Every finding on record at Aviata at West Palm Beach

Based on record review and interview, the facility failed to honor a resident's full code status and failed to perform emergency care/cardio-pulmonary resuscitation (CPR) on 1 of 3 resident's reviewed for advanced directives (Resident #1). The facility did not perform basic life support according to the physician's orders and advanced directives and the resident died. The Immediate Jeopardy began on [DATE] at 11:15 PM. The Immediate Jeopardy was removed effective [DATE]. The facility self-identified the serious incident as noncompliance that was Immediate Jeopardy and took immediate actions to remove the Immediate Jeopardy on [DATE]. The facility continued to implement corrective actions until they achieved substantial compliance for F678. During the survey, the facility provided to the surveyor a corrective action plan. The surveyor verified the facility's corrective actions to correct the noncompliance for F678 on [DATE], prior to the survey visit.F678 was determined to be past noncompliance as of [DATE]. The findings included:Facility policy on Cardiopulmonary Resuscitation (CPR), effective date, [DATE], included CPR will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Do Not Resuscitate (DNR) order. In the event of cardiac arrest, immediately call for assistance. Two nurses are to verify resident identification, and fully executed DNR order located in the advanced directive section of the medical record. In the absence of a fully executed DNR order, the nurse will immediately begin CPR and will continue performing CPR until Emergency Medical Services assume responsibility. Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/max assist with activities of daily living, had a tracheostomy (tube in the throat to breath), and a feeding tube. The assessment further documented the resident was receiving hospice services.A review of Resident #1's care plan revealed a care plan dated [DATE] for an advanced directive of full code.A review of Resident #1's orders revealed an order dated [DATE] for a full code.Resident #1 was admitted to hospice on [DATE]. An interview was conducted with the Hospice nurse on [DATE] at 4:00 PM. She stated the resident was alert and oriented and was the one that made the determination that he wanted to be a full code. Some residents come on as full code and some do not. We honor the right to be a full code. A progress note by Staff A, Registered Nurse, dated [DATE] at 12:36 AM documented Resident #1 was found with no chest rising and no vital signs. Hospice was called and report was given. A hospice nurse was dispatched to the facility for further assistance. Post mortem care provided.An interview was conducted with the Regional Nurse Consultant (RNC) on [DATE] at 11:00 AM. The RNC stated she was conducting chart audits on [DATE] on discharged residents when she discovered there was an issue with no CPR performed on a resident that was a full code. The RNC stated she immediately notified the Administrator and it was reported to the required agencies.An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at 11:30 AM. The NHA stated he was notified by the RNC that Resident #1 did not receive emergency service/CPR when he was found without a pulse. The NHA stated he called Staff A, a Registered Nurse, who worked the 7P-7A shift on [DATE], who had already left the facility. The NHA stated he received a statement from Staff A by text confirming CPR and 911 was not initiated on Resident #1. The NHA stated Staff A was suspended pending investigation, and had since been terminated and reported to the board of nursing. An interview was conducted with the interim Director of Nursing (DON) on [DATE] at 11:00 AM regarding the expectations of the licensed nurses to perform basic life support including CPR and she stated she would expect the licensed nurses to follow the facility policy and perform CPR if there is no DNR orders. An interview was conducted with Staff B, a Certified Nurse Assistant (CNA) on [DATE] at 10:00 AM. Staff B stated she worked 11P-7A on [DATE]. Staff B stated when she rounded at the start of her shift, she found Resident #1 unresponsive and immediately notified Staff A. Staff B stated she continued with her rounds. An interview was conducted with Staff C, a Registered Nurse on [DATE] at 11:00 AM. Staff C stated he worked 7P-7A on [DATE]. Staff C stated he had returned from break around 12:30 AM and saw the hospice chaplain at the nursing station. Staff C stated he saw Staff A charting at the nursing station and he inquired what was happening. Staff C stated Staff A told him that Resident #1 had died. Staff C stated he saw that Resident #1 was a full code on the computer screen that Staff A was on. Staff C stated he told Staff A that the resident was a full code. Staff C stated he then returned to his assignment. Staff C stated he did not tell anyone of the situation, continued his shift and left the facility. Staff C stated he has since been educated on CPR. An interview was conducted with Staff A on [DATE] at 9:00 AM. Staff A stated she worked 7P-7A on [DATE] and was responsible for Resident #1. Staff A stated Staff B notified her that Resident #1 was unresponsive on [DATE] at approximately 11:15 PM. Staff A stated she went to check on the resident and the resident was not breathing and had no vital signs. Staff A stated she did not check the resident's chart for code status. Staff A stated she assumed the resident was a Do Not resuscitate (DNR) because the resident was on hospice. Staff A stated she called the physician who told her to call hospice. Staff A stated she called hospice. Staff A stated Staff C informed her that Resident #1 was a full code over an hour after the resident had died. Staff A stated she did not tell anyone. Staff A stated she was suspended pending investigation and had not heard from the facility since the event. Staff A stated she was educated on CPR. The facility's Immediate Jeopardy Removal Plan was verified as having been completed by the surveyor included:Criteria 1On [DATE] the Registered nurse involved with the resident received individualized training regarding Florida Cardiopulmonary Resuscitation Policy with emphasis on steps to take when a resident is unresponsive.On [DATE] the Registered nurse involved was suspended pending investigation.On [DATE] the Registered nurse's employment was terminated.25 of 25 current licensed nurses have active BLS certified CPR card.As of [DATE] 25 of 25 licensed nurses had completed a code blue drill, education, and post test.Criteria 2On [DATE] an audit of Advanced Directive Discussion forms was completed to ensure resident code status honored their wishes.On [DATE] an Ad hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services.The Ad hoc QAPI committee approved the recommendations.On [DATE], a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). RCA identified as failure to follow the Advanced Directive Policy and Procedure.Criteria 3Code Drills were initiated on [DATE] and continued until current nursing staff have participated. As of [DATE] , 25 of 25 licensed nurses have participated in a drill. Education was provided to the the second nurse who found the code status regarding the importance of reporting the incident to facility administration.On [DATE] licensed nurses' education was initiated. As of [DATE], 25 of 25 licensed facility nurses, received education to include CPR Policy / Procedure, Advanced Directives Policy / Procedure, Abuse/Neglect. Education accompanied by post testing and participation in code blue drills to validate understanding and competency. All nurses obtained a passing score. Criteria 4 After review of the results of the drills, post test and education we have removed the Immediate Jeopardy as of [DATE]. The facility's Corrective Action Plan was verified as having been completed by the surveyor included:On [DATE] the Registered nurse involved with the resident received individualized training regarding Florida Cardiopulmonary Resuscitation Policy with emphasis on steps to take when a resident is unresponsive.On [DATE] the Registered nurse involved was suspended pending investigation.On [DATE] the Registered nurse's employment was terminated.25 of 25 current licensed nurses have active BLS certified CPR card.As of [DATE] 25 of 25 licensed nurses had completed a code blue drill, education, and post test. On [DATE] an Ad hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services.The Ad hoc QAPI committee approved the recommendations.On [DATE], a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). RCA identified as failure to follow the Advanced Directive Policy and Procedure.An Ad Hoc QAPI committee meeting was held at 9:30 AM on [DATE] to discuss the Performance Improvement Plan initiated by the committee on [DATE]. The findings of the review indicated all items completed on [DATE]. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services. After review of the results of the drills, post test and education we have reached compliance as of [DATE]. We will continue Code Blue Drills weekly each shift x4 weeks, then monthly thereafter. Results will be reviewed in the monthly QAPI meetings to determine need for further drills and/or education. The Human Resources Generalist will monitor licensed nurses' CPR cards to ensure active CPR certification, and will check for the same for all newly hired licensed nurses as well.

Based on record review and interview, the facility neglected to honor a resident's full code status and failed to perform emergency care/cardio-pulmonary resuscitation (CPR) on 1 of 3 residents reviewed for advanced directives (Resident #1). The facility did not perform basic life support according to the physician's orders and advanced directives and the resident died. The staff neglected to inform administration of the incident. The Immediate Jeopardy began on [DATE] at 11:15 PM. The Immediate Jeopardy was removed effective [DATE]. The facility self-identified the serious incident as noncompliance that was Immediate Jeopardy and took immediate actions to remove the Immediate Jeopardy on [DATE]. The facility continued to implement corrective actions until they achieved substantial compliance for F600. During the survey, the facility provided to the surveyor a corrective action plan. The surveyor verified the facility's corrective actions to correct the noncompliance for F600 on [DATE], prior to the survey visit.F600 was determined to be past noncompliance as of [DATE]. The findings include:Facility policy on Abuse and Neglect, effective date [DATE], included each resident be afforded basic human rights, including the right to be free from abuse and neglect. The facility established policies and procedures to protect these rights. Employees are charged with a continuing obligation to treat residents so they are free from abuse and neglect. No employee may at any time commit an act of abuse or neglect against any resident. The policy defined neglect as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It also included failure to report observed or suspected abuse or neglect to the proper authorities as an example of neglect. Record review revealed Resident #1 was admitted to the facility on [DATE], a comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/max assist with activities of daily living, had a tracheostomy (tube in the throat to breath), and a feeding tube. The assessment further documented the resident was receiving hospice services. A review of Resident #1's care plan revealed a care plan dated [DATE] for an advanced directive of full code. A review of Resident #1's orders revealed an order dated [DATE] for a full code. Resident #1 was admitted to hospice on [DATE]. An interview was conducted with the Hospice nurse on [DATE] at 4:00 PM. She stated the resident was alert and oriented and was the one that made the determination that he wanted to be a full code. Some residents come on as full code and some do not. We honor the right to be a full code. A progress note by Staff A, dated [DATE] at 12:36 AM documented Resident #1 was found with no chest rising and no vital signs. Hospice was called and report was given. A hospice nurse was dispatched to the facility for further assistance. Post mortem care provided. An interview was conducted with the Regional Nurse Consultant (RNC) on [DATE] at 11:00 AM. The RNC stated she was conducting chart audits on [DATE] on discharged residents when she discovered there was an issue with no CPR performed on a resident that was a full code. The RNC stated she immediately notified the Administrator and it was reported to the required agencies. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at 11:30 AM. The NHA, who is also the Abuse Coordinator, stated he was notified by the RNC that Resident #1 did not receive emergency service/CPR when he was found without a pulse. The NHA stated he called Staff A, a Registered Nurse, who worked the 7P-7A shift on [DATE], who had already left the facility. The NHA stated he got a statement from Staff A by text confirming CPR and 911 was not initiated on Resident #1. The NHA stated Staff A was suspended pending investigation, and had since been terminated and reported to the board of nursing. An interview was conducted with Staff B, a Certified Nurse Assistant (CNA) on [DATE] at 10:00 AM. Staff B stated she worked 11P-7A on [DATE]. Staff B stated when she rounded at the start of her shift, she found Resident #1 unresponsive and immediately notified Staff A. Staff B stated she continued with her rounds. An interview was conducted with Staff C, a Registered Nurse on [DATE] at 11:00 AM. Staff C stated he worked 7P-7A on [DATE]. Staff C stated he had returned from break around 12:30 AM and saw the hospice chaplain at the nursing station. Staff C stated he saw Staff A charting at the nursing station and he inquired what was happening. Staff C stated Staff A told him that Resident #1 had died. Staff C stated he saw that Resident #1 was a full code on the computer screen that Staff A was on. Staff C stated he told Staff A that the resident was a full code. Staff C stated he then returned to his assignment. Staff C stated he did not tell anyone of the situation, continued his shift and left the facility. Staff C stated he has since been educated on reporting occurrences of neglect related to failure to perform basic life support according to orders to administration, on abuse/neglect, and CPR. An interview was conducted with Staff A on [DATE] at 9:00 AM. Staff A stated she worked 7P-7A on [DATE] and was responsible for Resident #1. Staff A stated Staff B notified her that Resident #1 was unresponsive on [DATE] at approximately 11:15 PM. Staff A stated she went to check on the resident and the resident was not breathing and had no vital signs. Staff A stated she did not check the resident's chart for code status. Staff A stated she assumed the resident was a Do Not resuscitate (DNR) because the resident was on hospice. Staff A stated she called the physician who told her to call hospice. Staff A stated she called hospice. Staff A stated Staff C informed her that Resident #1 was a full code over an hour after the resident had died. Staff A stated she did not tell anyone. Staff A stated she was suspended pending investigation and had not heard from the facility since the event. Staff A stated she was educated on CPR, abuse/neglect, and reporting occurrences of neglect related to failure to perform basic life support according to orders to administration. The facility's Immediate Jeopardy Removal Plan was verified as completed by the surveyor included: Criteria 1On [DATE] the Registered nurse involved with the resident received individualized training regarding Florida Cardiopulmonary Resuscitation Policy with emphasis on steps to take when a resident is unresponsive.On [DATE] the Registered nurse involved was suspended pending investigation.On [DATE] the Registered nurse's employment was terminated.25 of 25 current licensed nurses have active BLS certified CPR card.As of [DATE] 25 of 25 licensed nurses had completed a code blue drill, education, and post test. Criteria 2On [DATE] an audit of Advanced Directive Discussion forms was completed to ensure resident code status honored their wishes.On [DATE] an Ad hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services.The Ad hoc QAPI committee approved the recommendations.On [DATE], a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). RCA identified as failure to follow the Advanced Directive Policy and Procedure. Criteria 3Code Drills were initiated on [DATE] and continued until current nursing staff have participated. As of [DATE], 25 of 25 licensed nurses have participated in a drill. Education was provided to the second nurse who found the code status regarding the importance of reporting the incident to facility administration.On [DATE] licensed nurses' education was initiated. As of [DATE] 25 of 25 licensed facility nurses, received education to include CPR Policy / Procedure, Advanced Directives Policy / Procedure, Abuse/Neglect and the requirement to report to administration when staff observe Neglect occurring.Education accompanied by post testing and participation in code blue drills to validate understanding and competency. All nurses obtained a passing score. As of [DATE], 111 of 111 employees have been educated on Abuse/Neglect policy and procedure that includes reporting requirements. Current staff included: Therapy, Housekeeping, Laundry, Dietary, CNAs, Nurses, Department Heads. Criteria 4 After review of the results of the drills, post test and education we had removed the Immediate Jeopardy as of [DATE]. The facility's Corrective Action Plan was verified as completed by the surveyor included: On [DATE] the Licensed nurses received training regarding Abuse and Neglect, with particular focus on performing CPR for a Full-Code patient, and reporting incidents to facility administration.Florida Cardiopulmonary Resuscitation Policy with emphasis on steps to take when a resident is unresponsive.On [DATE] the Registered nurse involved was suspended pending investigation.On [DATE] the Registered nurse's employment was terminated.25 of 25 current licensed nurses have active BLS certified CPR card.As of [DATE], 25 of 25 licensed nurses had completed a code blue drill, education, and post test.Quality Review audits will be conducted by Social Services/Designee for all new and readmitted patients using the Advanced Directive audit sheet, 5X/week for 4 weeks, then weekly for 4 weeks, then monthly for 1 month. A random audit will be conducted quarterly in line with the MDS schedule. The audits is to ensure appropriate code status is identified and carried out.All newly hired licensed nurses will be educated regarding Abuse and Neglect, and on the importance of checking all patient's code status when responding to a change in condition; including and especially for all Hospice patients.On [DATE] an Ad hoc Quality Assurance Performance (QAPI) Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services.The Ad hoc QAPI committee approved the recommendations.On [DATE], a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). RCA identified as failure to follow the Advanced Directive Policy and Procedure.An Ad Hoc QAPI committee meeting was held at 9:30 AM on [DATE] to discuss the Performance Improvement Plan initiated by the committee on [DATE]. The findings of the review indicated all items completed on [DATE]. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing, MDS Coordinator, Human Resource Coordinator, Central Supply, Business Office Manager, Activities Director, and Director of Rehab Services. After review of the results of the drills, post test and education we have reached compliance as of [DATE]. We will continue Code Blue Drills weekly each shift x4 weeks, then monthly thereafter. Results will be reviewed in the monthly QAPI meetings to determine need for further drills and/or education. The Human Resources Generalist will monitor licensed nurses' CPR cards to ensure active CPR certification, and will check for the same for all newly hired licensed nurses as well.

Based on facility policy review, record review, observations and interviews, the facility failed to provide treatment and services to prevent complications of enteral feeding (food delivered through a gastric tube) for 1 of 4 sampled residents as evidenced by failure to ensure aspiration (inhaling food or liquid in the airway) precautions for Resident #10 during enteral feeding.The findings included:Review of the facility policy titled Enteral Feeding-Enteral Nutrition Pump revised 11/12/18, documented in part Procedure: Assist resident to semi-Fowler_position (head and upper body raise 30-45 degrees) or turn on his or her right side. Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment. Review of medical history revealed a diagnosis of stroke and dysphagia (difficulty swallowing).Review of the quarterly care plan dated 08/16/25 revealed a focus that Resident #10 was at risk of aspiration problems due to history of stroke and dysphagia with a goal the resident will have minimal risk of injury related to aspiration. Another focus documented that the resident required enteral feeding due to dysphagia and the resident will remain free of side effects or complications related to tube feeding and staff is to elevate the head of the bed during and after enteral feeding. An observation was conducted on 09/24/2025 at 9:15 AM, Resident #10 noted in bed lying on her back with the head of the bed completely flat and her mouth wide open. The enteral feed was infusing. Staff K, License Practical Nurse (LPN) was notified of Resident #10 being observed with the head of the bed flat.An observation was conducted on 09/24/2025 at 10:55 AM, Resident #10 was noted in bed lying on her back with the head of the bed completely flat. The enteral feed was infusing. The Wound Care Nurse was at bedside and made aware of the resident's head being flat while enteral feed infusing and the risk of the resident aspirating. She stated, The resident's sister likes her head this way. There was a note posted, by the family, on the wall above the resident's bed, that said to ensure staff elevate the head of the bed 30 to 45 degrees to assist with breathing.During an interview on 09/24/2025 at 11:20 AM, Staff K, LPN was made aware Resident #10's head was again observed completely flat with the enteral feed infusing. She stated, Again, the doctor said her head should be elevated 90 degrees due to risk of aspirating. Staff K, LPN went to resident's room and observed the resident with her head lying flat. Staff M, Certified Nursing Assistant (CNA) was at the bedside. Staff K, LPN educated Staff M at that time. During an interview with The Unit Manager on 09/24/25 at 11:50 AM, she was brought to Resident #10's room and made aware that the resident was observed twice that morning with the head of her bed flat with the enteral feed infusing.

Based on observations, record reviews and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 17.14% (6 errors) with 35 opportunities due to failure to ensure that Resident #85 and Resident #42 received medications as ordered and were available.The findings included:1) During an observation of medication administration on 09/24/25 at 8:53 AM, Staff K, LPN prepared a total of 7 pills for Resident #85. She stated, I do not have the inhalers to administer, because they have not arrived from the pharmacy. I will have to call pharmacy to follow up. When asked which inhalers you don't have, Staff K stated The Mometasone and Budesonide. The resident just told me that he hasn't had them for a few days. Staff K, LPN entered the resident's room to administer the medications she had prepared. The resident asked if his gout medication was in the medicine cup, she stated, Yes, the allopurinol is in there. Staff K, LPN told the resident that she will follow up on getting the inhalers reordered. After administration of the medications Staff K, LPN was asked to look in computer to see if it showed when the inhalers were reordered, she said the Mometasone furoate (steroid inhaler) was reordered on 09/18/25 and Budesonide (steroid medication for breathing) was reordered on 09/19/25. Review of the physician orders and reconciliation of the medications administered revealed that Resident #85 had the following physician orders which were not administered during medication observation:Docusate Sodium Capsule give 1 capsule by mouth two times a day for constipation Hold for loose stools.Vitamin D (Ergocalciferol) capsule give 1 capsule by mouth one time a day every Wednesday for supplement.Fluticasone-Salmeterol Inhalation Aerosol 45-21MCG/ACT 1 application inhale orally twice a day for shortness of breath (SOB).Mometasone Furoate Inhalation Aerosol 100 MCG/ACT 2 puffs inhale orally twice a day for SOB/Wheezing. Budesonide Inhalation Suspension 0.5 MG/2ML 1 application inhale orally three times a day for SOB. During an interview on 09/25/2025 at 9:10 AM, when asked did you receive your inhalers last night, Resident #85 stated, No I didn't. When asked do you receive nebulizer treatments, he stated Yes, sometimes at night. When asked again if he only received the nebulizer treatments at night, the resident stated, Yes. During an interview on 09/25/2025 at 9:20 AM, when asked how many inhalers were not administered to Resident #85 during observation of medication pass, Staff K, LPN stated, Two. When asked do you recall what they were, she stated, I will look, she said it was Mometasone and Budesonide. When asked if there were any other inhalers that the resident was supposed to receive in the morning, she stated, I don't think so. I know that he has 2 of them. Staff K, LPN was asked to look at Resident #85s orders and the medication administration record (MAR) she signed on 09/24/25 during morning med pass, Staff K, LPN reviewed the orders and realized that the resident had an order for Fluticasone-Salmeterol and stated, I didn't realize he had an order for this inhaler. When asked was the resident supposed to get a nebulizer treatment, she stated, You mean with the machine? Oh yes, I remember he does get that, and I'm supposed to stay with him for 15mins while he gets it. She was made aware that the Budesonide was the medication that is used for the nebulizer treatment and administration of a nebulizer was not observed. Staff K stated, I'm sorry. I got confused. When asked did you administer a nebulizer treatment, she stated No. When asked did you administer the Colace on 09/24/25 that was scheduled at 9:00 AM during med observation, she stated, No, he gets it twice a day and I gave him the evening dose. When asked did you administer the Vitamin D on 09/24/25, that was scheduled at 9:00 AM during med observation, she stated No, I gave it to him later in the afternoon. Review of the time stamped medication administration audit report for 09/24/25 for Resident #85 revealed documentation of Colace administered at 9:06 AM on 09/24/25, Vitamin D was documented as given at 9:06AM on 09/24/25, Budesonide was documented as given at 3:52 PM on 09/24/25, Fluticasone-Salmeterol was documented as given at 11:32 AM on 09/24/25 and Mometasone Furoate was documented as given at 3:54 PM on 09/24/25.During an interview on 09/25/25 at 10:15AM, the Pharmacy Consultant stated, I just want to let you know that I am going to make sure Resident #85 has his inhalers today. The resident did not have one of the inhalers, because his insurance no longer covers it, we got the doctor to change that inhaler to a different one. When asked why the nurses are signing that the inhalers are being administered if they don't have them, the resident says he has not had them in a few days, I really don't know, but the Regional Nurse is going to do some education with the staff. 2) On 09/24/25 at 8:40 AM during medication administration observation for Resident #42, Staff N, Licensed Practical Nurse (LPN), verified with this surveyor a total of 6 pills were then given to Resident #42.Upon review of the electronic medical record, the nurse documented that the resident received 7 pills. A review of the timestamped documentation for the medications revealed that both Vitamin B1 and Vitamin B Complex were administered on 09/24/25 at 8:45 AM.On 09/25/25 at 9:25 AM, Staff Nurse N was asked to see the pill bottle for Vitamin B Complex, the nurse was unable to locate the bottle in the cart.

Based on observations, interviews, and record review, the facility failed to provide a Reacher for 1 out of 1 resident reviewed for Accidents (Resident #13). The findings included:Record review for Resident # 13 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease, a condition caused by damage to the airways or other parts of the lung, Low Back Pain, Unspecified Dementia, a medical term used for memory loss and confusion, but the cause of the decline cannot be determined and Age Related Osteoporosis without pathological fracture, a condition of progressive bone loss and reduced bone strength due to aging, which increases the risk of future fractures, but in the absence of a current fracture.Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident # 13 had a Brief Interview for Mental Status of 14, which indicated that she was cognitively intact. Review of Section GG of the MDS dated [DATE] revealed that Resident #13 required substantial/maximal assistance for movement and care.Review of the Physician's Orders showed that Resident #13 had an order dated 04/27/25 for Lumbar Spine Xray. An order dated 4/28/25 for Ortho Spine or Neurosurgeon appointment related to a fall and x-ray results and an order dated 05/06/25 for Neurosurgeon consult for lumbar spine compression fracture.Review of the Care Plan dated 04/27/25 and revised on 04/30/2025 documented that Resident # 13 had an actual fall without injury, and an alteration in musculoskeletal status compression fracture of L1. Interventions included but were not limited to anticipating and meeting needs, keeping call light within reach and encouraging the resident to call for assistance, bed in the lowest position, X-ray of lumbar region, and Reacher provided and encouraged to use. During an observation conducted on 09/22/25 at 11:46 AM, and 12:50 PM, and again on 09/24/25 at 12:37 PM, there was no Reacher visible in the room or on the resident's bedside table. The resident was asked if she had a device available to help her retrieve her belongings and she appeared unfamiliar with this device and said no. When asked if she knew how to request assistance from the staff, the resident responded, I press the button and pointed to the call bell.During an interview conducted on 09/25/25 at 10:00 AM with Staff G, Physical Therapy (PT) and Staff H, Occupational Therapy (OT) when asked to identify what is a Reacher, Staff H, OT showed this surveyor the device and stated that the facility orders and provides the resident if deemed necessary for use while in the facility. This is done by the OT Director if it is recommended. During a side-by-side review of the resident record, PT and OT services were discontinued on 12/20/2024 and there was no recommendation for a Reacher for this resident.During an interview conducted on 9/25/2025 at 11:20 AM with Staff I, CNA who is assigned to Resident #13 today. When asked if she saw a Reacher for the resident, Staff I escorted this surveyor back to the resident's room and looked in the closet which contained clothing and incontinent supplies. There was no Reacher in the closet.During an interview conducted on 09/25/25 at 11:40 AM with Staff F, Registered Nurse (RN), the nurse stated that she remembers the resident calling out after the fall. Resident #13 told me that she was reaching for her pants in the bedside table. The nurse stated that the resident is not a fall risk, they maintain her bed in a low position and keep her items within reach. When asked if the resident had a Reacher, the nurse said that she is not aware of any Reacher.During an interview conducted on 09/25/25 at 1:00 PM with the Staff J, MDS Coordinator she stated that a Reacher does not need to be ordered by the provider if it is care planned. Physical Therapy would do an evaluation and if deemed appropriate provide the Reacher. Staff J stated that she remembered the resident receiving one but not sure if it is still there. During an interview conducted on 09/25/25 at 2:45 PM with Staff D, Unit Manager, she stated that she is not sure if the resident had a Reacher but not sure that she has the cognition to use a Reacher.Review of the facility's Fall Investigation Form dated 04/27/25, had the following interventions: x-ray, Reacher (a device that enables a person to pick up objects that are difficult to reach), and call bell within reach.During a side-by-side review of the Fall investigation packet with Associate Director of Nursing (ADON) on 09/25/25 at 4:21 PM, she confirmed that she attended the meeting. When asked who is responsible to follow up with the interventions, she stated that I am or the UM.

Based on observation, record review, and interview, the facility failed to ensure timely and appropriate care and services for 5 of 27 sampled residents as evidenced by the failure to provide wound care for non-pressure wounds for Residents #9, #76, and #110; failure to complete weekly skin assessments for Residents #9, #76, #110 and #10; failure to provide supplies and treat edema as ordered for Residents #76 and #110; and failure to administer medications as ordered for Resident #13. The findings included: 1) Review of the record revealed Resident #9 was readmitted to the facility on [DATE] with diagnoses to include Diabetes, Morbid Obesity, Congestive Heart Failure, and Non-Pressure Chronic Ulcer of the Right Lower Leg. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. a) Review of the current physician ordered wound care dated 08/27/25 documented the need for daily wound care for Resident #9's right lower extremity. Review of the current Treatment Administration Record (TAR) for September 2025 lacked the provision of wound care on 09/12/25, 09/13/25, 09/20/25, and 09/21/25, as evidenced by the blank areas in the TAR and lack of the nurses' initials. During an observation and interview on 09/22/25 at 3:38 PM, a dressing was noted on the lower right leg of Resident #9. When asked about the provision of wound care by the nurses, the resident stated the dressing was changed daily, except on weekends. An interview was conducted on 09/24/25 at 4:08 PM with the Director of Nursing (DON) and the Wound Care Nurse. The Wound Care Nurse stated she worked Monday through Friday and was responsible for all wound care during the week. The Wound Care Nurse stated during the weekends, the nurse on duty should provide the wound care in her place. When asked when she returned after the weekends if the wound care had been completed, the Wound Care Nurse replied, Yes, it is. The DON interjected that the facility had hired a fifth nurse to help cover the weekends for the last two months to ensure that wound care and other responsibilities would be completed. The DON stated that sometimes the wound care had not been done. During this interview, a side-by-side review of the September 2025 TAR for Resident #9 was completed. The DON and the Wound Care Nurse were shown the missing days of treatment for Resident #9. The Wound Care Nurse stated that Resident #9 would only allow her to treat his wound. When asked where a resident's refusal would be documented, both the DON and Wound Care Nurse replied that it would be in a nurse's progress note and in the TAR. Both the DON and Wound Care Nurse were unable to locate any refusal of wound care treatment by Resident #9. The DON and Wound Care Nurse agreed with the findings for the lack of wound care treatments. b) Upon further review of the record, a current physician order dated 04/15/25 documented staff were to complete weekly skin sweeps. Review of the September 2025 TAR for Resident #9 lacked this order. Review of the Weekly Skin Integrity Reviews revealed the last weekly skin assessment for Resident #9 was completed on 07/15/25. During an interview on 09/24/25 at 12:04 PM, when asked who performed the weekly skin sweeps, Staff K, Licensed Practical Nurse (LPN), stated she completes them and documents them on the TAR. During the continued interview on 09/24/25 at 4:08 PM, the DON was made aware of the lack of documented weekly skin sweeps and had no response. 2) Review of the record revealed Resident #76 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses to include a right arm fracture, a left leg fracture, and Morbid Obesity. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 14, on a scale of 0 to 15, indicating the resident was cognitively intact. a) Review of the current physician orders included daily wound care for Resident #76's left knee as of 08/01/25 and an order for daily wound care to the resident's left lower leg as of 09/15/25. Review of the August 2025 TAR revealed the wound care for the left knee was not completed on 08/08/25, 08/19/25, and 08/25/25. Review of the September 2025 TAR revealed the same wound care was not completed on 09/11/25, 09/12/25, 09/20/25, and 09/21/25. The September 2025 TAR also revealed the left lower leg wound care was not completed on 09/20/25 and 09/21/25. An observation on 09/22/25 at 11:46 AM revealed one dressing to the left leg of Resident #76 dated 09/19/25. Photographic evidence obtained. An observation on 09/24/25 at 11:59 AM revealed one dressing to the left leg of Resident #76 dated 09/22/25. During the continued interview on 09/24/25 at 4:08 PM, the Wound Care Nurse clarified there was just one wound to Resident #76's left leg. During a side-by-side review of the record, the DON and Wound Care Nurse were made aware of the lack of wound care as per the August and September 2025 TARs and agreed with the findings. b) Further review of the record revealed the order for weekly skin sweeps every Saturday as of 08/16/25. Review of the September 2025 TAR documented the skin sweeps were completed on 09/13/25 and 09/20/25, as evidenced by a checkmark, but the record lacked the Weekly Skin Integrity Review assessments for these dates. During the interview on 09/24/25 at 4:08 PM, the DON confirmed the weekly skin sweeps were to be documented on the TAR as completed, and the nurse was to also complete the Weekly Skin Integrity Reviews to document the specifics of the assessment. The DON was again made aware of the lack of completed skin sweeps. c) Further review of the record revealed a physician order dated 09/18/25 for the use of compression stocking for Resident #76. Staff were to apply the compression stockings every morning and remove them at bedtime. Observations on both 09/22/25 at 11:46 AM and on 09/24/25 at 11:59 AM lacked any compression stockings being worn by Resident #76. During an interview on 09/24/25 at 4:59 PM, when asked if he was aware of or offered any special socks, Resident #76 stated he had never been offered any socks. During an interview on 09/24/25 at 5:04 PM, when asked if she was aware of the ordered compression stockings for Resident #76, Staff P, Certified Nursing Assistant (CNA) replied, No more socks, no special socks. During an interview on 09/24/25 at 5:15 PM, when asked if she was aware of the physician ordered compression stockings for Resident #76, Staff K, LPN, initially denied any orders for the stockings. The LPN reviewed the current orders and then confirmed the order for the compression stockings. The LPN stated she had been off for a few days, and the order came in while she was gone. 3) Review of the record revealed Resident #110 was admitted to the facility on [DATE]. Review of the BIMS Evaluation dated 09/04/25 documented the resident had a score of 14 indicating he was cognitively intact. a) Review of the current physician orders documented nursing was to provide daily wound care to the resident's bilateral lower extremities as of 09/15/25. Review of the corresponding September 2025 TAR revealed the ordered wound care was not provided on 09/11/25, 09/12/25, 09/13/25, 09/20/25, and 09/21/25. During an observation on 09/22/25 at 4:09 PM Resident #110 was noted with bilateral leg dressings dated 09/22/25. When asked about the frequency of wound care, Resident #110 stated the dressings hadn't been changed the past four days. During the continued interview on 09/24/25 at 4:08 PM the DON and Wound Care Nurse reviewed the September 2025 TAR and agreed with the findings. b) Review of the current orders revealed staff were to apply bilateral compression stocking from 09/11/25 through 09/18/25 to Resident #110's legs. The order was changed on 09/18/25 to apply bilateral Ace wraps daily in the morning and to remove at bedtime. Review of the corresponding September 2025 TAR lacked any documentation related to the compression stockings. Further review revealed the Ace wraps had not been applied on 09/21/25, 09/23/25, and 09/24/25. During an observation on 09/22/25 in the morning, Resident #110 was noted with bilateral lower extremity edema (swelling) as his jeans were tight against his legs. A second observation on 09/22/25 at 4:09 PM revealed Resident #110 wearing shorts. His legs were bare and remained very swollen with no compression stockings or Ace wraps noted. During an interview at this time, Resident #110 voiced concern about his swollen legs and the lack of Ace wraps. The resident stated he used Ace wraps in the past, but they got old and were thrown away. Resident #110 was unsure how long ago they had been thrown away. During a supplemental observation on 09/23/25 at 3:56 PM, Resident #110 had just returned to the facility after a short leave of absence and again was not wearing any Ace wraps. During an interview on 09/24/25 at 5:04 PM, when asked about any wraps for Resident #110's legs, Staff P, CNA, stated she was unaware of any type of leg wraps. During an interview on 09/24/25 at 5:15 PM, when asked about the Ace wraps for Resident #110, Staff K, LPN, stated he had them on earlier that day, but they had gotten wet and were removed just prior to leaving the facility. The Assistant Director of Nursing (ADON) approached, and during a side-by-side review of the record, both the ADON and LPN agreed the current order was for compression Ace wraps for Resident #110. The ADON confirmed they were available at the facility. c) Review of the current orders documented the nurses were to perform weekly skin sweeps every Sunday for Resident #110. Review of the current September 2025 TAR documented the skin assessment was completed on 09/14/25 as documented with a checkmark and nurse's initials. The skin assessment was not completed on 09/21/25 as per the noted blank in the TAR. Further review of the record lacked any documented Weekly Skin Integrity Review for 09/14/25 and 09/21/25. 4) Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment. a) Review of the quarterly care plan dated 08/16/25 documented a focus that Resident #10 had a potential risk for skin impairment due to impaired mobility, contractures, functional incontinence with a goal that the resident will have minimal complication. Review of a change in condition assessment dated [DATE], revealed Resident #10 had a pressure ulcer to her lumbar measuring 5.5cmx4.0x0cm with light drainage. Review of a wound care consultation note dated 07/03/25, documented that Resident #10 had a unstageable pressure ulcer to her sacrum measuring 5.5cmx5.0cmx0.2cm to her sacrum with 90% necrotic tissue. Review of the physician order dated 04/29/25 instructed staff to do weekly skin sweeps (assessment) on Resident #10 daily every Thursday. Further review revealed skin assessments dated 07/03/25, 07/17/25, 07/31/25, which documented Resident #10's skin as intact. Review of the skin assessments revealed no documented skin assessment for Resident #10 during the month of August 2025. Review of the August Treatment Administration Record (TAR) for Resident #10 revealed that staff had signed on 08/07/25, 08/14/25, 08/21/25, 08/28/25 indicating that the skin assessment was performed. During an interview with on 09/24/25 at 3:55PM, When asked where staff document the weekly skin assessments for a resident, the Unit Manager (UM) stated, The nurse document on the weekly skin assessment. When asked if that was the only place the nurse would document the skin assessment she stated, Yes. When asked if the nurse noticed that the resident had a wound while conducting the skin assessment, would they document that information on the skin assessment, she stated, Yes, when the nurse select yes on the assessment, it would open up a different area on the form to document the information for the wound found. When asked what the nurse should do when she finds a new wound on a resident, the UM stated, The nurse should notify the doctor and get an order for a wound care treatment until the resident is able to be seen by the wound care doctor. When asked would the order for the weekly skin assessment be on the treatment administration record or the medication administration record, she stated, Either one. When asked how the nurse knows when to do the skin assessment, she stated, There is an order. When asked does the order specify the day the skin assessment should be done, she stated, Yes. At that time, the UM was made aware that skin assessments were not being done on several residents that had an order. b) Review of a physician order dated 08/19/25 instructed staff to administer Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet via PEG-Tube three times a day for hypotension, give if SBP (top number of blood pressure) is less than 110. Review of the September Medication Administration Record (MAR) revealed that staff had administered the midodrine HCL 5mg on 9/2/25, 09/04,25, 09/05/25, 09/06/25, 09/11/25, 09/16/25, 09/20/25, 09/21/25 when the SBP was greater than 110. 5) Record review for Resident # 13 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease, a condition caused by damage to the airways or other parts of the lung, Low Back Pain, Unspecified Dementia, a medical term used for memory loss and confusion, but the cause of the decline cannot be determined and Age Related Osteoporosis without pathological fracture, a condition of progressive bone loss and reduced bone strength due to aging, which increases the risk of future fractures, but in the absence of a current fracture. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident # 13 had a Brief Interview for Mental Status of 14, which indicated that she was cognitively intact. Review of the Provider Note dated 09/11/25 documented the resident is to be started on Fosamax. Review of the Physician's Orders showed that Resident #13 had an order dated 09/11/25 for Fosamax Oral Tablet 70 mg every day in the morning. Review of the electronic medication administration record (MAR) revealed that the medication had been administered from 09/12/25 to 09/23/25. During an observation conducted on 9/24/2025 at 3:30 PM the resident was awake and alert watching TV. She doesn't remember going to a doctor's appointment last month. She stated that she does not have any pain and is able to adjust herself in bed. The call light was noted to be clipped on the resident's bed. During an interview conducted on 09/24/25 at 4:00 PM with surveyor colleague and Staff D, Unit Manager (UM), when asked for the phone number of the provider who placed the order for Fosamax on 09/11/25 she stated that the provider was no longer with the facility as of last Friday and that another provider had taken over the assignment. The UM was asked to review the orders for Fosamax, and she stated that this is not a new order, it was a time change. She stated that it appeared that the time was changed to 3:00 AM TO 6:00 AM from 7:00 AM TO 11:45 AM. She stated that the pharmacy calls the unit if there are any issues with an order. When asked to clarify if the order was for daily or weekly administration the UM called the provider via speaker phone, and he stated that the medication is a weekly dose and changed it in the system as the phone call was in progress. During the conversation, Staff Nurse F was at the nurse's station and said she never gave this medication and was talking to pharmacy to adjust the time of administration. During a side-by-side review of the MAR with the UM there was documentation that the nurse had administered the medication. During an interview conducted on 9/25/25 at 9:07 AM with the Consultant Pharmacist (CP) and the Director of Nursing (DON), the CP provided documentation for the original order on 9/11/2025 with an alert that was sent to the provider to clarify frequency. Usually given once a week. She stated the order was never filled by pharmacy or dispensed to the facility. The order was cancelled on 09/24/2025 and re-entered with the correct frequency and time to start on Saturday 09/27/2025. The DON addressed the documentation in the Medical Administration Record (MAR) that showed administration of Fosamax from 09/12/25 to 09/23/25 and is currently working on a Performance Improvement Plan (PIP) and will follow-up with nursing regarding the MAR documentation.

Based on observations, interviews and record reviews, the facility failed to provided care and devices in order to prevent a decrease in range of motion for 1 of 1 resident reviewed for position/mobility, Resident #23. The findings included:Record review for Resident #23 revealed an admission date of 11/29/24. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), with a reference date of 08/28/25, Resident #23 was not assessed for cognition due to 'resident is rarely/never understood'. The assessment documented that Resident #23 was dependent upon staff for all Activities of Daily Living (ADLs). Resident #23's diagnoses at the time of the MDS included: Anemia, Coronary Artery Disease, Diabetes Mellitus, Aphasia, Non-Alzheimer's dementia, Seizure disorder, Respiratory failure, Aphasia following Cerebrovascular accident, Dysphagia, Gastro Esophageal Reflux Disease (GERD), Contracture of left elbow. Resident #23's orders included:Restorative: Left elbow splint, 8hrs as tolerated - 11/30/24.Further review of resident's record revealed no additional orders for range of motion, devices, braces or splints. Resident #23's care plan documented, Alteration in Usual Functional Performance in Mobility/Transfer status related to CVA and left elbow contracture Date Initiated: 06/02/2025 Revision on: 06/02/2025 The goal of the care plan was documented as, Resident's Functional Performance in transfer/mobility status will maintain at current functioning level through next review date. Date Initiated: 06/02/2025 Target Date: 11/15/2025. There were no interventions to prevent contracture or further decrease in range of motion. Resident #23's care plan for pain documented, The resident has acute/chronic pain. -Chronic Physical Disability, -Contractures, -Muscle weakness Date Initiated: 01/13/2025 Revision on: 01/13/2025. The goal of the care plan was documented as, The resident will have minimal interruption in normal activities due to pain through the review date. Date Initiated: 01/13/2025 Target Date: 11/15/2025. There were no interventions to prevent contracture or a decrease in range of motion On 09/23/2025 at 7:16 AM, Resident #23 was observed in bed with his left hand noted to have fingers contracted and hand folded at the base of the fingers and palm of the hand. On 09/24/2025 at 7:56 AM, Resident #23 was observed in bed awake with his left hand noted to have fingers contracted and hand folded at the palm and his right hand contracted into a fist. During an interview, on 09/24/25 at 2:39 PM with Staff A, CNA, when asked about splints and devices for Resident #23's contractures, Staff A stated that Staff B, does the braces. During an interview, on 09/24/25 at 2:47 PM, with the Certified Occupational Therapist Assistant (COTA), when asked about Resident #23 being assessed for Range of motion devices, the COTA stated, he was on caseload 12/05/24 to 12/23/24 for Occupational therapy for a palm guard for left upper extremity. The palm guard was discontinued due to a hand wound on 12/2324. He was supposed to have a T-bar for the right upper extremity that never came in according to the discharge note. The therapy director recommended it 12/05/24.The COTA acknowledged that staff did not follow up with the resident after the wounds had healed and did not make any additional attempts to obtain the splint for the right upper extremity that did not come in after being ordered. During an interview, on 09/24/25 at 2:59 PM with the Assistant Director of Nursing (ADON), when asked about Resident #23 having any device to prevent contracture and to prevent further decrease in range of motion in Resident #23's extremities, the ADON replied, I just spoke with the aide and they said that they (therapy) didn't give him a splint. The usually give the Restorative aide the splints. A while back, he was on palm protectors and he got blisters from them. Therapy re-evaluated him and I don't know why they didn't give him any splints back. He has recurring water blisters. During an interview, on 09/25/25 at 2:33 PM, with Staff B Restorative CNA, when asked about Resident #23 having any device to prevent contracture and to prevent further decrease in range of motion, Staff B replied, We never got the order, it would have been in my splint book. Staff B further stated that there were no orders from therapy that included any such devices.

Based on record review, observation and interviews, the facility failed to provide care and services for a pressure ulcer as evidenced by not following physician orders to treat a facility acquired pressure ulcer for 1 of 2 sampled residents (Resident #10).The findings included:Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment.Review of the quarterly care plan dated 08/16/25 revealed a focus that Resident #10 had skin impairment to the sacrum with a goal to promote healing with intervention of staff to administer treatments as ordered and monitor for effectiveness. Review of a wound care consultation note dated 07/03/25, documented that Resident #10 had an unstageable pressure ulcer to her sacrum that measured 5.5cm x 5.0cm x 0.2cm with 90% necrotic tissue.Review of a physician order dated 08/16/2025 instructed staff to cleanse sacrum wound with normal saline or Dakin's (antibiotic wound cleanser) half strength, apply Santyl (debriding ointment) to wound bed, fill depth with gauze and cover with silicone superabsorbent border dressing every day at 12:00 PM. A second physician order dated 09/19/25 instructed staff to cleanse sacrum wound with normal saline or wound cleanser, apply collagen and calcium alginate rope and cover with silicone superabsorbent border dressing every day at 12:00 PM.During observation of wound care on 09/24/25 at 10:55 AM, The Wound Care Nurse prepared her supplies and donned her gown and gloves. Staff M, Certified Nursing Assistant (CNA) was present at bedside to assist with turning Resident #10. The Wound Care Nurse removed a beige colored dressing from the sacrum wound. The dressing removed was not dated and it was soiled with a moderate amount of serosanquinous (pink, yellow) drainage; there was redness surrounding the wound and the wound appeared to be the size of a quarter with depth. The wound care nurse cleansed the wound with wound cleanser, applied collagen powder to the wound bed and packed with calcium alginate rope and covered with silicone superabsorbent border.During an interview on 09/24/25 at 11:32 AM, When asked did you provide wound care to Resident #10 on 09/23/25, she stated No, I left early yesterday. When asked was there someone else scheduled to do wound care she stated Yes, the Unit Manager.Review of the August and September Treatment Administration Record (TAR) revealed that wound care was not provided to Resident #10 on 08/08/25, 08/16/25, 08/19/25, 09/11/25, 09/12/25 and 09/23/25.

Based on facility policy review, record reviews, observations, and interviews the facility failed to provide care and services for nebulizer and tracheal suctional for 3 of 3 sampled residents, as evidenced by failure to follow procedure for tracheal (opening that connect voice box to passage to airway) suctioning (remove secretions to keep airway open) and physician order for administration of oxygen for Resident #10, failure to follow physician orders for administration of nebulizer treatment and storage of nebulizer equipment for Resident #94, and failure to store nebulizer equipment properly for Resident #39. The findings included:Review of the facility policy titled Tracheal Suctioning revised 08/24/17, documented in part Tracheal suctioning is an effective way to maintain a clear airway and to aide in the removal of secretions for residents who are unable to clear their secretions with coughing. Procedure: Hyperventilate the resident either manually or mechanically for a few breaths. Assess resident condition and response. Document. Review of the policy titled Nebulizer (small volume nebulizer) revised 03/20/2018, documented in part. Procedure: Evaluate the resident. Establish respiratory rate pulse, oxygen saturation and breathe sounds. Disassemble the device and rinse the mouthpiece and nebulizer with water and air dry. Place entire unit in a bag to be maintained in the resident's room. 1) Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment.Review of the care plan dated 08/16/25 revealed a documented focus that Resident #10 had a tracheostomy related to impaired breathing mechanics and staff will ensure oxygen settings via tracheostomy and suction as necessary. Another focus revealed that the resident needed oxygen therapy related to ineffective gas exchange with a goal the resident will have no signs of poor oxygen absorption. An observation conducted on 09/24/25 at 10:56 AM, Resident #10 noted with oxygen via tracheostomy, with concentrator set at 4 liters per minute. Photographic evidence obtained. Review of a physician order dated 04/29/25, instructed staff to administer oxygen to Resident #10 continuously at 2 liter per minute via tracheostomy.During an interview on 09/24/2025 at 5:36PM, when asked how much oxygen Resident #10 was supposed to be on, Staff K, Licensed Practical Nurse (LPN) stated, I think 2L.An observation was conducted on 09/24/2025 at 5:10 PM with Staff K, LPN performing tracheal suctioning. She gathered the supplies and set them up on Resident #10 bedside table. Staff K, LPN, removed the oxygen from the tracheostomy and began to suction resident. She suctioned the resident twice and as she continued to suction the resident, she stated, I forgot my pulse ox, so I can check the resident's oxygen level. Also, I forgot to hyper oxygenate (administer oxygen prior) the resident before I started. Staff K, LPN continued with suctioning the resident.Review of the vital signs on 09/24/25 did not reveal documentation of an oxygen saturation assessed on Resident #10, after tracheal suctioning was performed by Staff K, LPN. Review the progress notes for 09/24/25 did not reveal documentation of an oxygen saturation assessed on Resident #10 or resident status after tracheal suctioning was performed by Staff K, LPN.2) Record review revealed that Resident #94 was admitted to the facility on [DATE]. Review of quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 14 on a 0-15 scale, indicating no cognitive impairment. During an observation on 09/22/2025 at 2:24 PM in Resident #94's room a nebulizer mask was noted hanging on bed frame touching the floor. The nebulizer was dated 9/11/25. Photographic evidence obtained. Review of a physician order dated 01/20/25 instructed staff to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) (steroid medication for breathing) 3 milliliters via inhalation four times a day for shortness of breath (SOB). A second order instructed staff to administer Acetylcysteine Inhalation Solution 20 % (Acetylcysteine) (used to treat cough and mucous) 2 milliliters via inhalation four times a day for SOB.Review of the care plan dated 08/28/25 revealed a focus documented that the resident had altered respiratory status and difficulty breathing due to history of respiratory failure, tracheostomy, and ventilator use with a goal that the resident will maintain normal breathing pattern as evidenced by regular respiratory rate, pattern with staff to administer medication and inhalers as ordered and monitor effectiveness and side effects. An observation was conducted on 09/23/2025 at 09:51 AM, a nebulizer mask dated 09/11/25 was observed on Resident #94's nightstand.During an interview on 09/25/2025 at 9:05 AM, when asked if Resident #94 had received the breathing treatments the spouse shook her head to acknowledge that she wasn't sure. She asked the resident in his language and showed him the nebulizer mask, and he stated, For 1 week and only 1 time. When asked if he had received the breathing treatment this week he stated No and shook his head no. Review of August and September Medication Administration Record for Resident #94 revealed documentation of staff indicating that the nebulizer treatments were administered.3) Record review reveal Resident #39 was admitted to the facility on [DATE]. Review of the quarterly assessment documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment.During an observation on 09/22/25 at 10:50 AM, a nebulizer mask was noted hanging on Resident #39's bed post. The nebulizer mask was not stored in a bag. Photographic evidence obtained. During an observation on 09/23/2025 at 8:49 AM, a nebulizer mask was noted hanging on Resident #39's bed post. The nebulizer mask was not stored in a bag. Photographic evidence obtained.Review of a physician order dated 09/11/25 instructed staff to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol give 3 milliliters via inhalation every three times a day for 5 days for cough. A second order dated 09/11/25 instructed staff to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol give 3 milliliters via inhalation give 3 milliliters via inhalation every 6 hours as need for SOB or congestion.Review of the September MAR revealed that staff had administered the nebulizer treatment. During an observation on 09/25/2025 at 9:23 AM, a nebulizer mask was noted hanging on Resident #39's bed post. The nebulizer mask was not stored in a bag. Photographic evidence obtained.

Based on facility assessment, staffing record review, and interview, the facility failed to ensure sufficient staff on 6 of 13 weekends reviewed as evidenced by failure to staff as per their facility assessment, failure to ensure provision of wound care on weekends and during the survey for 3 of 4 sampled residents (Residents #9, #10, and #76), and as evidenced by 11 grievances related to patient care logged from April 2025 to the survey date.The findings included:Review of the federal staffing numbers submitted for the third fiscal quarter of 2025 (04/01/25 through 06/30/25) revealed low weekend staffing.Review of the Facility Assessment, revised 02/19/25, documented a general staffing plan to meet resident needs as follows:a) The ratio of licensed nurses to residents on day shift would be 1:22 (7 AM to 3 PM).b) The ratio of licensed nurses to residents on the evening shift would be 1:29 (3 PM to 11 PM).c) The ratio of licensed nurses to residents on night shift would be 1:29 (11 PM to 7 AM). Note the nurses at this facility work 12 hours shifts, from 7 AM to 7 PM and 7 PM to 7 AM.d) The ratio of Certified Nursing Assistants (CNAs) to residents on day shift would be 1:9 (7 AM to 3 PM).e) The ratio of CNAs to residents on evening shift would be 1:9 (3 PM to 11 PM).f) The ratio of CNAs to residents on night shift would be 1:10 (11 PM to 7 AM).Review of the actual staffing, for weekends, revealed the following date for nursing that the facility did not follow their own facility assessment:g) On 04/19/25 the nurse to resident ratio was 1:33.33 on the day shift.h) On 04/26/25 the nurse to resident ratio was 1:25.25 on the day shift.i) On 06/22/25 the nurse to resident ratio was 1:25.75 on the day shift.Review of the actual staffing, for weekends , revealed the following dates for CNAs that the facility did not follow their own facility assessment:j) On 04/12/25 the CNA to resident ratio was 1:12.50 on the day shift.k) On 04/19/25 the CNA to resident ratio was 1:16.66 on the night shift.l) On 04/20/25 the CNA to resident ratio was 1:12.50 on the day shift.m) On 05/25/25 the CNA to resident ratio was 1:14.85 on the evening shift.n) On 06/06/25 the CNA to resident ratio was 1:15.57 on the night shift.o) On 06/07/25 the CNA to resident ratio was 1:11.44 on the day shift.During the initial pool process, three sampled residents, Resident #9, #10, and #76 stated their wound care was not being provided on weekends. An observation on Monday 09/22/25 in the morning revealed a dressing to the left leg of Resident #76 that was dated Friday 09/19/25. Record review revealed the dressing was ordered to be changed daily. Refer to F684 for details.Review of the grievance log from April 2025 through the survey date of 09/25/25 revealed the following grievances related to care and services:p) On 04/21/25 a grievance was lodged related to staff issues. The Regional Social Services Director was unable to locate the grievance report.q) On 04/29/25 a grievance was lodged related to staff inability to transfer a resident back into bed timely.r) On 05/19/25 a grievance was lodge related to a resident having to wait to be changed as the mechanical lift needed to be charged.s) On 05/20/25 a grievance was lodged related to a resident having to wait to be changed last.t) On 06/03/25 and 06/04/25 complaints were lodged related to improper incontinent care.u) On 08/18/25 a grievance was lodged related to care and services for a tracheostomy.v) On 08/26/25 a grievance was lodged related to personal care by a CNA.w) On 08/27/25 a grievance was lodged related to personal care by a CNA and lack of wound care by the nurses.x) On 09/02/25 and 09/03/25 complaints were lodged related to CNA care and services.

Based on observations, record reviews, and interviews, the facility failed to ensure standards of practice for administration of medication for 2 of 27 samples residents, as evidenced by failure to ensure medications not left at the beside for Resident #39 and Resident #14.The findings included:1) Record review reveal Resident #39 was admitted to the facility on [DATE]. Review of the quarterly assessment documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scaled, indicating no cognitive impairment. During an observation on 09/22/25 at 10:50 AM, Resident #39 was noted sleeping in his bed. A clear medication cup with 2 white capsules was observed on his bedside table.During an interview 09/22/2025 3:22 PM, when asked did you take the pills that were left in a medicine cup on your bedside table, Resident #39 he stated. Yes. When asked do you know what the medications was for, he stated, I pretty much know the medications I take when I see them and if it's something I don't recognize, I will let them know, because they make mistakes. The pills were white and they were for the pain in my legs. During an interview on 09/22/2025 at 3:30 PM, when asked did you leave medication at the bedside for Resident #39, Staff O, Licensed Practical Nurse (LPN) asked, There was medications at the bedside? Staff O was made aware that there were 2 white capsules in a medication cup observed on the resident's bedside table this morning. She stated, They wasn't from me, I watched him take his pills. When asked to see the resident's medications, Staff O, LPN, showed a packet of white capsules with a label that read Gabapentin 100mg capsules. She said he takes 3 pills in the morning. When asked what time you gave him his morning medications, Staff O, LPN stated It was at 9:36 AM. Care plan dated 08/29/25 revealed a documented focus that Resident #94 has both cognition and communication deficit which include impaired thought processes, difficulty making decisions, short term memory loss with a goal that the resident will remain oriented to person, place, situation and time. Review of a physician order dated 05/19/25 instructed staff to administer Gabapentin Oral Tablet 100 MG (Gabapentin), give 3 tablets by mouth two times a day for neuropathy (nerve pain). 2) Record review revealed Resident #14 was admitted to the facility on [DATE]. Review of the comprehensive assessment date 04/23/25 documented a Brief Interview Mental Status (BIMS) score of 05 on a 0-15 scale, indicating severe cognitive impairment. Review of medical history revealed a diagnosis of Alzheimer's (memory loss). An observation of medication administration was conducted with Staff K, Licensed Practical Nurse (LPN) on 09/24/2025 at 08:40AM. She was observed administering the medications poured for Resident #14. After she administered the medications, surveyor noted a small white round pill on the resident's nightstand that was not in a cup. Staff K, LPN was called over to look at the pill sitting on the nightstand and verified that it was a pill. The pill was removed from the room in a napkin and taken to the med cart and placed on a pink tray. The ADON (assistant director of nursing) walked over to the medication cart and asked what was wrong. She was made aware that a pill was found on Resident #14's nightstand. The ADON looked at the pill and picked it up and placed the pill in a clear medication cup, she asked what the pill was. At that time the medication was not identified. After reviewing orders and medication prescribed to Resident #14, with Staff K, LPN, the medication was still not identified. The medication was disposed of properly.

Based on observation, record review, and interview, the facility failed to monitor behaviors and side effects of medications used for mood disorder, for 1 of 5 sampled residents, Resident #9. The findings included: Review of the record revealed Resident #9 was readmitted to the facility on [DATE] with a diagnosis to include Post Traumatic Stress Disorder (PTSD). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. Review of the current orders revealed Resident #9 had been receiving Valproic Acid 500 milligrams (mg) three times daily since 06/25/25 for a mood disorder. Review of the September 2025 Medication Administration Record (MAR), the Treatment Administration Record (TAR), and corresponding nursing progress notes lacked any documented side effect or behavior monitoring for the Valproic Acid. During an interview on 09/22/23 during the initial pool screening, when asked about his PTSD, Resident #9 became very emotional, and explained he served in the Army, was in combat and wounded four times, including a hit and run accident in South Florida, which left him unable to walk. He also spoke of his family and continued with tears noted. When asked what triggers him, Resident #9 stated it was mainly just when his history was brought up in conversation. On 09/24/25 at 12:04 PM Staff K, Licensed Practical Nurse (LPN), was interviewed and asked what was done if a resident presented with behavior issues. Staff K, LPN, stated that it was documented in the nurse's progress notes and a psychological evaluation would be requested. When asked if Resident #9 had acted out or had any behavior, Staff K, LPN, stated he had not done so with her, but she had heard otherwise from other staff. During an interview on 09/24/25 at 12:06 PM, when asked if Resident #9 acted out or exhibited any behaviors, Staff Q, Certified Nursing Assistant (CNA), stated Resident #9 had declined bathing and had acted out by yelling and screaming at her to get out of the room. Staff Q stated that when this had occurred, she had alerted the nurse on duty regarding his behavior. During a side-by-side review of the record and interview on 09/25/25 at 2:54 PM, the Assistant Director of Nursing (ADON) was informed of the lack of side effect and behavior monitoring for Resident #9. The ADON agreed with the findings.

Based on observations, interviews and record reviews, the facility failed to provide foods prepared in a sanitary manner and in accordance with professional standards for food safety. The findings included:1. During the initial kitchen tour, on 09/22/25 at 9:01 AM, accompanied by the Dietary Manager, the following were noted: a. The concentration of the quaternary ammonia used for sanitizer in a red bucket in the processing area was less than 200 parts per million necessary to sanitize food equipment and surfaces.b. The paint was peeling from the wall at the left of the door in the dry storage area.c. The ceiling over the reach in freezer #2 was damaged in a manner indicative of being wet.d. There was an accumulation of dust and condensation on the vents of the air conditioning unit in the dry storage area.e. Cleaned and sanitized pitchers used to provided fluids to the residents during meals had residue left from the date stickers that were placed on them.f. The hand washing sink was not sealed to the wall as the caulk had appeared to have worn.g. There was an accumulation of residue on the blade of the counter mounted can opener.h. The Teflon coating on a skillet was worn and appeared to be coming off of the cooking surface of the skillet.i. Plates that were not in use on a shelf in the hot holding area were not stored inverted in a manner to prevent dust and debris from contaminating the plates.j. There was peeling paint and an accumulation of rust on the ceiling over the coffee maker.k. Staff C, Dietary Aide, was observed removing a pair of single use gloves. Prior to donning another pair of clean single use gloves, the Dietary Aide did not perform hand hygiene. When asked about performing hand hygiene, the Dietary Aide stated that she was not aware of the need to do so when changing gloves. At the conclusion of the initial kitchen tour, the Dietary Manager acknowledged understanding of the concerns. 2. During a tour of the Food Service Area, where meals are placed into a cart to be transported to the units and the Dining Room, on 09/22/25 at 9:45 AM, the following were noted: a. On the shelves by the entrance from the service corridor, there were 16 cases of expired nutrition supplements - each case contained 24 8 ounce cartons of suppleent* 1 case was stamped with an expiration date of 11/01/24.* 1 case was stamped with an expiration date of 01/01/25.* 4 cases were stamped with an expiration date of 03/01/25.* 2 cases were stamped with an expiration date of 07/01/25.* 1 case was stamped with an expiration date of 08/01/25.* 6 cases were stamped with an expiration date of 09/01/25. b. Accumulation of debris under and behind pellet warmer and under and behind the reach in cooler.c. There was a hole in the wall to the right of the hand washing sink. At the conclusion of the tour, the Dietary Manager acknowledged the findings. 3. During the follow up kitchen tour, on 09/24/25 at 11:13 AM, there was an accumulation of mold around the inside of the door to the ice machine in the food service area.

Based on record review and interview, it was determined, the facility staff failed to provide necessary care and services for 1 of 2 sampled residents (Resident #1), who required antibiotic therapy and monthly catheter changes to minimize risk of infection. The findings included: Clinical record review conducted on 04/01/25 revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses including Paraplegia and Urinary Tract Infection. Minimum Data Set, quarterly assessment with reference date 12/20/24, documents the resident was assessed as independent for skills of daily decision making, is staff dependent for personal hygiene, bathing, dressing and toileting and has an indwelling urinary catheter. Care Plans implemented for Resident #1 and revised 12/30/24 included the following: Paraplegia, resident has Spinal Injury related to trauma with potential for decline in self care. The approaches noted give medications as ordered and monitor document for side effects and effectiveness. Risk for Urinary Tract Infection (UTI), Dysuria and Bladder Spasms related to catheter and multiple comorbidities documents the goal to minimize the risk of complications related to the potential for infection through the review date. The approaches noted administer antibiotic as ordered, maintain universal precautions, monitor and documents signs of UTI. Physician's orders dated 09/17/24 documents Tobramycin Sulfate injection 80 mg/2 milliliters intramuscularly every month on the 17th, prior to catheter change. Infectious Disease Consult dated 11/12/24 documents orders: Change catheter monthly as ordered. Review of the Medication Administration Records dated 10/2024, 11/2024, 12/2024 and 02/2025 provide no evidence that Resident #1 received the prescribed antibiotic therapy and provides no evidence of monthly catheter changes. Review of the progress notes failed to provide evidence of the resident's refusal of catheter changes or antibiotic therapy. The record indicates Resident #1 requested to be seen by the provider on 02/17/25 due to pain on urination, cough, and bladder spasms. The provider evaluation dated 02/17/25 at 10:10 AM documents the resident has a supra pubic catheter, history of recurrent UTI and is on Tobramycin monthly, the urine is slightly cloudy with sediments and diagnostic tests were ordered. Resident #1 was transferred to the hospital on 02/17/25 at approximately 10:30 PM via emergency personnel. Hospital records dated 02/18/25 document Resident #1 presented to the emergency department with complaints of abdominal pain, bladder spasms and chills that are worsening since this morning. Positive for UTI and suspected urosepsis. The resident was admitted for medical management. Interview with Director of Nursing conducted on 04/01/25 at approximately 2:10 PM revealed there is no evidence Resident #1 received the antibiotic therapy in October 2024, November 2024, December 2024 and February 2025. In addition, there is no evidence of monthly catheter changes, or evidence that the resident refused the care. The investigation concluded Resident #1 did not receive monthly catheter changes and the prescribed monthly antibiotic therapy to mitigate the risk of recurrent UTI's.

Based on observations, interviews and record reviews, the facility failed to provide foods prepared under sanitary conditions and in accordance with standards for food safety professionals. The findings included: 1). During the initial kitchen tour, on 05/28/24 at 8:48 AM, accompanied by the District Manager for Health Services Group (contracted to oversee the kitchen/dietary ) the following were noted: a. An employee's personal cellular device on prep table by the walk in cooler. b. There was an accumulation of food residue on the sharpening stones to slicer. c. A 1/3 sized six inch deep container of barbecued pork in the process of cooling from the previous day was 49 degrees Fahrenheit (F). The District Manager confirmed that the pork was in the process of cooling from being served the day before. d. A 1/3 sized six inch deep container of meatballs in the process of cooling from the previous day was 51 degrees F. The District Manager confirmed that the meatballs were in the process of cooling from being served the day before. e. In the food services area, the wall to the left of the hand washing sink was damaged. f. In the food services area, there was an accumulation of black residue inside of the ice machine. 2). During the follow up tour of the kitchen, on 05/30/24 at 11:01 AM, accompanied by the District Manager and the Account Manager, the following were noted: a. Staff A, Dietary Aide, was observed adjusting glasses that Staff A was wearing. Staff A then proceeded to another area of the food service area to answer a phone call on her personal cellular device, and then placed the cellular device into her back pocket before opening and closing the reach in cooler. As Staff A began retrieving trays through a window from the kitchen to the food service area, this Surveyor intervened and instructed Staff A to perform hand hygiene at the hand washing sink. Staff A and the District Manager acknowledged that Staff A had not performed hand hygiene at any time that the observation was being made. b. There was ice from an unknown source in the only hand washing sink in the food service area. c. Staff B, Dietary Aide, was noted to be wearing loose fitting bracelets while preparing to receive trays from the kitchen to the food services area. d. Staff A was observed handling portioned drinks with bare hands in direct contact with the lip contact surface of the cups.

Based on interview, observation, and record review, the facility failed to provide toenail care, in a timely manner for 1 (Resident #67) of 1 resident reviewed for foot care. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnosis in part to include: End stage Renal Disease with dependence on renal dialysis, unspecified Protein Calorie Malnutrition, Atrial Flutter, Bilateral Non Pressure Wounds of Lower Extremities, Anemia, Hypertension, Major Depressive Disorder and difficulty in walking. On 03/07/24 Resident #67 had an MDS (Minimum Data Set) assessment. The resident had a BIMS (Brief Interview for Mental Status) of 15, which indicates the resident is cognitively intact. The assessment also indicated the resident needed assistance with bathing, dressing and putting on and taking off footwear. On 05/28/24 at 1:50 PM, an interview was conducted with Resident #67. The resident was sitting outside in a wheelchair. He was wearing sandals. His toenails were observed. His right and left foot toenails were long. On the left foot on the 2-digit the toenail was curving down into his foot. The resident stated they hurt, and he stated he has told the nursing staff he wants them clipped. Photo evidence obtained with consent from Resident #67. He stated he wears sandals because his toenails hurt too much to put shoes on his feet. The orders were reviewed. When the resident arrived on 12/21/23 an order was written for Podiatry, as needed. On 05/29/24 at 7:58 AM, an interview was conducted with the MDS Coordinator. She was asked about Resident #67's toenails and why they had not been cut/trimmed. She stated they were working on it through the VA. In review of the record an order was written on 05/28/24 at 6:30 PM for podiatry consult for ingrown toenails after surveyor interview of Resident #67 on 05/28/24 at 1:50 PM. On 05/30/24 at 12:16 PM the MDS Coordinator was asked who is responsible for the residents getting their toenails cut/trimmed. She stated it is up to the nursing staff. She stated she thinks Resident #67 had previously been on a list for podiatry care at the facility. She stated she was looking for the documentation. On 05/30/24 at 12:18 PM Resident #67 was interviewed. He stated he has never had his toenails cut/trimmed since he arrived at the facility, and they had not been cut or trimmed anywhere else which includes the VA. He stated he has been asking the nurses and CNAs to cut/trim his toenails for the last 2 months. On 05/31/24 at 7:40 AM Staff E, a CNA (Certified Nursing Assistant) was interviewed. She was asked about residents and cutting/trimming fingernails and toenails. She stated she can cut the nails unless they are diabetic or have another problem. Then she would notify the nurse. On 05/31/24 at 7:50 AM Staff F, a CNA was interviewed. She stated if a resident needed their nails cut/trimmed and if she was unable to cut them, she would notify the resident's nurse. On 05/31/24 at 10:10 AM, an interview was conducted with Staff G, an LPN (licensed Practical Nurse). She stated if a resident needs to have a podiatry consult for nailcare then she can get a consult for the resident. In review of Resident #67's plan of care, he was assessed for an ADL (Activity of Daily Living) selfcare deficit. The intervention dated 01/01/24 was for showering/bathing and documents to check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. During the survey, no documentation was located to indicate Resident #67 had a previous consult for nail care.

Based on observation, interviews and record review, the facility failed to assess and provide Range of Motion (ROM) as requested by the resident for 1 of 1 resident reviewed for ROM (Resident #53). The findings included: Resident #53 was admitted to the facility originally on 08/24/22. Diagnoses included Guillain-Barre Syndrome, Type 2 Diabetes, Osteoarthritis, and Paraplegia. Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/26/24. Section O of the MDS revealed she has not received Physical therapy (PT), Occupational therapy (OT) or ROM in the last 7 days. Section GG of the MDS revealed her functional abilities was limitation in ROM on both sides. On 05/28/24 at 1:25 PM, an interview was conducted with Resident #53. She stated she was in the facility because she never recovered from Guillain-Barre. Guillain-Barre causes your immune system to attack your nerves, leading to symptoms such as weakness, tingling, numbness, and paralysis. She stated she feels like if she does not have ROM she will get weaker. A review of the resident's Physician orders revealed an order for Physical therapy evaluate and treat dated 08/10/23. A review of the resident's care plan with a focus of Acute/Chronic pain has an intervention of Rehab services date initiated 09/05/22 and revision on 11/06/23. On 05/31/24 at 9:28 AM, an interview was conducted with the Director of Rehabilitation (DOR). She was asked if the Certified Nursing Assistant (CNAs) perform ROM during personal care. She stated that they have a restorative aide who does ROM. The DOR stated that Resident #53's desire for ROM has not been brought to her attention but she will do a screening today. She has no past record of her having rehabilitation because previous therapies were with the previous company. An additional interview was conducted with Resident #53 on 05/31/24 at 11:05 AM. She was asked if she told any staff member that she would like additional ROM. She stated she told the MDS Coordinator in the different meetings she has had with her. She also stated when her family was in town that she told her that she would like to have more rehab or at least a screening so she can go home. Interview conducted with the MDS Coordinator on 05/31/24 at 11:15 AM. The MDS Coordinator was asked if she was aware that Resident #53 was asking for more rehab. She stated the resident refuses to get out of bed, refuses medication and she is care planned for this. Asked if she has specifically refused a rehab screening because that is not on the care plan and she stated she would have to look at her documentation. The MDS Coordinator did not provide any additional documentation by the end of the survey.

Based on observation, interview, record and policy review, the facility failed to maintain a PICC (Peripherally inserted central catheter) line in a sanitary manner for 1 of 1 resident sampled for PICC lines (Resident #375). The findings included: The facility's policy titled, Catheter Insertion Care effective 1/17/2019 revealed Change midline catheter dressing 24 hour after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Resident # 375 was admitted to the facility on [DATE] with diagnoses that included Acute Osteomyelitis of the left ankle and foot, Pressure Ulcer of the left heel and Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere. A Brief Interview for Mental Status (BIMS) was done on 05/13/24 and the resident scored a 15, which indicated he was cognitively intact. On 05/28/24 at 11:00 AM, Resident #375 was interviewed and a PICC line was observed on the resident's left upper arm. The dressing was covered with a tubular wrap. The resident was asked if the surveyor could look at the dressing under the wrap and he agreed. The dressing was dated 05/09/24 which was the day prior to the admission of the resident to the facility. The resident was asked if anyone had changed his dressing since he was admitted to this facility and he stated that they flush it but had not changed the dressing. Review of the Physician orders for Resident #375 revealed an order to change dressing on admission or 24 hours after insertion and weekly thereafter and PRN (as needed) every night shift every Fri change dressing weekly. Review of the Medication Administration Record (MAR) for Resident #375 revealed three days the dressing was initialed by a nurse as being changed on 05/10, 05/17 and 05/24. On 05/29/24 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the PICC line dressing for Resident #375 was changed yesterday. Discussed that the PICC line dressing was dated 05/09/24 yesterday. The DON was shown the MAR that showed nurses marked the dressing as changed three times. The DON acknowledged that the dressing change was not done on those dates and he will be doing in-services for the nurses.

Based on observations, interviews and record reviews, the facility failed to adhere to fluid restrictions for 1 of 2 residents reviewed for dialysis (Resident #37). The findings included: Resident #37 was initially admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual Minimum Data Set (MDS), date 03/23/24, Resident #37 had a Brief Interview for Mental Status score of 11, indicating that Resident #37 was moderately cognitively impaired and that the resident required setup help only for eating. Resident #37's diagnoses at the time of the assessment included: Anemia, Diabetes, Heart Failure, Hyperkalemia, Peripheral Vascular Disease, Thyroid disorder, Anxiety Disorder, Depression, Chronic Lung Disease, Disorders of Calcium Metabolism, Gangrene, Insomnia, Extrapyramidal and Movement Disorder, Long term use of insulin, Dysthymic Disorder. Resident #37's care plan for nutrition, initiated on 05/27/20 and most recently revised on 04/17/24, documented, The resident has nutritional problem or potential nutritional problem increased nutrient needs related to history of poor diet compliance, as evidenced by End Stage Renal Disease (ESRD) on Hemodialysis (HD), and needs for therapeutic diet. - increased risk for fluid imbalances/weight fluctuations due to HD treatment. 10/23/23: 1000 ml a day fluid restrictions - increased risk for altered hydration status. The goal of the care plan was documented as, Will maintain adequate nutritional status as evidenced by maintaining weight no signs/symptoms of malnutrition and consuming at least 76% of at least 2 meals daily through review date. 05/27/20 with a revision date of 04/11/24 and a target date of 06/29/24. Interventions included: *Fluid restrictions per HD MD clinic1000 ml/day - 720 ml for dietary (240 ml per meal) 280 ml for nursing staff (180 ml/6 oz 7 AM to 7 PM) 100 ml for 7 PM - 7 AM this exclude any supplements Resident #37's care plan for Rejection of Care, initiated on 12/11/20 with a revision date of 04/02/24, documented, Non-compliant with Dialysis fluid restrictions - independent with taking of fluids .May demand that staff provide her with foods/fluids that are not recommended. Aware of the benefit - stability of medical conditions. Family aware. The goal of the care plan was documented as, Medical needs may not be adversely affected by her non-compliance. 12/11/20 with a revision date of 04/11/24 and a target date of 06/29/24. interventions to the care plan included: * Allow the resident to make decisions about treatment regime, to provide sense of control. * Educate resident/resident's representative/ caregivers of the possible outcome(s) of not complying with treatment of care. Resident #37's care plan for Mood and Behavior, 08/07/22 with a revision date of 04/02/24, Resident is alert: frequently request/demand food and fluids not recommended for her due to ESRD - dialysis dependent/fluid restrictions. She is not easily redirected, dismissive, and may be verbally and or physically disruptive - swearing .Refusing to comply with dietary restrictions/Fluid restrictions. interventions included: * Document/report behavior attempt to determine underlying cause. Resident #37's care plan for dialysis, initated 05/27/20 with a revision date of 05/07/24, documented, Dialysis: Hemodialysis secondary to ESRD on Monday, Wednesday, Friday at Dialysis center The goal of the care plan was documented as, will have no signs/symptoms of complications from dialysis 05/27/24 with a revision date of 04/11/24 and at target date of 06/29/24. Interventions included: *Fluid restriction. See POS/MAR Resident #37's orders included: Hemodialysis secondary to ESRD on Monday, Wednesday, Friday at Dialysis center. Chair time at 9:15 AM. Pick up time: 8:00-8:30 AM. Estimated return time 1:45 PM - 3:00 PM. Transportation with VCT - 03/30/24. CCD Renal diet Regular texture, Regular/thin Liquids consistency - all meats fortified: Tuna sandwich and applesauce @ HS. 1000 ml day Fluid restrictions per HD MD. 720 ML Total/Day: 8 oz coffee @ B 8 oz apple juice at L/D Nursing 280 ml Total/Day 7 AM-7 PM: 180ml/6ox 7 PM-7 AM: 100 ml for Hemodialysis related to End Stage Renal Disease - 03/15/24. On 05/28/24 at 12:46 PM, Resident #37 was noted with a 16 ounce Styrofoam cup of water on the over bed table. On 05/29/24 at 7:30 AM, Resident #37 was observed in bed with breakfast in bed. Resident #37 was noted to have a cup with approximately 4 ounces of apple juice and a cup with approximately 6 ounces of coffee and a 16 ounce Styrofoam cup of water on the overbed table. Resident appeared to be confused and not interviewable at the time of the observation and was not able to demonstrate knowledge or understanding of fluid restrictions. On 05/29/24 at 7:35 AM, the MDS Coordinator stated that 11-7 staff responsible for the water at 6 AM and that staff on the 7-3 shift would be passing water again prior to the lunch meal. On 05/31/24 at 6:38 AM, Resident #37 was observed sitting on right side of the bed. The resident was noted to have a cup with approximately 4 oz of clear fluid, a cup with approximately 4 oz of apple juice and a cup with approximately 8 oz of hot tea on over bed table. At the time of the observation, Resident #37 appeared confused and was not able to demonstrate knowledge or understanding of fluid restrictions. During an interview, on 05/31/24 at 7:01 AM, with Staff C, LPN, when asked about the fluids provided to Resident #37, Staff C replied, every time when someone passes by, she will ask for something to eat and something to drink. After she is done and we try to take it away, she will get angry so we leave it for her. During an interview, on 05/31/24 at 7:06 AM, with the Director of Nursing (DON), when asked about the fluids provided to Resident #37, the DON replied, her fluid came from kitchen, the only time the nurses give fluid is during medications. The dietitian determines the fluid restrictions and how much fluids she can have. She is sneaky, she will go to the vending machine as well and we have to keep telling her that she can't have it. Asked about resident being aware of fluid restrictions, we educate her. On 05/31/24 at 7:20 AM, Staff D, CNA, was observed serving a tray to Resident #37's room for breakfast. It was noted that the resident was being served approximately 4 ounces of apple juice and 6 ounces of coffee, while there was already 4 oz of clear fluid, a cup with approximately 4 oz of apple juice and a cup with approximately 8 oz of hot tea on over bed table. During an interview with Staff D at the time of the observation, when asked about the fluids provided to Resident #37, Staff D replied, that was from 3-11 (referring to the fluids that were already in the room prior to breakfast being served). She is very difficult. When we take her fluids away, she will go to the kitchen and ask for fluids and the Director says that she is alert and oriented, so he gives them. On 05/31/24 at 7:34 AM, the District Manager from the contract company overseeing the kitchen reported to this Surveyor, the CNA came and asked for apple juice, and we gave it to her and we didn't know that it was for the resident (referring to Resident #37). On 05/31/24 at 8:22 AM, Resident appeared to be confused during attempted interview and was unable to demonstrate knowledge of fluid restrictions. During an interview, on 05/31/24 at 9:20 AM, with the Registered Dietitian, when asked about the risks associated with no adhering to the fluid restrictions, the Registered Dietitian replied, fluid overload - she can get worse and cause cardiac arrest due to the fluid overload. Her edema can be exasperated. The main issues is cardiac issues. In the past, she was more oriented and able to understand.

Based on observation, interview, and record review, it was determined that the facility failed to provide 1 of 1 (Resident #1) sampled residents with foot care and treatment in accordance with professional standards of practice , including to prevent complications from the resident's medical condition. The findings included: During an observation conducted of Resident #1 on 03/19/24 at 11:15 AM and accompanied with the Director of Nursing (DON) and Assistant Director of Nursing , the resident was asked permission by the DON and granted permission to have both feet examined. The examination noted the following: < Observation of the Left foot noted that the sock was caked with a black substance and was noted difficult to peel the sock away from the foot. The resident was noted to have pain/discomfort during the sock removal. Photographic evidence obtained. < Observation of the Left foot noted the entire top surface and toes to be covered with thickened, brown/black scaly type matter and had an offensive odor. The toenails (5) were elongated, thickened, brittle, cracked/crumbly, odorous, and discolored black /brown. The great toe was especially noted to be discolored, cracked, and skin area around the nail to be inflamed and painful to the touch. The Director of Nursing (DON) was noted to spread the toes apart and it was noted to have large accumulations of a reddish/black substance between each toe. The DON stated that the black substance between each toe was a type of Fungus and further stated that the resident required immediate podiatry treatment for the foot, toes, and fungus. Photographic evidence obtained. < Observation of the Right foot noted that the shin area had what appeared to be deep scabs (2) . The entire top of the Right foot and toes was noted to be covered with a black/brown scaly matter and odorous. The toenails (5) were noted to be discolored brown, elongated, thick, brittle, and crumbly. The DON stated again stated that the resident required immediate podiatry care. Photographic evidence obtained. Following the observations conducted on 03/19/24 the Director of Nursing again stated that Resident #1 required immediate podiatry care for bilateral feet, toes, and toenails. He also stated he had not been made aware of the conditions of the resident's feet. Following the 03/19/24 observations a review of the clinical record of Resident #1 noted a Podiatry evaluation that was dated 02/15/24. Review of the evaluation noted the following documentation: * History & Physical: Type 2 Diabetes without complications. Referred by the medical doctor who treats and manages the patient's diabetic condition. * Medical History: Type II Diabetes, Muscle Weakness, Arterioscleroses of Arteries of the Extremities, Blindness One Eye, and Legal Blindness. * Vascular Exam: DP and PT Pulse (left) : non-palpable, and DP and PT (right): non-palpable. * Dermatological Exam: Hair growth absent bilateral feet, Toenails feet bilateral, painful, thickened, brittle, onychomycosis, subungual debris, crumbly , malodorous, elongated, varicosities feet bilateral, and hematoma right 3rd toenail. * Orthopedic Exam: Muscle Weakness feet bilateral. * Gait Exam: Bedridden, legally blind and ambulates infrequently. * Condition: Poor Circulation * Assessment: Peripheral Vascular Disease, Type 2 Diabetes, and Poor Circulation. * Plan: The patient is not an eligible candidate for diabetic shoes. The patient is under a diabetic treatment plan from his medical doctor. Diabetic evaluation of the extremities should be done at least twice per year. Patient to be seen in 12 months. Further review of the evaluation noted no physician orders to treat bilateral foot conditions present in the exam or physician orders for vascular consultation. Following the review of the evaluation the facility's Director of Nursing and Corporate Regional Nurse stated that the evaluation failed to include physician treatment orders. On 03/19/24 the Director of Nursing (DON) submitted a verbal Podiatry Consult with diagnoses to r/o fungal infection one time only for 5 days. The also submitted a physician's order date 03/19/24 for: Lotrisone 1% cream - and Podiatry Consult apply to both feet in between toes Q HS for 14 days (diagnosis Tinea Pedis), and Podiatry Consult Left Foot Bunion Redness. Review of the clinical record of Resident #1 on 03/19/24 noted the following: Date of Admission: 04/05/2019 Diagnoses: Type 2 Diabetes, Heart Failure, Cerebral Infarction, Long Term Insulin Use, and Legal Blindness. Current Physician's Orders: 03/19/24: Podiatry Consult Diagnosis: rule out fungal infection (new order during complaint survey) 03/19/24: Podiatry Consult - Tinea-Pedis (new order during complaint survey) 03/19/24: Cleanse Right shin with wound cleaner, apply skin prep daily for old scab (new order during complaint survey). 03/19/24: Cleanse with wound cleaner, apply skin prep daily (new order during complaint survey) 03/19/24: Lotrisone Cream 1% - Apply between toes topically at bedtime for tinea-pedis for 14 days (new order during complaint survey) 07/29/21: Podiatry as needed. MDS: 12/22/23 - Quarterly: Section B: Sometimes Understood and Usually Understands Section C: BIMS Score = 7 (Some Cognitive Impairment) Section D: Depressed and Little Interests Section E: No Behaviors Section GG: ADL's Dependent to Moderately Assist Section M: No Pressure Ulcers/Risk for Pressure Ulcers Section N: Insulin Use Review of current care plans on 03/19/24 noted: * Diabetes - Risk of Diabetic related complication Date Initiated: 08/04/21 Revision: 09/28/21 Intervention: Inspect feet daily for open areas, blister, edema, or redness (initiated 08/04/21) to be completed by CNA, LPN, RN. Following the review of the care plan on 03/19/24 the surveyor requested the Director of Nursing (DON) and MDS/Care Plan Coordinator to provide documentation of the daily inspection of the feet of Resident #1. Following the DON review, it was revealed that there was no documentation of daily foot inspections.

Based on staff interviews, observations, and clinical record review, the facility failed to provide complete and correct Cardiopulmonary Resuscitation (CPR) in accordance with healthcare professional standards of practice, the resident's documented wishes, and physician's order for 1 of 3 residents reviewed for emergency care (Resident #1). Resident #1 had a full code status effective [DATE]. On [DATE] at 12:24 PM the resident was unresponsive and had no pulse or respiration. A code blue was called, and CPR was initiated consisting of chest compressions only, no rescue breathing was performed due to no bag-valve-mask (also known as an Ambu bag) available. When Emergency Medical Services (EMS) arrived, they pronounced the resident had expired. The facility's failure to initiate and perform correct CPR in accordance with healthcare professional standards of practice, with the resident's expressed wishes and physician's order, resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE]. On [DATE] at 2:30 PM, the Immediate Jeopardy was removed after implementation of an acceptable Removal Plan was verified, and the scope and severity was reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). There were 59 out of 76 residents with a full code status at the time of the survey on [DATE]. The findings included: The Adult Basic Life Support Algorithm for Healthcare Providers as per the American Heart Association at https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/Algorithms/AlgorithmBLS_Adult_200624.pdf includes for person with no breathing, pulse not felt, the next step is to start CPR and perform cycles of 30 chest compressions and 2 breaths. Bag-valve-mask (BVM), also referred to as a Ambu bag is a handheld device used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths (physiopedia.com). Non-rebreather masks are used to deliver oxygen therapy to people who require high-concentration oxygen but aren't in need of breathing assistance (healthline.com). Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE] included: In the absence of physician's order for do not resuscitate (DNR) the facility will immediately begin CPR. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if the resident responds. Review of the facility policy titled, Emergency Equipment Cart with an effective date of [DATE] included the Center will maintain an emergency equipment cart. Procedure: 1. Center will establish an emergency equipment cart that is accessible to nursing stations. 2. Check the emergency cart daily. 3. Restock/replenish the emergency cart following use and as needed. The closed record review for Resident #1 revealed the resident was originally admitted to the facility on [DATE] with the most recent Readmission on [DATE]. Diagnoses included: Crohn's Disease, Ileostomy, Malignant Neoplasm of Thyroid Gland, Type 1 Diabetes Mellitus, Hypertension, Phlebitis and Thrombophlebitis of Deep Vessels of Lower Extremity, Malignant Neoplasm of Female Breast, Major Depressive Disorder, and Covid-19. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. The MDS also revealed the resident required extensive assistance in ADLs (Activities of Daily Living) including bed mobility, transfers, dressing, and personal hygiene. Review of physician's orders for Resident #1 revealed an order dated [DATE] for a Full Code. Review of the care plan for Resident #1 with a revision date of [DATE], and a focus on Advanced Directives: Full Code, with the goal to have advance directives followed. Interventions included: Discuss advanced directives with resident and or resident's representative. Review of the Nursing Progress notes for Resident #1 dated [DATE] included: 12:06 PM patient blood pressure ,d+[DATE], pulse 64, temperature 97.0, O2 sat (Oxygen Saturation) 98% room air, blood sugar 141, family member at bedside, patient alert and responsive, no distress noted. 12:10 PM patient family member left the facility. 12:24 PM patient noted to be unresponsive without any pulse. Code Blue called, status verified by two nurses at 12:24 PM CPR initiated and 911 call placed. 911 arrived to facility to take over resident care. 12:25 PM doctor notified. 12:43 PM 911 pronounced the passing of patient. 1:00 PM family member notified. Review of the facility investigation revealed a Code Blue Documentation Nurses Note dated [DATE] revealed: Witnessed- yes. Time Code Blue was called - 12:35 PM. Time CPR started 12:35 PM. Type of Ventilation (blank). Vital Signs 12:35 (PM) BP (Blood Pressure) 0, Pulse 0, Respirations 0, O2 Sat 0, Bedside glucose 121 drawn at 12:24 PM. Resuscitation terminated 12:43 PM. During an interview conducted on [DATE] at 12:20 PM with the Assistant Director of Nursing (ADON), she stated she was assigned to Resident #1 on [DATE]. She stated there was a family member in the resident's room earlier that day. On [DATE] at 12:24 PM she found the resident unresponsive in their room, checked for a carotid pulse, checked for responsiveness, unsure if she checked for an obstruction in the resident's mouth at this time, and did not see a rise/fall of chest, code blue called. She stated the chart was verified with 2 other nurses that the resident was a full code. Immediately she started chest compressions. The Director of Rehab (DOR), the Unit Manager (UM), and the DON were present. She stated that the Code Blue Documentation Nurses Note was completed by her after the paramedics came in and took over the care of the resident. During the code blue while CPR was performed by the ADON, another staff member in the room was taking notes. When asked if she still had the notes she said no. When asked who was the person taking notes she said she did not remember. When questioned about the code blue documentation nurses note, she stated she had put the incorrect time the code was called, and the CPR was started as 12:35 PM. It should have been 12:24 PM. At 12:35 PM the Executive Director notified the physician. The family was notified at 12:35 PM, and at 1:00 PM they were notified the resident passed. She stated that there was no Ambu-bag located on the crash cart. When asked where back up supplies for the crash cart are kept, she stated in the central supply/clean utility room. When asked if the resident had a non-rebreather mask placed on her during the code blue, she stated she believes it was the unit manager who instructed staff to place a non-rebreather mask with 15 liters of oxygen on the resident. All staff members present in the room were taking turns to do the chest compressions. She stated the paramedics arrived (unsure of the time) and at 12:43 PM the paramedics pronounced the resident deceased . When asked if she was following the CPR standard of practice for healthcare professionals, she said yes, she believed she was except the resident did not receive the 2 breaths because they did not have the Ambu bag available. During an interview conducted on [DATE] at 1:05 PM with the Unit Manager (UM), she stated there was no Ambu bag available, chest compressions were being performed, she checked the resident's airway to make sure there was no obstruction, and a non-rebreather mask was placed on the resident with oxygen at 15 liters. Within approximately ,d+[DATE] minutes the resident vomited, the non-rebreather was removed and a nasal canula was applied and the resident and her head was turned to the side, at the time the resident's head was turned to the side by the DOR, the UM had checked the resident's airway and there was no visible obstruction, she did not perform a finger sweep of the resident's mouth as she was continuously providing chest compressions. The paramedics arrived approximately ,d+[DATE] minutes later and the paramedics instructed the staff to stop CPR and they applied the AED pads and there was no indication to shock the resident. The paramedics were aware the resident was a full code and did not perform any chest compressions or rescue breathing. When asked if she had followed the standard of practice for CPR for healthcare professionals, she stated yes. When asked if that included rescue breathing, she stated no because we had no Ambu bag, but we did apply oxygen to the resident. During an interview conducted on [DATE] at 1:20 PM with the Director of Nursing (DON), she stated she arrived at the resident's room just after the code blue was called. She and the ADON were looking for the Ambu bag on the crash cart and there was no Ambu bag found on the crash cart. She left the room to look for an Ambu bag in the back up supply room (Clean Utility Room) near the nursing station and no Ambu bag was found. She then looked in the main central supply room and there was no Ambu bag there. The Central Supply Clerk helped her locate an Ambu bag in the back up supply room (Clean Utility Room). She had brought the Ambu bag to the resident's room as the paramedics had arrived at the resident's room. When asked if the staff had followed the standard of practice for CPR for healthcare professionals, she stated yes except for the 2 breaths with an Ambu bag, because there was no Ambu bag available. When asked about the root cause analysis, she stated she identified that the cause was the Ambu bag not present on the crash cart and the backup supply of an Ambu bag was not easily accessible in the back up supply room (Clean Utility Room). She stated there are checks of the crash cart by the UM or the ADON daily and this is signed off on the flow sheet (the flow sheet is located on the crash cart). There is only 1 crash cart for the facility. It is the responsibility of the unit manager/ADON to restock a crash cart after a code. During a telephone interview conducted on [DATE] at 5:30 PM with the Director of Rehabilitation, he stated he was involved in the code for Resident #1. He stated he took over chest compressions briefly when the ADON became fatigued. He left when the UM took over doing chest compression. He stated no rescue breaths were given while he was in the room. He did not see an Ambu bag. Normally the Ambu bag would be used during CPR in a healthcare setting. When asked if he noticed the resident vomiting, he said there may have been some drool coming from the resident's mouth. When asked if the standard of practice for CPR for healthcare professionals was followed, he said yes. When asked if any rescue breathing was provided to the resident during CPR he stated no, the resident had on a non-rebreather mask. An interview and a review of the Emergency Equipment Cart Checklist, was conducted on [DATE] at 11:30 AM with the Unit Manger. When asked about the Emergency Equipment Cart Checklist for the dates of [DATE] and [DATE], she stated that either she or the ADON verifies the Emergency Equipment Cart Checklist is completed (whoever arrives at the facility first). She stated she completed the Emergency Equipment Cart Checklist on [DATE] in the morning. When asked why there were no initials for the Ambu bag on [DATE], she stated I just forgot to initial for the Ambu bag. When asked why there was a check mark instead of her initials for the Ambu bag on [DATE], she stated the Emergency Equipment Cart Checklist was completed by her on [DATE] in the afternoon, after the code blue had been finished, and that she had placed a Ambu bag on the cart. Review of the Fire Rescue report, dated [DATE], revealed the following information: Dispatched at 12:34:54; at Patient at 12:41:00. Primary Impression: Dead on scene, exam/eval only Narrative: Responded to a cardiac arrest . On arrival made contact with nursing staff who were performing CPR. Nursing staff could not give a time frame on last seen responsive, but stated it was greater than 30 minutes. Assessed patient, patient was pulseless, apneic, with fixed and dilated pupils. Placed pads and leads on patient, asystole was confirmed. Patient was pronounced dead on scene. **The Immediate Jeopardy Removal Plan was submitted by the facility and implementation was verified by the survey team on [DATE]. The actions included: An Ad Hoc QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance on [DATE] and [DATE]. Root Cause Analysis was performed with addendum on [DATE] which identified the problem as CPR conducted with missing ambu bag on [DATE], and the root cause was identified as a system failure on checking/restocking the emergency cart. The Performance Plan was implemented that included: -An audit of the facility licensed nurses' CPR certification were reviewed and current as of [DATE]. On [DATE], review of 24 of 24 facility licensed nurses revealed all nurses had a current Basic Life Support (BLS). -Licensed nurse education to include CPR Policy/Procedure, emergency cart policy and Abuse/Neglect/Exploitation/Misappropriation beginning [DATE]. -Newly hired licensed nurses will receive education upon hire to include CPR Policy/Procedure, abuse/neglect, emergency cart policy. -Mock Code Blue drills initiated on [DATE], with licensed nurses. -Code blue drills will continue with licensed nurses bi-weekly on each shift for 2 months or until QAPI committee determines substantial compliance has been achieved. On [DATE], review of 24 of 24 licensed nurses' education revealed the following: On [DATE] education on Abuse/Neglect/Exploitation/Misappropriation was provided to 85 employees. On [DATE], [DATE] and [DATE], education on location of back up supplies for the crash cart, mock code blue drill, performing effective CPR was provided to 18 out of 24 nurses in person and 6 nurses via telephone. On [DATE] education on location of back up supplies for the crash cart, mock code blue drill, performing effective CPR was provided to nurses that had already received the training on [DATE] or [DATE]. On [DATE], interviews were conducted with 9 of the 24 licensed nurses, including one new hire, who all stated they received education on back up supplies for the crash cart, performing effective CPR, and had attended a mock code blue drill. Review of the schedule for the biweekly mock code blue drills revealed the following: [DATE] night shift, [DATE] day shift, [DATE] day shift, [DATE] night shift, [DATE] day shift, [DATE] night shift, [DATE] night shift, [DATE] day shift, [DATE] day shift, and [DATE] night shift. -The DON/ADON/Designee is to validate the Emergency Cart checklist is completed daily until substantial compliance is met. On [DATE], review of the Emergency Cart checklist from [DATE] to [DATE] revealed each item was initialed for each day. -In addition to the plan implemented on [DATE], during the [DATE] QAPI meeting, the following was added to the plan: The Emergency Equipment Cart was secured on [DATE], and the policy was updated on [DATE]. On [DATE], an observation was made of the Emergency Equipment Cart, and it was secured and contained two Ambu bags (Photographic evidence obtained). The updated policy was reviewed, and it included that the Cart 200 nurse for the 7PM to 7AM shift is designated as Charge Nurse. Duties include checking Emergency Crash Cart to ensure accurate placement and functionality/content of equipment. The Cart 200 nurse will document on the Emergency Cart checklist the findings of the inventory.