Every finding on record at Aviata at Venice

Based on observations, record review, resident and staff interviews, the facility failed to provide resident centered activities to meet the interests of 2 (Residents #43 and #6) of 3 residents reviewed for activities.The findings included:Review of the facility's policy titled, Group Programs and Activities Calendar revised June 2018 revealed, Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental, and emotional needs . Activities professionals plan scheduled activities for the month . Review of Resident #43's clinical record revealed an admission date of 11/20/24. Diagnoses included Alzheimer's Disease, Major Depressive Disorders and Adjustment Disorder. Resident #43 resided on the secured memory care unit of the facility. Review of the Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/27/25 revealed Resident #43 scored 08 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The MDS noted that it was somewhat important to the resident to go outside to get fresh air when the weather is good. Review of the care plan revealed Resident #43 was dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations. The care plan goals noted Resident #43, loves snacks and going outside in the sun and The resident will attend/participate in Community Life activities of choice 3-5 times by next review date. The interventions included to provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Review of the Community Life Progress Review dated 11/6/25 revealed Resident #43's physical reaction during programming and emotion usually expressed was, Happy she enjoys being outside in the sun. On 2/2/26 at 11:25 a.m., in an interview Resident #43 said she was legally blind and struggles with activities. Resident #43 said she wants to go outside for 15 minutes a day, but no one ever lets her. Resident #43 said she has not been outside for years. Review of Resident #43's facility provided, Individual Resident Daily Activities log for November 2025, December 2025 and January 2026 revealed the resident went to the patio once on 11/23/25 and once on 12/23/25. No other outside activities were documented. Review of Resident #43's electronic medical record responses for Group Activities from 1/6/26 to 2/3/26 showed no participation of outside activities. Review of Resident #43's electronic medical record responses for one on one activities from 1/6/26 to 2/3/26 had no responses. Review of Resident #43's electronic medical record responses for selected directed activities from 1/6/26 to 2/3/26 showed no completion of outside activities. Review of the activities calendar for February 2026 showed no scheduled outside activities. On 2/4/26 at 9:06 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said when deciding activities, the residents will either tell us what they want to do, or we follow the activities calendar. CNA Staff F said the memory care residents never go outside in the sun. On 2/4/26 at 9:11 a.m., in an interview CNA Staff E said she has worked here a long time and knows the residents' activities preferences. CNA Staff E said the residents on the memory care unit do not go outside. CNA Staff E said they used to go outside a long time ago, but the previous ownership stopped that. CNA Staff E said the previous ownership would not even let the memory care resident's go outside with family. CNA Staff E said Resident #43 used to like to go outside. When asked if the patio is ever used, CNA Staff E said no one uses the patio. On 2/4/26 at 9:17 a.m., in an interview Registered Nurse (RN) Staff G said they have an activities person who organizes the activities for the memory care residents. RN Staff G said the residents do not go outside in the sun. RN Staff G said she has worked on the memory care unit for a long time and has never seen the patio used. On 2/4/26 at 9:24 a.m., in an interview the Activities Director said the resident's Care Plan reflects their activities preference. The Activities Director confirmed that Resident #43's Care Plan says she likes to go outside in the sun. The Activities Director said activities preferences are determined through the community life assessment. The Activities Director said the community life assessment is completed upon admission, quarterly and when there is a change in condition. The Activities Director said her expectation is if a resident expresses an activities preference, it goes on the Care Plan and needs to be done. The Activities Director confirmed Resident #43 does not go outside. Review of the clinical record revealed Resident #6 had an admission date of 9/19/2019. Diagnoses included anoxic brain injury, cardiac arrest, seizures, contractures of left and right hands and elbows, anxiety and major depressive disorder. Review of the plan of care for Resident #6 initiated on 10/8/2019 specified the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to brain trauma, cognitive deficits, immobility, and is alert with severely impaired cognition. The care plan documented the resident spends most time in her room in bed watching television (TV), she enjoys a variety on TV and listening to music on her radio and enjoys a [NAME] of music stations. The goal for Resident #6 documented to be offered music daily. On 2/2/26 at 10:17 a.m., and 4:00 p.m., Resident #6's bedroom door was observed to be closed. Observation of the room revealed Resident #6 was in bed awake. No television or radio were turned on. Review of the activity calendar for 2/2/26 revealed activities for day were 8:30 a.m., Coffee Social, 10:00 a.m., Church Volunteer Group, 1:30 p.m., Valentine Trivia, 2:23 p.m., Choice Stations/1-1, 4:30 p.m., Netflix and chill, 5:30 p.m., Courtyard Connection. On 2/3/2026 at 9:40 a.m., and 2:11 p.m., Resident #6 was observed in her room in bed with the TV and radio off. The bedroom door was closed and the lights were off. The room was dark and the privacy curtain was pulled blocking light from the window. Resident #6 was awake and was able to answer yes and no questions. When asked if she enjoyed listening to music or watching television, Resident #6 replied, Yes. Review of the activity calendar for 2/3/26 revealed the activities for the day were 8:30 a.m., Coffee Social, 10:00 a.m., Seated Upper Extremity Exercises, 1:30 p.m., Heartfelt Creations, 2:30 p.m., Choice Station/1-1, 4:30 p.m., Netflix and Chill, 5:30 p.m., Golden Hour Club. Review of the Activity Documentation for Resident #6 for December 2025 revealed one-to-one activities were provided 7 of 31 days. Group activities were provided 3 of 31 days. Review of the Activity Documentation for January 2026 revealed one-to-one activities were provided 3 of 31 days. Group activities were provided to Resident #6 on 4 of 31 days. On 2/3/2026 at 5:10 p.m., in an interview the Activity Director said Resident #6 was her project. She said, I'm trying to get her to group activities. Last month she came out for 2. When asked about activities provided for the resident when she was in her room, the Activity Director said, There is a radio and a TV that are on for her. She loves music. The multiple observations of Resident #46 lying in bed in her room with the television and radio off were shared with the Activity Director. She said, Well, the CNAs are supposed to put it on for her.

Based on observation, record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to provide assistance with showers, personal hygiene and incontinent care as outlined in the resident's care plan and according to residents' preferences for 3 (Residents #6, #13 and #57) of 5 dependent residents reviewed for activities of daily living (ADL's).The findings included:Review of the facility's policy titled, Activities of Daily Living, Supporting (no effective date) revealed, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated, Appropriate care and services are provided for residents who are unable to carry out ADLs (activities of daily living) independently. The policy defined hygiene as bathing, dressing, grooming, and oral care. The policy defined elimination as toileting. The policy further stated, refusal and details of the interventions refused are documented in the resident's clinical record. Review of a facility provided incident investigation for Resident #6 showed an allegation of neglect on 9/7/25 for right ear is full of wax, hair greasy, horrible dandruff. On 2/2/26 at 7:56 a.m., Resident #6 was observed in bed. The resident was noted to have a strong foul odor. Resident #6 only responded yes to interview questions. When responding, a white gunk substance was observed in Resident #6's mouth. A foul odor was noted from the resident's mouth. Resident #6 was determined to be non-interviewable. Record review for Resident #6 revealed a date of admission of 9/19/19. Diagnoses included anoxic brain injury (brain is completely deprived of oxygen, causing brain cells to die), contracture of the right elbow, left hand/elbow, and need for assistance with personal care. The clinical record noted on 1/2/26, Resident #6 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of the care plan initiated on 10/7/19 and revised on 9/24/25 revealed Resident #6 had an ADL self-care performance deficit related to seizure disorder, chronic hypoxic ischemic brain injury, status post cardiac arrest, and impaired communication and cognition. The care plan noted Resident #6 was totally dependent on 1 staff for personal hygiene and oral care. The interventions included for the CNA to provide oral hygiene every shift and as needed; oral care routine in the morning after meals and at bedtime: Brush teeth, clean gums with toothette (foam-tipped applicator), rinse mouth with wash. On 2/2/26 at 2:58 p.m., an unidentified Certified Nursing Assistant (CNA) was observed exiting Resident #6's room and said she had just finished providing care to the resident. During observation and interview, Resident #6's lips were observed to be dry. Hair growth was observed on the resident's upper lip. A white, gunky substance was observed in the resident's mouth. Resident #6's arms and hands were observed contracted. A chunk of black hair was observed in Resident #6's contracted right hand. On 2/3/26 at 9:15 a.m., Resident #6 was observed with dry lips and white debris in her mouth. A foul odor was noted from the resident's mouth. Review of Resident #6's CNA documentation revealed CNAs worked three 8-hour shifts per day. The CNA documentation for November 2025 lacked documentation oral care was provided for 9 shifts. N/A (not applicable) was documented for oral care for 30 shifts. The CNA documentation for December 2025 lacked documentation oral care was provided for 7 shifts. N/A was entered for oral care for 35 shifts. 3 shifts were documented as Resident #6 being independent to perform oral hygiene. 2 shifts documented Resident #6 as being a setup assistance for oral care. The CNA documentation for January 2026 lacked documentation oral care was provided for 5 shifts. N/A was entered for oral care for 29 shifts. 4 shifts were documented as Resident #6 being independent to perform oral hygiene. 1 shift documented Resident #6 as being a setup assistance for oral care. Review of the dental hygienist note dated 12/8/25 revealed, Patient's teeth were not scaled (deep cleaning that removes hardened plaque and bacteria from teeth surface) due to the presence of heavy gross calculus and patient's inability to open their mouth adequately. The note stated that scaling could not be done without suction since a dislodged calculus could present an aspiration (entering of foreign materials into the airway/lungs) hazard. On 2/5/26 at 8:18 a.m., in an interview CNA Staff A said oral care is done every shift. She said they obtain their information on how often tasks should be completed by reviewing the Kardex (Provides instructions for care) and the care plan. The CNA said that everything was documented in the electronic chart. When asked to see the supplies used to provide oral care to Resident #6 (toothbrush, toothette, wash), CNA Staff A searched Resident #6's rooms and drawers. She said she was not able to locate oral care supplies in the resident's room. Further review of Resident #6's care plan revealed the resident had functional bladder incontinence secondary to self-care deficit (Revision date of 1/10/2024) and bowel incontinence related to immobility, and hypoxic brain injury (Revision date of 12/12/2019). The interventions included for the resident to remain free from skin breakdown due to incontinence and brief use. The interventions included to check resident frequently and assist with toileting/incontinent care as needed, change disposable briefs frequently and as needed, clean peri-area with each incontinence episode, Review of the CNA documentation for July 2025 failed to reveal documentation of bladder incontinence care for 34 shifts. Review of the CNA documentation for August 2025 failed to reveal documentation of bladder incontinence care for 21 shifts. 2 shifts were documented as n/a. Review of the CNA documentation for September 2025 failed to reveal documentation of bladder incontinence care for 6 shifts. On 2/5/26 at 8:18 a.m., in an interview CNA Staff A said incontinent residents are checked every 2 hours. CNA Staff A said Resident #6 was completely dependent on staff for oral and incontinence care and the care provided is documented in the electronic chart. On 2/5/26 at 8:29 a.m., in an interview related to oral care and incontinent care, CNA Staff B said they do oral care every morning for residents and residents are checked for incontinence every 2 hours. Staff B said the resident's Kardex or the care plan provides information on how often tasks should be completed, oral care and incontinent care are documented in the electronic charting system. After reviewing the lack of documentation of oral care and/or incontinent care for multiple shifts from July 2025 through January 2026, CNA Staff B said, If it's not documented, it didn't happen. On 2/5/26 at 8:34 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said she was assigned to Resident #6 for the shift. LPN Staff C said incontinence care is done every 2 hours and oral care is done twice a day and as needed. LPN Staff C said you can find out how often tasks should be completed by reviewing the residents' medication record, treatment record or Care Plan. LPN Staff C said the CNAs document incontinence and oral care in the electronic record. LPN Staff C reviewed the CNA documentation for oral care and incontinence care for Resident #6 and verified there was no documentation of oral care and/or incontinence care for multiple shifts from July 2025 through January 2026. LPN Staff C said, it looks like it has not been done. On 2/5/26 at 8:39 a.m., in an interview LPN Staff D said incontinence care is done every 2 hours and oral care is done every morning and night. Upon reviewing the lack of CNA documentation that oral care and/or incontinent care were provided for multiple shifts from July 2025 through January 2026 for Resident #6, LPN Staff D said, blank spaces mean it was not done. On 2/5/26 at 8:42 a.m., in an interview CNA Staff E said incontinent care should be done every 2 hours and oral care should be done before and after meals. CNA Staff E said tasks that need to be completed show up in the resident's electronic medical record. CNA Staff E said once interventions are added to the resident's care plan, it reflects on the task list. Upon reviewing Resident #6's incontinence and oral care documentation, CNA Staff E said, if there is no documentation, it was not done. On 2/5/26 at 9:55 a.m., in an interview the Director of Nursing (DON) said incontinence care should be done every 2 hours, and oral care should be done every shift and as needed. The DON said incontinence and oral care show up on the resident's electronic medical record every shift as a task for staff to complete. The DON said Resident #6 should be receiving incontinence care every 2 hours and oral care every shift. Upon reviewing the CNA documentation for oral care and incontinence care, the DON confirmed the lack of documentation of oral care and/or incontinent care for multiple shifts from July 2025 through January 2026. When asked if Resident #6 was independent or set-up assistance for oral care, the DON said no. On 2/5/26 at 10:26 a.m., in an interview the Nursing Home Administrator (NHA) said her expectation is to document the care provided. Review of the clinical record revealed Resident #13 had a date of admission of 10/23/25. Diagnoses included muscle weakness, repeated falls, adult failure to thrive, and anxiety. Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/10/26 documented Resident 13 was always incontinent of bowel and bladder and required supervision/touching assistance with bathing, dressing, and toileting. The MDS noted Resident #13 scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognitive skills for daily decision making were intact. Review of the care plan initiated on 11/3/25 revealed that Resident #13 had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and generalized weakness. The interventions included for staff to check for incontinence upon rising, before and after meals and as required. Staff was to wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Resident #13 required supervision on 1 staff to provide shower. On 2/2/2026 at 12:21 p.m., in an interview Resident #13 said she does not get changed when she is wet. Resident #13 said, I wait for hours when I'm wet and it hurts. The resident said she gets an irritation in her upper inner thighs from the brief being wet and rubbing. When she requests assistance, the staff come in and ask what she needs. They say, Ok, someone will be here to change you and guess what? No one comes back for 30 minutes to an hour. Resident #13 said, They don't give me showers, I don't know why. On 2/3/2026 at 1:00 p.m., in an interview Resident #13 said, Some mornings I'm wet and they come in with my breakfast tray and put it on the table. I don't want to eat when I'm wet. Resident #13 said she was scheduled for showers on Wednesday and Saturday on the day shift but, They just don't want to do it and I can't walk. She said she sometimes refuses her shower but not often. She said she was tired and had no strength to get out of bed. Review of the CNA documentation for December 2025 and January 2026 revealed: Resident #13's shower days were scheduled for Wednesday and Saturday on the 7:00 a.m. to 3:00 p.m., shift. On 12/1/25, 12/3/25, and 1/10/26, a bed bath was provided in place of the scheduled shower. On 12/6/25, 12/17/25, 12/24/25, 1/7/26, and 1/14/26, NA was documented. On 12/13/25 and 1/3/26, no care was documented. On 1/24/26, 1/28/26 and 1/31/26, Resident #13 refused the shower. Review of the documentation for bladder function revealed: For the 7:00 a.m., to 3:00 p.m., shift, no care was documented on 12/6/25, 12/13/25, 12/23/25, 12/26/25, 12/31/25, 1/3/26, 1/18/26, and 1/19/26. On 12/2/25, 12/4/25, 12/8/25, 12/21/25, 12/22/25 NA was documented. For the 3:00 p.m., to 11:00 p.m., shift, no care was documented on 12/22/25, 12/24/25, and 12/27/25. On 12/21/25, 12/30/25, 1/1/26, 1/5/26, 1/6/26, 1/15/26, 1/16/25, 1/19/26, 1/21/26, 1/23/26, 1/24/26, 1/25/26, 1/27/26 and 1/28/26, NA was documented. For the 11:00 p.m., to 7:00 a.m., shift, no incontinent care was documented on 12/19/25, 12/27/25, 12/29/25 and 12/31/25. On 12/1/25 through 12/18/25, 1/2/26, 1/4/26, 1/27/26, 1/9/26, and 1/19/26 NA was documented. Review of Resident #57's clinical record revealed an admission date of 6/28/23 and a readmission date of 7/12/23. Diagnoses included cerebral palsy, epilepsy, major depressive disorder, stage 2 chronic kidney disease, chronic a-fib and need for assistance with personal care. Review of the Quarterly MDS with an ARD of 8/22/25 revealed Resident #57 scored 10 on the BIMS, indicating moderately impaired cognition. The MDS noted that the resident was frequently incontinent of bowel and bladder and required partial to moderate assistance with bathing, dressing, toileting and personal hygiene. Review of the Care Plan initiated 7/20/23 revealed Resident #57 had an ADL self-care performance deficit related to fatigue, impaired balance, limited mobility, and cerebral palsy. The interventions included: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse: Provide sponge bath when a full bath or shower cannot be tolerated. The resident requires partial assistance by 1 staff for toileting and with bathing/showering 2 times weekly and as necessary. Staff was to encourage the resident to use bell to call for assistance. On 2/2/26 at 3:34 p.m., during observation and interview, Resident #57 was noted to have a foul urine smell, and foul breath from 3 feet away. The Resident's nails extended 1/2 inch from the fingertips. An accumulation of black substance was observed under the nails. In an interview, Resident #57 said staff took his nail clippers. He said he's been asking for someone to trim his nails, but they have not done it. Resident #57 said no one comes to set him up to brush his teeth. Resident #57 had an unopened tube of toothpaste from his drawer. He said, Today they put this tube of toothpaste in my drawer. Where was it before? I ask for help and they don't do it, I'm here because I need help. What am I supposed to do? Resident #57 said he has been asking to go to bed since lunch was over. They told him to go to his room and put the light on. Resident #57 said, What good does it do if no one comes. Resident #57 said staff don't come to help him use the toilet. He said he wheels himself in the bathroom, grabs the bar and try to pull his pants down, but he can't do it. Resident #57 said, I end up wetting myself and it is horrible. On 2/3/26 at 9:36 a.m., Resident #57 was observed in his room in bed. The resident remained with his fingernails extending 1/2 inch from the fingertip with a black substance under the nails. He said his nails were not trimmed or cleaned and he did not receive assistance with oral care. The tube of toothpaste observed on 2/2/26 remained unopened. Resident #57 said he was not changed during the night and did not like being wet. Review of the CNA documentation for December 2025, and January 2026 revealed: Resident #57's shower days were Monday and Thursday during the 7:00 a.m., to 3:00 p.m., shift. On 12/1/25, and 1/22/26, a partial bed bath was documented. On 12/11/25, 12/22/25, 12/25/25, 12/29/25, 1/12/26, 1/19/26, 1/26/26 and 1/29/26 NA was documented. On 12/28/25, 1/5/26 and 1/8/26 there was no shower documented. Review of the CNA documentation of incontinent care/toileting care revealed: For the 7:00 a.m., to 3:00 p.m., shift, there was no documentation of incontinent/toileting care on 12/6/25, 12/13/25, 12/18/25, 1/3/26, 1/5/26, 1/6/26, and 1/17/26. On 12/2/25, 12/4/25, 12/8/25, 12/20/25,1/15/26, 1/28/26, 1/29/26, and 1/31/26, NA was documented. For the 3:00 p.m., to 11:00 p.m., shift, there was no documentation of incontinent/toileting care on 12/12/25, 12/20/25, and 1/3/26. On 1/6/26, 1/27/26, NA was documented. For the 11:00 p.m., to 7:00 a.m., shift, there was no documentation of incontinent/toileting care on 12/31/25,1/21/26, 1/22/26, 1/25/26, 1/26/26, 1/27/26 and 1/31/26. On 1/2/26, 1/8/26, 1/9/26, 1/16/26, 1/19/26, 1/23/26, 1/28/26, 1/29/26 and 1/30/26, NA was documented. On 2/3/26 at 4:00 p.m., Resident #57 was observed in the hallway in his wheelchair outside of the dining room. The resident was noted to have a strong, unpleasant body odor. The resident's fingernails remained with a black substance. Resident #57 was wearing a blue shirt covered in white flakes of dried skin. In an interview, Resident #57 said no one assisted him with care this morning. He said, They think I can do it myself, but I need help. On 2/3/26 at 4:10 p.m., in an interview CNA Staff Q said they follow the shower list at the desk. CNA Staff Q demonstrated how they pull up the resident care Kardex on the computer system to find the shower preferences of the resident. She said if someone wanted a shower and it was not their day, of course if I have the time, I will do it. Whatever the resident wants. Nail care is done when the resident asks for it. On 2/4/26 at 11:40 a.m., in an interview CNA Staff A said if a resident refuses a shower they go back and ask a couple of times and maybe offer a bed bath. If the resident continues to refuse, they tell the nurse. The nurse will try and encourage them. If the resident still doesn't want a shower or a bed bath the resident and the CNA sign a form that is found in the shower book. The form is then given to the nurse. CNA Staff A said they check on incontinent residents every 2 hours. She said they take residents to the bathroom upon request.

Based on observations, record review, and staff interviews, the facility failed to provide appropriate care in accordance with current standards of care to prevent complications of tube feeding for 1 (Resident #81) of 3 residents reviewed with feeding tubes (tube inserted directly in the stomach to deliver liquid nutrition, fluids, and medications).The findings included:Review of the clinical record for Resident #81 revealed an admission date of 1/30/26. Diagnoses included unspecified brain injury, fracture of the neck and dysphagia (difficulty swallowing).Review of the admission Minimum Data Set (MDS) Assessment with an assessment reference date of 2/2/26 revealed Resident #81scored 08 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The MDS noted Resident #81 had a feeding tube had a feeding tube and was dependent on staff for nutrition.Review of the physician's order dated 1/30/26 revealed to elevate the head of the bed 30-45 degrees during enteral feeding or flushing every shift.Review of the Care Plan initiated on 2/2/26 revealed Resident #81 requires tube feeding related to abnormal swallow evaluation status post bike accident.The interventions as of 2/2/26 included that the resident needs the head of the bed elevated 45 degrees during and thirty minutes after tube feed; monitor/document/report any signs of symptoms of aspiration; the resident is dependent with tube feeding and water flushes.On 2/2/26 at 11:06 a.m., and 2/3/26 at 1:11p.m., Resident #81 was observed lying completely flat in bed on his back with the head of the bed down and leveled with the foot of the bed. The pump delivering the tube feeding was on and indicated the feeding was infusing at 70cc/hour.On 2/3/26 at 1:22 p.m., Licensed Practical Nurse (LPN) Staff K observed Resident #81and verified he was lying completely flat in bed while the feeding was infusing. She said lying flat in bed while the feeding was infusing created a risk for aspiration. LPN Staff K said the head of the bed should be raised 45 degrees when the feeding is infusing.On 2/3/26 at 3:07 p.m., and 2/4/26 at 10:16 a.m., Resident #81 was observed lying completely flat in bed on his back. The pump delivering the tube feeding was on and indicated the feeding was infusing at 70cc/hour. On 2/4/26 at 10:20 a.m., LPN Staff H observed Resident #81and verified he was lying completely flat in bed while the feeding was infusing. In an interview LPN Staff H said the head of the bed should be elevated at a 45-degrees angle while the feeding is infusing. She said if the head of the bed is not elevated when the tube feeding is running, the resident is at risk for nausea, vomiting and aspiration.On 2/5/26 at 10:30 a.m., in an interview the Director of Nursing (DON) said the head of the bed should be raised 45 degrees when the tube feeding is running to prevent aspiration.

Based on record review and staff interview, the facility failed to ensure the irregularities identified during the pharmacy consultant's drug regimen review were acted upon for 1 (Resident #13) of 5 residents reviewed for unnecessary medications.The findings included:Review of the facility policy Pharmacy Services - Role of the Consultant Pharmacist, documented The Consultant Pharmacist will provide specific activities related to medication regime review including:a. A documented review of the medication regime of each resident at least monthly.b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications including medication irregularities.Review of the clinical record for Resident #13 revealed an admission date of 10/23/25. Diagnoses included repeated falls, muscle weakness, depression and anxiety.Review of the Consultant Pharmacist Medication Review dated 10/31/25, the Pharmacist documented The use of Atorvastatin and Fenofibrate (medication used to lower cholesterol and triglycerides) should be avoided due to an increase of myopathy (muscle weakness and fatigue) and rhabdomyolysis (rapid breakdown of skeletal muscle) without additional cardiovascular benefits.Please consider discontinuing the Fenofibrate and ordering a fasting lipid panel in 4 weeks.There was no documentation of the physician response on the form.Review of Resident #13's physician orders for February 2026 included the medications Atorvastatin Calcium 80 milligrams (mg) give one tablet at bedtime and Fenofibrate 54 mg one tablet daily.Review of the progress notes found no documentation the physician reviewed the recommendations of the pharmacist.On 2/3/2026 at 2:34 p.m., Unit Manager Licensed Practical Nurse Staff I reviewed the Consultant Pharmacist Medication Regimen Review. In an interview she said the Pharmacist Recommendations are given to the Director of Nursing (DON). The DON will send them to the physician. Once they are signed, they are sent back to pharmacy, and we follow the physician order.On 2/3/2026 at 2:46 p.m., in an interview the Advanced Practice Registered Nurse (APRN) said, We review the pharmacy consultant's recommendations, and we sign off on them if we agree with the recommendations. The APRN reviewed Resident #13's clinical record and confirmed the resident was still receiving Atorvastatin Calcium 80 milligrams (mg) one tablet at bedtime and Fenofibrate 54 mg one tablet daily. The APRN said, I can look at her medications and I can discontinue one. We do not order Lipid panels on residents over 80.On 2/3/26 at 2:52 p.m., an interview was held with the DON related to the process to ensure the pharmacy consultant's recommendations are reported to the attending physician and acted upon.The DON verified the pharmacy consultant's Recommendations to the physician for Resident #13 on 10/31/25 were not acted upon. The DON said, I was not here at that time.

Based on observation, record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to ensure the safe storage of medications for 3 (Residents #37, #70, and #74) of 3 residents observed with unsecured medications at the bedside.The findings included:Review of Facility Policy Storage of Medications dated 2001, revised 2020 documented the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation (1) Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 2/2/26 at 11:43 a.m., observation of Resident #37's room revealed a bottle of Milk [NAME] stored on the bedside table. A bottle of Nystatin antifungal powder and a jar of Triamcinolone Acetonide cream were observed on a table in the resident's room. Photographic evidence obtained. On 2/3/26 at 10:15 a.m., Registered Nurse (RN) Staff P observed Resident #37's room and verified the bottle of Milk [NAME], the bottle of Nystatin antifungal powder and the jar of Triamcinolone Acetonide cream were unsecured. RN Staff P reviewed Resident #37's clinical record and said the physician's orders did not include Milk [NAME], Nystatin antifungal powder and Triamcinolone Acetonide cream. On 2/3/26 at 10:28 a.m., and at 3:08 p.m., observation of Resident #37's room revealed the bottle of Milk [NAME], the bottle of Nystatin antifungal powder and the jar of Triamcinolone Acetonide cream remained unsecured at the resident's bedside. On 2/2/26 at 12:02 p.m., observation of Resident #70's room revealed a bottle of Fluticasone Propionate Nasal spray stored at the resident's bedside in a tray. In an interview, Resident #70 said she used the spray when her nose gets stuffy. Photographic evidence obtained. On 2/3/26 at 9:34 a.m., in an interview the Director of Nursing (DON) said Resident #70 was not to have medications at bedside. On 2/2/26 at 10:06 a.m., during the initial tour of facility, a tube of Santyl Ointment (used to remove dead tissue from skin ulcers) and a bottle of sodium hypochlorite solution 0.125% (prescription strength, topical solution used to treat chronic wounds) were observed stored on the resident's nightstand. Photographic evidence obtained On 2/2/26 at 10:21 a.m., in an interview LPN Staff N, said the treatment medications should not be in the resident's room. She said they should be kept in the treatment cart and always locked. On 2/2/26 at 10:47 a.m., observation of Resident #74's room revealed an Albuterol Sulfate inhaler stored on the resident's overbed table. In an interview, Resident #74 said she keeps the medication in her room and uses it as needed. Photographic evidence obtained. On 2/2/26 at 11:02 a.m., in an interview LPN Staff O verified the Albuterol Sulfate inhaler was unsecured and should be locked in the medication cart.

Based on record review, review of facility policy and facility staff interview, the facility failed to report an allegation of neglect to the proper authorities within the required timeframe for 1 (Resident #80) of 3 residents reviewed with an allegation of neglect.The findings included.Review of the facility's policy titled Risk Management: Incident Management noted the facility's Administrator was responsible for oversight of all Risk Management activity and assuring resident safety, including the freedom from risk of abuse as holding the highest priority. Abuse will not be tolerated by anyone including staff, residents/patient, volunteers, family members or legal guardians or any other individual. Allegations of abuse, neglect, exploitation/misappropriation, injuries of unknown origin and potentially Resident to Resident Altercation will be reported per federal regulation.The policy also noted, 3. Documenting . e. Nursing Home Administrator is responsible for doing the Federal Immediate and Five-Day Reports, Adverse Incident Report and DCF [Department of Children Family] notification. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation with an effective date of 11/30/14 and a revision date of 11/16/22, revealed, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.5. Investigation. The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation.Preliminary investigation: Immediately upon an allegation of abuse or neglect, the suspects(s) shall be segregated from residents pending the investigation of the resident allegation.Review of Report: Report the results of all investigation to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.Review of the facility provided log for Nursing Home Federal Reports revealed the facility filed a Federal Immediate/Day 1 report on 6/28/25 for an allegation of neglect on 6/8/25 for Resident #80. The allegation of neglect investigation said Resident #80 was served the wrong textured diet on 6/8/25 causing a piece of Italian sausage to get caught in her throat. A nurse in the dining room assessed the resident with no air exchanged and initiated the Heimlich maneuver with one abdominal thrust resulting in a piece of sausage being dislodged. Resident #80's medical record revealed she was on a dysphagia puree diet with honey thickened fluids at the time of the event. A chest x-ray was ordered and results stated Resident #80's lung fields were clear without evidence of infiltration, effusion, or pneumothorax. Resident #80 was seen by the Respiratory Therapist, Pulmonologist and the primary care physician with no significant findings.The facility filed the Five-Day report on 7/7/25 stating after a complete and thorough investigation including Resident #80's medical record review and interviews with staff the allegation of neglect was verified. Resident #80 did receive the wrong meal tray which resulted in a choking episode with the Heimlich being performed. As part of the facility's corrective actions taken, they provided education to the Executive Director (ED) and Director of Nursing (DON) regarding timely reporting. On 2/4/26 at 9:48 a.m., in an interview with the DON and ED, they confirmed the facility filed a Federal Immediate report for neglect on 6/28/25 related to Resident #80 being served the wrong textured diet on 6/8/25, causing Resident #80 to choke, and the nurse in the dining room performing the Heimlich maneuver resulting in a piece of sausage being dislodged. The DON and ED said the facility's Federal Immediate report stated the ED was notified on 6/8/25 at 1:01 p.m. of Resident #80 being served the incorrect texture diet but the ED did not file the Federal Immediate report until 6/28/25, 20 days after the incident. They confirmed the facility's Five-Day report dated 7/7/25, concluded the allegation of neglect was verified because Resident #80 did receive the wrong meal tray which resulted in a choking episode with the Heimlich being performed. They also confirmed the facility's Five-Day report concluded that the Federal Immediate report was filed 20 days late and part of the facility's corrective action taken included education with the ED and DON regarding timely reporting of the Federal Immediate report as required per their Risk Management: Incident Management and the Abuse, Neglect, Exploitation and Misappropriation policies and procedures.

Based on observation, review of clinical records and staff interviews the facility failed to provide the necessary care and services to maintain urinary catheters in a safe and sanitary manner for 3 (Resident #900, #899 and #800) of 4 residents reviewed with indwelling urinary catheters. The findings included: During the initial facility tour on 3/4/25 at 9:47 a.m., Resident #900's indwelling catheter drainage bag was observed on the floor. Photographic evidence obtained. On 3/4/25 at 9:52 a.m., Registered Nurse (RN) Staff A verified Resident #900's catheter drainage bag was on the floor. On 3/4/25 at 10:00 a.m., an observation from the 100 hall revealed Resident #899's catheter drainage bag was located on the side of the bed facing the doorway to his room and was very full. There was no privacy cover and the drainage bag and urine were visible by staff, other residents and visitors, passing by the room. On 4/4/25 at 10:05 a.m., in an interview RN Staff A confirmed Resident #899's catheter drainage bag was very full and visible to anyone passing by the residents room. Photographic evidence obtained. On 4/4/25 at 2:56 p.m., in an interview Certified Nursing Assistant (CNA) Staff G said the urinary catheter drainage bag of residents who have indwelling urinary catheters was to be attached to the bed frame on the side away from the door so no one can see it. CNA Staff G said if the resident was up in a wheelchair or walking you have a leg bag or a privacy bag. The CNA said, Always privacy, cover them, and keep the drainage bag off the floor. On 3/4/25 at 3:15 p.m., during an observation from the 200 hallway Resident #800's catheter drainage bag was noted to be on the floor and visible from the hallway. Photographic evidence obtained. On 3/4/25 at 3:20 p.m., RN Staff C said Ok when informed that Resident #800's catheter drainage bag was on the floor. RN Staff C did not remove the resident's urinary catheter bag from the floor.

Based on observation, resident and staff interviews, the facility failed to sufficient nursing staffing to ensure timely response to request for assistance for 3 (Residents #5, #6 and #7) of 3 sampled residents. The findings included: On 11/6/24 at 10:54 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said the facility is often short staffed and Residents complain about call lights not being answered. On 11/6/24 at 12:45 p.m., Registered Nurse (RN) Staff B said she didn't think residents were getting the care they need. She said she felt the CNAs just didn't care. On 11/6/24 at 12:30 p.m., in an interview RN Staff C said the facility could always use more staff. She said she gave Administration credit as they are trying to hire, but the people stay two weeks and they leave. On 11/6/24 at 1:15 p.m., in an interview Resident #5 said when he presses his call bell there had been times no one comes and he's had to scream out in order to get someone to come. He said it had happened just within the last few days. He said it can be over an hour, if they come at all. On 11/6/24 at 12:15 p.m., Resident #6 and her husband were in her room. Both said even though Resident #6 had only been there a short time, it could take quite a bit of time for someone to answer the call light. On 11/6/24 at 2:50 p.m., Resident #7's daughter came out of the room requesting assistance for her father. She was redirected to a staff member near the nurse's station whom she was observed speaking with. On 11/6/24 at 2:55 p.m., in an interview Resident #7's daughter said her mother and father shared a room at the facility. She said her father was receiving hospice services and needed to be repositioned every two hours. A friend had been with them since 8:00 a.m., and no one came in to change her father until 1:00 p.m. The daughter also complained her mother's call light was not working and the light did not turn on when pressed. She said her mother suffered from dementia. A month she fell and had to crawl on the floor to get help. The daughter said the staff were overwhelmed and it can take up to 1.5 hours for someone to come and assist. The daughter said she was still waiting for someone to come and assist her father. On 11/6/24 at 3:02 p.m., four staff members wearing scrubs were observed speaking to each other in the hallway. The staff members walked away and did not enter Resident #7's room to provide the assistance requested. On 11/6/24 at 3:07 a staff member dressed in scrubs was observed coming down hall to retrieve supply cart near Resident #7's room. The staff member did not enter the resident's room. On 11/6/24 at 3:10 p.m., Registered Nurse (RN) Staff C was observed pushing her medication cart down the hall, past Resident #7's room. She placed the cart one door away from Resident #7's room and began passing medications. On 11/6/24 at 3:11 p.m., an aide walked slowly down hall past Resident #7's room and conversed with Staff C, then returned down hallway past Resident #7's room again. On 11/6/24 at 3:24 p.m., The Director of Nursing (DON) was observed entering the hallway. She spoke with Staff C. When the DON walked past Resident #7's room, the resident's daughter called her in the room. When the DON exited room, she was heard saying, I have to find (Maintenance Director's name) On 11/6/24 at 3:27 p.m., the Activity Director was observed entering and exiting Resident #7's room. The DON, Activity Director and Maintenance Director were observed in the hallway having a short discussion then leave. On 11/6/24 at 3:33 p.m., a Certified Nursing Assistant was observed going into Resident #7's room and provided the requested assistance. On 11/6/24 at 4:00 p.m., the DON said she had been employed at the facility about two weeks. She said she felt a good response time for call lights would be within five minutes. She said waiting 43 minutes for assistance was excessive. She said when she went in the room, the daughter told her the call light wasn't working and she contacted maintenance. She explained when pressed it would go off at the desk but the light outside the room was not working. She agreed then that when the daughter pressed the call light button it alerted at the nurses station, and no one responded. She said she would begin doing call light response audits.

Based on observation, record review, resident and staff interviews, the facility failed to ensure adequate supervision to prevent the elopement of 1 (Resident #2) of 1 sampled resident who left the facility without staff knowledge. The findings included: Facility policy Elopement/Wandering Risk Guidelines Document Name N-1031, Revision date 8/1/2020 indicated: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. Review of the clinical record for Resident #2 revealed a re-admitted [DATE] post hospitalization . Diagnoses included alcohol withdrawal and delirium. The Admission Minimum Data Set (MDS) Assessment with a target date of 10/7/24 noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 10. The care plan initiated on 9/20/24 noted the resident was an elopement risk/wanderer related to disorientation to place, history of attempts to leave the facility unattended, and impaired safety awareness. The care plan noted Resident #2 wandered aimlessly and attempted to exit the front door and attempted to remove the wander alert device (alerts staff when a resident attempts to leave a designated safe area). Review of facility notes revealed a note from the Speech Therapist which read: Last encounter with patient on 10/24/24. Brief Cognitive Assessment Tool (BCAT) completed with score 47/50. Errors in orientation/day of week: alternating /divided attention. Significant improvement with confusion. According to BCAT scoring, pt (patient) presents without functional deficits and potential independent living. Patient anticipated going home so he could return to work and pay the bills. Improvement of cognitive skills was discussed with rehab manager. A score of 47 on the Brief Cognitive Assessment Tool (BCAT) indicates normal cognitive functioning. The Social Worker documented in a progress note for 10/24/24 an Interdisciplinary Team meeting was held. Resident #2 reported he was doing well but wanted to be discharged . She discussed that she would need to verify where he was going first due to initial confusion when he was admitted to the facility. The Social Worker documented in a progress note for 10/25/24 Resident #2 was at the Administrator's office discussing discharge. On 10/26/24 at 2:04 p.m., a nursing progress note documented Resident #2 was missing. He left the premises without authorization. Resident #2 was last seen around 11:30 a.m. when the nurse was passing medication. The nurse noted the resident had a wander alert device to the right leg and was at risk for elopement. The facility was locked in for head count. The manager on duty and Administrator were aware. Review of the facility investigation revealed on 10/26/24 between 8:00 a.m., to 9:30 a.m., Resident #2 asked a staff member to remove his wander alert bracelet. He was redirected to talk to the nurse. On 10/26/24 around 9:30 a.m., or 10:00 a.m., Resident #2 was seen on the facility phone making calls with his credit card in hand. Resident #2 was later seen walking in the hallways around 11:30 a.m. When staff went in to retrieve his tray after lunch he was noted to be missing. The sign-out log indicated Resident #2 had not signed out of the building. Search ensued including notifying the police but Resident #2 was not found. On Sunday 10/28/24 the Social Worker (SW) was able to contact a friend of Resident #2 who explained he had spoken to Resident #2 on Friday. Resident #2 told him he was being discharged on Saturday. On 10/28/24 Resident #2's emergency contact called the Social Worker and told her Resident #2 had a storage unit where he stores a Recreational Vehicle (RV). On 10/31/24 Resident #2 called the Social Worker and told her he was under the impression that he was discharged per his conversation with the Administrator on 10/28/24. He reported he was picking up a friend from the airport, getting his RV and driving to Virginia. On 11/5/24 at 11:30 a.m., in a telephone interview Resident #2 said he was fine, he was safe and was in Virginia where he lives. He said he thought he was discharged and wasn't sure if the miscommunication was on his part or the facility. He said he had no complaints against the facility, and they had been absolutely wonderful. On 11/5/24 at 11:45 a.m., in an interview the Social Worker said Resident #2 came to her several times wanting to be discharged . She explained on initial admission he was confused and couldn't give information on his family but they were able to look through his phone and found family in Virginia. She said at the time he was confused and thought he was in Virginia and was not ok to discharge at that time. She said the Friday before he left, he again asked about discharge, he was calm, stable, and his overall confusion level was significantly improved. He wasn't making confusing statements. She said she came in on Sunday, the day after he left, and was trying to contact family/friends to verify where he was. When she did finally speak with him, he told her he was picking up a friend from the airport, then going to get his RV and driving to Virginia. She said a family member did call to confirm that he did have an RV in a public storage facility and all the things he had told her was accurate. The Social Worker said they found the wander alert bracelet; Resident #2 had taken it off. He told her he had been waiting outside her door on Saturday to tell her he was leaving, but she didn't come in and he left. On 11/5/24 2:00 p.m., in an interview the receptionist on duty on 10/26/24 said Resident #2 came to her that day around 10:00 a.m., to 10:30 a.m. He asked who he may see to remove the wander alert bracelet. She advised him to talk to a nurse. She said he walked away and came back up front about 20-30 minutes later and asked for the Director of Nursing (DON), but she wasn't working. He said he was told it was the DON that was who removes it, and he went back into the facility. The Receptionist said she never saw him leave out the front door and she would have had to buzz him out. She said she would have recognized him as a resident as he had been up to the desk twice that morning. She said she was aware of the elopement book kept at the front desk. On 11/5/24 at 11:40 a.m., in an interview the Administrator said Resident #2 was very close to being discharged from the facility but had his own plan and followed his own plan. The Administrator said Resident #2 was his own person and did not lack capacity. He had an order for leave of absence with responsible party and he was his own responsible party. The only thing he did wrong was not signing out. The Administrator said he cut off the wander alert bracelet. He said the facility doors are alarmed. During the day the receptionist hits a button to let a person out. He said they did not know but maybe the receptionist let him out. Resident #2 was younger than most of the residents and looked like a regular person. He said it was possible the resident tailgated another person out of the facility.

Based on observation, record review, residents and staff interviews, review of facility's policy and procedure, the facility failed to ensure ongoing monitoring of staff competency for use of mechanical lifts to ensure the safety of residents during transfers for 2 (Residents #1 and #2) of 3 sampled residents of 16 residents who use mechanical lifts for transfers. The findings included: The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and Kardex [provides instructions for care]. Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by: Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job. 1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation. Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m. Resident #1 was admitted to the hospital and returned to the facility on [DATE]. The hospital discharge summary noted imaging studies showed no evidence of fracture. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness. The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift. The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, Kardex: Transfer status is verified prior to transferring. Two staff members are used during transfer. The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly. The statement from Resident #1 read, I heard a pop when I was being transferred in the [Sit to Stand] mechanical lift. On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills. On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. PT Staff C said he counseled the resident about only using a full body mechanical lift. On 6/20/24 at approximately 3:00 p.m., in a joint interview the Director of Nursing and the Regional Nurse said PT Staff C did not report to them Resident #1 requested to use the Stand up lift. Review of all discontinued and current electronic physician's orders in the electronic record shows Resident #1 had not used Opioid pain medications since being admitted to the facility until 6/9/24. Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5. A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift . The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days. The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24. Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and Kardex did not have the updated transfer status. The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies. 2. Review of the list of residents who use a mechanical lift for transfer revealed Resident #2 used a full body mechanical lift for transfer. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's Kardex before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling. On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great. Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included Kardex: Transfer status is verified prior to transferring. On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over.

Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect the residents' right to be free from neglect by failure to ensure staff used the appropriate mechanical lift, and failure to follow safety protocol when using a mechanical lift to transfer 2 (Residents #1 and #2) of 3 sampled residents who use mechanical lifts for transfers. The findings included: Review of the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift with and effective date of 11/30/2014 and a revision date of 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift. Lift status will be indicated on the resident's care plan and Kardex [Provides instructions for care]. The completed evaluation will be filed in the medical record. Review of the facility's skills competency assessments for CNA (Certified Nursing Assistant) Staff noted, Skills competency is your ability to apply your skill, knowledge, and experience to perform a duty correctly . The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in: 1. Kardex [document that provides instructions for care]: Transfer status is verified prior to transferring. 2. Two staff members are used during transfer . 1. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness. The Quarterly Minimum data Set (MDS) with a target date of 4/11/24 noted Resident #1's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #1 had functional limitation in range of motion of upper and lower extremities on one side. The resident was dependent (helper does all of the effort) for chair to bed or bed to chair transfer. The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) sit to stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room . Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m. Resident #1 was admitted to the hospital and returned to the facility on [DATE]. The hospital discharge summary noted imaging studies showed no evidence of fracture. The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. The statement from CNA Staff A read, I transferred him in the [brand name sit to stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name sit to stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. The statement did not note CNA Staff A verified the transfer status before using the (sit to stand) mechanical lift to transfer Resident #1. Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competence in the use of the Sit to Stand lift. The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly]. The statement from Resident #1 read, I heard a pop when I was being transferred in the [sit to stand] lift. The facility documented CNA Staff A was immediately suspended pending investigation. Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and Kardex did not have the updated transfer status. On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills. The resident said he did not trust the staff to use the mechanical lift to transfer him. As a result, he has not taken a shower since the incident and only receives bed baths. Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5. A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift . The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days. The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24. On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. PT Staff C said he counseled the resident about only using a full body mechanical lift. Review of the sling reference guide for the stand up patient lift used by the facility showed, standing lift requirements include, Standing slings are for residents who are partially dependent, have at least 60% weight bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hip, knees and ankles. On 6/20/24 at 2:01 p.m., in a telephone interview CNA Staff B said on 6/4/24 he was in a room assisting a resident when CNA Staff A told him Resident #1 was sliding out of a sit to stand lift and asked for his help. He said CNA Staff A was using the lift by herself. When he walked into the shower room, Resident #1 was sliding from the sit to stand lift and holding onto the lift. Resident #1 was saying, My knee, my knee. Staff B said Staff A brought the chair while he was holding Resident #1 from behind. Staff A used the sit to stand mechanical lift to lower the resident into the chair. He reported the incident to Registered Nurse (RN) Staff J and told her to remind staff never to use a mechanical lift alone. Review of RN Staff J statement dated 6/7/24 read, Around 1050 [10:50 a.m.] CNA [Certified Nursing Assistant] [Staff A] informed me [Resident #1] had pain in his knee D/T [due to] his shower. I went and assessed [Resident #1] and he was in 10/10 [10 of 10 Severe] pain and his Left knee was swollen. ARNP [Advanced Registered Nurse Practitioner] was contacted and a new order for stat [immediately] Xray of left knee was completed. When I assessed [Resident #1] he stated these idiots had him in the sling wrong and He was slipping out of it B/C [because] She left a pillow behind him. He said he was sliding down to the ground and heard his knee pop and was asking them to stop and just lay him on the ground B/C [because] it hurt so badly. 2. Review of the clinical record for Resident #2 revealed an admitted [DATE]. Diagnoses included muscle weakness, unsteadiness on feet, and seizures. Review of the Significant Change in Status MDS assessment with a target date of 6/7/24 noted the resident's cognition was moderately impaired with a BIMS score of 12. The assessment noted Resident #2 was dependent on staff (Helper does all of the effort) to move from sitting on the side of the bed to lying flat on the bed, and transfers (Chair/bed-to-chair). Review of the CNA Kardex, and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's Kardex before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling. On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great. Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included Kardex: Transfer status is verified prior to transferring. On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over.

Based on observation, record review and interviews, the facility failed to ensure 4 (Staff A, Staff E, Staff F, Staff G) of 4 sampled Certified Nursing Assistants (CNAs) were knowledgeable and competent to ensure the safe use of mechanical lifts to transfer residents. The findings included: The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and Kardex [provides instructions for care]. Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by: Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job. The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in: 1. Kardex [document that provides instructions for care]: Transfer status is verified prior to transferring. 2. Two staff members are used during transfer . 1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation. The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift. The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, Kardex: Transfer status is verified prior to transferring. Two staff members are used during transfer. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness. The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and Kardex did not have the updated transfer status. The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies. 2. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. Review of the CNA Kardex, and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary. Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included Kardex: Transfer status is verified prior to transferring. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's Kardex before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great. 3. Review of the user manual for the Stand up lift used by the facility revealed, Warning: The legs of the stand up lift MUST be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the stand up lift under a bed, close the legs only as long as it takes to position the stand up lift over the patient and lift the patient off the surface of the bed. When the legs of the stand up lift are no longer under the bed, return the legs to the maximum open position. [Manufacturer name] does not recommend locking the rear casters of the stand up lift when lifting and transferring an individual. Doing so could cause the lift to tip and endanger the patient and assistants. [Manufacturer name] recommends that the rear casters be left unlocked during lifting and transferring procedures to allow the stand up lift to stabilize itself when the patient is initially lifted from and transferred to a chair, bed or any stationary object. Review of the skills competency assessment for CNAs for the Sit to Stand (Stand up) mechanical lift revealed, Lock the rear swivel casters only when positioning or removing the stand assist sling from the patient. Unlock the rear casters while lifting/transferring the resident . On 6/19/24 at 12:43 p.m., CNAs Staff F, and Staff G were observed transferring Staff H with a Stand up mechanical lift to demonstrate the proper use of the mechanical lift. The Assistant Director of Nursing (ADON) was present during the observation. After placing the transfer sling around Staff H, Staff F was observed to place the lift next to the chair without completely opening the base of the lift. Staff F locked the rear casters and attempted to lift Staff H with the Stand Up mechanical lift. The lift did not respond. Staff changed the battery twice and lifted Staff H off the chair. The lift stopped in the middle of the lift and would not respond. Staff F was observed trying to wiggle the wires on the bottom of the lift to get the lift to respond. When the lift would not respond Staff F and G were observed transferring Staff H to the chair without ensuring Staff H was fully standing. Staff F was observed to unlock the casters and move Staff H without fully extending the base of the lift. Staff F then locked the rear casters before lowering Staff H. On 6/19/24 at 1:45 p.m., in an interview the ADON verified she instructed all staff both verbally and by observation on the use of the facility's mechanical lifts after the incident on 6/4/24.

Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure medications were appropriately labeled in 3 (Carts #1, #2, and #3) of 3 medications carts reviewed. Without an open date on the medication there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The facility also failed to secure medication and treatment carts were secured when not in view of the licensed nurse. The findings included: The facility policy, Administering Medications (revised 4/19) documented, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 1. On 10/2/23 at 10:39 a.m., during an observation of medication cart identified by Licensed Practical Nurse (LPN) Staff F as cart #1 (rooms 204-208), the following was observed: One Novolog insulin flex pen without an open date on the package. The directions on the pharmacy label instructed to discard 28 days after opening. Photographic evidence obtained. One Novolin R flex pen for without an open date recorded. The directions on the pharmacy label instructed to discard after 28 days. The findings were verified by LPN Staff F. 2. On 10/2/23 at 11:30 a.m., during an observation of medication identified as Cart #3 with LPN Staff E, the following was observed: One Levemir Flex Pen without an open date. Photographic evidence obtained. One Novolog Flex pen in a clear plastic bag with a date opened of 8/15/23. The plastic bag did not have a pharmacy label. The instructions specified to discard 28 days after opening. The Novolog flex pen should have been discarded on on 9/12/23. Photographic evidence obtained. One Levemir Flex Pen dated 8/15/23 on the insulin pen and a date of 9/1/23 on the pharmacy label. The label instructed to discard after 28 days. LPN Staff E confirmed she did not know which date was the actual open date of the insulin. Staff E confirmed the findings in the medication cart. 3. On 10/2/23 at 11:45 a.m., during an observation of medication cart identified as cart #2 with Registered Nurse (RN) Staff D the following was observed: One Lispro Insulin Pen without an open date. The pharmacy label instructed to discard the medication 28 days after opening. RN Staff D confirmed the findings in the medication cart. On 10/4/23 at 1:38 p.m. in an interview, the Assistant Director of Nursing (ADON) said the expectation was when you open an insulin you date it. The ADON confirmed the opened insulin should be dated when the nurse opens the medication. 4. On 10/2/23 at 12:11 p.m., during an observation, RN Staff D unlocked medication cart #3 to retrieve medications. The cart was against the wall in front of the nursing station. RN Staff D walked away from the unsecured medication cart and went down the hallway to the other nursing unit. There were residents and staff in the hall. RN Staff D returned to the unit and confirmed the medication cart had been left unlocked and unattended. Photographic evidence obtained. 5. On 10/2/23 at 1:17 p.m., on the secured Memory Care Unit the medication room was left unlocked and the door was open. The medication cart was in the room and was unlocked. There were residents wandering by past the open medication room. The nurse was not present for five minutes and the medication cart was unsecured. LPN Staff F returned to the open medication room and verified she had left the medication room and the medication cart unsecured and unattended. Photographic evidence obtained. 6. On 10/3/23 from 8:56 a.m. to 9:06 a.m., a medication cart labeled cart #2 was observed unlocked at nursing station 1. A treatment cart located in the hallway across from nursing station 1 was unlocked. The treatment cart contained medications and wound care supplies. Residents and staff were observed walking by the unlocked medication and treatment carts. On 10/3/23 at 9:06 a.m., LPN Staff E verified the medication and treatment carts were unlocked and unattended. 7. LPN Staff E walked away from an unlocked cart in the hallway in front of room [ROOM NUMBER]. On 10/3/23 at 9:11 a.m., LPN Staff E returned to the unsecured medication cart in front of room [ROOM NUMBER] and confirmed the medication cart was unlocked with the contents easily accessible. Photographic evidence obtained. On 10/4/23 at 11:08 a.m., the Director of Nursing said the carts were to be locked when not in view of the nurse.

Based on observations, review of the clinical record, review of the facility policies and procedures, and staff interviews the facility failed to develop and implement a program of meaningful activities to meet the needs of 6 of 16 residents in the memory care unit. The facility failed to implement meaningful individualized activities to meet the interest and wellbeing of 1 (Resident #58) of 1 resident in the memory unit sampled for individualized activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. The findings included: The facility policy, MC-200 Activity-Intensive Program effective date 11/30/14 (revised 3/19/19) documented, A structured activity intensive program shall be the focus of the memory care unit to minimize the confusion residents with dementia and related disorders experience as they attempt to cope with difficulties in short term memory, attention span, comprehension, learning, conceptualization, judgment, reasoning, abstract thought, perception and psychosocial well-being . Procedure: The activity intensive program shall provide a minimum of 12 hours per day, 84 hours per week of structured activity programming . A review of the clinical record revealed Resident #58 was admitted on [DATE] with diagnosis including dementia, anxiety, and major depressive disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 7/6/23 documented Resident #58's cognitive skills for daily decision making were severely impaired. The care plan initiated on 9/30/21 and revised on 7/11/23 documented Resident #58 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. The goal for Resident #58 was to attend and participate in community life activities of choice three to five times. The care plan noted, She loves company. She loves music and BINGO, she loves chocolate. The interventions included assisting with arranging community activities. Ensure that the activities the resident is attending are compatible with physical and mental capabilities. Compatible with known interest and preferences, adapted as needed such as large print. Compatible with individual needs and abilities. The activity calendar listed Exercise for 10/2/23 at 10:00 a.m. On 10/2/23 at 10:20 a.m., Resident #58 was observed seated at the dining room table with her forehead resting on the table. No music was playing, and no activity program was in progress. On 10/2/23 at 12:21 p.m., Resident #58 was observed at the same table in the dining room resting her forehead on the table. The activity calendar for 10/3/23 listed News at 9:00 a.m., and Rosary at 10:00 a.m. On 10/3/23 Resident #58 was observed sitting at a table in the dining room from 10:00 a.m. to 10:30 a.m., and on 10/3/23 at 11:21 a.m. During both observations, Resident #58 was staring at the wall. There was no activity in progress, no television or music playing. There were no staff in the dining room during the observations. On 10/4/23 at 8:13 a.m., Resident #58 was observed in a wheelchair in the unit dining room. There was no group or individual activity in progress and no music playing. On 10/4/23 at 8:23 a.m., Registered Nurse (RN) Staff D said there were no activities provided to the Memory Care Unit residents. Staff D said the unit used to have an activity aide who was wonderful, but she was no longer here. Staff D said, The CNAs (Certified Nursing Assistants) try to do little things for the residents, but they have patient care to do and can only do so much. I have not seen the Activity Director come back here to do any activities during the day when I am working. On 10/4/23 at 8:36 a.m., CNA Staff A said, No one comes to the memory care unit to do activities. We have this large activity calendar on the wall and, if we have time, we do something with the residents. The residents back here are not able to do most of the things on the calendar, they use the same one as the main unit and the activities listed, most of the residents are not able to do. We are not allowed to take the residents from the unit for the general activities in the main area of the facility. The CNA said, The calendar says to do news at 9:00 a.m. The residents don't read the newspaper and if I try, they can't participate. Karaoke is at 10:00 a.m., today but they don't have the equipment here and the residents can't read along. On 10/4/23 at 9:01 a.m., the Activity Director (AD) said she tries to go back to the unit as often as she can, but with the COVID outbreak on the unit it is harder. The AD said she was the only activity person for the facility and the CNAs were to provide the activities on the Memory Care Unit. The AD said she goes back to the unit daily to ensure the activities are being provided. The AD said she does not place individual activity calendars in resident rooms because the residents cannot read it. The AD said she only placed a large calendar on the unit wall by the television (TV). The AD said she had provided education to all the staff who work on the memory care unit on how to do each activity and said everything is on the unit for the activities. The AD said she makes sure the CNAs are providing the activities and completing the charting. The AD provided a copy of the same general population calendar for the Dementia residents, and said the calendar was the same one used for the Memory Care Unit residents. On 10/4/23, during observation of the Memory Care Unit from 10:00 a.m. to 10:27 a.m., Resident #58 remained at the table facing a wall with no activity in progress. The Calendar specified Karaoke at 10:00 a.m. No music was playing. No activity of any kind was in progress. On 10/4/23 at 10:20 a.m., CNA Staff B said there was no Karaoke machine on the unit. Staff B said she had not received in-service education on providing activities on the unit and said, The residents wander, and you have to stop and redirect them frequently, you can't be in two places at the same time, and we can't do our patient care and do activities at the same time. On 10/4/23 at 10:31 a.m., during observation in the main dining room of the general population, Karaoke was in progress. No residents from the memory care unit were in attendance. The Activity Director was present. On 10/4/23 at 11:03 a.m., an observation on the Memory Care Unit, one resident was wandering the halls, three residents were in the dining room unattended. Resident #58 was seated at the table, with crayons and a paper to color, but the resident had pushed them to the other side of the table. Resident #58 responded when greeted but did not respond appropriately to questions. There was no structured activity in progress and no music was playing. One CNA was observed in the TV area attending to other residents. On 10/4/23 at 1:59 p.m., the activity calendar specified nails to be done at 2:00 p.m. Observation of the unit noted five residents sleeping in the TV area, while the TV was on. One resident was wandering in the dining room. The CNAs were observed providing toileting and care to the residents. On 10/4/23 at 2:03 p.m., RN Staff D said, The Activity Director came back here this afternoon and told the staff they were to do nail care, I told her we had no supplies back here on the unit. The AD left and returned with a caddy that had a few nail polishes in it. On 10/4/23 at 2:16 p.m., CNA Staff B said no one from activities had come to the unit to provide nail care. The CNA said, if we have time, we try and do an activity with the residents, but we are always busy. On 10/4/23 at 2:22 p.m., CNA Staff A said, We toilet everyone back here every two hours, I take that very seriously. If they need to be changed or put to bed, I do it. My main concern is with the resident's care and if I have time, I don't mind doing the activity with them. I love to spend time with them doing appropriate activities for them but some days there is no time. On 10/5/23 at 8:30 a.m., the Activity Director confirmed the activity calendar for the Memory Care Unit was the same as the general population and the residents did not leave the secured unit to attend activities in the main area of the facility. The Activity Director said the residents like Karaoke, and they sing along to it but confirmed the activity did not occur on the memory unit as listed on the calendar. The Activity Director said she was aware the residents on the Memory Care Unit required activities to meet their cognitive level and said she was doing her best, but she was the only person in the facility for activities. I used to have an assistant, but she left suddenly and had not been replaced yet. The Activity Director confirmed the activities on the general population calendar were not provided to the memory care residents.

Based on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders for 2 (Residents #18 and #30) of 4 residents observed for medication administration. Three licensed nurses on the morning shift with 29 opportunities were observed. Two medication errors were observed resulting in a 6.9% error rate. The findings included: The facility policy Administering Medications (revised 4/19) documented, Medications are administered in a safe and timely manner and as prescribed.Medications are administered in accordance with prescriber orders including any required time frame. 1. On 10/3/23 at 8:31 a.m., Registered Nurse (RN) Staff C was observed administering eight different medications to Resident #18. RN Staff C said she was not able to administer Duloxetine 40 milligrams (mg) as ordered medications. She said the medication was not available and was not included in the emergency drug kit. Review of the clinical record revealed a physician's order dated 9/3/23 to administer Duloxetine HCL (Hydrochloride) 40 milligrams (mg), one capsule by mouth daily related to Recurrent Major Depressive Disorder. On 10/3/23 at 4:00 p.m., RN Staff C documented in a progress note she notified the Advanced Practice Registered Nurse the medication will be given late as it will be sent STAT (immediately) from the pharmacy. On 10/4/23 at 12:15 p.m., Review of the Medication Administration Record failed to show documentation Resident #18 received the Duloxetine 40 mg as ordered on 10/3/23. On 10/4/23 at 12:32 p.m., the Assisted Director of Nursing (ADON) said Resident #18 did not receive the Duloxetine on 10/3/23 because it was not here. On 10/4/23 at 12:46 p.m., review of the Pharmacy Delivery Slip showed the Duloxetine 40 mg capsule was delivered and available on 10/3/23 at 12:48 p.m. 2. On 10/3/23 at 9:39 a.m., Licensed Practical Nurse (LPN) Staff E was observed administering seven different medications to Resident #30, including one chewable tablet of Aspirin 81 mg. LPN Staff E crushed all the medications and administered them to the resident. Review of the clinical record revealed a physician's order dated 1/20/23 to administer Aspirin EC (enteric coated) tablet delayed release, one tablet by mouth one time a day related to atrial fibrillation. On 10/3/23 at 11:00 a.m., LPN Staff E said she did not know what enteric coated was. She verified Aspirin 81 mg enteric coated was not available in the medication cart.

Based on record review, and staff interviews the facility failed to ensure they maintained communication between the nursing facility and the dialysis center related to the ongoing assessment of dialysis resident before and after each dialysis treatment for 2 (Residents #7 and #24) of 2 residents receiving dialysis. The findings included: The facility policy titled, Coordination of Hemodialysis Services N-1359, with an effective date of 11/30/2014 and a revision date of 7/2/2019, stated residents that required an outside ESRD (End Stage Renal Disease) facility would have services coordinated by the facility. The Dialysis Communication form would be initiated by the facility and sent to the ESRD center. The nurse would collect and complete the information regarding the resident to send to the ESRD center and upon the resident's return to the facility, the nurse would review the Dialysis Communication form and the information sent by the ESRD center and complete the post dialysis information on the Dialysis Communication form and file it in the resident's medical record. 1. Review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with a medical diagnosis of End Stage Renal Disease. Resident #7 had a physician's order for hemodialysis (Treatment to filter wastes and water from the blood) every Tuesday, Thursday and Saturday related to ESRD. On 10/4/23 at 4:38 p.m., Licensed Practical Nurse (LPN) Staff F confirmed Resident #7 went to the dialysis center every Tuesday, Thursday and Saturday. She said the nurses were responsible to fully fill out the prior to dialysis section on the Dialysis Communication Record form and send it to the dialysis center. When the resident returned from the dialysis center, the receiving nurse was required to review the Dialysis Communication Record form for any new orders and/or concerns the dialysis center documented on the form. The receiving nurse then was responsible to complete the return from dialysis section of the form to show they had completed a full assessment of the dialysis port site to check for any bleeding and/or possible infection and to complete a full set of vital signs to indicate the resident was stable and not in any distress. Staff F searched Resident #7's dialysis communication logbook and Resident #7's medical record and she said she was unable to find any of Resident #7's Dialysis Communication Record forms. On 10/4/23 at 5:00 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed Resident #7 went to the dialysis center every Tuesday, Thursday and Saturday. They said the nursing staff were required to complete the pre and post assessment on the Dialysis Communication Record form. The ADON said all of Resident #7's Dialysis forms were kept in the medical records office. Resident #7's Dialysis Communication Records forms for September and October 2023 were reviewed with the ADON. The ADON verified the post return section of the dialysis communication form was not completed on September 2, 19 and 21. The ADON said she was not able to find the dialysis communication form for September 7, 9, 14, 16, 23, 26, 30, and October 2, 2023. On 10/5/23 at 8:30 a.m., in an interview, the Charge Nurse at the Dialysis Center confirmed Resident #7 came to their facility every Tuesday, Thursday and Saturday for hemodialysis service. She said the facility did not always send the Dialysis Communication Record form with Resident #7 as required. She said even though the facility did not always send the Dialysis Communication Record form, they always faxed their Information Exchange form to the facility for their records. She said their main concern was Resident #7 came to their facility without a dressing covering the left chest dialysis port site which could lead to an infection. She said they had written this information on the Dialysis Communication form as required but Resident #7 still came to the facility without a dressing to his dialysis port site. On 10/5/23 at 10:00 a.m., the ADON said she was unable to find Resident #7's Dialysis Communication form for September 7, 9, 14, 16, 23, 26, 30, and October 2, 2023. The ADON confirmed the dialysis center had written on their Information Exchange form dated 9/19/23 Resident #7's dialysis port dressing was missing. She said she had identified on 9/26/23, the nursing staff were not completing the pre and post assessments on the Dialysis Communication form but had not conducted staff education with the nursing staff to ensure they completed the required components on the Dialysis Communication Record form and making sure Resident #7's dialysis dressing remained intact at all times. 38570 2. On 10/5/23 at 4:10 p.m., Resident #24's dialysis communication book located in the dialysis bag in the resident's room was reviewed. The dialysis communication form dated 10/5/23 did not document the resident's name and was not filled out by the facility prior to going to dialysis at 6:30 a.m. On 10/05/23 at 4:18 p.m., Registered Nurse (RN) Staff J stated when she received the resident back from dialysis today, the pre dialysis part of the form dated 10/5/23 was not filled out, and the form did not have the resident's name.

Based on observations, interviews, and record review the facility failed to provide care and services to prevent reduction in range of motion (ROM) for 1 (Resident #78) of 2 residents reviewed for limitation in ROM. The findings included: Review of the facility policy for Contracture Prevention revised 8/22/17 revealed the purpose is to prevent contracture of extremities for those residents who no longer have full use of their extremities. Each resident must be evaluated for the need of contracture prevention procedure on admission and readmission as needed. Review of the clinical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including paralysis of right side due to cerebral vascular accident (CVA). The physician's orders dated 8/12/23 included an Occupational and Physical Therapy evaluation and treatment. The physician's History and Physical progress note dated 8/14/23 at 5:47 p.m., noted Resident #78 had a right hand contracture. Physical Therapy (PT) and Occupational Therapy (OT) to assess and treat. The clinical record lacked documentation of an Occupational Therapy evaluation and treatment as per the physician's order. On 10/02/23 at 10:37 a.m., Resident #78 was observed in his room. The resident's right hand was in a closed fist. The resident was not wearing an orthotic device such as a splint to the right hand. Resident #78 was not able to speak and shook his head no when asked if the facility had evaluated and was treating his right hand. On 10/4/23 at 11:35 a.m., observed Resident #78 in his room, nothing in the right hand, closed fist position. On 10/4/23 at 1:09 p.m., Resident #78 was observed in his room with his daughter. The daughter said Resident #78 had a CVA on 2/14/23. His right hand became paralyzed. She retrieved a splint from a box in the closet which she said was for Resident #78's right hand. On 10/4/23 at 1:29 p.m., the Director of Rehabilitation Services said Resident #78 was not evaluated or treated by Occupational Therapy and was not receiving services to prevent a decline in the range of motion of the right hand. The Director of Rehabilitation said Resident #78's payor source was Private Pay, the daughter wanted to start with Physical Therapy, therefore, he did not receive Occupational Therapy. On 10/4/23 at 2:16 p.m., Certified Nursing Assistant (CNA) Staff X said she takes care of the resident regularly, no one told her to do any range of motion (ROM) for Resident #78. On 10/4/23 at 3:58 p.m., the Minimum Data Set (MDS) Coordinator said the Rehabilitation Department should have addressed the right-hand fist and applied a rolled-up towel or something to keep the hand from closing. After reviewing the clinical record, she said Resident #78 was not receiving restorative nursing for his right hand to prevent a decline in the range of motion. On 10/5/23 at 9:11 a.m., the Director of Rehabilitation Services attempted to open Resident #78's right hand. The Rehabilitation Director said she cannot open the fist. She said she could not tell if the hand was contracted or hypertonia (abnormal muscle tone), both of which indicate a ROM decline. She said without treatment the hand would get worse. She said that is what happens when the hand is paralyzed. On 10/5/23 at 9:29 a.m., the Director of Nursing (DON) went to the room and confirmed the right hand was closed in a fist, and she could not open it. On 10/5/23 at 9:48 a.m., the Business Office Manager (BOM) said OT should have evaluated and treated per the physician's orders, regardless of the payor source.

Based on observation, review of the clinical record, review of facility policies and procedures, and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #19, and #68) of 3 residents reviewed for activities of daily living (ADLs). The findings included: The facility policy, N-1130 Bathing/Showering effective 11/30/2014 (revised 9/1/17) documented, Assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. 1. Review of the clinical record revealed Resident #19 had an admitted [DATE] with diagnoses including Alzheimer's disease, paranoid schizophrenia, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 8/16/23 documented Resident #19 required extensive physical assistance of one person for personal hygiene and was dependent on staff for bathing. The MDS assessment noted Resident #19's cognitive skills for daily decision making were severely impaired. On 10/2/23 at 3:08 p.m., Resident #19 was observed sitting at a table in the dining room of the secured Memory Care Unit. Her fingernails were very long extending approximately half inch in length and had a brown substance under the nail beds. Resident #19's hair was flat, uncombed, and greasy. On 10/3/23 at 8:06 a.m., Resident #19 was observed being assisted from her room dressed in her own clothing. Her hair was combed and appeared greasy. Resident #19's fingernails remained untrimmed with a brown substance under the nail beds. Review of the Certified Nursing Assistant (CNA) documentation for August 2023 and September 2023 revealed Resident #19 was scheduled for showers on the day shift on Tuesdays and Fridays. The CNA documentation lacked evidence Resident #19 received her scheduled shower on 8/8/23, 8/15/23, 8/18/23, 8/25/23, 9/1/23, 9/15/23, 9/22/23 and 9/29/23. On 9/12/23 the documentation reported a partial shower was provided. There was no documentation Resident #19 received assistance with personal hygiene during the day shift on 8/6/23, 8/8/23, 8/10/23, 8/11/23, 8/25/23, 8/28/23, 9/1/23, 9/2/23, 9/3/23, 9/15/23, 9/17/23, 9/22/23, 9/23/23, 9/24/23 and 9/29/23. There was no documentation Resident #19 received assistance with personal hygiene during the evening shift on 8/3/23, 8/4/23, 8/5/23, 8/9/23, 8/11/23, 8/18/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/28/23, 8/31/23, 9/1/23, 9/3/23, 9/7/23, 9/8/23, 9/10/23, 9/15/23, 9/17/23, 9/19/23, 9/22/23, 9/23/23, 9/24/23, 9/26/23, 9/27/23, 9/28/23 and 9/29/23 . The clinical record lacked documentation of assistance with personal hygiene for the night shift on 8/9/23, 8/12/23, 8/16/23, 8/19/23, 8/21/23, 8/22/23, 8/26/23, 8/27/23, 9/3/23, 9/6/23. 2. Review of the clinical record revealed Resident #68 had an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety. The Quarterly MDS assessment dated [DATE] documented Resident #68 required extensive physical assistance of one person with dressing, personal hygiene and was dependent on staff for bathing. The MDS noted Resident #68's cognitive skills for daily decision making were severely impaired. Review of the CNA documentation for August 2023 and September 2023 revealed Resident #68 was scheduled for showers on the 3-11 shift on Mondays and Thursdays. There was no documentation Resident #68 received her scheduled shower on 8/3/23, 8/28/23, 8/31/23, 9/11/23, and 9/14/23. A bed bath was provided on 9/7/23. The CNA documentation showed Resident #68 received no assistance with personal hygiene as follows: The day shift on 8/6/23, 8/8/23, 8/10/23, 8/11/23, 8/14/23, 8/15/23, 8/25/23, 8/28/23, 9/1/23, 9/2/23 , 9/7/23, 9/17/23, 9/18/23, 9/22/23 and 9/29/23. The evening shift on 8/3/23, 8/4/23, 8/5/23, 8/9/23, 8/11/23, 8/18/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/28/23, 8/31/23, 9/2/23 9/5/23, 9/8/23, 9/9/23, 9/11/23, 9/15/23, 9/16/23, 9/22/23, 9/23/23, and 9/30/23. The night shift on 8/9/23, 8/12/23, 8/16/23, 8/17/23, 8/19/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 9/3/23, 9/6/23, 9/7/23, 9/11/23, 9/17/23, 9/18/23, 9/21/23, 9/23/23, 9/26/23 and 9/29/23. On 10/02/23 at 12:14 p.m., Resident #68 was observed in the dining room at the table for the noon meal, dressed in a hospital gown. The gown was opened on the left side exposing her incontinent brief, upper thigh, and abdomen as she sat eating lunch. Three staff members were present in the dining room and did not adjust the resident's gown to cover her thigh, abdomen, and exposed brief. On 10/2/23 at 3:16 p.m., Resident #68 was observed sitting at a table in the dining room dressed in her own clothing. Her fingers nails were long with a brown substance under the nail beds. Her hair was messy and uncombed. On 10/4/23 at 8:12 a.m., Resident #68 was observed seated at the dining room table dressed in her own clothing. Her nails remained long with a brown substance under the nails. On 10/4/23 at 11:00 a.m. in an interview, CNA Staff A said if a resident refuses a shower, she will leave and approach the resident again. She said, I have a three-time process, if they decline after 3 times, I ask another staff member to try. If the resident continues to refuse a shower, I document it and I notify the nurse. Review of the Resident Council Minutes showed the following repeated concern with residents not receiving showers as scheduled. On 4/15/23, 14 residents attended the meeting and reported showers were not given. On 6/18/23, eight residents attended the meeting and reported the shower schedule was not being kept. On 7/11/23, nine residents attended the meeting and reported showers were getting better. On 8/12/23, nine residents attended the meeting and reported showers are sometimes being provided. On 10/5/23 at 10:00 a.m., Registered Nurse Staff J said the nurse was responsible to ensure the residents showers are completed. Staff J said sometimes, if the resident doesn't want to take a shower, she goes and ask them to please take a shower. She will try three times and if they say no, she documents the resident refused.

Based on observations, record review and staff interview the facility failed to ensure they applied and removed an AFO (ankle-foot orthosis) device for 1 (Resident #66) of 1 out of 6 residents coded as having an AFO. The use of an AFO is to improve standing, transfers, and/or walking patterns by reducing, preventing, or limiting the movement of the lower leg and foot and by supporting weak muscles. The findings included: On 10/03/23 at 9:10 a.m., Resident #66 was observed sitting in her wheelchair in the doorway to her room. During the observation, Resident #66 was noted to be dragging her right foot and her right arm and her hand appeared to be contracted. Resident #66 stated she had a cerebral vascular accident (CVA) causing her weakness on the right side of her body. She said she used to have a right foot splint, but therapy took it away a long time ago and she didn't know why. Review of Resident #66's medical record revealed diagnoses included a medical history of Multiple Sclerosis (disorder marked by decreased nerve function), Hemiplegia (paralysis of one side of the body), and Hemiparesis (weakness of one side of the body) following a Cerebral Infarction affecting the Right Dominant Side, Weakness, Unsteadiness on Feet, and a History of Falls. Resident #66's plan of care, dated 1/9/23 and revised 9/7/23, noted the resident had an activity of daily living (ADL) self-care performance deficit related to the disease process of Multiple Sclerosis, Vision Impairment, and Right Lower Leg/Extremity (RLE) Impairment and wore an AFO. Under interventions, it stated staff was to assist the resident with applying and removing the RLE AFO daily. The Certified Nursing Assistant (CNA)'s plan of care (KARDEX) for Resident #66, noted in the Resident Care section to assist Resident #66 with applying and removing her RLE AFO daily and observe for discoloration and bruising at least daily. On 10/4/23 at 9:15 a.m., CNA Staff K, said she was normally assigned to work with Resident #66. She said Resident #66 was independent but due to CVA she was very weak on her right side and had an unsteady gait. She said she had never seen or applied any splinting device to Resident #66's right foot. She said she was never told or aware the CNA's KARDEX stated they had to assist Resident #66 with applying and removing her RLE AFO daily and check for any discoloration to her leg. On 10/4/23 at 9:30 a.m., the Rehabilitation Director, said she had conducted an Occupational Therapy (OT) evaluation on Resident #66 on 9/7/23 because the resident was referred to them due to worsening vision, falls, decreased strength, impaired endurance, anxious behaviors and decreased quality of life. She said via her OT evaluation of Resident #66, she determined to start OT sessions with Resident #66, four times a week for four weeks. She said during her evaluation of Resident #66 on 9/7/23 she noted the resident did not have any splinting devices. The Rehabilitation Director said on 9/11/23 the Minimal Data Set (MDS) Coordinator gave her a list of 11 residents that had a splint/orthotics device and asked her to determine if the residents were using their splints/orthotics and to determine if they still needed them. The Rehabilitation Director confirmed Resident #66 was on the list for a right AFO to be worn out of bed. She said she did not have any documentation the therapy department had conducted the evaluation of Resident #66's RLE for use of AFO as requested by the MDS Coordinator on 9/11/23. By observation of Resident #66 and a search of Resident #66's room, the Rehabilitation Director confirmed Resident #66 was not wearing the RLE AFO as ordered, and she was unable to find the RLE AFO in Resident #66's room. On 10/4/23 at 10:06 a.m., the MDS Coordinator, said Resident #66 was admitted on [DATE] and the physician had ordered on 12/13/22 for a RLE AFO to be worn daily when Resident #66 was out of her bed. She said Resident #66 had a care plan created on 1/09/23 and revised on 9/7/23 for her to wear the RLE AFO because of her vision impairment, history of Multiple Sclerosis, and falls. The MDS Coordinator said she had given the therapy department a list of residents on 9/11/23 to conduct an evaluation of their splints/orthotics to determine if the residents still needed the splints/orthotics, including Resident #66. The MDS Coordinator said she had no documentation the therapy department had conducted an evaluation of Resident #66's RLE AFO as requested on 9/11/23. By observation the MDS Coordinator confirmed Resident #66 was not wearing the RLE AFO and the AFO was not in Resident #66's room. Resident #66 told the MDS Coordinator she had not worn the AFO in months. The MDS Coordinator said she was not informed Resident #66 was not wearing the RLE as ordered by the physician and written in Resident #66's ADL plan of care.

Based on record review, review of facility's policy and procedure, and staff interview the facility failed to ensure the baseline care plan was developed within 48 hours of admission for 1(Resident #283) of 3 newly admitted residents reviewed. The findings included: The facility policy, Plan of Care effective 11/30/14 (revised 9/25/17 documented, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Develop and implement an individualized plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. Review of the clinical record for resident #283 revealed an admitted [DATE]. The Admission data collection form with an effective date of 9/2/23 noted diagnoses including chronic obstructive pulmonary disease, anemia, presence of cardiac pacemaker, heart failure, and muscle weakness. Resident #283 was dependent on continuous oxygen and was frequently incontinent of bowel and bladder. Resident #283 had dark discoloration, redness, and open area to the sacrum (Bone in the lower back). The clinical record lacked documentation of a baseline care plan to promote continuity of care, increase the resident's safety, and safeguard against adverse events. On 10/5/23 at 12:06 p.m., the Regional Assistant Director of Nursing confirmed a baseline care plan was not completed for Resident #283.

Based on observation, staff interview, and record review the facility failed to provide care and services to prevent the development of a pressure injury for 1 (Resident #9) of 3 residents reviewed for pressure injuries. Failure to treat a pressure injury can lead to an infection and prevent healing, which has a high likelihood of harm to the resident. The findings included: Review of the facility policy and procedures: 1. Clinical Guideline Skin & Wound (WC-100) with an effective date of 4/1/2017 (no revision date) showed the following: Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process: 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 Develop individualized goals and interventions and document on the care plan and the CNA Kardex 2. Skin Evaluation (WC-190) revision date 4/01/2017 showed the following: Policy: If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the Pressure Injury Record. The licensed Nurse will document the observations on the Skin evaluation form. On 8/30/20 at 10:30 a.m., Registered Nurse/Unit Manager (RN/UM) Staff I was observed doing a clean dressing change to Resident #9's shoulder wounds with Zinc Ointment and a dry dressing. After completing the wound care, RN/UM Staff I turned the resident on her side to visualize the residents back. A soiled dressing dated 8/28/20 was observed on the resident's coccyx. RN/UM Staff I said she was not aware Resident #9 had a wound on his coccyx. She removed the dressing. RN/UM Staff I observed a pressure injury under the dressing. The area was approximately 2 centimeters (c.m.) long by 1 c.m. wide with yellow eschar tissue covering the wound. Staff I checked the Treatment Administration Record (TAR) for Resident #9 and no treatment order was found for a coccyx wound. On 8/30/20 at 11:00 a.m., RN/UM Staff I looked for a coccyx treatment order in the resident's clinical record. No medical doctor (MD) treatment order was found for a coccyx wound. Review of the nurses notes from 8/28/20 to present showed no documentation of a treatment to the resident's coccyx. No documentation found on a Pressure Injury Record for Resident #9. RN/UM Staff I informed the Assistant Director of Nursing ADON of the coccyx wound. On 8/30/20 at 11:35 a.m., the ADON found a copy of the 24-hour report dated 8/28/20 at 6:00 p.m., for the 3-11 shift which showed documentation for Resident #9 under section Remarks/Change of Condition. The note showed Coccyx wound. T.O. (telephone order) wrote for request for wound Dr eval. The ADON said she did not know Resident #9 had a coccyx wound. A Situation, Background, Appearance, and Review Communication Form was completed. The form showed a change of condition, an open wound in coccyx. The documentation showed This started on 8/30/20. Under the section Review and Notify, MD notified on 8/30/20 at 11:20 a.m., of open area to right buttock and sacrum. Treatment ordered until seen for wound consult. Resident #9's wife notified 8/30/20 at 11:20 a.m. The T.O. dated 8/30/20 at 11:30 a.m., showed a treatment order apply [MEDICATION NAME] to open area to r (right) buttock and sacrum until seen by Wound Care (Dr's name) for consult. The facility failed to provide treatment to an open coccyx wound identified on 3/28/20 at 6:00 p.m., until 8/30/20 at 11:30 a.m. The ADON said she was unable to find documentation the facility notified the doctor or provided treatment of [REDACTED].#9, from its identification 8/28/20 at 6:00 p.m., until 8/30/20 at 11:30 a.m.

Based on record review and staff interview, the facility neglected to immediately initiate basic life support, including cardiopulmonary resuscitation (CPR) to 1 (Resident #773) of 3 residents reviewed for appropriate emergency care. The facility neglected the resident's needs for emergency care allowing her to expire despite a full code status. This situation was determined to be an immediate jeopardy. The immediate jeopardy started on [DATE] at 5:50 a.m. and ended on [DATE] when the facility provided documentation the majority of the licensed nurses were properly trained on when to perform cardiopulmonary resuscitation. The findings included: Review of the facility's policy and procedure for residents rights (SS-260) with an effective date of [DATE] revealed residents and their representatives will be made aware of their rights upon admission to the nursing home. Resident or their representative will sign an acknowledgment that they have been made aware of their rights and have been furnished written information on residents' rights. Review of the facility's policy and procedure for CPR (N-302), revised on [DATE], revealed CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a physician's orders [REDACTED]. In the absence of the physician's orders [REDACTED]. Clinical record review revealed a physician's orders [REDACTED].#773 had a full code status. A full code status allows for all interventions needed to restore breathing or heart functioning, including chest compressions. On [DATE], the Social Service Director documented a late entry for [DATE] indicating she spoke to the resident's son and reviewed Resident #773's advance directives and full code status. The resident's son, who is the health care surrogate, said he wanted Resident #773 to remain a full code. On [DATE] at 5:50 a.m., Registered Nurse (RN) Staff A documented in an interdisciplinary progress note Assessed resident 0 (no) V/S (vital signs) present. Verified by second nurse. On [DATE] at 6:00 a.m., RN Staff A documented he entered a note in the physician's book noting the event. On [DATE] at 6:40 a.m., RN Staff A documented he filled out the paperwork and provided the information to the funeral home with instructions that a relative needs to call and determine further actions. On [DATE] at 7:10 a.m., RN Staff A wrote a note indicating he placed a call to the physician and Resident #773's spouse to inform them of the event and that the resident was a full code. On [DATE] at 7:15 a.m., the next entry made by RN Staff A indicated a code blue was called and CPR was provided. On [DATE] at 7:20 a.m., RN Staff A documented EMS (Emergency Medical Services) on site. Notified that MD (Medical Doctor) has been notified and stated that at this point, no CPR is necessary. RN Staff A also provided a witness statement on [DATE] at 5:50 a.m., he assessed Resident #773. The resident was laying in bed motionless, pale, with signs and symptoms of rigor mortis. (Rigor mortis is the stiffening of the joints and muscles of a body a few hours after death. Rigor mortis usually sets in within four hours of death.) Based on RN Staff A's documentation in the interdisciplinary notes, CPR was initiated 1 hour and 25 minutes after the resident was found without respiration or pulse. According to the Mayo Clinic, when the heart stops, the lack of [MEDICATION NAME] blood can cause brain damage in only a few minutes. Death or permanent brain damage can occur within four to six minutes. Time is critical when you're helping an unconscious person who isn't breathing. Take immediate action. During a telephone interview on [DATE] at 9:25 a.m., Certified Nursing Assistant (CNA) Staff E said she was on duty the night Resident #773 expired. She said she last saw her alive on [DATE] at 4:00 a.m., when she made her rounds. She said on [DATE] at 5:30 a.m., she checked on the resident again. As she was removing the incontinent pad, the resident just rolled over on her face and was not responsive. She immediately called for help and asked CNA Staff F to get the nurse. She said RN Staff A walked in the room around 5:45 a.m. and instructed her to put a clean gown on the resident and left. She cannot remember if RN Staff A checked the resident's vital signs. She said she remained in the room with CNA Staff F for approximately 20 minutes. RN Staff A never came back while she was in the room. During a telephone interview on [DATE] at 10:37 a.m., CNA Staff F said on [DATE] at approximately 5:30 a.m., CNA Staff E asked her to get the nurse because Resident #773 had expired. She called RN Staff A to the room. She does not know what happened after that. During a telephone interview on [DATE] at 12:15 p.m., RN Staff A said on [DATE] at 5:00 a.m. he went in Resident #773's room to administer medications to her roommate. He said Resident #773 was in bed sleeping and was definitely breathing. RN Staff A said sometime later, a CNA approached him and told him Resident #773 had expired. He immediately went to the room and checked for vital signs, she had no vital signs whatsoever. He went back to the nurse's station and opened her chart. There was an orange paper in the chart with the insurance company's name. He thought the insurance company was some type of hospice and called them to inform them of the resident's passing. He then called the family and filled out the death report. RN Staff A said on [DATE] at approximately 7:00 a.m., he heard Licensed Practical Nurse (LPN) Staff G say Resident #773 was a full code and she called a code blue. He went to the room around 7:05 a.m. - 7:10 a.m. and started CPR. EMS arrived and pronounced her dead after doing an electrocardiogram. RN Staff A said I completely got distracted and never found out she is a full code. The mistake is completely mine, I am not blaming anyone else. I got distracted in the paperwork. RN Staff A said he documented in a statement Resident #773 had rigor mortis on [DATE] at 5:50 a.m. because her lower extremities and her fingers were bluish but she was warm in the torso area. During an interview on [DATE] at 9:30 a.m., the Medical Director explained that rigor mortis takes from 3 to 6 hours to have a stiffening effect on the body. During a telephone interview on [DATE] at 9:51 a.m., LPN Staff C said she was on duty on [DATE] when Resident #773 expired. She said RN Staff A called her to the room at approximately 5:45 a.m. and asked her to verify Resident #773 was deceased . LPN Staff C said Resident #773 was extremely pale and had no pulse. She said parts of her body were really cold but other parts were warm. She said no one was doing anything and she did not realize Resident #773 was a full code. She said per facility's policy is when a resident is found without a pulse or respiration, 2 nurses must verify the code status. She said she did not check the code status when she realized the resident had expired. LPN Staff C said she was trained many times on how to approach full codes. She stated, It just kills me that this happened. I learned my lesson. On [DATE] at 12:10 p.m., the Director of Nursing (DON) said on [DATE] at approximately 7:15 a.m. LPN Staff G called her via telephone to inform her of Resident #773's passing and CPR was not performed despite a full code status. She immediately gave the order to start CPR and call 911. The DON said at the time she did not know the resident had expired at 5:45 a.m. She though the incident had just happened. She said all nurses and CNAs, full time, part time, and PRN (as needed) were educated on [DATE] through [DATE] on policy and procedure for CPR. The facility ran mock hands on code blue drills daily on all shifts until [DATE] to reinforce the policy and procedure of what to do when a resident is found unresponsive. No nurse was allowed to work until they completed the training. The facility identified the immediate jeopardy and began putting corrective actions into place on [DATE]. The education and daily mock drills continued until [DATE], when the majority of the licensed nurses were in-serviced, removing the immediacy of the situation. The facility completed a Federal day 1 and day 5 adverse incident report. In their investigation, the facility concluded RN Staff A did not follow the facility's policy for CPR. The facility immediately suspended RN Staff A and later terminated him at the conclusion of their internal investigation. His licensed was referred to the board of nursing. Mock code blue drills were conducted on all shifts. On [DATE], 27 employees participated in the drill during the day shift and 7 employees participated in the evening drill. On [DATE], 53 employees participated in the drill during the morning shift, and 2 employees participated at night. On [DATE], the facility licensed nurses were interviewed and answered questions correctly regarding current CPR policy at the facility. The facility identified the incident as an event that needed to be looked at in their quality assurance and performance improvement plan. The facility put systems in place which will be on-going and monitored monthly via mock drills. The corrective actions put in place, the mock code drills, and the QAPI reviews corrected the non-compliance as of [DATE] when the licensed nurses were educated and participated in a mock code blue drill.

Based on record review and staff interview, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 (Resident #773) of 3 residents. The facility neglected the resident's needs for emergency care allowing her to expire despite a full code status. The facility's failure to provide CPR resulted in a terminal neglect. This situation was determined to be an immediate jeopardy. The immediate jeopardy started on [DATE] at 5:50 a.m. and ended on [DATE] when the facility provided documentation the majority of the licensed nurses were properly trained on advance directives and when to perform cardiopulmonary resuscitation. The findings include: Review of the facility Policy #N-1265 Abuse, Neglect, Exploitation and Misappropriation (revised [DATE]) revealed each resident has the right to be free from abuse, neglect, and mistreatment. Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect and mistreatment. The policy defines neglect as failure of the center, it's employees, to provide goods and services to a resident that are necessary to avoid physical harm. The policy included examples of failure to take precautionary measures to protect the health and safety of a resident. Non-action, which results in emotional, psychological, or physical injury is viewed in the same manner as improper or excessive action. Review of the facility's policy and procedure for CPR (N-302), revised on [DATE], revealed CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a physician's order for Do Not Resuscitate (DNR). In the absence of the physician's order for DNR, the facility will immediately begin CPR. Clinical record review revealed a physician's order sheet for ,[DATE] indicating Resident #773 had a full code status. A full code status allows for all interventions needed to restore breathing or heart functioning, including chest compressions. On [DATE], the Social Service Director documented a late entry for [DATE] indicating she spoke to the resident's son and reviewed Resident #773's advance directives and full code status. The resident's son, who is the health care surrogate, said he wanted Resident #773 to remain a full code. On [DATE] at 5:50 a.m., Registered Nurse (RN) Staff A documented in an interdisciplinary progress note Assessed resident 0 (no) V/S (vital signs) present. Verified by second nurse. On [DATE] at 7:10 a.m., RN Staff A wrote a note indicating he placed a call to the physician and Resident #773's spouse to inform them of the event and that the resident was a full code. On [DATE] at 7:15 a.m., the next entry made by RN Staff A indicated a code blue was called and CPR was provided. On [DATE] at 7:20 a.m., RN Staff A documented EMS (Emergency Medical Services) on site. Notified that MD (Medical Doctor) has been notified and stated that at this point, no CPR is necessary. RN Staff A also provided a witness statement on [DATE] at 5:50 a.m., he assessed Resident #773. The resident was laying in bed motionless, pale, with signs and symptoms of rigor mortis. Rigor mortis is the stiffening of the joints and muscles of a body a few hours after death. Rigor mortis usually sets in within four hours of death. Based on RN Staff A's documentation in the interdisciplinary notes, CPR was initiated 1 hour and 25 minutes after the resident was found without respiration or pulse. According to the Mayo Clinic, when the heart stops, the lack of [MEDICATION NAME] blood can cause brain damage in only a few minutes. Death or permanent brain damage can occur within four to six minutes. Time is critical when you're helping an unconscious person who isn't breathing. Take immediate action. During a telephone interview on [DATE] at 9:25 a.m., Certified Nursing Assistant (CNA) Staff E said she was on duty the night Resident #773 expired. She said she last saw her alive on [DATE] at 4:00 a.m., when she made her rounds. She said on [DATE] at 5:30 a.m., she checked on the resident again. As she was removing the incontinent pad, the resident just rolled over on her face and was not responsive. She immediately called for help and asked CNA Staff F to get the nurse. She said RN Staff A walked in the room around 5:45 a.m. and instructed her to put a clean gown on the resident and left. She cannot remember if RN Staff A checked the resident's vital signs. She said she remained in the room with CNA Staff J for approximately 20 minutes. RN Staff A never came back while she was in the room. During a telephone interview on [DATE] at 10:37 a.m., CNA Staff F said on [DATE] at approximately 5:30 a.m., CNA Staff E asked her to get the nurse because Resident #773 had expired. She called RN Staff A to the room. She does not know what happened after that. During a telephone interview on [DATE] at 12:15 p.m., RN Staff A said on [DATE] at 5:00 a.m. he went in Resident #773's room to administer medications to her roommate. He said Resident #773 was in bed sleeping and was definitely breathing. RN Staff A said sometime later, a CNA approached him and told him Resident #773 had expired. He immediately went to the room and checked for vital signs, she had no vital signs whatsoever. He went back to the nurse's station and opened her chart. There was an orange paper in the chart with the insurance company's name. He thought the insurance company was some type of hospice and called them to inform them of the resident's passing. He then called the family and filled out the death report. RN Staff A said on [DATE] at approximately 7:00 a.m., he heard Licensed Practical Nurse (LPN) Staff G say Resident #773 was a full code and she called a code blue. He went to the room around 7:05 a.m. - 7:10 a.m. and started CPR. EMS arrived and pronounced her dead after doing an electrocardiogram. RN Staff A said I completely got distracted and never found out she is a full code. The mistake is completely mine, I am not blaming anyone else. I got distracted in the paperwork. RN Staff A said he documented in a statement Resident #773 had rigor mortis on [DATE] at 5:50 a.m. because her lower extremities and her fingers were bluish but she was warm in the torso area. During an interview on [DATE] at 9:30 a.m., the Medical Director explained that rigor mortis takes from 3 to 6 hours to have a stiffening effect on the body. During a telephone interview on [DATE] at 9:51 a.m., LPN Staff C said she was on duty on [DATE] when Resident #773 expired. She said RN Staff A called her to the room at approximately 5:45 a.m. and asked her to verify Resident #773 was deceased . LPN Staff C said Resident #773 was extremely pale and had no pulse. She said parts of her body were really cold but other parts were warm. She said no one was doing anything and she did not realize Resident #773 was a full code. She said per facility's policy is when a resident is found without a pulse or respiration, 2 nurses must verify the code status. She said she did not check the code status when she realized the resident had expired. LPN Staff C said she was trained many times on how to approach full codes. She stated, It just kills me that this happened. I learned my lesson. On [DATE] at 12:10 p.m., the Director of Nursing (DON) said on [DATE] at approximately 7:15 a.m. LPN Staff G called her via telephone to inform her of Resident #773's passing and CPR was not performed despite a full code status. She immediately gave the order to start CPR and call 911. The DON said at the time she did not know the resident had expired at 5:45 a.m. She though the incident had just happened. She said all nurses and CNAs, full time, part time, and PRN (as needed) were educated on [DATE] through [DATE] on policy and procedure for CPR. The facility ran mock hands on code blue drills daily on all shifts until [DATE] to reinforce the policy and procedure of what to do when a resident is found unresponsive. No nurse was allowed to work until they completed the training. The facility identified the immediate jeopardy and began putting corrective actions into place on [DATE]. The education and daily mock drills continued until [DATE], when the majority of the licensed nurses were in-serviced, removing the immediacy of the situation. The facility completed a Federal day 1 and day 5 adverse incident report. In their investigation, the facility concluded RN Staff A did not follow the facility's policy for CPR. The facility immediately suspended RN Staff A and later terminated him at the conclusion of their internal investigation. His licensed was referred to the board of nursing. Staff were inserviced on Abuse/Neglect on [DATE] and [DATE]. Mock code blue drills were conducted on all shifts. On [DATE], 27 employees participated in the drill during the day shift and 7 employees participated in the evening drill. On [DATE], 53 employees participated in the drill during the morning shift, and 2 employees participated at night. On [DATE], the facility licensed nurses were interviewed and answered questions correctly regarding current CPR policy at the facility. The facility identified the incident as an event that needed to be looked at in their quality assurance and performance improvement plan. The facility put systems in place which will be on-going and monitored monthly via mock drills. The corrective actions put in place, the mock code drills, and the QAPI reviews corrected the non-compliance as of [DATE] when the licensed nurses were educated and participated in a mock code blue drill.

Based on record review and interview, the facility failed to protect a resident's right to appropriate health care regardless of the severity of the resident's condition, by not immediately initiating cardiopulmonary resuscitation (CPR) for 1 (Resident #773) of 3 residents reviewed. This failure was determined to be an immediate jeopardy. The immediate jeopardy started on [DATE] at 5:50 a.m. and ended on [DATE] when the facility provided documentation the majority of the licensed nurses were properly trained on when to perform cardiopulmonary resuscitation. The findings included: Review of the facility's policy and procedure for CPR (N-302), revised on [DATE], revealed CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a physician's orders [REDACTED]. In the absence of the physician's orders [REDACTED]. Clinical record review revealed a signed physician's orders [REDACTED].#773 had a full code status. A full code status allows for all interventions needed to restore breathing or heart functioning, including chest compressions. On [DATE] at 5:50 a.m., Registered Nurse (RN) Staff A documented in an interdisciplinary progress note, assessed resident as having no vital signs (pulse, blood pressure, and respirations) present. RN Staff A noted a second nurse verified this finding. During a telephone interview on [DATE] at 9:25 a.m., Certified Nursing Assistant (CNA) Staff E said she was on duty the night Resident #773 expired. She said on [DATE] at 5:30 a.m., she checked on Resident #773 and found the resident was not responsive. She immediately called for help and asked CNA Staff F to get the nurse. She said RN Staff A walked in the room around 5:45 a.m. and instructed her to put a clean gown on the resident and left. She remained in the resident's room for approximately 20 minutes and during this time, RN Staff A never came back into the room. During a telephone interview on [DATE] at 12:15 p.m., RN Staff A said on [DATE] sometime after 5:00 a.m., a CNA approached him and said Resident #773 had expired. He immediately went to the room and the resident had no vital signs. He went back to the nurse's station and opened her chart. There was an orange paper in the chart with the insurance company's name. He thought the insurance company was some type of hospice and called them to inform them of the resident's passing. RN Staff A said on [DATE] at approximately 7:00 a.m., he heard Licensed Practical Nurse (LPN) Staff G say Resident #773 was a full code. He went to the room around 7:05 a.m. - 7:10 a.m. and started CPR. EMS arrived and pronounced her dead after doing an electrocardiogram. During a telephone interview on [DATE] at 9:51 a.m., LPN Staff C said she was on duty on [DATE] when Resident #773 expired. She said RN Staff A called her to the room at approximately 5:45 a.m. and asked her to verify Resident #773 was deceased . LPN Staff C said Resident #773 was extremely pale and had no pulse. Staff C said parts of the resident's body were cold, but other parts were warm. She said no one was doing anything and she did not realize Resident #773 was a full code. She said per facility's policy is when a resident is found without a pulse or respiration; two nurses must verify the code status. She said she did not check the code status when she realized the resident had expired. Based on documentation in the interdisciplinary notes and staff interviews, CPR was initiated 1 hour and 25 minutes after the resident was found without respiration or pulse. According to the Mayo Clinic, when the heart stops, the lack of [MEDICATION NAME] blood can cause brain damage in only a few minutes. Death or permanent brain damage can occur within four to six minutes. Time is critical when you're helping an unconscious person who isn't breathing. Take immediate action. On [DATE] at 12:10 p.m., the Director of Nursing (DON) said on [DATE] at approximately 7:15 a.m. LPN Staff G called her via telephone to inform her of Resident #773's passing and CPR was not performed despite a full code status. She immediately gave the order to start CPR and call 911. The DON said at the time she did not know the resident had expired at 5:45 a.m. She though the incident had just happened. She said all nurses and CNAs, full time, part time, and PRN (as needed) were educated on [DATE] through [DATE] on policy and procedure for CPR. The facility ran mock hands on code blue drills daily on all shifts until [DATE] to reinforce the policy and procedure of what to do when a resident is found unresponsive. No nurse was allowed to work until they completed the training. The facility identified the immediate jeopardy and began putting corrective actions into place on [DATE]. The education and daily mock drills continued until [DATE], when the majority of the licensed nurses were in-serviced, removing the immediacy of the situation. The facility completed a Federal day 1 and day 5 adverse incident report. In their investigation, the facility concluded RN Staff A did not follow the facility's policy for CPR. The facility immediately suspended RN Staff A and later terminated him at the conclusion of their internal investigation. His licensed was referred to the board of nursing. Mock code blue (CPR) drills were conducted on all shifts. On [DATE], 27 employees participated in the drill during the day shift and 7 employees participated in the evening drill. On [DATE], 53 employees participated in the drill during the morning shift, and 2 employees participated at night. On [DATE], the facility's licensed nurses were interviewed and answered questions correctly regarding current CPR policy at the facility. The facility identified the incident as an event that needed to be looked at in their quality assurance and performance improvement plan. The facility put systems in place which will be on-going and monitored monthly via mock drills. The corrective actions put in place, the mock code drills, and the QAPI reviews corrected the non-compliance as of [DATE] when the licensed nurses were educated and participated in a mock code blue drill.