepancy Report and disciplinary action for missing a breathing medication, [MEDICATION NAME], for 6 days from 7/24 - 7/30/2019. Review of LPN D's personnel record showed no medication training was provided after the errors were documented. During an interview with the Director of Nursing (DON) on 10/16/2019 at approximately 11:26 AM regarding training and competency or skills checklists for nursing staff, the DON stated, We are not in substantial compliance. We have an action plan. The DON confirmed that there was no current clinical skills competency or checklist process in place for staff. When the DON was asked for a target date for compliance with the clinical skills competency training, the DON stated, We don't have one. The DON stated the current Staff Development Coordinator was hired about 1 month ago and was transitioning into the role. During an interview with the Staff Development Coordinator on 10/16/19 at approximately 1:45 PM, the Staff Development Coordinator stated that he started about a month ago and has recently transitioned into the Staff Development role. The Staff Development Coordinator stated he had no training checklist for any facility employee, and he had no current written training plans. A follow-up interview was conducted on 10/17/2019 at approximately 3:30 PM with the DON regarding medication training for LPN D. The DON provided a Certificate of Completion showing that LPN D has successfully completed Medication Administration: Avoiding Common Errors- Training Hours 0.5. The completion certificate had no completion date and no print date. The DON stated that LPN D had 17 shifts of new employee orientation which included shadowing a facility nurse for medication pass and insulin administration. The DON was unable to provide a clinical checklist or clinical skills competency record signed and dated by LPN D and the nurse she shadowed indicating medication pass and insulin administration training. The immediate jeopardy was removed onsite after the receipt of the removal plan and verification of corrective actions. License Nurse D was immediately removed from the medication cart on 10/17/19 at 8:30 AM and was provided one on one education regarding 7 rights of medication administration & new systemic change for verification of ALL Insulin to be verified by 2 licensed nurses prior to administration to ensure correct insulin and correct dose. Director of Nursing/Designee began immediate re-education to License Nurses regarding the 7 rights to medication administration & systemic change in insulin verification. Education was initiated on 10/17/19 with all current Licenses nurses working and will continue until all License Nurses have received the education. As of 10/17/19 at 12:00 PM no license nurse will be permitted to work until education has been received. Interviews conducted with 8 nurses confirmed the above. Beginning 10/17/19 at 12:00 PM a new process was put into place that was as follows: All insulin administrations will be verified by 2 licensed nurses prior to the administration and both nurses will initial on the Medication Administration Record [REDACTED]. As of 10/17/19 at 12:00 PM no licensed nurse will be permitted to work until education has been received. This process observed in practice by the survey team for 4 different nurses. Director of Nursing/Designee will conduct Medication Administration Observations with each License Nurse. Observation began on 10/17/19 at 12:00 and will continue until all current employed Licensed nurses have been observed and competencies checked off. Currently 14 of 26 licensed nurses have received the education and medication observation. The survey team observed the training and monitoring being conducted. Current residents receiving long acting and short acting insulin were reviewed and a red highlighted paper placed in their MAR indicated [REDACTED]. Director of Nursing/Designee to include both the education of the 7 rights to Medication Pass and Medication Administration Competencies are included as part of the New hire orientation of all License Nurses beginning 10/17/19. The facility submitted an Employee Education Action Plan that included reviewing the current education status of nursing department staff and developing education/competency needs; developing and implementing a plan to ensure all areas of missed education/competencies are completed by nursing staff; and a plan for annual re-education and evaluation.

Based on observation of insulin administration, staff interviews, clinical record review and policy review, the facility failed to ensure residents were free of significant medication errors regarding insulin administration. Significant insulin medication error was identified for 1 of 3 residents sampled for insulin review, (#19). A nurse was preparing to administer 55 units of [MEDICATION NAME], a fast-acting insulin, instead of [MEDICATION NAME] N, the ordered intermediate-acting insulin. This type of insulin error could potentially result in dangerously low blood sugar levels ([DIAGNOSES REDACTED]) which can cause unconsciousness, [MEDICAL CONDITION], and death. There were 31 current residents in the facility receiving insulin injections. The situation resulted in a finding of Immediate Jeopardy and Substandard Quality of Care. The facility's Administrator was notified of the Immediate Jeopardy finding on 10/17/19 at 5:07 PM. Immediate Jeopardy was removed on 10/17/19 at 6:30 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions which included immediate retraining of nursing staff on insulin administration and implementation of a two-step verification process for insulin injections. The deficient practice remains at a scope and severity level of a D. Cross reference to F726, F835 and F867. The findings include: On 10/17/19 at approximately 8:05 AM, during the medication administration observation, nurse D, a Licensed Practical Nurse (LPN) was observed removing a vial of [MEDICATION NAME]from the medication administration cart to prepare for administration to Resident #19. [MEDICATION NAME] is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. The surveyor asked LPN D to double check the insulin order. LPN D identified the medication ordered was [MEDICATION NAME] N insulin and confirmed the [MEDICATION NAME]was the wrong medication. [MEDICATION NAME] N is an intermediate-acting insulin that starts to work 2-4 hours after injection, peaks in 4-12 hours, and keeps working 12-18 hours after injection. LPN D revealed the [MEDICATION NAME] N insulin was not in the medication cart and would need to be removed from the refrigerator. LPN D was observed returning from the medication room with a [MEDICATION NAME]injection pen, a fast acting insulin, and was observed preparing the medication for administration. LPN D went to the medication cart, and dialed the pen to 55 units in preparation for administration. LPN D confirmed the medication was a [MEDICATION NAME]pen and confirmed there was no pharmacy label on the insulin pen because it had been removed from the emergency drug kit (EDK). LPN D was observed entering resident #19's room and informed resident #19 that she was there to administer insulin. LPN D opened the alcohol swab to prepare resident #19 for the injection. The surveyor intervened and requested LPN D to step out of the room. LPN D confirmed the medication pen was [MEDICATION NAME] and was set to 55 units and confirmed she would have administered the medication. At this time, on 10/17/19 at approximately 8:20 AM, an interview was conducted with the Unit Manager, Nurse E, LPN. The Unit Manager , LPN E, confirmed that LPN D had a [MEDICATION NAME] pen, and that this was the wrong medication. The Unit Manager stated that she, LPN E, was the one who obtained the [MEDICATION NAME] Pen from the EDK at the request of LPN D. On 10/17/19 at approximately 8:30 AM, an interview with the Director of Nurses, (DON) confirmed the Medication Administration Record [REDACTED]. A review of Resident #19's medical record revealed a physician's orders [REDACTED]. Resident #19 is a [AGE] year-old male with a [DIAGNOSES REDACTED]. Resident #19 has been on Insulin since admission to the facility. He was on 40 units of [MEDICATION NAME] N bid until 8/7/19 when the [MEDICATION NAME] N was increased to the current order of 55 units. On 10/17/19 at approximately 10:53 AM, a telephone interview was conducted with the pharmacy consultant for the facility. The pharmacist stated that [MEDICATION NAME] N was a long acting basal insulin and often was given morning and evening. The pharmacist stated that [MEDICATION NAME] was a fast-acting insulin and was often used for sliding scale insulin coverage. The surveyor asked the pharmacist what the possible effects were if [MEDICATION NAME]was administered instead of ordered [MEDICATION NAME] N Insulin. The pharmacist indicated that if [MEDICATION NAME]were to be administered at a time when [MEDICATION NAME] N insulin was ordered, the possible effect to the resident could include initial control of blood glucose but that the resident might not be able to maintain the desired blood glucose level control throughout the day. Further review of Resident 19's MAR indicated [REDACTED]. The maximum dosage of [MEDICATION NAME] that Resident #19 was ordered to receive was 10 units if the blood sugar test was greater than 350mg/dl (milligrams per deciliter). The residents blood sugar the morning of 10/17/19 was 112mg/dl. Per the physician's orders [REDACTED]. A review of the Medication policy, Document N-845; Insulin Administration dated 11/30/14 with revision date of 9/5/17 revealed: utilizing the medication card or medication sheet, check the label of the medication three times: Upon removal of the medication from its storage area, immediately before preparation and upon returning the medication to its storage area. Literature Review was conducted of the Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults from the Institute for Safe Medication Practices (ISMP) and review of the package insert from the Food and Drug Administration (FDA). The Institute for Safe Medication Practices (ISMP) stated: On page 3, One of the primary goals in diabetes treatment is to reduce episodes of [MEDICAL CONDITION] (high blood sugar) while minimizing the risk of hypoglycemic (low blood sugar) episodes. While subcutaneous insulin therapy is the cornerstone of hyperglycemic treatment, insulin is a high alert medication that can be associated with significant patient harm when used in error . On page 5, Although insulin can be lifesaving, it can also cause life-threatening injuries or death when used inappropriately as both overdoses and under-doses of insulin can cause harm. [DIAGNOSES REDACTED] is associated with significant morbidity and mortality, particularly from cardiovascular, [MEDICAL CONDITION], and patient fall events. Insulin was implicated in 33% of medical errors that caused death within 48 hours of the error. A review in 2011 of more than 16,000 patient safety incidents involving insulin showed that 24% resulted in patient harm. https://www.ismp.org/sites/default/files/attachments/2018-09/ISMP138D-Insulin%20Guideline- 8.pdf. The website was accessed 10/22/2019. Review of the [MEDICATION NAME]package insert from the Food and Drug Administration (FDA). 5.3 [DIAGNOSES REDACTED] is the most common adverse effect of all insulin therapies, including [MEDICATION NAME]. Severe [DIAGNOSES REDACTED] may lead to unconsciousness and/or convulsions and may result in temporary or permanent impairment of brain function or death. Severe [DIAGNOSES REDACTED] requiring the assistance of another person and/or [MEDICATION NAME] glucose infusion or [MEDICATION NAME] (medication for low blood sugar) administration has been observed in clinical trials with insulin, including trials with [MEDICATION NAME]. Rapid changes in serum glucose levels may induce symptoms of [DIAGNOSES REDACTED] in persons with diabetes, regardless of the glucose value. The website was accessed 10/22/2019. https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/ 6s082lbl.pdf The immediate jeopardy was removed onsite after the receipt of the removal plan and verification of corrective actions. License Nurse D was immediately removed from the medication cart on 10/17/19 at 8:30 AM and was provided one on one education regarding 7 rights of medication administration & new systemic change for verification of all Insulin to be verified by 2 licensed nurses prior to administration to ensure correct insulin and correct dose. Director of Nursing/Designee began immediate re-education to License Nurses regarding the 7 rights to medication administration & systemic change in insulin verification. Education was initiated on 10/17/19 with all current Licenses nurses working and will continue until all License Nurses have received the education. As of 10/17/19 at 12:00 PM no license nurse will be permitted to work until education has been received. Interviews conducted with 8 nurses confirmed the above. Beginning 10/17/19 at 12:00 PM a new process was put into place that was as follows: All insulin administrations will be verified by 2 licensed nurses prior to the administration and both nurses will initial on the Medication Administration Record [REDACTED]. As of 10/17/19 at 12:00 PM no licensed nurse will be permitted to work until education has been received. This process observed in practice by the survey team for 4 different nurses. Director of Nursing/Designee will conduct Medication Administration Observations with each License Nurse. Observation began on 10/17/19 at 12:00 and will continue until all current employed Licensed nurses have been observed and competencies checked off. Currently 14 of 26 licensed nurses have received the education and medication observation. The survey team observed the training and monitoring being conducted. Current residents receiving long acting and short acting insulin were reviewed and a red highlighted paper placed in their MAR indicated [REDACTED]. Director of Nursing/Designee to include both the education of the 7 rights to Medication Pass and Medication Administration Competencies are included as part of the New hire orientation of all License Nurses beginning 10/17/19.

Based on observations, staff interviews, and record reviews, the facility administration failed to ensure that nursing staff had training and competency evaluations in insulin administration and failed to ensure re-training after identified medication errors. A significant insulin medication error was identified for 1 of 3 residents sampled for insulin review, (#19). A nurse was preparing to administer 55 units of [MEDICATION NAME], a fast-acting insulin, instead of [MEDICATION NAME] N, the ordered intermediate-acting insulin. This type of insulin error could potentially result in dangerously low blood sugar levels ([DIAGNOSES REDACTED]) which can cause unconsciousness, [MEDICAL CONDITION], and death. There were 31 current residents in the facility receiving insulin injections. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator was notified of the Immediate Jeopardy finding on 10/17/19 at 5:07 PM. Immediate Jeopardy was removed on 10/17/19 at 6:30 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions which included immediate retraining of nursing staff on insulin administration and implementation of a two-step verification process for insulin injections. The deficient practice remains at a scope and severity level of a D. Cross reference to F726, F762, and F867. The findings include: On 10/17/2019 at approximately 8:05 AM, nurse D, a Licensed Practical Nurse (LPN), obtained a vial of [MEDICATION NAME](a fast acting insulin) from the medication drawer to administer ordered 55 units of [MEDICATION NAME] N (an intermediate-acting insulin). The nurse was stopped at that point to review the medication order. The nurse recognized the error, then told the surveyor that she would have to get the [MEDICATION NAME]from the refrigerator. The nurse then returned to the medication cart with a [MEDICATION NAME] flex pen from the EDK (emergency drug kit), and dialed 55 units, and attached the needle. LPN D entered resident #19's room, informed the resident that she was there to administer insulin, and opened an alcohol swab. The surveyor asked LPN D to step out of the room. The nurse confirmed that she was going to administer the medication and did not recognize that she had pulled the wrong medication. The surveyor confirmed with the Director of Nursing (DON) that the order was for 55 units of [MEDICATION NAME] N. Cross Reference F760. On 10/17/2019 at approximately 12:00 PM, an interview was conducted with LPN D. LPN D stated she was a new nurse, and had taken her nursing boards in (MONTH) of 2019 and started working as a nurse on (MONTH) 1, 2019. LPN D stated she only received 5 days of new employee orientation to include medication and insulin administration, and was not comfortable with the training she had received. LPN D stated that some days she feels comfortable giving medications and other days she does not. She stated, for example, she did not receive any training on giving medications during a tube feeding. LPN D stated no one has monitored her during medication pass or evaluated her readiness to administer medications. During an interview with the Director of Nursing (DON) on 10/16/2019 at approximately 11:26 AM regarding training and competency or skills checklists for nursing staff, the DON stated, We are not in substantial compliance. We have an action plan. The DON confirmed that there was no current clinical skills competency or checklist process in place for staff. When the DON was asked for a target date for compliance with the clinical skills competency training, the DON stated, We don't have one. The DON stated the current Staff Development Coordinator was hired about 1 month ago and was transitioning into the role. During an interview with the Staff Development Coordinator on 10/16/2019 at approximately 1:45 PM, the Staff Development Coordinator stated that he started about a month ago and has recently transitioned into the Staff Development role. The Staff Development Coordinator stated he had no training checklist for any facility employee, and he had no current written training plans. A personnel record review was conducted for the training and competency evaluations for LPN D. LPN D was hired on 5/1/2019 and had an Occupational Associate Degree for Practical Nursing dated 2/19/2019. The only documentation of orientation was a form entitled, Facility Blue Ribbon Orientation Checklist which was completed on 5/1/2019. The orientation items included items such as organizational structure, core values, and employment policies. There were no clinical skill evaluations noted. Also found was evidence of previous medication errors to include: On 7/31/2019, a Medication Discrepancy Report for missed antibiotic doses on 7/27 and 7/28/19 of the antibiotic [MEDICATION NAME] and subsequent Employee Corrective Action form dated 8/07/2019. On 7/30/2019, a Medication Discrepancy Report and disciplinary action for missing a breathing medication, [MEDICATION NAME], for 6 days from 7/24 - 7/30/2019. Review of LPN D's personnel record showed no medication training was provided after the errors were documented. A follow-up interview was conducted on 10/17/2019 at approximately 3:30 PM with the DON regarding medication training for LPN D. The DON provided a Certificate of Completion showing that LPN D has successfully completed Medication Administration: Avoiding Common Errors- Training Hours 0.5. The completion certificate had no completion date and no print date. The DON stated that LPN D had 17 shifts of new employee orientation which included shadowing a facility nurse for medication pass and insulin administration. The DON was unable to provide a clinical checklist or clinical skills competency record signed and dated by LPN D and the nurse she shadowed indicating medication pass and insulin administration training. Review of the Consulate Director of Clinical Service II (DON) Job Description (no date), Duties and Responsibilities section, #7 on page 1 of 3, indicates that the Director of Clinical Service II will, Establish, implement, and continually update competency/skills checklists for nursing staff. Review of the Consulate Staff Developer Job Description, dated (MONTH) 2006, Duties and Responsibilities section, #10 on page 1 of 3, indicates that the Staff Developer will, Develop, direct and schedule refresher training, as necessary, for assigned staff and licensed professional personnel. Section #16 on page 1 of 3, indicates that the Staff Developer will, Assure that individual employee training records are maintained and filed in the employee's personnel record. The immediate jeopardy was removed onsite after the receipt of the removal plan and verification of corrective actions. License Nurse D was immediately removed from the medication cart on 10/17/19 at 8:30 AM and was provided one on one education regarding 7 rights of medication administration & new systemic change for verification of ALL Insulin to be verified by 2 licensed nurses prior to administration to ensure correct insulin and correct dose. Director of Nursing/Designee began immediate re-education to License Nurses regarding the 7 rights to medication administration & systemic change in insulin verification. Education was initiated on 10/17/19 with all current Licenses nurses working and will continue until all License Nurses have received the education. As of 10/17/19 at 12:00 PM no license nurse will be permitted to work until education has been received. Interviews conducted with 8 nurses confirmed the above. Beginning 10/17/19 at 12:00 PM a new process was put into place that was as follows: All insulin administrations will be verified by 2 licensed nurses prior to the administration and both nurses will initial on the Medication Administration Record [REDACTED]. As of 10/17/19 at 12:00 PM no licensed nurse will be permitted to work until education has been received. This process observed in practice by the survey team for 4 different nurses. Director of Nursing/Designee will conduct Medication Administration Observations with each License Nurse. Observation began on 10/17/19 at 12:00 and will continue until all current employed Licensed nurses have been observed and competencies checked off. Currently 14 of 26 licensed nurses have received the education and medication observation. The survey team observed the training and monitoring being conducted. Current residents receiving long acting and short acting insulin were reviewed and a red highlighted paper placed in their MAR indicated [REDACTED]. Director of Nursing/Designee to include both the education of the 7 rights to Medication Pass and Medication Administration Competencies are included as part of the New hire orientation of all License Nurses beginning 10/17/19. The facility submitted an Employee Education Action Plan that included reviewing the current education status of nursing department staff and developing education/competency needs; developing and implementing a plan to ensure all areas of missed education/competencies are completed by nursing staff; and a plan for annual re-education and evaluation.

Based on observation of insulin administration, staff interviews, clinical record reviews, and policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to nursing staff training and competencies. A significant insulin medication error was identified for 1 of 3 residents sampled for insulin review, (#19). A nurse was preparing to administer 55 units of [MEDICATION NAME], a fast-acting insulin, instead of [MEDICATION NAME] N, the ordered intermediate-acting insulin. There were 31 current residents in the facility receiving insulin injections. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator was notified of the Immediate Jeopardy finding on 10/17/19 at 5:07 PM. Immediate Jeopardy was removed on 10/17/19 at 6:30 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions which included immediate retraining of nursing staff on insulin administration and implementation of a two-step verification process for insulin injections. The deficient practice remains at a scope and severity level of a D. Cross reference to F726, F762, and F835. The findings include: On 10/17/2019 at approximately 8:05 AM, nurse D, a Licensed Practical Nurse (LPN), obtained a vial of [MEDICATION NAME](a fast acting insulin) from the medication drawer to administer ordered 55 units of [MEDICATION NAME] N (an intermediate-acting insulin). The nurse was stopped at that point to review the medication order. The nurse recognized the error, then told the surveyor that she would have to get the [MEDICATION NAME]from the refrigerator. The nurse then returned to the medication cart with a [MEDICATION NAME] flex pen from the EDK (emergency drug kit), and dialed 55 units, and attached the needle. LPN D entered resident #19's room, informed the resident that she was there to administer insulin, and opened an alcohol swab. The surveyor asked LPN D to step out of the room. The nurse confirmed that she was going to administer the medication and did not recognize that she had pulled the wrong medication. The surveyor confirmed with the Director of Nursing (DON) that the order was for 55 units of [MEDICATION NAME] N. Cross Reference F760. On 10/17/2019 at approximately 12:00 PM, an interview was conducted with LPN D. LPN D stated she was a new nurse, and had taken her nursing boards in (MONTH) of 2019 and started working as a nurse on (MONTH) 1, 2019. LPN D stated she only received 5 days of new employee orientation to include medication and insulin administration, and was not comfortable with the training she had received. LPN D stated that some days she feels comfortable giving medications and other days she does not. She stated, for example, she did not receive any training on giving medications during a tube feeding. LPN D stated no one has monitored her during medication pass or evaluated her readiness to administer medications. During an interview with the Director of Nursing (DON) on 10/16/2019 at approximately 11:26 AM regarding training and competency or skills checklists for nursing staff, the DON stated, We are not in substantial compliance. We have an action plan. The DON confirmed that there was no current clinical skills competency or checklist process in place for staff. When the DON was asked for a target date for compliance with the clinical skills competency training, the DON stated, We don't have one. The DON stated the current Staff Development Coordinator was hired about 1 month ago and was transitioning into the role. During an interview with the Staff Development Coordinator on 10/16/2019 at approximately 1:45 PM, the Staff Development Coordinator stated that he started about a month ago and has recently transitioned into the Staff Development role. The Staff Development Coordinator stated he had no training checklist for any facility employee, and he had no current written training plans. A personnel record review was conducted for the training and competency evaluations for LPN D. LPN D was hired on 5/1/2019 and had an Occupational Associate Degree for Practical Nursing dated 2/19/2019. The only documentation of orientation was a form entitled, Facility Blue Ribbon Orientation Checklist which was completed on 5/1/2019. The orientation items included items such as organizational structure, core values, and employment policies. There were no clinical skill evaluations noted. Also found was evidence of previous medication errors to include: On 7/31/2019, a Medication Discrepancy Report for missed antibiotic doses on 7/27 and 7/28/19 of the antibiotic [MEDICATION NAME] and subsequent Employee Corrective Action form dated 8/07/2019. On 7/30/2019, a Medication Discrepancy Report and disciplinary action for missing a breathing medication, [MEDICATION NAME], for 6 days from 7/24 - 7/30/2019. Review of LPN D's personnel record showed no medication training was provided after the errors were documented. A follow-up interview was conducted on 10/17/2019 at approximately 3:30 PM with the DON regarding medication training for LPN D. The DON provided a Certificate of Completion showing that LPN D has successfully completed Medication Administration: Avoiding Common Errors- Training Hours 0.5. The completion certificate had no completion date and no print date. The DON stated that LPN D had 17 shifts of new employee orientation which included shadowing a facility nurse for medication pass and insulin administration. The DON was unable to provide a clinical checklist or clinical skills competency record signed and dated by LPN D and the nurse she shadowed indicating medication pass and insulin administration training. On 10/ 17/19 at approximately 2:39 PM an interview was conducted with the Director of Nursing (DON) as part of the Quality assessment and assurance program review (QAA). The DON stated that she felt their QAA was an effective program and they had recently identified and corrected quality care issues. The DON stated that their current process was more reactive than proactive. The DON stated the QAA committee does not have specific target dates for any of their currently identified concerns. On 10/17/19 at approximately 2:50 PM, an interview was conducted with the Administrator who stated he had recently attended State Agency and State Nursing Home Association Joint Training where he received training in the QAA process and was planning on implementing that training at the next QAA meeting, but had not yet shared that information with the rest of the QAA committee. The immediate jeopardy was removed onsite after the receipt of the removal plan and verification of corrective actions. An Ad Hoc QAA committee meeting was held on 10/17/2019 at 5:20 PM with the Medical Director. License Nurse D was immediately removed from the medication cart on 10/17/19 at 8:30 AM and was provided one on one education regarding 7 rights of medication administration & new systemic change for verification of ALL Insulin to be verified by 2 licensed nurses prior to administration to ensure correct insulin and correct dose. Director of Nursing/Designee began immediate re-education to License Nurses regarding the 7 rights to medication administration & systemic change in insulin verification. Education was initiated on 10/17/19 with all current Licenses nurses working and will continue until all License Nurses have received the education. As of 10/17/19 at 12:00 PM no license nurse will be permitted to work until education has been received. Interviews conducted with 8 nurses confirmed the above. Beginning 10/17/19 at 12:00 PM a new process was put into place that was as follows: All insulin administrations will be verified by 2 licensed nurses prior to the administration and both nurses will initial on the Medication Administration Record [REDACTED]. As of 10/17/19 at 12:00 PM no licensed nurse will be permitted to work until education has been received. This process observed in practice by the survey team for 4 different nurses. Director of Nursing/Designee will conduct Medication Administration Observations with each License Nurse. Observation began on 10/17/19 at 12:00 and will continue until all current employed Licensed nurses have been observed and competencies checked off. Currently 14 of 26 licensed nurses have received the education and medication observation. The survey team observed the training and monitoring being conducted. Current residents receiving long acting and short acting insulin were reviewed and a red highlighted paper placed in their MAR indicated [REDACTED]. Director of Nursing/Designee to include both the education of the 7 rights to Medication Pass and Medication Administration Competencies are included as part of the New hire orientation of all License Nurses beginning 10/17/19. The facility submitted an Employee Education Action Plan that included reviewing the current education status of nursing department staff and developing education/competency needs; developing and implementing a plan to ensure all areas of missed education/competencies are completed by nursing staff; and a plan for annual re-education and evaluation. New QA Data Collection Tool immediately put in place for monitoring and ensuring nursing staff is properly administering insulin and Medication Administration. On 10/17/19 at 12:00 PM, the Regional Director of Clinical Services provided education to the executive director, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Staff Development Nurse on expectations of providing all newly hired license nurses education upon hire regarding the 7 rights to medication administration specifically reviewing the different types of insulins and actions of each fast acting verse long acting and the importance of accuracy to following physician orders, and systemic changes expected regarding 2 license nurses to verify and validate insulin prior to administration ensuring correct insulin and accurate dose, lastly the expectation of the education and skills check off to be included in new hire orientation. Medical director and physician of each resident notified for insulin dependent diabetic residents, with no new orders added. Routine vital signs and any abnormal findings reported to physicians and medical director.

Based on observation, record review, resident interview and staff interview, the facility failed to implement the resident's care plan related to providing incontinent care for 1 of 3 residents sampled for activities of daily living (resident #8) and 1 of 3 residents sampled for pressure ulcers (Resident #3), which resulted in the development and worsening of the pressure injuries and subsequent hospitalization for resident #3. The findings were: Resident #3 Review of resident #3's admission Minimum Data Assessment (MDS) assessment, with Assessment Reference Date (ARD) of 4/26/19, documented the resident was admitted on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Section M, skin conditions, of the MDS assessment documented the resident had one unstageable pressure ulcer with treatments documented as pressure reducing device for bed and chair, pressure ulcer care and application of dressings. Based on this assessment, a comprehensive plan of care was initiated on 04/29/2019 for actual impairment to skin integrity of the buttock related to spinal cord injury and debility. The care plan goal was for the resident to have minimal complications related to non-stageable pressure ulcer of the buttock and care interventions included: monitor/document location, size and treatment of [REDACTED]. to the physician. On 6/3/19 at approximately 10:00 AM, an interview was conducted with the facility's designated wound care nurse, Licensed Practical Nurse A (LPN A). She stated the resident had been discharged to the hospital a couple of weeks ago and had been admitted with large necrotic areas to both buttocks and was being treated with Santyl for debridement. She further stated Resident #3 was also was followed in-house by a consulting wound care ARNP (Advanced Registered Nurse Practitioner) when the resident would allow and stated the ARNP visited weekly to assess, measure and stage wounds and provide wound care orders. Review of the facility's nursing admission assessment, dated 4/19/19, included a body diagram with labeled markings of surgical wounds and a marking of the sacral/coccyx (base of spine/tailbone) area without labeling of the type of impairment in that area. The admission nurse, LPN S, documented in her narrative admission note that patient has open area to coccyx but unwilling to let me look at this time due to severe pain when moving, medicated and will assess after pain managed. On 4/30/19 (11 days following admission), the resident's wounds were assessed by the consulting wound care ARNP, who documented that physical examination revealed an unstageable sacral ulcer (base of spine) measuring 4cm x 1.5cm (centimeters) with eschar (dried necrotic tissue), an unstageable left ischial (buttocks) ulcer measuring 5.5cm x 4cm with eschar and a suspected Deep Tissue Injury of the resident's right ischial tuberosity (area of buttocks that takes the body's weight during sitting). Following the wound care ARNP assessment on 4/30/19, the assessments conducted by the facility's designated wound care nurse demonstrated worsening of the wounds. The left ischial wound, measuring 5.5cm x 4cm on 4/30/19 as documented by the ARNP, was documented by LPN A to be 9cm x 10.5cm on 5/7/19 and documented by LPN A to measure 10cm x 11cm on 5/14/19. The right ischial wound assessed to be suspected deep tissue injury by the ARNP on 4/30/19 was documented by LPN A to be 6cm x 5cm x 0.5cm on 5/7/19 and documented by LPN A to measure 7.5cm x 5cm x 0.5cm on 5/14/19. There was no documentation the consulting ARNP, the vascular physician (who provided oversight for the ARNP), the facility's physician assistant nor the facility's physician were informed of these changes in accordance with the comprehensive plan of care until the ARNP assessment of 5/21/19. Review of the wound care ARNP assessment, dated 5/21/19, which had been a suspected deep tissue injury on her 4/30/19 visit, revealed the resident's right ischial wound now measured 8.6cm x 6.5cm with eschar. The left ischial wound, which had measured 5.5cm x 4cm on her 4/30/19 visit, now measured 10cm x 11cm with eschar and a strong odor. The ARNP recommended sending Resident #3 to the emergency room due to the strong odor of the wounds and scheduled a wound care center appointment for the next day, 5/22/19. On 5/23/19 at 3:00 PM, resident was transported to an acute care hospital and subsequently admitted with [DIAGNOSES REDACTED]. Resident #8 Review of the plan of care for Resident #8 for Activities of Daily Living (ADLs), initiated 12/27/18 and updated 5/03/19, revealed resident #8 had the potential for ADL self-care performance deficit related to muscle weakness and lack of coordination. The care plan indicated that the resident required extensive assistance by one staff for toileting and interventions included, but were not limited to: encouraging the resident to participate to the fullest extent possible with each interaction, providing extensive assistance by one staff for toileting, and encouraging the resident to use his call bell for assistance. Review of the resident's most recent Minimum Data Set (MDS) assessment, dated 4/25/19, confirmed Resident #8 continued to require extensive, one person physical assistance for toilet use and/or incontinent care. On 6/3/19 at approximately 9:00am, Resident #8 was observed to be lying in bed on a bed pad. He stated he had a complaint of staff taking long times (normally 30 minutes) to provide him assistance with incontinent care. Resident #8 stated, for example, I've been waiting 25 plus minutes for someone to change me. I put my call light on and staff came in and told me they would be back, but no one has been back to change me yet. The smell of feces could be smelled during the interview with the resident and he informed this surveyor that he had a bowel movement. Resident #8 was asked how often this occurred and he stated, quite frequently. The resident was asked to put his call light on, so this surveyor could observe how long it took staff to provide assistance with incontinent care. The resident placed the call light on at approximately 9:08 AM. On 6/3/19 from 9:20am-9:40am, this surveyor was at the nurses' station that faced Resident #8's room and observed the resident's call light was still activated. Also observed at the nurse's station were the Assistant Director of Nursing (ADON) and Employee U, the Licensed Practical Nurse (LPN) assigned to Resident #8; however, neither seemed to notice the call light for Resident #8 ringing at the nurses' station. The ADON was asked how much assistance Resident #8 required with toileting and she replied, he needs total assistance, but could be more independent if he put effort into it. The ADON further stated Resident #8 preferred for staff to provide him assistance with all care instead of doing what he could for himself. At no time did either the ADON or Employee U go down to the resident room to ask if he needed assistance. While interviewing the ADON, Employee T, a Certified Nursing Assistant (CNA), was observed to enter the room of Resident #8 at about 9:30 AM, where she stayed for approximately 2 minutes. When Employee T exited the resident's room, the call light was no longer observed to be activated on the outside of the door. On 6/3/19 at 9:51 AM, a follow-up interview was conducted with Resident #8. The resident stated he had still not had his bed pad changed and the smell of feces could still be smelled in the room. He stated staff came in the room and stated it would still be a while. The resident put his call light back on and the surveyor exited the room again and went back to the nurse's station. On 6/3/19 at approximately 9:54 AM, Employee U and Employee T were observed to be in the room across from Resident #8's room and the ADON was observed to be walking the 600 hall. This surveyor went back to the nurse's station and observed Employee U leave another resident's room, right across from Resident's #8's room, without acknowledging the activated call light of Resident #8 and without going to check on Resident #8 to see what he needed. On 6/3/19 at approximately 10:40am, Employee T, assigned CNA for Resident #8, was asked if the resident required assistance and confirmed the resident required extensive assistance with toileting. She was asked if she had provided incontinent care to the resident that morning, and she stated she had completed the care about 5-10 minutes ago. Employee T was also asked if she knew how long the resident had to wait for incontinent care and stated, I'm not sure, but I know it wasn't long. Can't tell you what he considers to be long. On 6/3/19 at approximately 10:45 AM, a follow-up observation with Resident #8 revealed a clean bed pad and the resident confirmed the CNA returned and changed the pad and provided incontinent care.

Based on observation, staff interview, resident interview, family interview, record review and policy review, the facility failed to ensure 2 of 3 residents received necessary treatment and services to prevent the development of pressure ulcers and promote wound healing (#3 & #10). The Findings Include: Resident #3. Review of the resident's admission Minimum Data Assessment (MDS), with Assessment Reference Date (ARD) of 4/26/19, documented the resident was admitted on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Section M, Skin Conditions, of the MDS assessment documented the resident had one unstageable pressure ulcer with treatments documented as pressure reducing device for bed and chair, pressure ulcer care and application of dressings. Section C, Cognitive Patterns, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. On 6/3/19 at approximately 10:00 AM, an interview was conducted with the facility's designated wound care nurse, Licensed Practical Nurse A (LPN A). She stated the resident had been admitted with large necrotic areas to both buttocks and 3+ [MEDICAL CONDITION] from the waist down. On 5/21/19, the in-house consulting wound care ARNP (Advanced Registered Nurse Practitioner) wanted to send him to the hospital for surgical debridement, but he refused to go. Resident #3 was being treated with Santyl for debridement prior to his discharge to the hospital a couple weeks ago (on 5/23/19). She stated the wound care ARNP visited weekly to assess, measure and stage wounds. Resident #3 was assessed by the ARNP when the resident would allow. She stated he was noncompliant with care and would sit up playing video games and watching television for hours. He had an alternating air mattress, but he did not like it, and he would deflate the mattress. She stated he refused to turn and reposition although he was able to use his upper body and had a trapeze to assist in repositioning. She stated that the only way they convinced resident #3 to go to the hospital was to reassure him he would be allowed back. Review of the facility's nursing admission assessment, dated 4/19/19, included a body diagram with labeled markings of surgical wounds and a marking of a sacral/coccyx (base of spine/tailbone) area without labeling of the type of impairment in that area. The admission nurse, LPN S, documented in her narrative admission note that patient has open area to coccyx but unwilling to let me look at this time due to severe pain when moving, medicated and will assess after pain managed. A telephone interview with LPN S, who performed the admission assessment, was conducted on 6/6/19 at approximately 5:00 PM. She stated she did not recall seeing the wounds and what she documented in her nursing admission assessment was correct. There was no further wound assessment documentation until 4/23/2019, four days later, when the wound care nurse, licensed practical nurse A (LPN A) completed her assessment. admission orders [REDACTED]. The first documentation of pressure wounds was written by the facility's designated wound care nurse, Licensed Practical Nurse A (LPN A) on the Interdisciplinary Progress Note (IDT) dated 4/23/19 at 9:00 AM (4 days following admission). LPN A documented 3 unstageable pressure wounds (1) sacrum (base of spine) with yellow slough (dead skin tissue) to wound bed, (2) left ischium (buttocks) with black eschar (dried necrotic tissue) and (3) right ischium (buttocks) with yellow slough and dark discoloration. LPN documented that all 3 pressure ulcers were present on admission and resident refused to allow the consulting Wound Care ARNP (Advanced Registered Nurse Practitioner) to assess. On the Pressure Injury Record for 4/23/19, LPN A documented wound measurements. (All wound measurements are in centimeters (cm), length x width x depth). (1) Sacrum: unstageable sacral pressure ulcer measuring 3cm x 2.5cm with yellow slough, (2) left ischium: unstageable pressure wound of left ischium (buttock) measuring 8.5cm x 10.5cm with black eschar and (3) right ischium: unstageable pressure wound of the right ischium (buttock) measuring 4cm x 5cm x 0.1cm with black eschar. Also documented in the IDT note of 4/23/19 was, continues on low air loss mattress, however, mattress noted in off position. Resident educated on the importance of off loading wounds and mattress always being on. Resident stated, I hate this mattress so I had my friend turn it off. On 4/23/19 at 10:00 AM, physician orders were obtained for dressing changes with Santyl/Dakin's solution pressure wounds of the sacrum (base of spine), right ischium (buttocks) and left ischium (buttocks). Review of the TAR from 4/23/19 to discharge on 5/23/19 documented dressing changes per order with five resident refusals of dressing changes. On 4/30/19, (11 days following admission), the resident's wounds were assessed by the consulting wound care ARNP, who documented that physical examination revealed an unstageable sacral ulcer measuring 4cm x 1.5cm with eschar (dead tissue), an unstageable left ischial ulcer measuring 5.5cm x 4cm with eschar and a suspected Deep Tissue Injury of the resident's right ischial tuberosity (bony prominence in buttock). The ARNP documented, nurses report he sits up most of the day and now has pressure ulcers of bilateral sacroiliac areas and sacrum (areas on buttocks). He is refusing nursing care and dressing changes per the staff. The ARNP ordered a consult with a plastic surgeon, a pressure relief mattress, and ordered to keep resident off backside as much as possible. Following the wound care ARNP assessment on 4/30/19, the assessments conducted by the facility's designated wound care nurse demonstrated worsening of the wounds. The left ischial wound, measuring 5.5cm x 4cm on 4/30/19 as documented by the ARNP, was documented by LPN A to measure 9cm x 10.5cm on 5/7/19 and measure 10cm x 11cm on 5/14/19. The right ischial wound assessed to be suspected deep tissue injury by the ARNP on 4/30/19 was documented by LPN A to measure 6cm x 5cm x 0.5cm on 5/7/19 and measure 7.5cm x 5cm x 0.5cm on 5/14/19. The sacral wound measuring 4cm x 1.5cm as documented by the ARNP, was documented by LPN A to measure 3cm x 2.5cm. There was no documentation that a physician or the consulting ARNP were informed of these changes in accordance with the comprehensive plan of care. There were inconsistencies noted in the documentation of the wound assessments, although all wound assessments demonstrated wound worsening, please refer to F842. In the IDT notes for 4/30/19 at 10:00 AM, the wound care nurse, LPN A, documented that resident #3 was assessed by the wound care ARNP. Resident #3 continued with [MEDICAL CONDITION] to lower extremities. Resident noted sitting up in bed playing game on television. Resident educated on importance of repositioning every 2 hours. Wound care ARNP also educated resident on importance of off-loading wounds. Resident stated, How can I play my game and make bracelets on my side? Resident repositioned. In the IDT notes for 5/07/19 at 11:00 AM, LPN A documented, resident noted sitting up in bed playing game. When asked if he had allowed staff to reposition him, he stated he let the CNA (certified nursing assistant) due it once. Resident continues to be educated on importance of repositioning to off-load wounds. No odor or signs/symptoms of infection. Attempted to reposition resident, but he refused. In the IDT notes for 5/14/19 at 10:30 AM, LPN A documented, resident in bed sitting up making bracelets. Refused to be assessed by the wound care ARNP. Right ischium continues with black eschar and left ischium continues with dark discoloration and eschar. Sacral wound continues with yellow slough to wound bed. No odor or signs/symptoms of infection. Educated on importance of off-loading wounds. Resident repositioned. Review of the wound care ARNP assessment, dated 5/21/19, which had been a suspected deep tissue injury on her 4/30/19 visit, revealed the resident's right ischial wound now measured 8.6cm x 6.5cm with eschar. The left ischial wound, which had measured 5.5 x 4cm on her 4/30/19 visit, now measured 10cm x 11cm with eschar and had a strong odor. The ARNP documented that staff was reporting resident #3 was non-compliant with care, refusing dressing changes and stays on his back all day playing video games and making bracelets. The ARNP recommended sending Resident #3 to the emergency room due to the strong odor of the wounds and scheduled a wound care center appointment for the next day, 5/22/19. Review of the medical director's progress notes, dated 4/23/19, 4/30/19, 5/7/19, and 5/14/19 failed to document any notes related to the pressure wounds of Resident #3. There was a progress note, dated 5/21/19, which documented, patient has been noncompliant from the standpoint of his wound care. He is not turning as directed and has refused to have wounds evaluated by vascular surgeon. He is scheduled to see wound care center tomorrow. In the IDT notes for 5/21/19 at 9:00 AM, LPN A documented that the ARNP assessed the wounds. ARNP requests resident be sent to emergency room (ER) for evaluation and possible debridement of wounds, however, resident #3 is refusing because he wants to be able to take his television, game and all personal belongings on ambulance. Resident offered secondary transportation, but continues to refuse. Appointment with outside wound care scheduled for tomorrow. On 5/22/19 at 2:00 PM, LPN A documented that resident #3 was transported to the scheduled wound consult appointment and returned with orders to be sent to ER, but resident is refusing. Review of Wound Care Center note of 5/22/19 at 3:00 PM revealed the wound physician assessed the 3 pressure wounds and documented, I strongly recommend the patient go immediately to the hospital for admission for suspected infection and treatment of [REDACTED]. On 5/23/19 at 3:00 PM, resident was transported to an acute care hospital and subsequently admitted with [DIAGNOSES REDACTED]. Review of the discharge MDS assessment, with an assessment reference date of 5/23/19, documented the presence of three unstageable pressure ulcers upon discharge, with 1 of the 3 being present on admission. On 6/6/19 at approximately 9:00 AM, the resident was visited for interview at the acute care hospital to which he transferred on 5/23/19. In the interview he stated he did not have an alternating air mattress on his bed until approximately 2 weeks before his discharge date of [DATE]. He also stated he had not had any wounds to his buttocks when he arrived at the facility and verbalized he had not received good care and did not desire to return to that facility. On 6/6/19 at 1:15 PM an interview with LPN A was conducted regarding the air mattress. LPN A stated she had requested an air mattress on 4/23/19, but it took a couple of days to get it. (See IDT entry on 4/23, above). During that interview she stated the air mattress that had been applied on the resident's bed (on unknown date) was one they keep in-house, but was malfunctioning and would not hold air pressure. On 6/6/19 at approximately 5:30 PM, a follow-up interview was conducted with LPN A regarding the air mattress. LPN A acknowledged the 4/23/19 documentation on the IDT note was not correct and stated I meant to write that on the 4/30/19 note. She stated she ordered a pressure relief air mattress after the 4/30/19 visit by the ARNP, and that the mattress was received on 5/6/19 per the invoice provided to this surveyor. (Please refer to F842). Resident #10 On 6/4/19 at 12:25 PM, Resident #10 was observed seated in a wheelchair in his room having lunch. His wife, who stated she visited the resident daily, was at his side. Interview with the resident's wife at the time of the observation revealed Resident #10 had wounds on both of his heels, that were present at the time of admission to the facility and an area on his buttocks that had developed since his admission to the facility. She stated the resident received treatments for the heel wounds, but she was not sure if any treatment was being provided to the buttocks. She confirmed the resident was unable to move independently and remained seated in his wheelchair or lying on his back for long periods of time. She further stated his heels were supposed to be elevated, but that was not being done. Review of the resident's nursing admission assessment, dated 5/17/19, documented pressure wounds to his bilateral heels and redness to his sacrum/buttocks area as indicated by a circle on the skin diagram. The nursing admission note also documented a [MEDICATION NAME] dressing to bilateral heels, will advise to have ARNP for wound care. There was a physician order, dated 5/19/19, to consult ARNP for wound care and an order to apply a [MEDICATION NAME] dressing to the resident's bilateral heels. There were no physician orders for treatment to the skin impairment of the resident's buttocks. Weekly skin evaluations, dated 5/17/19 and 5/21/19, documented redness to the sacrum/buttocks area as indicated by a circle on the skin diagrams. The weekly skin evaluation, dated 5/28/19, had markings on the skin diagram of bilateral heels and coccyx area, but there was no description of the skin impairments. Review of the medical record failed to include further assessment of the redness to sacrum/buttocks area and failed to include any treatment orders. Interview with the Assistant Director of Nursing, also serving as Unit Manager of the skilled unit, on 6/4/19 at approximately 1:30 PM, revealed she did not include a description of the skin impairments on the weekly skin evaluations because they had already been identified on the prior weeks' evaluations. The ADON confirmed the facility's wound care nurse should have been made aware of the resident's skin impairments. On 6/4/19 at approximately 1:00 PM, this surveyor asked the facility's designated wound care nurse, LPN A, if she was aware of the reddened area. LPN A stated she was not, but should have been told by the staff member who discovered the area during a skin assessment and that she would have the physician look at it. On 6/5/19 at approximately 7:35 AM, (18 days following the first observation of the skin impairment), the facility's wound care nurse was observed writing a telephone order for a low air loss mattress and an order to cleanse the resident's buttocks with normal saline and apply zinc barrier cream every shift and as needed. She stated the physician did not see the skin impairment, but he was informed. The medical record interdisciplinary progress note, dated 6/5/19, documented: resident noted with red rash to buttocks. No drainage or signs and symptoms of infection noted. Order for zinc oxide barrier cream in place. Responsible party notified of rash with no concerns voiced. Physician also notified. Will continue to monitor. On 6/5/19 at 4:30 PM, LPN A wrote a telephone order for low air loss mattress for the resident's bed. On 6/5/19 at 7:30 AM, 9:30 AM and 11:30 AM, the resident was observed laying in a supine position in bed with heels not floated. The wedge cushion for floating his heels was observed in a chair bedside the bed. On 6/5/19 at 1:30 PM, the resident remained supine with heels not floated. The wedge cushion for floating his heels was observed on the floor next to the dresser. (Photographic evidence obtained). On 6/5/19 at 3:30 PM, resident #10 observed to remain in supine position with heels not elevated. Interview with resident's wife at bedside stated she moved the wedge cushion to the floor from the chair when she arrived. She stated she had been sitting with her husband since 12:00 PM and he had not been repositioned and heels had not been elevated. Interview with the wife confirmed she had received a phone call this morning informing her of the reddened area to buttocks, but stated I already knew because I am the one that told them several days ago when he started complaining of pain in that area. Wound care was observed by the facility's designated wound care nurse, LPN A, on 6/5/19 at approximately 3:30 PM. Bilateral heel wounds observed to measure approximately 3cm x 3cm with yellow slough. Request was made to observe buttocks area where a red rash had been being documented since admission date of [DATE]. The sacral/buttocks area was observed to be reddened with a non-blanchable area and an area with purplish-blue discoloration, suspicious of deep tissue injury. There were no open areas. Zinc oxide was applied to the area. Interview was conducted with the resident's assigned 7 AM -3 PM shift nurse (LPN L) on 6/5/19 at approximately 3:45 PM in the presence of the wound care nurse. When asked why the resident had not been turned and repositioned; and why the heels had not been elevated, she replied she had. LPN L was informed the resident was observed every 2 hours from 7:30 AM until 3:30 PM by this surveyor, and wife has been at bedside since noon; and resident #10 has remained on his back with heels not elevated off the mattress. Interview was conducted with the resident's assigned 3 PM -11 PM shift nurse, (RN G), on 6/5/19 at approximately 3:50 PM in the presence of the wound care nurse. She verbalized she was not aware of the resident's skin impairments and did not know he was to have his heels elevated for unstageable pressure ulcers. She stated she was his nurse yesterday on 3 PM -11 PM, but he had been up in his wheelchair then had been put to bed. When asked how she would know if a resident has a pressure ulcer, she stated I guess would have to look in the chart.

Based on observations, record review, resident interview, staff interview and policy review, the facility failed to provide catheter care in accordance with physician orders [REDACTED].#1, #3, & #6), contributing to the development of a urinary tract infection for Resident #3. The facility also failed to follow facility policy on keeping catheter bags off the floor to prevent a urinary tract infection for 1 of 3 residents (Resident #6). The findings included: Resident #6 On 6/3/19 at approximately 9:10 AM, Resident #6 was observed to be lying in bed. The resident's catheter bag was observed to be on the floor. Resident revealed he was unaware the catheter was not supposed to be on the floor because it's been there (photographic evidence obtained). The Assistant Director of Nursing, who was present at the time of this observation, also observed the resident's catheter bag to be on the floor and confirmed it should not be on the floor. Review of the medical record for Resident #6 revealed a physician's orders [REDACTED]. The physician ordered catheter care every shift and as needed; a privacy bag with leg strap, and to check every shift. Review of the Treatment Administration Record (TAR) for the month of (MONTH) 2019 revealed catheter care had been documented as provided on the 7AM to 3PM shift on the 18th, 19th, 21st, 22nd, 23rd, 24th, & 28th. There was no documentation for the entire month to indicate that staff had performed catheter care for the resident on the 3PM to 11PM shift. The only documentation for the 11PM to 7AM shift were resident refusals documented on the 25th & 28th. Review of the resident's TAR do date on (MONTH) 3, 2019, showed the resident had received catheter care on each shift the 1st day of the month with no further documentation of care on any of the other days of the month. On 6/3/19 at approximately 2:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON) and Acting Unit Manager for the Sub Acute Unit. She was asked how often staff should be performing catheter care and she replied, catheter care should be performed per shift. When asked how often staff were expected to document that catheter care was performed, she stated, per shift at least by the end of the shift. She was shown the TARs for Resident #6 for (MONTH) and to date in (MONTH) 2019 and could not provide a response as to why staff had not documented catheter care had been performed. On 6/4/19 at 11:30 AM, an interview was conducted with Resident #6, who was asked if facility staff performed catheter care for him. He stated, if you mean do they clean it, not often, but I'm not sure how often they are supposed to. He stated that when he was at the hospital, staff there had provided catheter care routinely and he noticed the nursing home did not perform the care as often as the hospital staff did. Resident #6 was asked staff performed catheter care per shift to include cleaning and emptying the bag, and the resident replied, No. A review of the facility's policy, Guidelines for Preventing Catheter Associated Urinary Tract Infections, with an effective date of 9/1/2017, indicated staff should document the provision of treatment as ordered and instructed: Do not place the drainage bag on the floor. Resident #3: Review of admission physician orders, dated 4/19/19, included an order to perform Foley catheter care every shift. Review of the resident's (MONTH) 2019 Treatment Administration Record (TAR) documented the catheter care to have been performed on 16 shifts as indicated by nursing staff initials. There were 17 shifts that failed to indicate any catheter care had been performed as indicated by blanks on the TAR. Review of the (MONTH) 2019 TAR failed to demonstrate catheter care had been performed from (MONTH) 1, 2019 through (MONTH) 19, 2019 as indicated by blanks on the TAR. Care was documented as being performed on the 3 PM -11 PM shift on 5/20/19, 7 AM -3 PM and 3 PM -11 PM shift on 5/21/19 and the 11 PM -7 AM shift on 5/22/19. The medical record included a urinalysis and urine culture performed on 5/1/19 that noted the resident's urine to have cloudy, amber appearance with a moderate amount of blood. A urine infection was confirmed on 5/5/19 by culture results documenting presence of Escherichia coli for which Resident #3 received a 7-day course of an antibiotic therapy. On 5/23/19, resident #3 was sent to a local hospital emergency department. Documentation from the emergency department (ED) where the resident was seen on 5/23/19 at 3:05 PM showed the resident's temperature was 101.8 at the time he was seen in the ED. Resident #3 was subsequently admitted to the hospital from the ED with [DIAGNOSES REDACTED]. The urine culture report from 5/23/19 and wound culture report from 5/24/19 both showed growth of a bacteria called Acinetobacter baumannii. Resident #1 Resident #1 was readmitted to the facility on [DATE] following an acute care hospital stay for an urine infection. Review of the resident's physician orders [REDACTED]. On 6/6/19 at approximately 3:45 PM, Resident #1 was observed, in the presence of a Certified Nursing Assistant (CNA J), to be in bed with urine draining to a collection bag affixed to the resident's bedrail. The resident was observed not to have a device in place securing the catheter tubing to the resident's thigh. CNA J stated the resident had a catheter leg strap in place the last time she had been her assigned CNA, but it had become soiled, so she removed it and did not replace it, as she was unaware of where to obtain a replacement. On 6/6/19 at approximately 3:50 PM, the resident's assigned CNA (CNA M) was asked why the resident did not have a securing device for the catheter tubing and she stated, she does not get out of the bed. Interview with the resident's assigned Licensed Nurse (LPN T) on 6/6/19 at approximately 3:55 PM revealed she was not aware the device was not in place and stated she would obtain one; however, the resident's TAR showed LPN T had initialed that the strap had been in place on the 7AM to 3PM shift for that day. The nurse confirmed she had signed the TAR without visually observing the device to be in place.

Based on repeated patterns of deficient practice and harm to residents, the facility administration failed to ensure the facility was operating in an effective and efficient manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Findings Include: On (MONTH) 4, (YEAR) a recertification survey was conducted at the facility which resulted in the identification of quality issues related to failure of the facility to develop and implement resident plans of care; failure to provide treatment and services to prevent the development of pressure ulcers; and failure to ensure resident medical records were complete and accurately documented. During this complaint survey, these same quality deficiencies were again identified, and resulted in harm to Resident #3. On the 10/4/18 recertification survey the facility was cited for failure to develop a plan of care and failure to implement a developed plan of care for 2 different residents related to limited range of motion and respiratory care. The facility submitted a plan of correction stating they had corrected the quality deficiencies for the 2 residents identified and had provided education to staff responsible for care plan development. It further stated the Minimum Data Set (MDS) Coordinator would be responsible for monitoring the facility implemented interventions to ensure corrective action was being sustained and stated this would be done through audits that would be presented quarterly to the facility's Quality Assurance Committee and monitoring would be modified as necessary based on the findings of these audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the implementation of resident care plans that resulted in harm to Resident #3 (See F656). On the 10/4/18 recertification survey the facility was cited at a harm level for failure to provide treatment and services to prevent the development of pressure ulcers for one resident who had blisters that progressed to to a stage 4 pressure ulcer that subsequently required hospitalization and surgical intervention prior to the placement of a wound vac. The ordered treatment for [REDACTED]. The facility submitted a plan of correction that stated they had re-evaluated this resident to ensure treatment was being provided in accordance with physician orders [REDACTED]. The facility also stated they had provided re-education to nursing staff regarding the provision of care to prevent the development of pressure ulcers and that they would complete audits to ensure the issues did not recur. The facility stated the findings from their audits would be presented in the facility's monthly quality assurance meeting and monitoring would be modified based on the findings of these audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the provision of care and services to prevent the development of pressure ulcers that resulted in harm to Resident #3 (See F686). On the 10/4/18 recertification survey the facility was cited for failure to ensure resident records were complete and accurately documented for 2 residents by failing to document a fall for one of the residents and for failure to locate records for the other resident. The facility submitted a plan of correction for this deficiency that stated they had corrected the records for these two residents and had reviewed the records of other residents to ensure no one else had been affected. The facility also stated they had provided education to the medical records staff about ensuring records were completed and documented accurately and would have medical records staff complete audits and findings from these audits would be discusses monthly during the facility's quality assurance meetings and monitoring would be modified based on results of the audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the inaccuracy and incompleteness of resident medical records (See F842). On 6/4/19 at approximately 3:30 PM, an interview regarding identified concerns was conducted with the Administrator and both Regional Nursing Consultants. The staff stated they were in the process of investigating a reported documentation issue. The staff stated they had recently become aware of some care issues, including pressure ulcers, in the last few weeks and had begun corrective actions. They had identified issues with the clinical management of the Director of Nursing that they were addressing. The staff reported they were committed to quality care, and were in the process of developing corrective actions for all identified concerns. Position Job Descriptions for the Administrator, Assistant Administrator and the Director of Nursing were requested and reviewed. The Job Description for the Executive Director I (Administrator), undated, was reviewed. The section entitled Purpose of Your Job Position stated, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. The section entitled Job Functions stated, As Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Supervises Director of Clinical Services (DON) . The Job Description for the Director of Clinical Services I (Director of Nursing), undated, was reviewed. The section entitled Purpose of Your Job Position stated, As a Consulate Health Care Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, coworkers, visitors, and all others; . The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. The section entitled Job Functions stated, As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility.

Based on record review and interviews, the facility failed to sustain implementation of action plans to correct quality deficiencies for implementation of resident plans of care, services to prevent the development of pressure ulcers and accuracy of resident medical records. The Findings Include: On (MONTH) 4, (YEAR) a recertification survey was conducted at the facility, which resulted in the identification of quality issues related to failure of the facility to develop and implement resident plans of care; failure to provide treatment and services to prevent the development of pressure ulcers; and failure to ensure resident medical records were complete and accurately documented. During this complaint survey, these same quality deficiencies were again identified, and resulted in harm to Resident #3. On the 10/4/18 recertification survey the facility was cited for failure to develop a plan of care and failure to implement a developed plan of care for 2 different residents related to limited range of motion and respiratory care. The facility submitted a plan of correction stating they had corrected the quality deficiencies for the 2 residents identified and had provided education to staff responsible for care plan development. It further stated the Minimum Data Set (MDS) Coordinator would be responsible for monitoring the facility implemented interventions to ensure corrective action was being sustained and stated this would be done through audits that would be presented quarterly to the facility's Quality Assurance Committee and monitoring would be modified as necessary based on the findings of these audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the implementation of resident care plans that resulted in harm to Resident #3 (See F656). On the 10/4/18 recertification survey the facility was cited at a harm level for failure to provide treatment and services to prevent the development of pressure ulcers for one resident who had blisters that progressed to to a stage 4 pressure ulcer that subsequently required hospitalization and surgical intervention prior to the placement of a wound vac. The ordered treatment for [REDACTED]. The facility submitted a plan of correction that stated they had re-evaluated this resident to ensure treatment was being provided in accordance with physician orders [REDACTED]. The facility also stated they had provided re-education to nursing staff regarding the provision of care to prevent the development of pressure ulcers and that they would complete audits to ensure the issues did not recur. The facility stated the findings from their audits would be presented in the facility's monthly quality assurance meeting and monitoring would be modified based on the findings of these audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the provision of care and services to prevent the development of pressure ulcers that resulted in harm to Resident #3 (See F686). On the 10/4/18 recertification survey the facility was cited for failure to ensure resident records were complete and accurately documented for 2 residents by failing to document a fall for one of the residents and for failure to locate records for the other resident. The facility submitted a plan of correction for this deficiency that stated they had corrected the records for these two residents and had reviewed the records of other residents to ensure no one else had been affected. The facility also stated they had provided education to the medical records staff about ensuring records were completed and documented accurately and would have medical records staff complete audits and findings from these audits would be discusses monthly during the facility's quality assurance meetings and monitoring would be modified based on results of the audits. During a subsequent revisit conducted on (MONTH) 20, (YEAR), the facility was found to be in compliance with this regulation; however, during this complaint survey the facility was found to have deficient practice related to the inaccuracy and incompleteness of resident medical records (See F842). Interview with the administrator and corporate nurse on 6/6/2019 at about 2:00pm revealed the facility had identified some concerns with nursing services. The administrator stated that clinical meetings were not taking place as they should and that they were implementing a corrective action plan to address nursing services, wounds, and other identified nursing care issues. On 6/4/19 at approximately 3:30 PM, an interview regarding identified concerns was conducted with the Administrator and both Regional Nursing Consultants. The staff stated they were in the process of investigating a reported documentation issue. The staff stated they had recently become aware of some care issues, including pressure ulcers, in the last few weeks and had begun corrective actions. They had identified issues with the clinical management of the Director of Nursing that they were addressing. The staff reported they were committed to quality care, and were in the process of developing corrective actions for all identified concerns.

Based on observation, interview and record review, the facility failed to provide care and services to prevent the development and worsening of pressures ulcers for 1 of 1 residents sampled for pressure ulcers (#89). The findings included: On 10/4/2018, a record review was conducted for resident #89. Review of a nurses note revealed on (MONTH) 29, (YEAR), Staff member G, an LPN, identified the resident as having blisters on her coccyx. A physician assessment dated (MONTH) 30, (YEAR) identified the blisters as Stage 1 excoriation of the sacral ulcer with new orders written to cleanse sacrum with soap and water, apply zinc 20% ointment every shift and PRN (as needed). A review of the Treatment record revealed documentation that the zinc ointment was applied a total of three times between the dates of (MONTH) 1 to (MONTH) 6 on the 7AM-3PM shift on (MONTH) 1, 3, & 4, (YEAR). Further review of the record revealed that on (MONTH) 6, (YEAR) (6 days after identification of blisters), the wound care physician assessed the wound as Stage 3 pressure ulcer of the L Buttocks & Sacral ulcer. Stage 2 ulcer to right buttocks. With new orders written Wound Care instructions: L buttocks & Sacrum: Clean with ¼ Dakins solution, pat dry. Pack open area with Dakins moist gauze cover with ADB pad and tape Change daily and PRN. Review of the Pressure Ulcer Record identified the area on the resident's sacrum as Now involves L sacrum & buttocks with measurements of 3.5x1x0. Stage III Continued review of the record found that on (MONTH) 12, (YEAR), resident# #89 was transferred to the hospital for debridement of stage IV to her coccyx and placement of a wound Vac. She returned to the facility on (MONTH) 24, (YEAR). On (MONTH) 22, (YEAR) the facility submitted an Adverse Incident Report to the Agency for Health Care Administration (AHCA) after a neglect allegation was filed with another state agency. Review of this documentation found the facility failed to identify concerns with the resident's care. On 10/1/2018 at approximately 11:30 AM, an interview was conducted with the wound care nurse in which she stated we (the facility) are taking the hit for this wound, because she came back from the hospital with a stage IV. She stated the wound vac was changed on Mondays, Wednesdays and Fridays and was very painful for the resident and received pain mediation prior to the change. She stated the wound had been improving and that resident #89 was seen by the wound care clinic every two weeks.

Based on staff interview and record review, the facility failed to develop and implement quality assurance plans related to a preventative maintenance program. The facility was notified on August 20, 2014 that 67 of the facility's 108 smoke detectors did not pass sensitivity testing. The facility failed to develop and implement an action plan to address the functioning of the facility's smoke detection system. This systematic failure led to a finding of Immediate Jeopardy on 8/28/2015 at 10:00 AM. Immediate Jeopardy was removed on 8/28/15 at 3:05pm after receipt of a credible allegation of compliance, an emergency Quality Assurance meeting and an observation of the continuous fire watch system in place. The facility remains out of compliance at a lower severity and scope of F (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that monitoring of systems put in place are effective. The findings are: On 8/27/15 a life safety inspection revealed a widespread issue with the sensitivity testing of the facility's smoke detection system (see K0052). The last testing had been completed on August 20, 2014 and showed that 67 of the facility's 108 smoke detectors did not pass sensitivity testing. A sensitivity test measures if the actual threshold of smoke detection is within a specified range. Smoke detectors are designed to activate at a certain level of smoke detection. If they are too sensitive it can cause false alarms, and if not sensitive enough, this can result in slow or no detection of smoke, thus endangering all occupants within a facility. The facility census was 118. No repeat sensitivity testing was conducted by the facility until the second day of the survey, 8/28/15. The repeat smoke alarm sensitivity test was conducted by the contractor who conducted the test in August 2014. The results showed that 53 of the 108 in-house fire detectors failed the test. On 8/27/15 at 3:39pm an interview was conducted with the facility administrator who stated that he has only been the administrator at the facility for a month but stated that he is the head of the Quality Assurance (QA) Program for the facility. The administrator stated that department heads including the maintenance director is required to attend the meetings and that each department head had certain items and data that they have to collect and present during the QA meeting. The administrator also reviewed the QA documentation and was not able to find where the sensitivity failure of the facility smoke detectors had been presented or addressed by the committee at the time of discovery by the contracting company who performed the testing. The corporate vice president was also present during the interview and stated that the maintenance director utilized a computerized system to collect information (TELS) and that he has to present that information to the QA Committee monthly at the meetings. She stated that the system is all inclusive and tracks the preventative maintenance for the facility. She also stated that prior to discovery by the Agency's Life Safety Inspector, she had not been aware of any report that indicated that there was a failure in the smoke detector system. On 8/27/15 at 3:55pm an interview was conducted with the facility's maintenance director. He stated that he had been the maintenance director for over a year at the facility and that he was required to regularly attend the facility's Quality Assurance (QA) meetings. He stated that he reviewed a variety of issues in QA including findings from the facility safety meetings and any issues that could be a safety risk. He stated that he also would review any environmental issues that had developed during the prior month or since the last QA meeting and that he would discuss any issues that were currently being addressed. He stated that any issues identified would require a plan for how the issues would be fixed and those plans would also be discussed with the group. He stated that he had been the maintenance director in August of 2014 when the facility had hired a contracting company to come perform the smoke detector sensitivity testing as required by regulations every two years. He stated that the company had shared the results of the testing with him and that he was aware of the numerous detectors that had failed the testing. He stated that he had turned this report over to the facility administrator at that time, but had not addressed the issue at the next QA Committee Meeting. He stated that he had been told that the contracting company would contact the facility's corporate office and that the needed repairs would be handled through the two corporate entities. He stated that after the testing, he and his assistant had cleaned many of the smoke detectors to improve their performance but had not cleaned all of them. He admits that no further intervention had been taken to correct the multiple failures indicated by the sensitivity testing. Immediate Jeopardy was removed on 8-28-2015 at 3:05 PM after receipt of a credible allegation of compliance and an observation of the continuous fire watch system in place. The allegation of compliance stated: -Ad Hoc quality assurance (QA/PI) meeting held on 8/27/15 to review current system issues. The team discussed fire watch and the need to be ongoing till all issues are in compliance. The team discussed re-testing and replacement of smoke detectors and conducting weekly fire drills to ensure system remains fully functional for 1 month and then the facility will resume monthly drills if all okay. -Fire watch was initiated on 8/27/15 and will continue until the required smoke detectors are installed and determined to be functioning. -Staff that are conducting fire watch have been inserviced. Staff inserviced that fire watch consists of opening every door and checking every room. In addition electrical closets and water heater/boiler rooms which are located outside, are also included in rounds. Master keys have been given to fire watch personnel. Fire watch employees have no other duties. -Facility staff inserviced on fire watch. -Weekly fire drills will be conducted to ensure system remains fully functional for 1 month and then the facility will resume monthly drills. -A contract vendor is currently cleaning and retesting the smoke detectors in question. -The replacement smoke detectors will be on site by 9/2/15 and will be installed as needed. -An additional certified vendor will be contracted to do parallel testing of the smoke detectors to ensure previous testing was accurate. -Sensitivity testing has been added to the preventative maintenance system to ensure completion on a biennial basis. -The facility fire alarm service provider was in the facility and working on the fire panel on 8/27/15. Work was completed and the fire alarm system was fully functioning on 8/27/15 at 7:30pm. System was again tested on [DATE] at 7:30am and remained fully functional.