Every finding on record at Balanced Healthcare

The facility failed to report sexual abuse between two residents (#1 and #2), out of six residents sampled for abuse allegations, within the required timeframes. Findings included:On 7/9/26 at 11:49 AM an interview was conducted with Resident #2. Resident #2 stated he would have sexual interactions with Resident #1 a few times a week. Resident #2 stated Resident #1 enjoyed the interaction between them. On 7/9/26 at 12:21 PM an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN stated Resident #2 has behavior issues and has multiple sexual behaviors towards staff and residents documented. Staff A, LPN stated on the morning of 6/9/26 around 5:55 AM during medication pass she witnessed Resident #2's brief down around the ankles and standing over Resident #1's bed. Staff A, LPN stated Resident #2 was bent over with the hand under the covers of Resident #1 and stopped the situation as soon as the staff member witnessed it. Staff A, LPN stated shortly after the incident occurred, she saw the Assistant Administrator (AA) in the hallway and advised her of what was seen. Staff A, LPN stated the AA instructed the staff member to document the issue while the AA called psychiatry. Staff A, LPN stated later that evening for their next shift during report, Staff B, LPN/Supervisor (LPNS) was not aware of the incident or if anything had been done with Resident #1 and Resident #2. Staff A, LPN stated Staff B, LPNS advised her she had done everything she was supposed to do since it was reported to the AA and was documented in Resident #2's chart. Staff A, LPN stated three days later, the AA stopped her at the end of their shift to find out what had happened due to the progress note that was entered on 6/9/26. Staff A, LPN stated when they spoke with the police on 6/12/26, Staff A, LPN told the authorities she had informed the AA on 6/9/26 of the incident within 15 minutes of it occurring and did not delay in reporting the issue to administration.On 7/9/26 at 1:04 PM an interview was conducted with the facility's Mental Health Therapist (MHT). The MHT advised they were not made aware of the situation until the current date. The MHT stated even though it is not a requirement to notify them of the assault, it is best practice to have been notified so they can provide cognitive behavioral therapy for both Resident #1 and Resident #2. The MHT stated they do need to be notified of care plan changes and was not notified on any changes to Resident #2's care plan for the most recent behavioral interventions that were put into place related to sexual behaviors. The MHT stated Resident #2 has had a decline in health and increase in behaviors ever since they started seeing the resident. The MHT said Resident #2 participates in therapy to a degree but is unsure of the last time they provided therapy care to the resident. The MHT stated Resident #2 is known for having sexual behaviors towards staff and residents and Resident #2 was not a safety risk as long as he remains on 1:1 but is a risk to vulnerable residents if Resident #2 was not on 1:1.On 7/09/2026 at 2:05 PM an interview was conducted with the Nursing Home Administrator (NHA), Regional [NAME] President (RVP), Risk Manager (RM), and the Director of Nursing (DON). The RM stated they review progress notes every morning; however, they did not see the progress notes about the sexual abuse allegation on 6/9/26 between Resident # 1 and #2 and only saw part of the note which stated Resident #2 was standing over Resident #1. The RM stated they attempted to gather more information by contacting Staff A, LPN who made the allegation, but Staff A, LPN did not respond. The RM discussed this allegation in the morning meeting on 6/10/26. The risk manager said after the morning meeting on 6/10/26 they continued investigating the allegation before calling the authorities. The RM stated upon further investigation, they finally read the full progress note stating the resident was fondled by another resident on. The RM claimed this was never brought to their attention by anyone, including Staff A, LPN who reported it. The RM asked Staff B, LPNS if they knew about this to which the staff member responded yes. The RM then informed the DON on 6/11/26 when she found the full note about the resident fondling the other resident. The RM stated they did not see the note on 6/10/26 even though they review the facility's health system every morning. The RVP stated the RM should have reported and called the proper authorities as soon as they were aware of the situation, not to do an independent investigation first. The RVP stated even though Resident #2 was having documented sexual behaviors towards staff and residents on 5/31/26 and 6/6/26, Resident #2 was not physically abusing the other residents, and their sexual behaviors were harmless. The RVP stated the sexual behaviors could not be interpreted as abuse if the residents cannot even comprehend they were being abused. The RM stated this resident-to-resident allegation was an oversight. The RVP stated they could improve their process and believes the facility was not properly reviewing their notes in the facility's health system because the NHA and RM would have seen the progress notes. The RM said they did not have documented investigations for the incidents occurring on 5/31 and 6/8, and no interventions were put into place after the incidents on 6/6 and 6/8.On 7/9/26 at 3:30 PM an interview was conducted with the AA. The AA stated Staff A, LPN came to her on the morning on 6/9/26 and advised of Resident #2 fondling himself, but did not know Resident #2 was in Resident #1's room. The AA stated they instructed Staff A, LPN to make a progress note and the AA would contact Psychiatry. The AA stated after Staff A, LPN advised of Resident #2's behavior, the AA went and told the DON [Resident #2's Name] is being extra again today, let's contact psych. The AA stated once she realized Resident #2 was in Resident #1's brief on 6/12/26 they called the RM then the police and went from there.On 7/9/26 at 3:38 PM an interview was conducted with the NHA. The NHA stated their expectation was for the AA to notify them of the situation had they clearly understood what had happened with the situation, and to have escalated the situation especially after reviewing the progress notes made. The NHA stated an ADHOC was conducted on 6/19/26 for this incident about timeliness of reporting by staff, proper investigating, and proper actions to be taken to all staff. Despite this ADHOC being conducted on 6/19/26, the AA was not at this particular meeting, but they are sure they have the AA's education somewhere.A Copy of the training for the ADHOC for the AA was requested but not provided.Record review showed Resident #1 was admitted [DATE], with diagnoses including legal blindness, unspecified dementia, paranoid schizophrenia, major depressive disorder, other anxiety disorders and unspecified intellectual disabilities.A Quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 08, indicating moderately impaired.The resident's Care Plan documented the resident having impaired cognitive function, impaired thought processes related to dementia, and to supervise the resident as needed. Further review of Resident #1's care plan revealed the resident has potential for psychosocial well-being related to anxiety and depression.Review of Resident #1's progress notes revealed a palliative care note from 6/24/26 as; Resident #1 is a poor historian due to cognitive/psychiatric impairment.A 6/12/26 psychiatry note revealed Resident #1 was reported to being unstable, and the Resident being a victim of sexual inappropriateness by another resident, and Resident #1 being confused at baseline.Record review showed Resident #2 was admitted [DATE], readmitted on [DATE], with diagnoses including generalized anxiety, primary insomnia, major depressive disorder, Alzheimer's disease, paranoid schizophrenia, bipolar disorder, unspecified dementia, unspecified psychosis, restlessness and agitation.A Quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 11, indicating moderately impaired.The resident's Care Plan documented the resident has a potential for psychosocial distress related to a history of sexual abuse, and psychosocial well-being problems related to anxiety due to trauma from childhood. Further review of Resident #2's care plan revealed the resident has behaviors of going into other resident's rooms, going through their belongings, putting on others clothing and using their things. Resident #2 is also documented to being a res-to-res aggressor.A copy of Resident #2's care plan was requested and not provided.Review of Resident #2's progress notes revealed a behavior nursing note by Staff A, LPN on 6/1/26 revealing Resident #2 was noncompliant with staff refusing to put on brief and to cover themselves. Resident #2 was documented to making sexual statements towards staff and residents, refusing to stay in his room until he put his briefs back on.A psychology progress note, dated 6/2/26, documented Resident #2 was having depressive symptoms of isolation, inappropriate behaviors with staff and other residents, and irritability ongoing for the last few weeks with increased documented behaviors.A 6/6/26 behavior note made by Staff A, LPN revealed Resident #2 was observed in his roommate's bed, and it was explained that behavior was inappropriate.A 6/9/26 at 6:24 AM a nursing note was documented by Staff A, LPN stating the following: THIS RESIDENT WAS WITNESS STANDING OVER ANOTHER REISDENT WITH HIS BRIEF DOWN AROUND HIS ANKLES FONDLING HIS GENITALS. HE WAS ASKED TO GO BACK TO HIS ROOM THIS REISDENT IS SEXUALLY INAPPROPRIATE WITH RESIDENTS AND STAFF. At 6:45 AM on 6/9/26 a following nursing note made by Staff A, LPN stated the following: RESIDENT WAS INSIDE [RESIDENT#2'S ROOM] BRIEF FONDLING HIM. A nursing progress note dated 6/11/26 revealed Resident #2 was on 1:1.A psychiatry note dated 6/12/26 revealed Resident #2 was being seen due to being unstable and having been more sexually inappropriate with another resident.A review of the facility's Quality Assurance Meeting Ethics and Compliance Meeting- AD HOC, dated 6/19/26, revealed the AA was not in attendance for the meeting.A review of the facility's P&P Adverse Event Reporting policy, dated 5/1/26, revealed the following: It will be the policy of this facility to ensure that events determined to be adverse are timely identified, investigated, and reported to the facility risk manager as defined by the Florida statutes. In the event of a potential adverse event, the facility administrator will be notified as soon as possible.A review of the facility's P&P ANE and Investigations policy revealed the following: It will be the policy of this facility to ensure that all alleged violations of Federal or State laws, which involved mistreatment, neglect, abuse (verbal, mental, physical, sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/Abuse Coordinator/Designee. Appropriate agencies will be notified in accordance with existing laws. When any allegation or confirmed abuse, neglect, mistreatment or exploitation of a resident occurs including suspicion, the appropriate state agencies will be notified immediately. All allegations of abuse, neglect, mistreatment, exploitation of residents' funds or property are to be reported immediately to the Administrator and according to Federal and State Regulations. The facility will notify the Department of Children and Families as practically possible and file the Federal Immediate Report to the State Agency.

Based on record reviews, observations, and interviews the facility failed to provide adequate supervision to two (#4 and #5) of two residents which resulted in an physical altercation perpetrated by one resident (#4).Findings included:Review of the facility's reported incident log showed a resident - resident physical abuse incident had occurred on 3/8/26 between Resident #4 and Resident #5.On 3/26/26 at 10:37 a.m. Resident #5 was observed in room lying on bed with eyes closed.Review of Resident #5s progress notes showed a note dated 3/8/26 at 10:11 p.m. The note referred to a linked incident: Resident to Resident 3/8/26 at 4:20 p.m. go to incident. The note revealed Staff C, Licensed Practical Nurse (LPN) was sitting at desk charting with staff members then writer looked up and see (Resident #5) get hit on the right side of the face by another resident. CNA and writer got up and redirected resident to room, (Resident #5) stayed in his chair till we came to check on him, (Resident #5) has no complaints of pain or discomfort.Review of a psychiatry provider note dated 3/9/26 showed during the last visit Resident #5 was stable and was recently in a physical altercation with another patient where (Resident #5) was the victim. The resident denied pain and did not know why he was hit, doesn't worry this will happen again, (and) appeared to be at psychosocial baseline. Review of Resident #5s admission Record showed the resident was admitted on [DATE] and 5/28/25. The record revealed diagnoses not limited to psychotic disorder with hallucinations due to known physiological condition, generalized anxiety disorder, paranoid schizophrenia, recurrent moderate major depressive disorder, and pseudobulbar affect. Review of Resident #5s comprehensive assessment revealed a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicative of a moderate cognitive impairment.Review of Resident #5s care plan revealed the following focuses and interventions:Has the following behavior problem(s): rights on wall with pens or markers, places pictures on wall with toothpaste, howls and makes disruptive noises at times, will sit down in various places in the halls, scratches walls, floors, and ceilings with fork or spoon, hear's things, resident to resident non-aggressor, will take foods from meal trays and discard in room trash at times, continues to be non-compliant with fluid restriction, continuously clapping hands/ screaming, calling 911 stating (pronoun) drink soap, (and) throwing stuff on floor. The focus was revised on 3/23/26.Has a communication problem due to impaired cognition, revised on 10/01/24.2.Review of Resident #4s progress notes showed on 3/8/26 at 4:30 p.m. Resident remains in room, 1: 1 supervision in progress, no further aggression nor combative Behavior noted. Resident whom affected by Behavior denied any pain nor discomforts.Review of Resident #4s progress notes showed on 3/8/26 the psych provider returned call and was updated on the resident's behavioral status as well as follow up (f/u) interventions a well as 1:1 supervision and the facility was notified of psych intent to follow up with a telehealth visit tomorrow.Review of psychiatry note on 3/9/26 showed the reason for the encounter was it had been reported Resident #4 was unstable requiring psychiatric assessment, as per collected information patient was recently in a physical altercation where he was the aggressor. Patient stated the other patient had rattle snakes who were trying to hurt him. The note revealed per collected information and interview it appears that patient is unstable.On 3/26/26 at 10:34 a.m. Resident #4 was observed in room lying on bed. The resident stated the facility took good care of him and no behaviors were observed. The resident's roommate was lying in bed and there was no observed interaction between the two residents.Review of Resident #4s admission Record showed the resident was admitted on [DATE] and 3/14/26. The record included diagnoses not limited to unspecified dementia unspecified severity with other behavioral disturbances, reoccurring mild major depressive disorder, other specified persistent mood disorders, and generalized anxiety disorder.Review of Resident #4s quarterly Minimum Data Set (MDS) on 2/17/26 showed the resident's Brief Interview of Mental Status (BIMS) score was 11 of 15 indicating a moderate cognitive impairment. The comprehensive assessment revealed the resident did not exhibit any behaviors during the assessment period. The facility was requested to provide the BIMS section C of MDS dated [DATE]. The facility provided an incomplete BIMS assessment dated [DATE].Review of Resident #4s care plan included the following focuses with related interventions:Has impaired cognitive function/ impaired thought processes related to (r/t) dementia.Is/has Potential to be physically aggressive related to (r/t) dementia and poor impulse control - punched mirror in bathroom breaking glass. The focus was initiated in revised on 5/12/25.Has potential for psychosocial well-being problem related to (r/t) anxiety (and) depression.Has the following behaviors: wandering/exit-seeking, attempting to take television (TV) down on smoke patio, Risk for harm to others/ physically aggressive, lying in shower letting water run over him, striking peer with wet floor sign, pulling fire alarm, wandering about taking cups (and) drinks from rooms of peers, takes personal clothing from rooms and places on clothing in other places, ambulates about without a shirt, pulling call light out of wall, broke mirror in bathroom and attempted to break mirror in room over a dresser, slapped peer, and grabbed peer by wrist. The focus was revised on 1/26/26. The interventions revealed the following: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, in situations. Document behavior and potential causes. An interview was conducted on 3/266/26 at 11:23 a.m. with Staff D, Certified Nursing Assistant (CNA). The staff member stated Resident #4s behaviors were walking around and stealing food, staff have to constantly tell resident to get out of other rooms. The staff member stated Resident #5 has the behaviors as walking up and down hallways, yelling and screaming. The staff member was not in attendance for the incident involving Resident #4 and #5.An interview was conducted on 3/26/26 at 12:20 p.m. with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member reported nurses document every shift if a resident was on 1:1 or on a 15-minute form if on 15 minute checks. During a continued interview on 3/26/26 at 1:13 p.m. the staff member reported not being at facility during the altercation between Resident #4 and #5 but had heard Resident #5 had rolled up (to nursing station) in wheelchair, Resident #4 had been seen walking in hallway and hit Resident #5, saying he did not like Resident #5. Staff A stated there had never been a problem between the two residents before, were roommates.An interview was conducted on 3/26/26 at 1:48 p.m. with the Risk Manager (RM), Regulatory Compliance Consultant (RCC) , Director of Nursing (DON) and the assistant DON (ADON). The RM reviewed the incident between Residents #4 and #5. The RM reported the assigned CNA (Staff B) and Staff C, LPN, on Sunday 3/8/26, were at nursing station and Resident #5 was sitting near nursing station in wheelchair trying to talk with the staff members. Resident #4 was seen walking down hallway from conference room area, saw Resident #5, stopped to say something to the resident and punched Resident #5 to the right side of face. The RM stated Staff B didn't know if it was closed fist or open handed. Staff C had reported seeing the hit and following the incident asked why, Resident #4 had responded I don't like him. The RM stated Resident #4 does not have a lot of language; one or two words. The RM stated the psych Nurse Practitioner (NP) had been rounding on 3/8/26 and when asked about the incident Resident #4 had reported rattlesnakes were trying to get Resident #5. The RM reported speaking with Resident #4 on 3/8/25 and couldn't get any information was babbling. The RM clarified the assistant administrator had reported the incident and the RM interviewed Resident #4 on Monday morning (3/9/26) and the resident didn't remember the incident. The day after the event the RM reported interviewing Staff B and Staff C. Staff C had reported sitting at desk charting and saw Resident #5 get hit on right side by Resident #4, the staff member jumped up, separated the residents and placed Resident #4 on 1:1 supervision. The RM did not know who had done the 1:1 supervision for Resident #4 immediately following the incident. The RM stated the nurse documents on 1:1 every shift and if a resident had behaviors the aide would notify the nurse. The RM stated Resident #4 was on 1:1 supervision until the next day, 3/9/26. The RM stated Staff B reported Resident #5 was at the nursing station, Resident #4 was walking in the hallway and hit Resident #5 on the right side of face, Staff B and C separated the residents and Resident #4 was placed on 1:1. The RM reported no one else had witnessed the incident and had not interviewed any other staff as Staff B had witnessed it. The RM allowed this writer to review Staff B's written statement, Resident #4 (statement identified resident by room number) was walking in hallway, walked toward Resident #5 and punched him, resident back turned so couldn't see if it was open or closed fist but Resident #5 hat came off after the punch. The nurse asked Resident #4 why and the resident said he didn't like (Resident #5). The RM did not have a written statement from Staff C who also witnessed the incident. The RM stated the incident had been refuted and being schizophrenic they can be very impulsive. The RM stated the incident was refuted based on policy Resident #4 did not have intent, no harm to Resident #5, and Resident #5 had told psychiatry (the next day) he had seen rattlesnakes.A request for the staff schedule on 3/8/26 was made during the RM interview, the facility failed to provide it.Review of policy - Abuse, Neglect and Exploitation, revised 11/29/22, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policy and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined Abuse as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse in certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.VI. Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents.

Based on observations and interviews, the facility did not ensure a clean, sanitary, and homelike environment for three (1 [NAME] [also known as the secured unit], 1East, and Lifestyle 2) out of six Wings. Findings included: On 11/4/24 at 10:13 a.m., a tour of the 1 East wing was conducted. Observations of room [ROOM NUMBER] revealed the privacy curtains between bed A and B with stains and dirty. Further observations of room [ROOM NUMBER] revealed paint was peeled from the ceiling above the window. An observation of the bathroom shared by rooms [ROOM NUMBERS] revealed a detached shower head, white washcloth, and a light cover fixture on the shower seat. Further observations of the floor of the shower revealed multiple unknown particles and debris that were black and white colored. Further observations of the bathroom revealed multiple brown stains on the seat of the toilet. On 11/4/24 at 10:27 a.m., an observation of room [ROOM NUMBER] revealed two dresser knobs were separated from the drawer. An observation of the window revealed multiple, individual blinds were broken and/or missing. Observations of the ceiling, above the window, revealed paint was peeled from the ceiling and pieces of plaster were separated from where the wall meets the ceiling. An observation of the bathroom revealed the border trim was separated from the wall. Further observation of the bathroom revealed a brown and yellow substance on the front of the sink. A blue-colored cleaning rag was observed on one of the residents' bedside table. On 11/4/24 at 10:37 a.m., an observation of room [ROOM NUMBER] revealed one of the dresser knobs was separated from the drawer. An observation of the area above the window revealed the paint was separated from the ceiling in multiple areas. An observation of the floor and the leg of the bedside table, by the B Bed, revealed brown substances in multiple areas. An observation of the bathroom shared by room [ROOM NUMBER] and 103 revealed multiple unknown black particles on the shower floor. An observation of the shower curtain revealed it was dirty and stained. Further observations of the bathroom revealed multiple black particles to the left of the toilet. Another observation of the bathroom revealed a used paper towel on the floor and toilet paper between the tank and seat. On 11/4/24 at 10:46 a.m., an observation of room [ROOM NUMBER], to include the window, revealed two blind panels were missing. Further observation of room [ROOM NUMBER] revealed the paint surrounding the air conditioning unit was separated and peeled from the wall. Multiple holes were observed in the wall by the air conditioning unit. On 11/4/24 at 10:52 a.m., an observation of the bathroom, shared by room [ROOM NUMBER] and 101 revealed a hole in the ceiling surrounded by a black colored ring. Further observation of the bathroom revealed the bottom of the shower curtain appeared dirty with a dark brown and black color. An observation of the bathroom floor revealed multiple black, white and grey colored debris and unknown particles. On 11/4/24 at 11:16 a.m., an observation of room [ROOM NUMBER] revealed the ceiling closest to the bathroom, had stains that were dark brown and black colored. Further observation of that area revealed a crack/small opening where the wall and ceiling met. The same wall observed had cracks towards the top of the ceiling. An observation of the bathroom revealed a shower curtain stained with a dark brown substance. Observations of the ceiling, above the window in the bathroom, revealed an open area with exposed metal pieces. The windowsill in the bathroom had a piece of knotted hair that was observed. Further observation of the bathroom ceiling revealed a hole around the water sprinkler where the paint was separated from the ceiling. On 11/4/24 at 11:19 a.m., an observation of room [ROOM NUMBER] revealed the wall on the left on the B bed side had multiple scratches which caused the paint to separate from the wall. An observation of the bathroom revealed the sink was full of liquid that contained chunks of a white and yellow colored substance. An interview with the residents in room [ROOM NUMBER] revealed the sink had not been functional for weeks. They stated the maintenance team was made aware, but the sink was not fixed. On 11/4/24 at 11:25 a.m., an observation of room [ROOM NUMBER] revealed the bottom dresser drawer was not there. Further observations of room [ROOM NUMBER] revealed the wall behind the head of the bed, on the B side, had multiple scratches which caused the paint to separate from the wall. On 11/4/24 at 11:44 a.m., an observation of the floor in room [ROOM NUMBER] revealed a dead cockroach, food wrappers and other unidentified items. Further observation of room [ROOM NUMBER] revealed missing and broken window blinds in the A bed area. Observations by the window, on the B bed side, revealed black spots and paint separated from the ceiling. On 11/4/24 at 12:00 p.m., an observation of room [ROOM NUMBER] revealed a hole in the wall, to the right of the outlet by the air conditioning unit. Further observation of that area revealed cracks and paint separated from the wall by the door frame of the bathroom. An observation of D bed revealed wood laminate and plaster was missing from the bottom of the foot of the bed. Further observation of room [ROOM NUMBER] revealed a dark brown substance on the floor, towards the bathroom door. Observations in the bathroom revealed the border trim had holes and started to separate from the wall. Small cracks and holes were observed by blue and white colored tile on the bathroom wall. A screw on the right side of the toilet was observed on its side, laying on the bottom part of the toilet. An observation of the ceiling, in the bathroom of room [ROOM NUMBER], revealed a small hole and black spots surrounding the water sprinkler. On 11/4/24 at 12:16 p.m., an observation of the 1 East hallway, between rooms [ROOM NUMBERS], revealed caution tape and wet floor signs on top of missing tiles on the floor and wall. On 11/4/24 at 12:54 p.m., an observation of room [ROOM NUMBER] revealed a brown substance on the blinds closest to the bathroom door. Further observation of room [ROOM NUMBER] revealed a hole above the outlet, to the right of the air conditioning unit. Another hole was observed to the right of the air conditioning, between the unit and the outlet. Observations of the air conditioning revealed the paint around the unit and the outlet was separated from the wall. On 11/4/24 at 1:02 p.m., an observation of the assisted dining area on the first floor revealed multiple ceiling tiles with small to large water stains. The ceiling tile above table 10 was observed with a large water stain that covered the majority of the tile and appeared warped/bubbled. An observation of the ceiling above the exit sign/door revealed a large ceiling tile was missing. On 11/4/24 at 1:47 p.m., an observation of the end of the 1 East hallway, in front of room [ROOM NUMBER], revealed a dead cockroach, [Vendor name] individual packet, and other unidentified items/debris. On 11/5/24 at 10:18 a.m., an observation of room [ROOM NUMBER] revealed the area above the window had paint that was separated from the ceiling. Observations of multiple areas in the ceiling above the window were cracked and had chipped paint/plaster. On 11/5/24 at 3:20 p.m., an observation was made in room [ROOM NUMBER], Lifestyle 2 unit. An observation of the Air Conditioner (AC) revealed two wet towels underneath the unit. The towels observed were slightly discolored with a tan to light brown color, and saturated with water. The residents in room [ROOM NUMBER], Lifestyle 2 stated the AC unit had been repaired twice, but continued to leak water. The residents stated the staff knew about this and explained they [staff] are the ones who placed the towels under the AC unit. During the interview and observation, a staff member entered the room. The unidentified staff member observed the AC unit and when asked about it she said, Have you seen this place. She stated she would tell the nurse about the AC unit that leaked water. On 11/6/24 at 9:45 a.m., an observation of room [ROOM NUMBER] revealed the sink was fixed and did not have the same concerns that were identified on 11/4/24. The residents in the room stated it was fixed after the observation made on 11/4/24. Further observations of the bathroom revealed the toilet was off center and shifted to the right side. Observations of the call light system in the bathroom revealed it did not have a cord, and it appeared to be separated from the wall. A box of gloves, with a few gloves coming out from the top, were observed on the bathroom floor next to the toilet. On 11/6/24 at 11:39 a.m., an observation of the secured unit in 1 [NAME] revealed the nourishment room ceiling had paint separated from it, and plaster exposed. Patches of exposed plaster and concrete were observed in the ceiling of the nourishment room. On 11/6/24 at 12:00 p.m., an interview was conducted with Staff F, Registered Nurse (RN). He stated room [ROOM NUMBER], in the Lifestyle 2 wing, has a trash can in the room to catch water that comes from the roof when it rains. Staff F, RN stated the ceiling keeps getting patched, but the actual problem has not been fixed. He stated, The room has been that way for a long time. On 11/6/24 at 12:50 p.m., a tour and interview with the Director of Maintenance Director (DOM) was conducted related to rooms in the secured unit and1 West. An observation in room [ROOM NUMBER] in 1 [NAME] revealed the shower area was not clean and when he turned on the water in the shower, there was low water pressure. An observation of room [ROOM NUMBER] in 1 [NAME] revealed the bathroom tiles were separated from the ceiling and yellow-colored spots were observed throughout the ceiling. An observation of room [ROOM NUMBER] in 1 [NAME] revealed the call light was pulled out of the wall. An observation of room [ROOM NUMBER] in 1 [NAME] revealed the bathroom door was not able to close. An observation of room [ROOM NUMBER], in the unit known as Lifestyle 2, was observed with a large, commercial size trash can in the left corner of the room. The ceiling of room [ROOM NUMBER], specifically in the left corner over the trash can, was observed with water damage and paint separated from the ceiling. An interview was conducted with the DOM, who stated his process for identifying concerns is staff putting in a work order in the [Vendor name] system. He stated when a work order is submitted, he will receive an alert to his phone. The DOM stated he was not aware of the concerns observed in the secured unit and in room [ROOM NUMBER], in the Lifestyle 2 unit. He stated he had not been to the secured unit in 3 months, and he was not aware of the issues. The DOM stated, If staff don't put a work order in the system, then I'm not aware that things need to be repaired in the building. On 11/6/24 at 1:29 p.m., room [ROOM NUMBER] had the same concerns observed on 11/4/24. On 11/6/2024 at 2:20 p.m., an interview was conducted with the DOM, in room [ROOM NUMBER] on the Lifestyle 2 unit. The DOM observed the towels under the AC unit. The DOM stated he had not received a work order for this AC unit. The DOM stated anyone in the facility can place a work request for maintenance through the facility's electronic software. The DOM stated he would immediately address the AC unit leaking water. On 11/7/24 at 11:52 a.m., a tour of the assisted dining room on the first floor was conducted with the DOM. An interview with the DOM at 11:54 a.m. regarding the concerns in the assisted dining room revealed the maintenance team who was assisted by the housekeeping staff members, had worked on replacing the ceiling tiles. He stated he thought the staff members were done with the project. The DOM stated he did not follow up to confirm the project was completed. During the observation and interview, 6 ceiling tiles were identified as needing to be replaced. The DOM stated the ceiling tiles were previously wet and needed to be replaced. An observation of the ceiling by the exit sign, in the assisted dining room, revealed there was water dripping into a large, commercial sized garbage can. There was a white towel observed next to the trash can. The DOM stated, I had no idea about the leak in the dining room. He stated the leak could be coming from an air conditioning unit on the 2nd floor. The DOM stated it was not the maintenance team who put the trash can and towel under the missing tile that was leaking water. On 11/7/24 at 12:06 p.m., a tour of the 1 East unit was conducted with the DOM, Area Manager for Housekeeping, and Staff E, Housekeeping. The following rooms/areas, to include bathrooms and hallways, were toured: 101, 102, 104, 106, 107, 108, 110, 112, 113, 117, 118, and 1 East hallway by room [ROOM NUMBER]. Staff E, Housekeeping stated the housekeeping staff work from 7 a.m. to 3:30 p.m. He stated housekeeping staff don't clean while the residents are in their rooms. At 12:09 p.m., the Area Manager for Housekeeping stated they recently had an issue with staffing, specifically in 1 East. She stated a staff member in housekeeping who was previously a, Floater, is now permanently in 1 East as of Monday, 11/4/24. During the tour, a dead cockroach was observed in the bathroom shared by room [ROOM NUMBER] and 103. At 12:11 p.m., the Area Manager for Housekeeping stated two days ago new shower curtains were ordered for the facility. She stated over 40 new privacy curtains arrived this week, however, they are currently in the laundry area. At 12:22 p.m., the DOM stated he was not aware of most of the concerns observed in 1 East, except for the hallway by room [ROOM NUMBER]. He stated the maintenance team is in progress with laying down the tiles in that area. Regarding the concern with the sink in room [ROOM NUMBER], the DOM stated he does not know who repaired it and could not provide a completed work order because he does not have one. The DOM stated he expected Certified Nursing Assistant's (CNA's) and Nursing staff to put in work orders in the [Vendor name] system. He stated all staff members have access to the [Vendor name] system to put in work orders, except for housekeeping and dietary staff. He stated he does not conduct room audits. He stated, Angel rounds would be better. On 11/7/24 at 12:26 p.m., an observation of room [ROOM NUMBER], in the Lifestyle 2 unit, and interview with the DOM revealed the ceiling that is leaking water has been scraped and repatched multiple times. He stated the ceiling will be scraped and repatched again until the roof is repaired. The DOM stated they are currently in a cost comparison/bidding process with two roofing companies. He confirmed the roofing company came to the facility in September and October of this year to assess the roof. On 11/7/2024 at 12:45 p.m., an observation and interview was conducted in room [ROOM NUMBER], Lifestyle 2 unit. The AC unit continued to leak water, with a puddle of water observed close to the electrical cable for the unit. One of the residents, who was in the room during the observation, stated an individual came yesterday to repair the AC unit. An interview was conducted with Staff K, CNA and Staff F, RN. Staff K, CNA stated a work order was placed in the computer. Staff F, RN stated he assisted Staff K, CNA and showed her how to place a work request for room [ROOM NUMBER]'s leaking AC unit. On 11/7/2024 at 1:21 p.m., an interview was conducted with the DOM. The DOM was observed looking at his phone and confirmed he did not see a work order for room [ROOM NUMBER], in the Lifestyle 2 unit. The DOM confirmed he was aware of the leak, as discussed on 11/6/24, and stated he would have the leak immediately addressed. A review of the facility policy titled, Safe and Homelike Environment, with a revised date of 4/11/23, revealed the following, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safety and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Further review of the policy under, Policy Explanation and Compliance Guidelines, revealed the following, 1. The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 9. General Considerations: . e. Report any furniture in disrepair to Maintenance promptly. f. Report any unresolved environmental concerns to the Administrator. Photographic Evidence Obtained.

Based on observation, record review and interview, the facility did not ensure Enhanced Barrier Precautions (EBP) were initiated for three (#163, #138, and #237) of four residents sampled. Findings included: 1. On 11/04/2024 at 9:25 a.m., an observation was made of Residents #237. Resident #237 was in his room with a 1:1 sitter. Resident #237's room had a sign on his door for EBP. The signage was unclear on which resident was on EBP. Staff F, Registered Nurse, stated Resident in bed A was on EBP secondary to a wound. Resident #237 did not have an order for Enhanced Barrier Precautions. A review of Resident #237's physician orders showed the following: Sacrum: Cleanse with normal saline, apply collagen with calcium alginate to wound bed, cover with border foam gauze daily every day shift for pressure ulcer, dated 10/31/2024. 2. On 11/04/2024 at 10:00 a.m., an observation was made of Resident #163. Resident #163 had an intravenous (IV) medication infusion into a venous access catheter to his left arm. Outside Resident #163's room there was no signage for EBP or any personal protective equipment (PPE). A review of Resident #163 Admission Record showed a readmitted [DATE]. Review of the Admission Record showed Resident #163 with diagnoses of but not limited to: Pressure ulcer of right hip, stage two, dated 10/14/2024 Pressure ulcer of the left buttock, stage two, dated 10/14/2024 Pressure ulcer of the left ankle, unstageable, dated 10/14/2024 Pressure-induced deep tissue damage of the right heel, dated 10/14/2024 Pressure-induced deep tissue damage of the left heel, dated 10/14/2024 Pressure ulcer of other site, stage two, dated 10/14/2024 Pressure-induced deep tissue damage of other site, dated 10/14/2024 a review of resident A review of resident #163 physician orders showed the following: Change midline dressing to LUA (left upper arm) weekly, every evening shifts every seven days, dated 11/03/2024. Change needleless access device as needed for midline catheter, dated 11/05/2024. Change administration set for midline catheter every 24 hours intermittent. Label with date/time/initials, dated 11/05/2024. Right hip: Cleanse with normal saline, pat dry, apply Santyl and xeroform, apply bordered gauze daily/as needed every day shift for pressure ulcer dated 10/31/2024. Resident #163 did not have an order for Enhanced Barrier Precautions. On 11/05/2024 at 9:50 a.m., an observation was made of Resident #163. Resident #163 had an IV pole with an empty bag hanging from an IV pole. Outside Resident #163's room there was no signage for EBP or any personal protective equipment (PPE). On 11/06/2024 at 5:00 p.m., an observation was made of Resident #163 with IV medication hanging from an IV pole. Outside Resident #163's room there was no signage for EBP or any personal protective equipment (PPE). 3. 11/06/2024 at 4:45 p.m., an observation was conducted of the Lifestyle One wing. Resident # 138 was observed with EBP signage on the room door. Resident #138 was observed with nursing staff and emergency medics without wearing PPE. An unknown nursing staff member stated Resident #138 will be transferred to the hospital. A review of Resident #138's Admission Record showed an admitted [DATE]. A review of Resident #138's physician orders showed the following: Cleanse left buttocks with normal saline pat dry apply collagen powder apply border gauze dressing every day shift, dated 8/24/2024. Resident #138 did not have an order for Enhanced Barrier Precautions. On 11/07/2024 at 11:10 a.m., an interview was conducted with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). The ICP/ADON said residents would be discussed daily during the facility's clinical morning meetings. Residents newly admitted , new orders for wound care, antibiotics, catheters were reviewed on an ongoing basis. The ICP/ADON stated she would add the residents to her list for EBP and from there would walk to the residents' room to ensure a sign was posted and PPE was provided. The ICP/ADON provided a list of residents on her list with EBP orders. The list provided was a written list of residents on a notepad in the ICP/ADON's handwriting. Residents #163, 237,106, and 138 were not on her list. On 11/07/2024 at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was aware of the findings of missed opportunities to identify current residents requiring EBP isolation. A review of the facility's policy titled, Enhanced Barrier Precautions, implemented on 10/22/2023 showed a policy statement: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy explanation and compliance guidelines include the following: 1. Prompt recognition of need: . c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions- a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds for example chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers and/or indwelling medical devices such as central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes even if a resident is not known to be infected or colonized with a MDRO (multidrug resistant organism). ii. Infection or colonization with any resistant organisms targeted by the CDC (Centers for Disease Control and Prevention) and epidemiologically important MDRO when contact precautions do not apply. . 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed.

Based on observation, record review and interview the facility did not implement a comprehensive person-centered care plan consistent with resident rights for one resident (#51) out of eight residents sampled. Findings included: On 11/04/2024 at 10:30 a.m., an observation and interview were conducted with Resident #51 in her room. Resident #51 stated she did not consistently get her bath twice a week and had not had her hair washed in over two months. Resident #51 stated she would like to have a bath consistently at least twice a week and would like to have her hair washed. Resident #51 stated she had asked for this but stated she did not get this offered to her. Resident #51 preferred to stay in bed and have a bed bath and stated she did not know how they would wash her hair. A review of Resident #51's Admission Record showed diagnoses: Bipolar disorder Type 2 diabetes mellitus Depression Essential hypertension Post-traumatic stress disorder, chronic Paranoid schizophrenia Muscle weakness, general Morbid obesity A review of Resident #51's care plan showed a Focus area of Behavior problem related to false allegations, Androphobia (extreme fear of men), declines care and declines getting out of bed. Interventions include but are not limited to: Two staff persons for all care No Male CNAs (Certified Nursing Assistants) A review of the Minimal Data Set (MDS) dated [DATE] Category C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. In Section GG-Functional Abilities and Goals, item GG0130- Self Care, showed Resident #51 dependent for toileting hygiene, shower/bathe, lower body dressing and putting on and off footwear. A review of Resident #51's past 30-day BB-Bowel and Bladder Elimination task showed Resident #51 had been provided incontinence care by male CNAs. Photographic evidence obtained. On 11/07/24 9:50 a.m., an interview was conducted with Staff O, Minimum Data Set Coordinator/Licensed Practical Nurse (MDS coordinator/LPN). Staff O, MDS/LPN stated Resident #51 was care planned for no male CNAs. Staff O, MDS/LPN reviewed the toileting task documentation and agreed male CNAs had provided incontinence care. Staff O, MDS/LPN stated during the last care plan meeting she recalled Resident #51 stated she was ok with male CNAs but the plan of care decision amongst the facility was to continue with no male CNAs. On 11/07/24 at 12:50 p.m., an interview was conducted with Staff K, CNA. Staff K, CNA stated she did not know of Resident #51 requiring no male CNAs. On 11/07/2024 at 12:53 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J, LPN stated Resident #51 was not to have male CNAs but the resident had not stated any concerns to her. On 11/07/2024 at 12:55 p.m., an interview was conducted with Staff L, CNA. Staff L, CNA stated Resident #51 was not to have male CNAs and stated the resident had not voiced any concerns to her. On 11/07/2024 at 12:57 p.m., an interview was conducted with Staff M. CNA. Staff M, CNA stated she was not aware of Resident #51's concerns for no male CNAs. On 11/07/2024 at 1:25 p.m., an interview was conducted with Staff N, CNA. Staff N, CNA stated Resident #51 had to have no male CNAs in the past but stated she thought not anymore. A review of Resident #51's (Brand name of a nursing worksheet that summarizes patient information) under Special Considerations showed the following: Two persons present for all care No male CNAs 11/07/2024 at 4:00 p.m., an interview was conducted the Director of Nursing (DON). A review of the past 30-day BB-Bowel and Bladder Elimination task was reviewed. The DON agreed male staff members had provided incontinence care but stated the resident had stated she agreed with all staff providing care and would have psychiatry come see the resident for an evaluation on this subject matter. A review of the facility's policy titled, Comprehensive Care Plans revised 7/27/2022, showed a policy statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. The Comprehensive Care Plan showed the following: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma -informed. 2. 3. The comprehensive care plan will describe at a minimum the following: a. The services that are to be furnished to attain or maintain their resident's highest practicable physical, mental and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger- specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re- traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 4. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MSDS assessment. 6. The comprehensive care plan will include measurable objective and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 7. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on record review and interview, the facility did not honor the wishes for Activities of Daily Living (ADL) related to bathing of body and hair for two residents (#51 and #100) out of eight residents sampled. Findings included: 1. On 11/04/2024 at 9:30 a.m., observations and interviews were conducted with Resident #51 and #100. Resident #51 stated she had not consistently received her baths in weeks and her hair had not been washed in over a month. Resident #51 stated she preferred bed baths and stated baths were scheduled three times a week but could not state the days. Resident #100 stated she did not get her baths three times a week and her hair had not been washed in over a month. Resident #100 stated she preferred to have bed baths. A review of the facility's 30-day bathing task showed Resident #51 had three baths in 30 days. Resident #51's bathing schedule on the bathing task showed shower/bath every Monday, Wednesday and Friday during the 3-11 shift. A review of Resident #51's Minimum Data Set (MDS) dated [DATE], under Section C-Cognition, showed a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Section GG-Functional Abilities, area GG0130- Self -Care showed Resident #51 was dependent for shower/bathe self. A review of Resident #51's care plan dated 9/02/2024 showed a Focus Area of ADL-Care Deficits related to decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting due to impaired physical functioning related to weakness and morbid obesity. Resident #51 requires substantial assist with most ADLs. Interventions/Tasks include but are not limited to: Bathing/Showers: dependent on staff for bathing/showering on Tuesday, Thursdays and Saturdays 7-3 shift. 2. A review of the facility's 30-day bathing task showed Resident #100 had three baths in 30 days. Resident #100's bathing schedule on the bathing task showed shower/bath every Tuesday, Thursday and Saturday during the 3-11 shift. A review of Resident #100's Minimum Data Set (MDS) dated [DATE], under Section C-Cognition, a Brief Interview for Mental Status (BIMS) showed a 13 which indicated intact cognition. Section GG-Functional Abilities, area GG0130- Self -Care showed Resident #100 dependent for shower/bathe self. A review of Resident #100's care plan dated 9/27/2024 showed a focus area of dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility, enjoys animals, crochet, visits from staff, outdoors as tolerated, TV, enjoys attending beauty shop as needed/visits. The goal for this focus area: resident will participate in 1:1 visit of choice as tolerated two times a month through next review date. Interventions/Tasks include: all staff to converse with resident while providing care, invite the resident to scheduled activities, provide 1:1 opportunity in room resident enjoys crocheting, and outdoors as tolerated. A focus area of ADL self-care performance deficit related to dementia, chronic pain and fibromyalgia. Interventions include but are not limited to: Bathing/Showering: The resident is dependent on staff for bathing/showers. Scheduled shower days are Monday- Wednesday and Friday on 7-3 shift. Resident's preference is bed bath. On 11/07/2024 at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). A review of the documented shower/bath tasks were reviewed for Residents #51 and #100. The DON agreed of the limited baths provided but stated it could be a documentation concern by the Certified Nursing Assistants. A review of the facility's policy titled, Activities of Daily Living (ADLs), revised on 11/22/2021 showed the following policy statement: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care 2. Transfer and ambulation 3. Toileting 4. Eating to include meals and snacks, and 5. Using speech, language or other functional communication systems. A review of the facility's policy showed the following policy explanation and compliance guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. . 5-The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observations, interviews, and record reviews, the facility failed to provide quality care and services related to wound care management and treatment for two (#377 and #378) out of three sampled residents. Findings included: 1. Review of Resident #378's Admission Record revealed he was admitted to the facility with medical diagnoses of congestive heart failure, dementia with behavioral disturbances, unsteadiness on feet, cellulitis of other sites, mood affective disorder, and anxiety disorder. An observation was conducted on 11/04/24 at 10:30 AM. Resident #378 was observed sitting in the hallway in a recliner chair. He was observed to have bandages on his bilateral upper arms. He said he got the injuries from slipping and falling at home. He said he was not sure how often they changed the bandages. His left upper arm bandage was dated 11/4 and was clean and intact. The right upper arm bandage was intact and clean but dated 10-31. An observation was conducted on 11/4/24 at 3:39 PM. Resident #378 was observed self-propelling in his wheelchair down the hallway. His right upper arm bandage was intact dated 10-31. His left upper arm bandage was intact, clean, and dated 11/4. There was no bandage on his right elbow. An observation was made on 11/5/24 at 10:00 AM. Resident #378 was observed in bed, eyes closed. His right upper arm bandage was observed intact dated 10/31. His left upper arm bandage was soiled with red drainage dated 11/4. There was no bandage on his right elbow. An observation was made on 11/6/24 at 8:58 AM. Resident #378 was observed sitting up in bed eating his breakfast. He was observed with a bandage on his right upper arm that was not intact and dated 10-31. His left elbow was observed with scabs on it. He also had a bandage on his left upper arm, not intact and soiled with red drainage near the elbow dated 11/4. The dressing was observed below his wound on his upper right arm and the wound was exposed. The wound was circular with a moist, pink, wound bed. He said the bandages on his arms need to come off. Review of Resident #378's physician order with a start date of 10/22/24 revealed right elbow skin tear cleanse with normal saline, apply xeroform and bordered gauze. One time a day. There were no other physician orders for skin treatment. Review of Resident #378's October and November medication administration record (MAR) and treatment administration record (TAR) revealed a physician order with a start date of 10/22/2024 for right elbow skin tear cleanse with normal saline, apply xeroform and bordered gauze. One time a day. The physician order was signed off as completed every day except 10/25/24 including November 5th and 6th. There was no other skin care documentation on the October and November MAR or TAR for the right or left upper arm. Review of Resident #378's progress notes revealed a note dated 10/25/24 at 6:18 AM, .Bandages to right and left arms intact. Review of an incident note dated 10/22/24 at 10:19 PM revealed Resident found on the floor of his room, lying on his back with his legs stretched out in front of him. resident [sic] last seen in bed about an hour prior to him being found. resident [sic] assessed for injury then assisted from the floor by 3 staff members and placed in a recliner chair. resident [sic] has skin tear to right upper arm. Area cleansed with normal saline, tao [triple antibiotic ointment], and dry dressing applied. POA [Power of Attorney] and MD [Medical Doctor] notified. Review of Resident #378's Weekly Skin Evaluation dated 10/26/24 revealed Skin Condition: Skin Tear(s), left arm. Review of Resident #378's Weekly Skin Evaluation dated 11/5/24 revealed Skin Condition: Skin Intact An interview was conducted on 11/6/24 at 9:10 AM with Staff A, Registered Nurse (RN). She said she was taking care of Resident #378, and she reviewed Resident #378's medical record and said the resident came in on 10/16/24 and there were bandages noted on his left and right upper arm from the hospital because of skin tears. Staff A, RN reviewed Resident #378's physician orders and said there was only an order to apply a dressing to his right elbow daily. Staff A, RN went into Resident #378's room and confirmed the residents' right upper arm had a bandage on it and it was not intact and dated 10-31. She removed the bandage halfway and said it was a skin tear. She also said there was no bandage on his right elbow, and he had a scab there. She looked at his left upper arm bandage, confirmed it was dated 11/4 and not intact with red drainage on it. The wound was exposed, and she said that it was also a skin tear. She said normally the nurse would put in a wound care consult and the wound care nurse would come and assess the resident and treat the wounds daily. 2. Review of Resident #377's Admission Record revealed she was admitted to the facility with medical diagnoses of repeated falls, hepatic encephalopathy, dementia without behavioral disturbances, and extrapyramidal and movement disorder. An observation was conducted on 11/04/24 at 10:41 AM. Resident #377 was observed self-propelling down the hallway in her wheelchair. She was observed to have an undated bandage on her right eyebrow and reddish, green, black, discoloration around her right eye. The resident said she fell off a table. An observation was conducted on 11/5/24 at 10:06 AM. Resident #377 was observed in her wheelchair self-propelling out of her room. She was observed to have a reddish, black, and green bruise to her right eye with an undated bandage on her right eyebrow with dark drainage on it. An observation was conducted on 11/6/24 at 9:05 AM Resident #377 was observed in her wheelchair in the hallway near the nurse's station. She was observed to have an undated bandage on her right eyebrow. The bandage was intact but soiled with dark drainage. Review of Resident #377's physician orders did not reveal an order to change the right eyebrow bandage. Review of Resident #377's incident note dated 10/28/2024 at 6:18 PM showed Approximately 6.05 pm [sic], the writer hear [sic] res [resident] screaming. when [sic] the writer entry [sic] to her room found her on the floor. Res report to the writer she was traying [sic] to get hair brush[sic] on the floor. Upon skin examination res has skin tear on right eyebrow. VS [vital signs] WNL [within normal limits]. No complaint of pain or discomfort. No SOB [shortness of breath]. Supervisor notified. order given and noted. We continue to monitor. Review of Resident #377's progress notes dated 10/30/2024 at 6:40 AM showed . Bandage intact over right eyebrow. No bleeding noted at this time. Review of Resident #377's progress notes 10/30/2024 at 9:50 PM showed .Bandage changed over right eyebrow. No bleeding noted at this time. We [sic] continue to monitor. Review of Resident #377's Weekly Skin Evaluation dated 10/28/24 showed skin tear to the right eyebrow. Review of Resident #377's Weekly Skin Evaluation dated 10/29/24 showed .skin abrasion above right eye from fall. An interview was conducted on 11/6/24 at 9:45 AM with Staff A, RN, she confirmed she was taking care of Resident #377. She reviewed Resident #377's medical record and confirmed there was not a physician order to change the bandage to her right eye and there should have been. She also confirmed the residents bandage was not dated and it should have been. An interview was conducted on 11/6/24 at 9:54 AM with Staff B, Licensed Practical Nurse (LPN), Wound Care Nurse. She said there was a wound care nurse seven days a week. The expectation was whenever there was a wound the nurses should put in a wound care consult so they could be notified to perform the treatment and management of wounds. Staff B said she was not aware Resident #378 had any wounds or skin tears. She also said she was not aware Resident #377 had any wounds. She said all bandages and dressings should have physician orders to change them and the bandages and dressings should be labeled with a date, time, and signature. An interview was conducted on 11/6/24 at 2:57 AM with the Director of Nursing (DON). She said if there were any wounds there should be a wound care consult put in so the wound care nurse could be informed, and the wounds could be treated. The DON said the facility had a wound care nurse seven days a week. Review of the facility's Wound Treatment Management policy, with a revised date of 11/23/2022 revealed the following. Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise or is wet. 4. Dressings will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: .iii. Incidental (i.e. skin tear, medical adhesive related skin injury). .6. Guidelines for dressing selection may be utilized in obtaining physician orders . a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on observations, record review and interviews the facility failed to ensure smoking adaptive equipment was provided for one (#42) of 11 residents sampled. Findings included: During an observation made on 11/4/2024 at 10:15 a.m. and 11/6/2024 at 2:20 p.m., Resident #42 was observed outside smoking without using a smoking adaptor. Resident #42 said he did not use smoking adaptive equipment while smoking. Review of an Admission Record dated 11/ 7/2024, showed Resident #42 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinsonism, unspecified, Type 2 Diabetes, Aute Respiratory Failure, and Paranoid Schizophrenia. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Review of Resident # 42's care plan revised on 9/13/2024, showed the resident was at risk for smoking injuries to self - related to use of cigarettes. The care plan goals showed Resident #42 will continue to smoke safely in a designated area at scheduled times per facility smoking policy through the next review. The interventions included adaptor to be used while smoking, [Resident #42] requires a smoking apron while smoking. On 11/6/2024 at 10:20 am., an interview was conducted with Staff G, Certified Nursing Assistant (CNA) . Staff G stated Resident #42 was supposed to use a smoking adaptor while smoking because he smoked his cigarettes down to his fingertips. Staff G said, He has not used his adaptor in a while because he lost it and was not given another adaptor. On 11/6/2024 at 10: 20 am., an interview was conducted with Staff H, CNA. She stated she was familiar with Resident #42. She stated Resident #42 had not used a smoking adaptor in a long time because he lost it. On 11/6/2024 at 11:00 am., an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated Resident #42 used a smoking adaptor while smoking because he smoked his cigarettes down to his fingertips. She stated her expectations were for staff to provide residents with the items they needed to ensure safe smoking. On 11/6/2024 at 1:00 pm., an interview was conducted with Staff C, LPN/UM (Unit Manager). She stated Resident #42 used a smoking adaptor because he smoked his cigarettes down to his fingertips. Staff C stated she had to educate herself and her staff to ensure the resident's care plan interventions were followed while they were outside smoking. She stated her expectation was for staff to notify the nurse if a resident did not have a smoking adaptor before taking the resident outside to smoke. Review of the facility policy titled, Resident Smoking, Revised on 8/26/2024, showed it is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non- smoking residents. Under Policy Explanation and Compliance Guidelines: 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 12. If a resident or family does not abide by the smoking policy or care plan (e.g. does not wear protective gear), the plan of care may be revised to include additional safety measures. 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.

Based on observation, interview, and record review, the facility failed to provide enteral nutrition according to standards of practice related to expired nutritional formula for one resident (#246) out of one resident sampled. Findings included: On [DATE] at 12:11 p.m., an observation of Resident #246 revealed he was laying down in bed, with a family member at the bedside. On the left side of the bed, there was a pole and enteral feeding pump observed. An observation of the pole and enteral feeding pump revealed there was no tube feeding bag or container hanging. Further observation revealed the pump was off. An observation of the small dresser, to the left of Resident #246's bed, revealed three, 8-ounce bottles of TwoCal HN [high nutrient] 2.0 formula with a date observed at the top which indicated the following, 1 SEP 2024. A review of Resident #246's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. Further review of the Admission Record revealed diagnoses to include but not limited to dysphagia, oropharyngeal phase, unspecified protein-calorie malnutrition, and unspecified, and encounter for attention to gastrostomy. A review of Resident #246's Active Orders revealed the following, Enteral Feed Order one time a day provide two cal enteral feeding 55 ml/hr [milliliters/hour] from 7 pm to 7 am. for a total of 550 ml a day, with an order and start date of [DATE]. Further review of enteral feed orders revealed the following, Enteral Feed Order one time a day provide two cal enteral feeding 55 ml/hr from 7 pm to 7 am. for a total of 550 ml a day; Provide Nutren 2.0 if two cal is out of stock, with an order and start date of [DATE]. Further review of Resident #246's enteral feed orders revealed the following, Enteral Feed Order one time a day Stop eternal feed 7 am daily, with an order date of [DATE], and a start date of [DATE]. A review of Resident #246's Medication Administration Record (MAR) for [DATE] included the following: Enteral Feed Order one time a day provide two cal enteral feeding 55 ml/hr from 7 pm to 7 am. for a total of 550 ml a day, Start Date [DATE], D/C [discontinue] Date [DATE]. A review of the documentation in the MAR revealed it was administered daily as ordered. Dietitian consult one time a day, Start Date [DATE]. A review of the documentation in the MAR revealed it was completed daily as ordered. Enteral Feed Order every shift Enteral 4b - Observe for signs of intolerance, i.e. diarrhea, N&V [nausea and vomiting], constipation, abdominal distention/cramping, fluid overload, aspiration, hypo/hyper-glycemia every shift, Start Date [DATE]. A review of the documentation in the MAR revealed it was completed daily as ordered. On [DATE] at 9:40 a.m., an observation of the 1 East nourishment room, where the enteral feeding formula was stored, revealed multiple 8-ounce bottles and one case of TwoCal HN 2.0 with a use by date of [DATE]. A review of a manual found through an Internet search titled, Best Practices for Managing Tube Feeding, published [DATE] from [Vendor name] revealed the following, .3. Maintain proper storage and handling of formula: . G. Do not use after expiration date on container. The manual was viewed using the following link, https://static.abbottnutrition.com/cms-prod/abbottnutrition-2016.com/img/M4619.005%20Tube%20Feeding%20manual_tcm,d+[DATE].pdf, on [DATE]. TwoCal HN 2.0 is a product of [Vendor name]. On [DATE] at 9:45 a.m., an interview with Staff C, Unit Manager (UM)/Licensed Practical Nurse (LPN) revealed Central Supply staff put the enteral nutrition formula in the nourishment room. She stated Central Supply and the nursing staff reviewed the formula upon putting it into the nourishment room. Staff C stated the nursing staff reviewed the formula every time they used a bottle for the resident. An observation of the 1 East nourishment room was conducted with Staff C and she confirmed the TwoCal HN 2.0 was expired as of [DATE]. Staff C, UM/LPN stated she reviewed the pantry on Monday, [DATE] or Tuesday, [DATE] and didn't see the expired formula. She was observed removing the formula and stated she would provide education to Central Supply staff and all staff members. On [DATE] at 11:00 a.m., an interview with Staff D, Central Supply revealed he received the enteral nutrition formula and put it in the nourishment rooms. He stated his process consisted of comparing the formula received to the invoice. Staff D stated he checked the expiration date, ensured it was the right product, and verified the amount. He stated if the formula was expired, he would toss it. Staff D, Central Supply stated he was the primary staff member who received the enteral nutrition formula. He stated he received shipments on Tuesday and Thursday, and expected one today. On [DATE] at 1:36 p.m., an interview with the Director of Nursing (DON) revealed the nurse received the product that was brought from Central Supply. She stated the nurse put the enteral nutrition formula in the room, or Central Supply stocked the room. The DON stated she expected staff to make sure it was the right product they were receiving and providing to residents. She confirmed it was an issue that the resident was being provided formula that was expired. On [DATE] at 3:01 p.m., the Regional Nursing Home Administrator (NHA) stated the facility had no policy related to enteral nutrition or receiving formula from Central Supply. Photographic Evidence Obtained.

Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse to one (Resident #1) of three residents reviewed, by failing to provide medication and supervision to an unsafe resident. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. Resident #2 required two psychiatric medication changes in the first five days of his stay in the facility and four days later he assaulted Resident #1. Resident #2's admission medication was not correctly transcribed and of the two medication changes made only one was administered, and that one, only once. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA stated, on the evening of 1/20/2024, she was sitting at nurse station, charting. Staff D, CNA was assigned to Resident #1's room. Staff D, CNA was on the split assignment (assigned to rooms on two separate halls). Staff C, CNA stated she passed Resident #1's room [ROOM NUMBER] minutes earlier and Resident #1 was in her bed asleep with the door open. Staff C, CNA stated [Resident #1 name]'s call light went on. [Staff D name, CNA] went to answer the call light. [Staff D name, CNA] yelled for me that the door was jammed and there was a man on top of [Resident #1 name]. I ran to the room. We pushed the door open. [Resident #2 name] was in the chair naked, putting his clothes on. I was yelling for nurses to come. When the nurses arrived, we tried to get him out of the room. [Resident #2 name] started punching me and one of the nurses. [Resident #2 name] left the room followed by a nurse. [Resident #1 name] wanted to go to bathroom, so we assisted. [Resident #1 name]'s eyes were swollen shut, her face was bloody, and she was crying. The nurse assisted [Resident #1 name] from there. Staff C, CNA stated she later spoke to Resident #1. Resident #1 told me He tried to rape me but couldn't get 'it' in, so he stuck his finger up me. Staff C, CNA stated after Resident #1 left her room for a cigarette with the nurse, we changed the linens on her bed and found her tooth. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower east and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Skin Status Evaluation: Contusion Pain Status Evaluation: Does the resident/patient have pain? No Neurological Status Evaluation: Not clinically applicable to the change in condition being reported Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications changes as needed. Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: [Resident #1] . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, [Resident #1 name]'s impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 showed, Resident #1 returned from the hospital last night. Staff reports that [Resident #1 name] was involved in a resident-to-resident altercation where [Resident #1 name] was physically and sexually assaulted. [Resident #1 name] is alert and oriented to person and time. [Resident #1 name] is tearful on interview describing the assault . [Resident #1 name] reports he beat me up . My face is ruined. It hurts me badly. [Resident #1 name] reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. [Resident #1 name] has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. [Resident #1 name] is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. [Resident #1 name]'s speech is disorganized and includes frequent derailment. Despite [Resident # 1 name]'s mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. [Resident #1 name] has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. [Resident #1 name] should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on 12/23/2023 from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2's hospital Discharge Instructions dated 1/11/2024 at 11:02 AM a 10-page document, located in the facility's medical record, page 4 revealed Medications the following are listed: . (listing here limited to psychiatric mediations) Depakote 250 mg (milligram) oral delayed release tablet, one tablet two times per day; fluphenazine 25 mg/mL (milliliter) injectable solution, give 75 mg intramuscularly every two weeks; trazodone 50 mg oral tablet, one tablet at bedtime. Review of Resident #2's hospital Medication List - All Active Medications printed 1/8/2024, found in the facility's medical record (listing here limited to psychiatric mediations) reveals: Haldol 10 mg, = 2 tab(s), PO (by mouth), 2 x daily, 1/5/24, 21:00 EST, Routine Divalproex sodium (divalproex sodium 250 mg oral delayed release tablet) 250mg=1 tab (s), PO, 2xdaily, 0 refill(s), 12/26/23 9:32 EST, 1 Trazodone 50 mg, = 1 tab(s), PO, 1 x daily hs (at bedtime) #30 tabs, no refills, 1 Divalproex sodium (Depakote) 500 mg, = 1 tab(s), PO, EC tab, 2 x daily, 1/2/24, 09:00 EST, routine Fluphenazine (Prolixin Decanoate) 75 mg, = 3 mL, IM-intramuscular, injection, every 2 weeks, 12/28/23 Review of Resident #2's hospital Psychiatric Progress Note *Final Report* dated 1/8/2024, located in the facility's medical record with the section titled Assessment/Plan: revealed: Patient is a [AGE] year old man with a history of schizophrenia . was admitted to the hospital after he attacked another resident at his ALF. Given patients psychotic and violent behavior in the community patient is felt to be at high risk of imminent harm towards himself where he to be discharged in his current condition without further evidence of improvement and stability. Patient was started on Prolixin and transition to Prolixin decanoate. However, Prolixin was subsequently discontinued as proxy reported that patient tends to refuse injections if they are occurring too often and would prefer, he be placed on something once a month as he has been more compliant with that in the past. -Patients continue to show stability. He is stabilizing well on current medications . Allow time for medications to gain efficacy, and for discharge planning to occur. -continue Haldol 10 milligrams PO twice daily with plans to titrate to Haldol decanoate -continue Depakote 500 milligrams PO bid for sub therapeutic VPA (Valproic Acid), a medication used to treat certain types of seizures. Steady state VPA 74.8 on 1/7 -Artane 2 milligrams nightly . Review of Resident #2 Admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorder- recurrent- moderate, Other specified mood disorder , Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left side- with routine healing. Review of Resident #2's Pre-Admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person- Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; when the resident becomes, agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine Decanoate Injection Solution 25mg/ml inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3.Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: . (listing psychiatric mediations only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start date 1/22/2024 (after discharge) 3.Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) 4.Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5.Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . Resident #2 was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed Resident #2 sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed Resident #2 endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for Resident #2 shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed this patient PRN (as needed) IM was provided. Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed Resident #2 examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of medication. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed Resident #2 purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. Resident #2 then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. Resident #2 became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. Resident #2 finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. Resident #2 started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. Resident #2 continued to yell, 'I'm going to get you, etc', Resident #2 stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell . Resident #2 fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not informed anyone of the falls (his or the Resident's). Review of Resident #2's progress note dated 1/20/2024 at 7:47 AM revealed, Resident #2 went by nurses' station (East Unit) in his wheelchair around 3:15 AM about 20 minutes later the Certified Nursing Assistant (CNA) from Lifestyle 1 unit came running down the hall way (sic) telling me to come the ot [TRUNCATED]

Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to ensure adequate supervision to prevent physical and psychosocial harm to one (Resident #1) of three residents reviewed. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA stated, on the evening of 1/20/2024, she was sitting at nurse station, charting. Staff D, CNA was assigned to Resident #1's room. Staff D, CNA was on the split assignment (assigned to rooms on two separate halls). Staff C, CNA stated she passed Resident #1's room [ROOM NUMBER] minutes earlier and Resident #1 was in her bed asleep with the door open. Staff C, CNA stated [Resident #1 name]'s call light went on. [Staff D name, CNA] went to answer the call light. [Staff D name, CNA] yelled for me that the door was jammed and there was a man on top of [Resident #1 name]. I ran to the room. We pushed the door open. [Resident #2 name] was in the chair naked, putting his clothes on. I was yelling for nurses to come. When the nurses arrived, we tried to get him out of the room. [Resident #2 name] started punching me and one of the nurses. [Resident #2 name] left the room followed by a nurse. [Resident #1 name] wanted to go to bathroom, so we assisted. [Resident #1 name]'s eyes were swollen shut, her face was bloody, and she was crying. The nurse assisted [Resident #1 name] from there. Staff C, CNA stated she later spoke to Resident #1. Resident #1 told me He tried to rape me but couldn't get 'it' in, so he stuck his finger up me. Staff C, CNA stated after Resident #1 left her room for a cigarette with the nurse, we changed the linens on her bed and found her tooth. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower East and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR [Situation, Background, Assessment, Recommendation] Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Skin Status Evaluation: Contusion Pain Status Evaluation: Does the resident/patient have pain? No calmyNeurological Status Evaluation: Not clinically applicable to the change in condition being reported Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications changes as needed. Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: Resident #1 . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, Resident #1's impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 showed, Resident #1 returned from the hospital last night. Staff reports that Resident #1 was involved in a resident-to-resident altercation where Resident #1 was physically and sexually assaulted. Resident #1 is alert and oriented to person and time. Resident #1 is tearful on interview describing the assault . Resident #1 reports he beat me up . My face is ruined. It hurts me badly. Resident #1 reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. Resident #1 has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. Resident #1 is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. Resident #1's speech is disorganized and includes frequent derailment. Despite Resident # 1's mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. Resident #1 has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. Resident #1 should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on 12/23/2023 from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2 Admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorder- recurrent- moderate, Other specified mood disorder, Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left side-with routine healing. Review of Resident #2's Pre-Admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person-Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; when the resident becomes, agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1. Depakote 250 mg (milligrams) by mouth two times a day, order and start date 1/11/2024 2. Fluphenazine Decanoate Injection Solution 25mg/ml (milliliter) inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3. Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: (listing psychiatric mediations only) 1. Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2. Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start date 1/22/2024 (after discharge) 3. Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) 4. Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5. Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . [Resident #2 name] was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed [Resident #2 name] sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed [Resident #2 name] endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for [Resident #2 name] shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed this patient PRN (as needed) IM was provided. Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed [Resident #2 name] examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of Fluphenazine. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed [Resident #2 name] purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. [Resident #2 name] then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. [Resident #2 name] became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. [Resident #2 name] finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. [Resident #2 name] started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. [Resident #2 name] continued to yell, 'I'm going to get you, etc', [Resident #2 name] stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell . [Resident #2 name] fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not informed anyone of the falls (his or the Resident's). Review of Resident #2's progress note dated 1/20/2024 at 7:47 AM revealed, [Resident #2 name] went by nurses' station (East Unit) in his wheelchair around 3:15 AM about 20 minutes later the Certified Nursing Assistant (CNA) from Lifestyle 1 unit came running down the hall way (sic) telling me to come the other nurse and I ran down the hallway to the CNA . she was stating [Resident #2 name] was naked laying on top of the female resident in her room on her bed . when I got to room [Resident #2 name] was pulling up his pants . female resident whos (sic) room it was was (sic) laying on bed on her back . her pull up was tore off she was covering her face and crying . the other nurse, CNA and I were questioning [Resident #2 name] and trying to remove this resident from the room . [Resident #2 name] began cursing at staff and hit both me (in the chest) and the CNA . this resident then proceeded to go back to his room . I followed this resident to insure (sic) the safety of the other resident . Police called . call placed to DR (doctor) and after and update order to call psychiatric practitioner to have resident (sic) admitted to an acute psychiatric unit. Review of the Hospital History and Physical dated 1/20/2024 revealed Resident #2 presents under BA (Baker Act) at his facility .[Resident #2] has been with increased agitation, irritability, and combativeness. Review of Resident #2's Facility MAR dated 1/1/2024 to 1/31/2024 revealed the following psychiatric medications: Fluphenazine 25 mg/mL inject one dose intramuscularly one time a day every 14 days, order start date of 1/15/2024 at 0900 and a discharge date of [DATE] at 1544. Resident #2 was administered this medication once on 1/15/2024. The mg per dose was not specified. Haldol 5 mg, IM every 6 hours as needed for mood disorder. Start date of 1/12/2024 at 1:45 PM. Resident #2 was administered this medication once on 1/16/2024 at 12:13 AM. Trazodone HCl oral tablet 50 mg by mouth at bedtime Start date of 1/11/2024 at 2100 and a discharge date of [DATE] at 1142. Resident #2 was administered this medication on 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. Divalproex Sodium Oral Table Delayed Release 250 mg, give 250 mg by mouth two times a day, order start date of 1/11/2024 at 1700 and a discharge date of [DATE] at 1142. Resident was administered this medication at 0900, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024 and at 1700, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. An interview was conducted with Staff O, Psychiatric APRN, on 2/12/24 at 3:55 PM. When asked if other interventions for behavior were considered for Resident #2, Staff O, APRN stated medication changes were the only intervention changes that occurred with Resident #2. On 2/12/2024 at 10:30 AM an observation was made of the hallways and nursing unit locations. The facility's first floor has 3 nursing units located from west to east, [NAME] Unit, East Unit and Lifestyle 1 Unit. The [NAME] Unit is a locked

Based on medical record review, facility policies and procedures review, interviews with facility staff, Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA), Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Medical Director (MD), the facility failed to provide supervision during meal service to prevent choking for a vulnerable resident (#1), who was on a puree diet and had previously attempted to gain access to foods not on his prescribed diet, out of 12 sampled residents for dietary needs. On [DATE] Resident #1, who was on a puree diet for a diagnosis of dysphagia, accessed a roommate's food tray. On [DATE] during the dinner meal service, Resident #1 was observed attempting to access food trays from the tray cart when the cart was delivered to the floor and was redirected by staff. Resident #1 was witnessed by staff attempting to access trays from the tray cart again after the meal and was redirected back to his room. In his room, Resident #1 accessed a roommate's uneaten food tray. Resident #1 was found unresponsive with food in his mouth. EMS (Emergency Medical Services) were activated, CPR (Cardiopulmonary Resuscitation) was started, and the resident was transferred to the hospital. The resident was pronounced brain dead and expired on [DATE]. This failure created a situation that resulted in a serious injury and death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: A review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to, Parkinson's Disease, Mood Disorder, Atrial Fibrillation, Schizophrenia, Anxiety Disorder, Dysphagia, Dementia, Psychosis, Bipolar Disorder, COVID-19, and Sepsis with Septic Shock. A review of the Order Summary Report, dated [DATE], revealed the following physician orders: Regular diet, Puree texture, Honey consistency, ordered on [DATE]. Full Code, ordered on [DATE]. Depakote sprinkles oral capsule delayed release sprinkle 125 MG (milligrams) Give 750 MG by mouth one time a day for Mood Disorder, ordered on [DATE]. Quetiapine Fumarate oral tablet 200 MG Give one tablet by mouth two times a day related to Schizophrenia, ordered on [DATE]. Estradiol oral tablet 1 MG Give one by mouth one time a day for inappropriate sexual behavior, ordered on [DATE]. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 09, indicating severe cognitive impairment. In Section G: Functional Status the assessment revealed Resident #1 required extensive assistance by one person for locomotion on the unit, supervision by one person for eating, no impairment with range of motion for upper or lower extremities and utilized a wheelchair for mobility. A review of the Comprehensive Care Plan, last review date [DATE], revealed Resident #1 had the following focus areas in place: Focus--Resident #1 is at risk for alteration in nutrition and hydration related to: Dx (diagnosis) Dementia, dysphagia and need for mech altered diet. Will take food from peers that may not always be appropriate for diet consistency due to Dx, may not understand that the food he takes is not his or that it is not safe for him .(Initiated [DATE]). Goal-- .Will not choke or aspirate through next 90 days . Interventions included but not limited to: Assist and encourage as needed with meals; Monitor and provide preferences as available; Monitor meal intake and offer alternate items as needed; Redirect as needed, offer alternate items as needed that are appropriate for his diet; Review in risk meetings as needed; Thickened liquids as ordered. Focus-Resident #1 has the following behavior problems: verbally and physically aggressive, easily agitated, entering other residents' rooms without permission, sexually inappropriate ., resident to resident altercations, takes food off other residents' trays (Initiated [DATE]). Goal-Resident #1 will have fewer episodes of disruptive behavior by next review date. Interventions included but not limited to: Anticipate and meet the resident's needs; Intervene as necessary to protect the rights and safety of others; Redirect the resident as necessary. A review of a Modified Barium Swallow Study Final Report, dated [DATE], revealed a diagnosis after the study of moderate-severe oral with moderate pharyngeal phase dysphagia. The recommended oral diet was puree/honey. A review of Progress Notes for Resident #1 revealed the following: [DATE] 11:34 p.m. Resident was found unresponsive in room at 5:55 pm. Code was called Heimlich maneuver was provided while assisted to remove food out resident's mouth. Resident was brought to the floor and CPR was provided. Suction was provided to resident's mouth to remove and obstructions. EMT [Emergency Medical Technician] arrived and took over at 6:15pm. EMT took over CPR. Started an IV [Intravenous] bag via shin. Resident was intubated at 6:20pm EMT got at pulse at 6:28 pm and resident was taken to hospital at 6:30pm. [DATE] 2:12 a.m. res [resident] was admitted to ICU [Intensive Care] at [hospital name] with a diagnosis cardiac arrest. A review of the EMS patient care report, DOS (date of service) [DATE], revealed the following narrative: Dispatched to [facility name] for the [AGE] year-old male cardiac arrest/ Staff states that she saw the patient 30 minutes prior and when she next saw the patient, he was sitting in his scooter unresponsive with food on his lap. Staff states that the patient is on a puree diet but had a sandwich next to him. Staff states that they moved the patient to the floor and started CPR. FD [Fire Department] states that they found the patient on the ground with chest compressions being performed by staff. FD states that the patient's airway had soft food in his airway that was suctioned as much as possible before placing a king airway. Patient was found to be in asystole. Patient has a history of dementia and Parkinson's. Patient was found supine on the floor with staff/FD, unresponsive with chest compressions and assisted ventilations being performed. Cardiac arrest post asphyxiation with ROSC [Return of Spontaneous Circulation]. Patient was carried to the stretcher via back board, secured X5 seat belts, and transported to the closest appropriate facility as documented without incident. All interventions as listed were performed with positive patient outcomes. Transfer of care was completed at patient's bedside with a verbal report given to ED [Emergency Department] nursing staff. A review of the hospital record Intensive Care Consultation report, dated [DATE] at 6:57 a.m., revealed the following: Reason for consult: Cardiac Arrest HPI (History and Physical Information): (Resident #1) is a [AGE] year-old male with a previous history of Parkinson's Disease who presents from nursing home after a cardiac arrest. Patient is currently intubated and sedated .Patient has had dysphagia for years and is on a soft/puree diet at his nursing facility. Around 5:00 p.m. the previous evening he was given his assigned dinner. Around 5:40 p.m. he was placed back into his room. When staff checked on him around 5:55 p.m. they found him unresponsive. They noticed he had gotten food from his roommate's plate and suspected he chocked .Upon arrival to the ED, patient was minimally responsive but otherwise hemodynamically stable. Hypothermia protocol as initiated, and patient was transferred to ICU for further management. Diagnosis, Assessment & Plan: Cardiac arrest secondary to Hypoxia Acute Hypoxic Respiratory Failure Aspiration secondary to Dysphagia . Death Event Note: Pronouncement of Death Date: [DATE] Time: 1810 (6:10 p.m.) Clinical assessment: blood pressure absent, cerebral unresponsiveness, pulse absent, pupils dilated/unreactive, respirations absent. During an interview on [DATE] at 10:25 a.m. Staff A, Licensed Practical Nurse (LPN) stated she had worked at the facility for a long time. She stated the diet trays are checked by the nurse first to make sure the trays are accurate for each resident. She stated the aides are responsible for monitoring the residents on puree foods during their meals and they should keep them close so they can make sure the resident does not choke. She stated if the resident is able to eat on their own the staff have to go in and check on them often to make sure they are swallowing their food properly. During an interview on [DATE] at 11:15 a.m. Staff B, LPN stated residents who are on a puree diet have to be set up and assisted or monitored during their meals. She stated the staff have to keep a close eye out to watch for swallowing and choking when a resident is on a puree diet. During an interview on [DATE] at 11:55 a.m. Staff C, LPN stated she was the unit manager for the 2E and 2W nursing units. She said residents who receive altered diets are care planned, noted on the Kardex for staff information, and the food ticket will identify the consistency of the food and liquids for each resident. She stated she also keeps a list in the nourishment room of residents on honey and nectar thick liquids. She stated she updates the list if any diet changes occur for each resident. She stated she makes rounds during meals to observe staff assisting residents. She stated residents who can feed themselves may be out at the nurse's station during meals for closer observation. Staff C, LPN stated any changes in residents or concerns are discussed at morning team meeting and for residents with concerns about meals will be followed up with evaluation by speech therapy. During an interview on [DATE] at 12:25 p.m. with Staff D, Certified Nursing Aide (CNA) and Staff E, CNA they stated they had recent education and training related to assistance with meals for residents. They stated the education included: set up, checking liquids, oversight of residents during meals, elevating the head of the bed and not putting it down for 30 minutes after the meal, proper utensils, close monitoring to assure residents do not get the wrong food and risk choking, and monitoring of other residents to assure they do not give other food to residents at risk for choking. An interview was conducted with the Nursing Home Administrator (NHA), the Assistant Nursing Home Administrator (ANHA), and the Assistant Director of Nursing (ADON) on [DATE] at 1:56 p.m. They stated they were all are aware of the incident with Resident #1 and had conducted a full investigation and had reported the incident to all required agencies. The NHA stated the Director of Nursing (DON) was involved in the investigation at the time, but she is currently on leave. The ANHA stated she received notification from nursing Resident #1 was transferred to the hospital after the incident. She stated the incident occurred on a Sunday during the dinner meal. She stated the DON notified her at 6:19 p.m. The ANHA stated Staff E, LPN notified the DON after the incident because she was the nurse responsible for the care of Resident #1 on that evening. The NHA stated the incident was discussed over the phone with the ANHA and the DON right away and it was reported, and an investigation was begun. The ANHA stated Resident #1 was found in his wheelchair, unresponsive with food in his mouth, but they were unable to determine how much food he had consumed. She stated he had access to his roommate's dinner tray which was on the overbed table. She stated the roommate was not in the room. The ANHA stated Resident #1 liked to eat at the nurses' station, was able to eat on his own, and was on a puree diet. She stated the resident finished eating and could locomote on his own but slowly. She stated Resident #1 went back to his room on his own after the meal. She stated this was his routine. The ANHA stated Resident #1 had a history of taking other resident's food, but there had been no reports of this happening recently that she was aware of. She stated when the resident was discovered unresponsive, CPR was started, the Heimlich maneuver was done, EMS was called, and suction to remove the food was done by the nursing staff. When EMS arrived, they took over and the resident was taken to the hospital. The ANHA stated a complete investigation was conducted with interviews and record review with all of the staff involved in the incident. She stated they developed a timeline and confirmed the roommate was not in the room at the time of the incident. The ANHA stated during the interviews with staff it was determined the roommate would often eat some of his food and then leave it and return later to finish it. She stated the staff on the unit were very consistent and knowledgeable about the residents and their patterns. The ADON stated education was immediately started with verbal educations related to aspiration, choking, and coughing during meals. She stated they also have an electronic learning center that has been assigned to all staff related to aphasia and aspiration. The NHA stated the facility has initiated a manager doing rounds during dinner times, and they are currently getting ready to open the dining room so residents can be monitored by staff easier during meal times. The NHA said it was everyone's job to monitor for eating, dietary, feeding and aspiration. He stated meal times are 'all hands-on deck.' The ADON stated the reason Resident #1 was eating in the hallway by the nursing station was because it was his social element and he preferred hanging out at the nursing station. She stated the staff liked to see him there due to his risk for falls. She stated staff would monitor his eating at the nursing station also. She stated Resident #1 rarely ate in his room. The NHA stated the staff should have verified the roommate's food tray was left in the room unattended and should have removed it and placed it back in the cart until the roommate returned. During an interview on [DATE] at 2:53 p.m. Staff F, LPN stated she was the nurse assigned to Resident #1 on the day of the incident. She stated the resident received his puree diet around 5:00 p.m. and he ate it at the nurses station in the hallway. Staff E, LPN stated she was giving medications at the cart when she saw Resident #1 messing with the meal trays on the cart. She stated he was pulling the trays off the cart and attempting to get food off the used trays. Staff E, LPN told Resident #1 to stop, and he was redirected back to his room. She stated she continued to pass medications and she did see him once and he was sitting in the room with the other residents in his wheelchair. She stated the second time she checked on Resident #1 he was slumped in chair and blue, she called a code. She stated she saw bread in his mouth and tried to get it out. She stated an aide came in to help lower the resident to the ground. She stated the crash cart arrived and other staff came in to assist. She stated Resident #1 was not breathing and had no pulse. She stated she suctioned stuff out of his mouth and they began CPR. She stated when EMS arrived, they took over care. Staff F, LPN stated Resident #1 had eaten his puree diet without any problems. She stated she was a float nurse and had not had Resident #1 in about two weeks. She stated she was aware the resident was care planned for taking other residents' food. She stated there was one tray in room that she thought was from the B bed, but she was not sure. She stated the tray was untouched. She stated the trays were passed around 5:00 p.m. and she found Resident #1 around 5:55 p.m. She stated EMS intubated the resident at facility and had used suction while they were there to clear the food. She stated she told paramedics the resident was choking on food from another resident's tray. During an interview on [DATE] at 9:29 a.m. with the Advanced Registered Nurse Practitioner (ARNP) She stated she was familiar with Resident #1 and had cared for him for about two years. She stated the resident was wheelchair bound and could move around the facility in his chair on his own. She stated he was a pleasant man but did have some behavioral issues. She stated she was not sure if he was being seen by psychiatry. She stated he had dysphagia and was on a puree diet for a long time. The ARNP said she was not aware of any issues related to Resident #1 taking food from other trays. She stated she was made aware of the incident when she came in on the Monday morning following the incident. The ARNP stated she was not informed of the reason why Resident #1 coded, but she read the note in the record and was aware the resident expired. She stated her expectation would be the staff watch and check on residents who are on puree diets to make sure they are safe during the meals. During an interview on [DATE] at 9:43 a.m. Staff G, Speech Therapist (ST) stated Resident #1 was at the facility for a long time and she had known him for several years. She stated the resident was able to get around in his wheelchair. She stated she would do a quarterly screening on the resident to make sure his diet was appropriate. She stated he was on a puree honey thick liquids diet. She stated he had been on the diet for a long time because he was not able to masticate or swallow differing textures without problems. She stated her instructions to staff was to monitor Resident #1 during meals, but he could feed himself. The ST said she was unaware the resident was food seeking and she was not aware the resident was care planned for taking other resident's food but became aware after the incident occurred. The ST stated staff should be watching for any type of coughing, etc. while a resident on a puree diet is eating. During an interview on [DATE] at 9:53 a.m. Staff H, CNA stated she was working the floor during the evening of the event but was not assigned to care for Resident #1. She stated she started to pass trays and Resident #1 was trying to grab trays and food before she passed the trays. She stated she was assisting another resident and watching Resident #1 at same time. She stated Resident #1 eats 100% of the meal every time and eats well by himself. She stated after the meal she was picking up trays and saw the nurse redirecting Resident #1 to go to his room. She stated the nurse, and the resident were by the tray cart at the time. She stated about 10 minutes later she heard the nurse shout call a code. She said she went to the room and saw the nurse performing the Heimlich maneuver. She stated Resident #1 had food in his mouth and the nurse was trying to get it out. Staff H, CNA stated there was a tray in the room and she thought it belonged to B bed. She stated she gave a statement about the incident to the DON and ANHA and told the same story that she just relayed to surveyors. She stated she was aware Resident #1 was food seeking. She stated Resident #1 had sought food on a regular basis. She said she had seen the resident do this at least three times a week on the shifts she worked. She stated she had seen the resident food seeking in his room, in the hall, anywhere he was close to any food or drinks. She stated she was not aware he had dysphagia but was told Resident #1 ate his food too fast. She stated Resident #1 had to be watched to make sure he was safe. She stated Resident #1 was always seated in the hallway by the nurses station so he could be watched while eating. She said she would not leave a tray unattended in one of her rooms and if a resident was not in the room, she would store the tray in clean utility until resident was located. A telephone interview was conducted on [DATE] at 10:11 a.m. with the Medical Director (MD). The MD stated he was aware of Resident #1 and had discussed the resident in the psychotropic medical management meetings. He stated the resident was having increased behavioral issues. He stated he reviewed the resident's record and did not make any changes to his medications. He stated he was informed about the incident and what had occurred. He stated the resident had a choking incident as a result of accessing food that was not on his prescribed puree diet. The MD stated the incident was discussed with the NHA, the ANHA and the DON. He stated the findings were Resident #1 had access to another resident's tray and we could have been more careful to ensure he and other residents did not have access to other foods. The MD said Resident #1 was highly cognitively impaired and did not understand the dangers of eating others food. The MD stated the plan was to reopen the dining room so better supervision can be provided. He stated he was not personally aware of the food seeking concerns with Resident #1. The MD stated the expectation was residents were not given food in room where it was difficult to observe/supervise the residents. During a telephone interview on [DATE] at 10:30 a.m. with the Power of Attorney (POA) he stated Resident #1 had a Traumatic Brain Injury (TBI) and several strokes and had been in the facility since 2019. The POA stated he visited with the resident once a quarter and was working with social services on getting some dental work done for Resident #1. The POA stated the first two phases had been completed. He stated the facility called him and the call went to voicemail on the date of the incident. He stated before he could call the facility back, the hospital called him and updated him. He stated he called facility back and the nurse talked with him and told him the resident got a hold of his roommate's food and he choked and went into cardiac arrest. The POA stated the hospital told him Resident #1 was in critical condition, and in the Cardiovascular Intensive Care Unit (CVICU). He stated the hospital was doing cooling therapy to try to limit damage to Resident #1's brain. He said when he was at the hospital with the resident, 'I just knew, there was no reaction.' He stated the doctors came in and told him they were assessing to see if the resident's was brain dead. The POA made Resident #1 a Do Not Resuscitate (DNR) at the hospital. He stated the Neurologist saw Resident #1 and confirmed the resident was brain dead. The POA stated the ventilator was removed and the resident expired shortly after on Tuesday [DATE] at 6:10 p.m. The POA stated Resident #1 was on a puree diet for years because he would choke with regular food. The POA stated he had asked at several care plan meetings if the resident would ever be able to eat normal food, and he understood the answer was no. The POA stated Resident #1 was in the care of the funeral home and he had not received any death certificates at the time. During an interview on [DATE] at 10:48 a.m. Staff I, CNA stated she was the CNA assigned to Resident #1. She stated she was assisting residents with their meals at the time of the incident. She stated Resident #1 had already been served by another staff member and had eaten his food at the nursing station. She said she was aware Resident #1 was on a puree diet and was a risk for choking. She said she was aware the resident was food seeking. She stated she did not leave resident trays unattended in a resident's room. She stated she heard the code blue called and went to the room and helped the nurse get him onto the floor. She stated the nurse was getting food out of his mouth and was also suctioning. Staff I, CNA said it was about ,d+[DATE] sandwich that was in his mouth and she though it was a Philly Steak sandwich. During a telephone interview on [DATE] at 11:14 a.m. Staff J, CNA stated she was present on the date of the incident, and she was very familiar with Resident #1. She said she worked doubles on the weekend and was normally assigned to care for Resident #1 but on that date, he was assigned to a different CNA. She stated she was turning a resident and heard the code called and ran to the room. She said the nurse was trying get him resident to 'cough it up'. She stated Resident #1 was not alert and they got him unbuckled from his chair and tried the Heimlich maneuver and then got him on the floor. She stated it was evident he was choking on food. She stated there was bread in his mouth, and it belonged to his roommate. Staff J, CNA said Resident #1 attempted to get food off the carts and from other residents' trays all the time. The CNA stated Resident #1 would try to get food not on his diet every day. She stated she gave a statement and told the same story she conveyed to surveyors. She stated supervising a resident at meal time means she has to make sure they are swallowing correctly and not coughing or choking on their food. A review of the facility policy entitled Meal Supervision and Assistance, implemented on ,d+[DATE] and revised on ,d+[DATE], revealed the following: Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: -Identifying hazards and risks -Evaluating and analyzing hazards and risks -Implementing interventions to reduce hazards and risks -Monitoring for effectiveness and modifying interventions when necessary Compliance Guidelines: 1 The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff. 2 The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time . Facility immediate actions to remove the Immediate Jeopardy included: --On [DATE] to [DATE] RN/ADON and/or designee, initiated education for meal supervision and aiding residents who have been prescribed a modified diet. These educations included verbal and online education courses 100% completion between in person, online and telephone education obtained on [DATE]. --On [DATE] the IDT (Interdisciplinary Team) reviewed MDS section K05102 for mechanically altered diet for all residents requiring assistance and or supervision with meals. ADON / designee reviewed care plans to identify current residents who have been prescribed a modified diet and require assistance with meals. Results of these audits were forwarded to the ad-hoc QAPI meeting held on [DATE]. For residents identified in the audit, care plans were revised, and ADL task list were updated to include aiding and supervision with meals. --On [DATE] an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was conducted with the facility leadership team as well as the Medical Director to review the incident involving Resident #1. --On [DATE] an Ad Hoc QAPI meeting was conducted with the facility leadership team as well as the Medical Director to review IJ F 689 Abatement plan. Root Cause Analysis was completed. PIPs (Performance Improvement Plans) were developed based on audits completed to ensure adequate compliance with F689. Root caused determined to be lack of supervision. --On [DATE] Additional staff members are now assigned to round throughout the building on both floors to provide additional supervision to ensure all residents get the appropriate meal and they are supervised until all trays are returned to kitchen. Staff educated to remove trays from patients' rooms after meal is completed and/or if the patient is not eating the dinner tray or not in the room. The tray would be placed back in the food cart until the patient is ready to eat. New dietary orders to also to be reviewed daily to assure all diet change orders are documented and reviewed. All audits will be reviewed after each meal by the Administrator/Designee to ensure compliance daily for 30 days. --Facility removed immediacy as of [DATE]. Verification of the facility's removal plan was conducted by the survey team on [DATE]. Beginning on [DATE] at 11:50 A.M. Interviews were conducted with 59 staff members including: 20 licensed nurses, 26 CNAs, a receptionist, an activities aide, 2 business office staff, the Physical Therapy Director, and 7 housekeeping staff. The staff members were able to state they had been trained and were knowledgeable about the new policies. On [DATE] starting at 11:50 a.m. dining observations were conducted on the second-floor units. The nurse was observed to check all carts for accuracy of the trays for each resident. During the tray pass, staff were observed checking trays for accuracy. The manager and nurses were visible on the unit. Staff from administration were observing and supervising tray pass and resident dining. Staff were observed assisting residents with their meals. No trays were left unattended during the observations. On [DATE] starting at 12:30 p.m. Dining observations were conducted on the first-floor units. On the secured unit, all trays were observed to be checked by the nurses on the unit prior to passing them out. Trays were distributed to residents in rooms first and all residents were observed to be in the room at the time of the tray delivery. Trays were then brought to the dining room area and were checked again and placed in front of residents in the dining area. There were 21 residents in the dining room for the lunch meal and there were 4 staff members present in the dining room to monitor the meal in the secured unit. On [DATE] at 12:46 p.m. the dining room on the first floor was observed to be locked and not in use. An interview was conducted with Staff K, LPN. She stated the dining room was being cleaned and renovations were being done in preparation to open it up and begin serving residents once again in the dining room. On [DATE] at 12:49 p.m. the dining trays for the lunch meal were served on the Lifestyle 1 unit. Trays were checked by the nurses to assure correct meals for each resident and then the meal tray pass began. Trays were verified by staff as they were delivered into the resident rooms. All trays delivered to the rooms were placed in front of a resident and set up. No trays were observed to be delivered to any resident not in the room. Trays for residents needing assistance with meals were delivered last so staff could assist with the meal. The Unit Managers/Nurses/Activities staff/Business office personnel were all present in the hallways to assist with monitoring during the meal service. A review of a IJ removal plan book, supplied by the facility, was conducted on [DATE] at 1:45 p.m. during an interview with the ANHA and NHA. They stated they were able to educate all the staff on duty and 100% were completed as of [DATE]. On [DATE] an electronic medical record message was put in to notify all staff of mandatory education. They stated they also sent out a text message to all staff and 100% of staff received this message. They stated all staff receive the texting and clinical staff get both messages. The message will appear every time the staff sign in to the computer. They stated there were no changes to the policy. They stated there were five trainings for the dietary concerns related to the supervision, policy, aspiration, dysphasia, and choking with interventions for the staff to complete online. They stated the education had been ongoing since 14th of August. They stated they had made sure 100% had completed the supervision education and no staff will be allowed to work until the education is completed in the future. The NHA stated during the work week the extra person will be the managers on days and evenings for the meal service. The night shift is to be mindful of any food source. On the weekend it will be the staffing coordinators who are nursing assistants that will be the extra set of eyes at meal service. The NHA stated a Quality meeting was completed on ,d+[DATE], ,d+[DATE], and regularly done today on ,d+[DATE]. He stated they did a Performance Improvement Plan (PIP) on the incident which revealed the lack

Based on observation, interview, and record review, the facility failed to ensure the right to be informed of, and participate in treatment for one (Resident #4) of seven sampled residents Findings included: On 6/12/2023, a review of the electronic medical record showed Resident #4 was admitted to the facility originally on 11/16/2022 and readmitted from the hospital on 6/9/2023. Resident #4 was a long term care resident at the facility and had diagnoses to include but not limited to Encephalopathy, Bipolar disorder, Post Traumatic Stress Disorder, Dementia, Depression, Brief Psychotic disorder, Altered Mental Status, history of ETOH abuse, Psychosis, and Anxiety. A review of the advance directives showed Resident #4 had a Power of Attorney (POA) in place to make her medical and financial decisions. The POA attended and was involved with past Care Planning meetings, and had visited the resident at times. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed, Cognition/Brief Interview for Mental Status (BIMS) score 8 of 15, which indicated moderately impaired cognition. Behaviors - showed the resident had not presented with any types of behaviors during this assessment period. A review of the nurse progress notes and daily behavior notes from 2/1/2023 through current date, 6/13/2023, showed frequent documentation of Resident #4 presenting with behaviors to include; throwing herself on the ground, crawling on the ground, standing up from her wheelchair and nose diving on the bed, or the roommate's bed, going in and out from other resident rooms, screaming, yelling, crying, attempts to hit staff, and presented with daily Anxiety behaviors related to being scared of being alone. These behaviors were documented almost daily and it was determined that the in-house Psychiatric Nurse Practitioner had the resident on her case load and assessed and monitored the resident at least once a week, sometimes more times a week. Review of the Progress notes section of the electronic record revealed the following: 1. Psychiatry Nurse Practitioner Encounter note dated 4/21/2023 at 01:00 showed: Past medical history to include: reports of anxiety bipolar psychosis prior to [NAME] Act for being combative has been in jail for being combative and with history of drug use. Reason for assessment/visit included: Resident alert x 3 intermittently screaming and crying and wants somebody to sit with her at all times 24/7 she reports she does not understand why she cannot have somebody sit with her. Patient reports she gets lonely and if she does not have somebody looking at her at all times she feels the other residents gets more attention than she does. Patient verbalizes paranoia if she does not have somebody sitting with her. The assessment also indicated that she seems to be the patient's baseline since she came in the facility. Will recommend a weighted blanket or anxiety straps on Geri chair as patient has a history of standing up and sitting down multiple times for safety awareness poor impulse control is a baseline. 2. Behavior note dated 4/21/2023 at 11:27, Writer spoke with patient. Patient reported anxiety when sitting in chair. Educated patient on weighted anxiety blanket. Patient reported that she would think about it. Patient verbalized paranoia about being alone, I can't be alone. 3. Psychiatry Nurse Practitioner Encounter note dated 5/5/2023 at 01:00, Awaiting weighted anxiety blanket, it has been ordered. 4. Behavior note dated 5/12/23 at 14:15 (2:15 p.m.), Resident removed weighted blanket and began hollering help. Assisted resident with putting blanket back on, but resident pushed it back off. 5. Health Status note dated 5/12/2023 at 20:11 (8:11 p.m.), Resident in her room with no behaviors or issues. Resident was sleeping at the start of the shift, she was awakened and consumed all of her dinner. Resident lying in bed with a weighted blanket at her feet. 6. Behavior note dated 5/15/2023 at 03:58, She asks for her blanket in specific her green blanket, then takes it off. 7. Behavior note dated 5/15/2023 05:45, Resident had a change of condition and was ordered and transferred to the ER related to Altered Mental Status, via hospital transport. 8. Social Service note dated 5/15/2023 at 11:47, Resident interviewed in regard to her having any concerns with her blanket. She reported, No. Social Services asking if she could remove it and she picked it up and handed it to the Assistant Nursing Home Administrator. Resident reported that she did not have any other concerns at this time. A review of the record revealed Resident #4 returned to the facility from the hospital on 6/9/2023. A review the nurse's progress notes dated from 6/9/2023 through 6/13/2023, and the Psychiatric Nurse Practitioner notes/assessments since 6/9/2023 admission, did not show use of aweighted blanket or the attempt to encourage the resident to use a weighted blanket. An interview on 6/12/2023 at 11:30 a.m., with the Psychiatric Nurse Practitioner, Staff A revealed she ordered the weighted blanket as a sensory object as a new intervention to decrease anxiety behaviors. She revealed once she recommended it on 4/21/2023, she was no longer involved with how the facility effectively care plans the device. She also revealed she did not speak with Resident #4's POA prior to her recommendation and said that would be something the facility nursing management would do. On 6/12/2023 at 3:15 p.m. a telephone interview was conducted with Resident #4's POA/Responsible Party. The POA revealed that she had been a part of quarterly care planning before and was involved with Resident #4's care and services. The POA said she was now aware Resident #4 was provided with a weighted blanket to use for her anxiety. She did not know how long the resident had been using it and said she had not been asked to sign a consent for the weighted blanket. She was not given information about the effects of the weighted blanket or the Risks and Benefits of the device. Resident #4's POA confirmed the resident did not have the ability to give consent for this device on her own. On 6/13/2023 at 11:30 a.m., an interview with the Nursing Home Administrator (NHA) revealed she was very knowledgeable about Resident #4 and the purchase and use of the weighted blanket. She said the blanket was not used as a restraint and the resident could remove it and had demonstrated removal of the blanket per her desire. The NHA said she ordered the weighted blanket on 4/27/2023. She said there was not an actual physician's order for this intervention, as it was just a blanket to be used to reduce anxiety. The NHA provided the following document for review: Final Details for Order, order placed on 4/27/2023 with a shipped out date of 4/29/2023 to include: 2 of [vendor name] Weighted Blanket (15 lbs. 48 x 72 Twin size) Cooling Breathable Heavy Blanket Microfiber Material with Glass beads big blanket for Adult all-season soft thick comfort blanket. The NHA confirmed she, the nursing department, nor anyone from the facility called Resident #4's POA to go over the decision to utilize a weighted blanket to reduce anxiety episodes. She confirmed the POA was not given the right to be notified of the device prior to use. She said the POA should have been provided with information , including the Risks and Benefits and given the opportunity to refuse or consent to the weighted blanket. The NHA revealed she did speak with Resident #4's POA related to the blanket, but it was well after it had been in use. On 6/13/2023 at 2:00 p.m., the Nursing Home Administrator (NHA) provided the facility's Resident Rights, policy and procedure with no implement date, for review. The policy had a copyright date of 2023. The Resident Rights policy and procedure Policy section revealed; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The Policy Explanation and Compliance Guidelines section revealed the following, but not limited to: Resident Rights - The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the United States. (a.) The resident has the right to be free of interference, coercion, discrimination, and reprisal of his or her rights. (B.) In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law. (d.) The resident representative has the right to the resident's rights to the extent those rights are delegated to the resident representative. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (a.) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. (b.) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (iii) The right to be informed, in advance, of changes to the plan of care. (c.) The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (d.) The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternatives or options he or she prefers. (e.) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on observation, record review, and interview, the facility failed to implement a care plan for one (Resident #3) of three residents sampled related to NPO ((nothing by mouth) status. Findings included: A review of Resident #3's Admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to gastrostomy status, anoxic brain damage not elsewhere classified, unspecified white matter disease, and unspecified organism other pneumonia. A progress note, dated 5/4/23 at 11:33 p.m., described an incident that the writer (of the note) went into the residents room and saw the aide feeding the resident who is NPO. The note indicated that the resident had been given approximately one spoonful of food which the resident spat out. The note indicated the nurse assessed and suctioned the resident, and educated the aide on reading diet slips, checking name, room number, and bed number (of diet slip). The note did not identify if any food particles had been obtained from the oral cavity when Staff J had suctioned the resident. The review of Resident #3's Medication and Treatment Administration Records, May 2023, identified the following orders: - Enteral Feed Order, start 5/4/23 - every 4 hours bolus feed, Jevity 1.5, 1 can every 4 hours = 6 cans daily. - Enteral Feed Order, start 5/4/23 - every 4 hours Enteral 1 - Feeding: Administer Jevity 1.5 per G-tube via Bolus. Rate 237 milliliter (mL) per feeding 6 times a day. - Enteral Feed Order, start 5/4/23 - every 4 hours Enteral hydration: Bolus with 120 mL's water every 4 ours for hydration. - Oral suctioning as needed for excessive secretions every 6 hours as needed, start date 5/4/23. - Suction as needed (prn) as needed for congestion, start date 5/3/23, discontinued at 8:20 a.m. on 5/4/23. A review of the Resident #3's care plan identified the following: - (Resident) is at risk for malnutrition related to (r/t) low body mass index (BMI), dysphagia with dependence on enteral nutrition for meeting of needs, increased nutritional demand for wound healing, polysubstance abuse history, and 1/27/23 coughing on food and fluids - NPO status, initiated on 10/18/22 and canceled on 5/9/23 (5 days after resident was transferred). - (Resident) has decreased ability to perform Activities of Daily Living) ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to impaired cognition, activity intolerance, (and) impaired mobility, initiated on 10/18/22 revised and canceled on 5/9/23. The interventions identified Eating: NPO - receives enteral feeding, initiated 4/11/23 and canceled on 5/9/23. - 3/10/23 (Resident) has diagnosis of Emphysema and nodule to right lung per CT scan. An interview was conducted on 6/13/23 at 9:24 a.m. with Staff I, Certified Nursing Assistant (CNA). Staff I admitted to working for the facility (not agency), vaguely remembered Resident #3, and had only worked with this resident one time. Staff I said she was told by an unidentified aide during rounds (at the beginning of her shift), that one of the residents in the room was a feed and Resident #3 was the only resident in the room at that time. Staff I said at the time of the meal service (dinner), two trays came for the room, one for A-bed and one for B-bed, Staff I glanced at the ticket, and admitted to not fully reading the resident name on it then began to feed Resident #3. Staff I stated the resident pushed his lips toward the spoon, the nurse came into the room and informed the aide the resident was NPO. Staff I reported the resident never let her put the food into his mouth. She said the resident became upset and started extra coughing and right there Staff I decided not to feed the resident. She said, I'm not a forceful person. An interview was conducted, on 6/13/23 at 10:48 a.m., with Staff J, Licensed Practical Nurse (LPN). Staff J stated on 5/4/23 at dinner time she brought Resident #3's roommate in the room to eat and observed the CNA feeding Resident #3. Staff J asked Staff I how the tray got to Resident #3 and asked her to look at the picture, name, and verify the room number. Staff J stated the tray that was being fed to Resident #3 was for a resident on a different unit, and was a regular diet from Lifestyle 2 (upstairs from the resident). Staff J reported notifying the Director of Nursing (DON) and Nursing Home Administrator (NHA), suctioning Resident #3 to see if any food was in there to get it out, and reported removing a couple pieces of corn out of mouth. Staff J reported the resident was gurgling on admission, 5/3/23. Staff J had not suctioned the resident prior to the event, and the resident was not wearing oxygen prior to the incident. Staff J throughout the night Resident #3's oxygen saturation was lowering so oxygen was applied, and as needed Tylenol was administered as the resident began running a low-grade temperature. Staff J contacted Resident #3's family and Hospice, the Hospice staff called Emergency Medical Services (EMS) to transfer resident to Hospice House. The dietary slip/meal ticket (obtained from CDM on 6/13/23 at 8:12 a.m.), dated 5/4/23, showed Resident #3 was NPO, had the residents name, room number with bed letter, and picture. The diet slip/ticket did not identify any food/drink/supplemental items that would be served to Resident #3. The menu for 5/4/23, that the CDM provided, identified that on 5/4/23 the primary dinner served to residents included buttered kernel corn. The Nutrition/Dietary note from Registered Dietician, dated 5/4/23 at 10:43 a.m., identified that Resident #3 received 6 cans of Jevity 1.5 daily (1 can every 4 hours). The note did not identify any other type of diet for Resident #3. The Health Status note, dated 5/4/23 at 12:50 p.m., indicated that Resident #3 was suctioned this shift due to excessive secretions. The note did not identify how many times the resident had been suctioned. The note indicated the vital signs for the resident were 128/86, 97.7 temperature, pulse 92, respirations were 20, and oxygen saturation was 97% on room air. The note identified that hospice nurse had been in to see the resident and at the time of the note, the resident was in bed eyes closed, respirations even and unlabored. A Health Status note, dated 5/4/23 at 8:19 p.m., indicated that Resident #3 had increased secretions and cough and a STAT chest X-ray was ordered. On 5/4/23 at 11:40 p.m., Staff J noted that Resident #3 had increased secretions and cough, vital signs were 130/90, heart rate was 106, respirations 16, temperature was 98.2, and oxygen saturation on room air was 80%. The staff member documented oxygen was administered for shortness of breath, new orders were obtained for a STAT chest X-ray, hospice nurse and family member notified, and as needed Tylenol was administered with continued suctioning as needed. The staff member noted that oxygen saturation raised to 95% and resident was on 5 liters per minute (lpm) of oxygen, Resident resting comfortably in bed with (family member) by (resident) side. Hospice in facility to evaluate and new recommendations were to send resident to Hospice House. The note indicated Resident #3 left the facility via ambulance at approximately 11:00 p.m. On 6/13/23 at 11:24 a.m., an interview was conducted with Resident #3's Attending physician. The physician reported that the resident had aspiration syndrome and the next to the last time the resident came back with a feeding tube after not doing well with oral (intake). The expectation was for residents with NPO orders should be obvious, should not be getting fed orally. The physician stated the expectation was that staff know the resident was NPO and described that other facilities place signs up that identify the resident as NPO. The Assistant Director Nursing (ADON) stated on 6/12/23 at 3:04 p.m., that a spoonful of food was inadvertently fed to Resident #3 which was spat out and staff suctioned. The ADON stated that the facility addressed the incident with the aide, Staff I, and educated that if there were any changes with dietary status nurses inform aides of the changes during rounds. On 6/12/23 at 5:16 p.m., the Nursing Home Administrator (NHA) admitted to being aware that an aide reported feeding the resident one spoonful of food which Resident #3 spat out and the aide demonstrated that the resident pushed the food away with pursed lips and the nurse went in and immediately suctioned the resident. The NHA stated being pretty sure the resident came back from hospital with additional secretions that required additional suctioning and was to be transferred to Hospice House when a bed became available. An interview was conducted at 6/13/23 at 1:07 p.m., with the NHA, the Regional Nurse Consultant (RNC), Staff K (Licensed Practical Nurse (LPN)/Unit Manager), and Staff L (Facility Nurse Practitioner (NP). Staff L stated Resident #3 had been treated for recurrent pneumonia that the facility could not get rid of, the resident was sent for a pulmonary consult with results of right lower lobe nodule. The RNC stated that the first time the resident transferred to the hospital for pneumonia was in February (2023). The RNC said the resident had been sent to hospital numerous times for pneumonia, abnormal labs, and brown emesis. A telephone interview was conducted on 6/13/23 at 3:27 p.m., with the previous NHA, Staff M. Staff M reported that the DON, who was onsite at time of the incident, was onsite and it was reported that a newer aide gave Resident #3 a spoon of pureed food, the nurse had immediately suctioned the resident and it looked like the resident had spit everything out. The staff member stated that the nurse had called family, physician, and hospice. The facility incident log did not include the event on 5/4/23 involving Resident #3. The policy - Therapeutic Diet Orders, implemented on 11/3/2020, indicated that The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the reside's treatment/plan of care, in accordance with his/her goals and preferences. The explanation and compliance guidelines of the policy indicated that each residents nutritional status is assessed by the interdisciplinary team in accordance with assessment policies and Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. The policy - Serving a Meal, implemented 11/3/2020 and revised 11/29/2022, indicated that It is the policy of this facility to serve meals that meet the nutritional needs of the residents. The guidelines and explanation revealed that Diets should be served in accordance with the physician's order.

Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, homelike environment on four of six units and the kitchen. Findings included: On 4/03/23 at 9:35 a.m., an observation of the Lifestyle east unit was conducted that revealed multiple wheelchairs lined up against the east wall. Upon approaching the chairs, the smell of urine was noted. The back of one of the wheelchairs was marked with room [ROOM NUMBER] B. Where the seat/cushion connected, there was a burnt orange to brown colored substance. On closer observation, a foul overpowering smell of urine was present. A second chair was present and was observed with the name of a resident that was discharged on [DATE]. The back of the wheelchair had a large amount of dried liquid substance with dried debris. On 4/3/23 at 2:39 p.m., an observation was conducted in bedroom Lifestyle east 210 A and revealed a wheelchair seat with a thick brown substance that was dried with a foul odor. 46234 An observation was conducted on 4/3/23 at 8:43 a.m. of dirty towels on the floor in room [ROOM NUMBER] on the 1 East unit. An observation was conducted on 4/3/23 at 8:44 a.m. of two dead cock roaches in the hall of the 1 East unit. Sitting next to the deal roaches there was a used cup with lid. An observation was conducted on 4/3/23 at 9:13 a.m. of a dirty towel on the floor in room [ROOM NUMBER] E. An observation was conducted on 4/3/23 at 9:14 p.m. of broken blinds and coloring on the bathroom door with paint chipping off in room [ROOM NUMBER] W. An observation was conducted on 4/3/23 at 9:16 a.m. of a bag of dirty linen sitting on the floor inside room [ROOM NUMBER] E. An observation was conducted on 4/3/23 at 11:39 a.m. of broken kitchen tiles. The tiles were broken and had come up in two areas near the dish machine and the remaining holes were filled with water. An observation was conducted on 4/3/23 at 11:49 a.m. of a wheelchair in room [ROOM NUMBER] that had hair tangled around the axle of both wheels, the strap was caked with food, and the chair had a smell of urine. When the seat cushion was lifted several gnat-like flies flew out of the wheelchair. Underneath the cushion it was observed to be wet and have caked on food. An observation was conducted on 4/3/23 at 11:50 a.m. in room [ROOM NUMBER] E of a privacy curtain hanging on the floor detached from the railing. An observation was conducted on 4/3/23 at 11:52 a.m. in room [ROOM NUMBER] E. of a soiled privacy curtain that was resting on a resident bed. The toilet in the room was continuously running water and there was a dead lizard stuck in the shower drain, a second privacy curtain was off the track hanging on the floor, a window was observed to not be sealed with open gaps to the outside, and multiple used towels were on the floor around the room. An observation was conducted on 4/3/23 at 12:04 p.m. in room [ROOM NUMBER] L of a soiled privacy curtain. The room also contained a wheelchair that was observed to have food and dirty under the cushion with trash and hair around the wheel axle. An observation was conducted on 4/3/23 at 12:09 p.m. in room [ROOM NUMBER] L of a soiled privacy curtain. An observation was conducted on 4/3/23 at 12:14 p.m. in room [ROOM NUMBER] L. The door knob in the room was dented and the door had a chunk of wood missing from the door knob area. One privacy curtain was tied up and was dirty and the second curtain was soiled with an unknown substance. The bathroom door was locked. One of the residents said it was due to the toilet being clogged and it had been that was for two to three weeks. A CNA that was in the room said the resident had been using the bathroom in the room across the hall, but she didn't know why his bathroom was locked or what was wrong with it. An observation was conducted on 4/3/23 at 12:18 p.m. in room [ROOM NUMBER] L. There was a wire coming out of the wall under the window with an exposed end. Another wire was coming out of the wall above the wall vent in the corner. There was also observed to be something splattered on the ceiling. A CNA came in the room and said it was food from the previous resident and it had been there a while. An observation was conducted on 4/3/23 at 12:20 p.m. in the second-floor pantry. There was a towel that was soiled and mostly brown on the shelf in a cabinet. The cabinet and vents were observed to also be dirty. An observation was conducted on 4/3/23 at 12:24 p.m. in room [ROOM NUMBER] L. A wheelchair in the room had plastic and foam stuffing coming out of the top right side of the chair. The walls behind the bed were dirty and covered in black marks, the bathroom vent was covered in dust and the toilet caulking was pulled aware from the toilet base. An observation was conducted on 4/3/23 at 12:33 p.m. in room [ROOM NUMBER] L. The toilet in the room was continually running water. The cover to the toilet tank had been removed and placed on the floor. One of the residents in the room said it is on the floor so he can jiggle the chain to make it stop running. He said it had been that way for a while. A privacy curtain was observed to be soiled, there were dirty linens on the floor, and one bed had threadbare sheets with a hole in it, with no pillowcase. An observation was conducted on 4/3/23 at 12:36 p.m. in room [ROOM NUMBER] L. The bathroom vent was observed to be covered in dust; the toilet was continuously running water with water on the bathroom floor. The light above one of the beds was detached on one side and hanging crooked. An observation was conducted on 4/3/23 at 12:38 p.m. in room [ROOM NUMBER] L. The toilet in the room was observed to be continuously running water and the toilet caulk was loose and brown. An observation was conducted on 4/3/23 at 12:44 p.m. in the 2 East Shower room. In the middle of the room there were tiles that had come up and were still sitting on the floor. An observation was conducted on 4/3/23 at 12:49 p.m. in room [ROOM NUMBER] W. There were dirty towels observed to be on the floor and on top of a side table. The room was also on contact precautions and the used personal protective equipment (PPE) was being placed in a clear plastic trash bag that was sitting in a wheelchair. The floors in the room were also observed to be dirty. An observation was conducted on 4/3/23 at 12:51 p.m. in room [ROOM NUMBER] W. There was an approximate four-foot section of corner trim that was missing from the corner of the wall. The trim piece was observed to be propped up in another corner of the room. The air conditioning unit was not sealed and had visible light coming in around the perimeter. An observation was conducted on 4/3/23 at 12:52 p.m. of doors for the storage room off the track in the 2-west hall. An observation was conducted on 4/3/23 at 1:56 p.m. and again at 4:30 p.m. of an alcove on the east unit where the crash cart sits. Next to the crash cart there were clothing and plastic bags piled in the corner. An observation was conducted on 4/3/23 at 2:53 p.m. of the front elevator. The elevator had broken floor and edging tiles. This elevator was observed to be frequented by residents. Throughout the day on 4/3/23 multiple smoke detectors could be heard beeping due to low batteries. One was confirmed to be in room [ROOM NUMBER] W. There was an additional one beeping on the second floor and one on the first floor that were unable to be pinned down to a particular room due to the beeping being spaced out. The resident in 218 W said the smoke detector had been beeping for a while. An interview was conducted with the Environmental Services (EVS) Director on 4/3/23 at 3:07 p.m. He had provided a schedule of when wheelchairs should be cleaned for each unit. He said on the scheduled day, clinical staff put the wheelchairs outside of the resident rooms and the floor techs gather the chairs from the hallway and clean them. The EVS Director said he did not have a list for when chairs had been cleaned or any documentation showing when each resident's chair was cleaned. He said the floor techs just tell him they were doing the job. He said if wheelchairs are soiled any time other than their scheduled cleaning day, he must rely on nursing to notify him, and they would be cleaned. The EVS Director said all soiled linens should be taken to the soiled utility room and not be left in the resident rooms. He said the Certified Nursing Assistants (CNA) should gather dirty linen and EVS picked it up from the soiled utility to send out for cleaning. He said housekeeping cleans each resident room daily and they should be looking at privacy curtains to see if they are soiled. They should then let him know so they could be changed out. An interview was conducted with the Maintenance Director on 4/3/23 at 4:25 p.m. He stated staff should be putting work orders in the [computerized maintenance log] system. The [computerized maintenance log] is the system they use to track the maintenance work that needed to be completed. A tour of the facility was conducted with the Maintenance Director to review some of the concerns; he also reviewed pictures taken of maintenance concerns. He said the toilets did get backed up, but he was not aware of any with continuous running. As for the broken blinds, he stated those would be fixed that day. He said the kitchen staff keep breaking the tiles in the kitchen. As for the toilet running in room [ROOM NUMBER] L with the lid sitting on the floor, he said staff obviously had to see that, but no one had told him. He observed the alcove on the East unit where the crash cart sits. He said he did not know why clothes and bags were in there, but he would get someone to remove the items. During the tour the bathroom in 214 L was rechecked and had been unlocked. The toilet was observed to be clogged and there was feces on the floor and in the toilet. He said he would get housekeeping immediately, but he had no idea why the door would have been locked and why no one told him the toilet was clogged. As for the smoke detectors, he said he did not know why they had them. He said they are not connected to the main fire systems. He said he thought they were put in some rooms prior to him due to residents that smoked. He said maintenance changed the batteries on them when they need it. He was unaware any were currently beeping. The Maintenance Director said he depended on nursing and housekeeping to put in the work orders. The Maintenance Director stated he did walk around the building all day fixing issues and there were plenty of chances for staff to let him know if something was not working. An interview was conducted with the Nursing Home Administrator (NHA) on 4/3/23 at 5:30 p.m. Concerns that were found were reviewed with the NHA. She stated they did have Angels Rounds in the past, where the department heads toured the facility, including resident rooms, to look for concerns that needed addressing. The NHA said they stopped doing the rounds around September when they lost several unit managers, who were part of the Angel Rounds. She stated staff should be entering maintenance concerns into the [computerized maintenance log] system for the maintenance department to fix. The NHA said housekeepers did not have access to the [computerized maintenance log] system, so they would have to notify their supervisor of issues. The NHA administration provided a Method of Cleaning document and said housekeeping should be looking at the cleanliness or privacy curtains daily when they were in resident rooms. As for toilets continuously running, she said the toilet in her office had been running because it had a cheap flapper put in the back. She said she had maintenance replace it, but she didn't know toilets in resident rooms were also running continuously. A facility provided document titled Method of Cleaning, undated, was reviewed. The documented showed the following: Every facility in our system may have different dynamics to deal with, and every situation should be handled accordingly. But some general cleaning practices, routines and systems need to be in place and followed. Here are some broad methods to keep in mind when training and following up with staff. -TOP DOWN: always start cleaning surfaces, ledges, shelves, etc at the top and work your way down. Clean the face of services as well. -Restrooms address the same as a room, paying careful attention to the sink and commode. Infection control is critical here. -Check privacy curtains, linens, and the overall condition of the room (note any maintenance concerns) -Remove all debris from floors, counters, and edges. -Remove all trash and replace linens as needed. A facility policy titled Preventative Maintenance Program, copyright 2022, was reviewed. The policy stated the following: Policy: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plan to determine if preventative maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall develop a calendar in [computerized maintenance log] to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks in [computerized maintenance log] and records maintained in [computerized maintenance log] program.

Based on observation, interview, and record review, the facility failed to ensure the disposition of controlled medications reflected accurate accounting and record keeping for six (Residents #4, #5, #6, #7, #8, and #9) of six residents sampled for controlled medications. Findings Included: 1. A review of Resident #4's physician orders revealed an order for Klonopin Tablet 0.5 mg (Clonazepam) give 1 tablet by mouth at bedtime for general anxiety disorder (gad) start date 03/06/2023. A review of the Medication Administration Record (MAR) reflected the medication was administered at bedtime as ordered. A review of the Medication Monitoring/ Control Record revealed an omission of documentation for two doses on 03/23/2023 and 03/24/2023. 2. A review of Resident #5's physician orders revealed an order for Lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety related to schizophrenia start date 01/11/2023 with a stop date on 01/23/2023. On 01/23/2023, a new order was received for Lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety related to schizophrenia until 02/06/2023. A review of the Medication Monitoring/ Control Record between 01/11/2023 to 02/06/2023 revealed Lorazepam was administered twelve times. A review of the MAR between 01/11/2023 to 02/06/2023, revealed Lorazepam was administered eight times which, indicated an omission of documentation for three doses on 01/23/2023, 01/25/2023, and 02/6/2023. 46234 3. A review of admission records showed Resident #6 was admitted on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder, and autistic disorder. A review of physician orders showed Resident #6 had an order for Clonazepam tablet 0.5 milligram(mg). Give one tablet by mouth three times a day for anxiety. The order was dated 3/8/23. A review of the MAR showed Resident #6 was administered Clonazepam as ordered on 4/1/23 at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the Medication Monitoring/Control Record for Resident #6's Clonazepam showed the medication was only given one time on 4/1/23 at 9:00 p.m. Upon audit of the controlled medication in the medication cart, the Clonazepam pill count matched the number remaining on the Medication Monitoring/Control Record showing Clonazepam was not administered on 4/1/12 at 9:00 a.m. and 1:00 p.m. as ordered. 4. A review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including schizophrenia, dementia, and fibromyalgia. A review of physician orders showed Resident #7 had an order for Ambien oral tablet 5 mg. Give 5 mg by mouth at bedtime for insomnia. The order was dated 2/10/23. A review of the MAR showed Resident #7 was administered Ambien as ordered on 4/2/23 at 8:00 p.m. A review of the Medication Monitoring/Control Record for Resident #7's Ambien showed the medication was not given on 4/2/23. Upon audit of the controlled medication in the medication cart, the Ambien pill count matched the number remaining on the Medication Monitoring/Control Record showing the Ambien was not administered on 4/2/23 as ordered. 5. A review of admission records showed Resident #8 was readmitted on [DATE] with diagnoses including bipolar disorder, paranoid schizophrenia, anxiety disorder, and unspecified psychosis. A review of the March 2023 MAR showed Resident #8 had an order for Diazepam (Valium) 5 mg that was given on 3/1/23 through 3/26/23 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The order was discontinued on 3/27/23 at 8:13 a.m. The remaining days of the month 3/27/23 through 3/31/23 had an X placed on the MAR. A review of progress notes showed an entry dated 3/27/23 at 8:14 a.m. from the nurse practitioner that said, resident told writer she wanted a new anxiety med. Pt. feels valium is not working. Pt is scratching self on multiple dermatones, will stop valium add buspar. The MAR showed Buspirone HCL oral tablet 5 mg. Give 1 tablet by mouth two times a day was started on 3/27/23 at 9:00 a.m. According to the MAR, Resident #8 was administered the medication on 3/27/23 at 9:00 a.m. and 5:00 p.m. as ordered. A review of the Medication Monitoring/Control Record for Resident #8's Diazepam showed the medication was administered on 3/27/23 at 2:00 p.m. and 5:00 p.m. after the medication was discontinued. Upon audit of the controlled medication in the medication cart on 4/3/23, the Diazepam for Resident #8 remained in the locked narcotic drawer. The Diazepam pill count matched the number remaining on the Medication Monitoring/Control Record showing the Diazepam was administered on 3/27/23 at 2:00 p.m. and 5:00 p.m. According to the MAR and the Medication Monitoring/Control Record, Resident #8 was administered both Diazepam and Buspirone on 3/27/23. 6. A review of admission records showed Resident #9 was readmitted on [DATE] with diagnoses including generalized anxiety disorder, major depressive disorder, and dementia. A review of physician orders showed Resident #9 had an order for Ativan (Lorazepam) 0.5 mg tablet. Give 1 tablet via g-tube every 8 hours for anxiety/restlessness. The order was dated 12/27/22. A review of the MAR showed Resident #9 was administered Ativan as ordered on 3/28/23 at 6:00 a.m., 2:00 p.m. and 10:00 p.m. A review of the Medication Monitoring/Control Record for Resident #9's Ativan showed the medication was only given twice on 3/28/23, at 6:00 a.m. and 2:00 p.m. Upon audit of the controlled medication in the medication cart, the Ativan pill count matched the number remaining on the Medication Monitoring/Control Record showing Ativan was not administered on 3/28/23 at 10:00 p.m. as ordered. An interview with completed on 4/3/23 at 8:40 a.m. with Staff A, Licensed Practical Nurse (LPN). Staff A demonstrated the process of signing out a controlled medication. She showed how the medication should be marked as prepped in the computer then marked given after the resident takes the medication. She said the medication should be signed off on the Medication Monitoring/Control Record that was in a binder on the medication cart. Staff A confirmed controlled medication should be signed off in both places every time it was given. An interview was conducted with the Director of Nursing (DON) on 4/3/23 at 5:06 p.m. The DON reviewed the discrepancies found in the MAR and Medication Monitoring/Control Record. She said the nurse should be checking the order, giving the medication then coming back and signing the medication off. She said the MAR and the Medication Monitoring/Control Record should always match. The DON was unaware of these discrepancies. An interview was conducted with the Consultant Pharmacist on 4/3/23 at 5:15 p.m. He stated there should not be any discrepancies in the MAR and the Medication Monitoring/Control Record and he would expect both to match. The Pharmacist said last time he was in the facility he did not look at the controlled medication log, due to checking other things. He said they did look at narcotics, but it was a team approach. He said he always expects when something is documented it should be dispensed. A facility policy titled Medication Administration, copyright 2022, was reviewed. The policy showed the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this stated, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 10. Review MAR to identify medication to be administered. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book. 20. Correct any discrepancies and report to nurse manager.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and/or implement policies and procedures to assure that all persons working in the facility were either vaccinated against COVID-19, had an approved delay that met CDC (Centers for Disease Control and Prevention) standard, or had requested and been granted an exemption. The facility was 100% compliant with its own employees all either being fully vaccinated or exempted. However, the facility failed to verify a contracted (agency) staff member's vaccination status prior to the staff repeatedly working in the building. The failures to develop/implement policies and assure all persons working in the facility were either fully vaccinated or exempted has the potential to affect all residents. Findings include: 1. Review of the facility's policy titled, Employee COVID-19 Vaccination Mandate, revised 04/05/22, revealed, Employees who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated (CMS [Centers for Medicare and Medicaid Services] term) or up to date (CDC) term against COVID-19. These include the following .Individuals who provide care, treatment, or other services for the facility and/or its residents under contract or by other arrangement This policy also stated, The facility will ensure that all staff (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 must be temporarily delayed, as recommended by the CDC, due to clinical precautions and consideration) are fully vaccinated (CMS term) or up to date (CDC term). Further review of the policy revealed that it did not describe specific procedures to be utilized to ensure that contract or agency staff met this requirement prior to working in the facility. 2. Observation on 07/18/22 at 3:58 PM revealed that Certified Nursing Assistant (CNA) 3 was working on the first floor of the facility, providing care to residents. Interview with CNA3 revealed that she had one dose of the COVID-19 vaccine several months ago. CNA3 stated that she was going to go back for the second dose; however, she had not yet done so. She stated she had not asked for an exemption because of her plan to eventually get the second dose. CNA3 stated that she had spoken to her provider when she got the first vaccination, and They told me I had to wait six months for the next dose. Review of CNA3's vaccination record revealed that only one dose of the two-step Pfizer vaccine series was listed as being administered. Per her vaccination card, CNA3 received the first dose of the Pfizer vaccine on 12/18/21, and there was no evidence the second dose was ever received. Interview with the Administrator on 07/18/22 at 5:35 PM revealed that CNA3 was an agency staff, working in the facility. The Administrator confirmed that CNA3 was not fully vaccinated, as she had received only one dose of the two-step Pfizer vaccine series and had not returned for the second vaccine after receiving her first dose in December 2021. Additional interview with the Administrator on 07/18/22 at 5:45 PM revealed that she was going to check on the CNA's status, noting, If she doesn't have a vaccination card, we will be sending her home. The Administrator stated that the nursing agency for whom CNA3 worked had a computer app[lication] that showed green if an employee was fully vaccinated and had met all other requirements to work at a facility. She stated she would need to check and see what showed up on the computer app, adding, I need to see how she got booked. We've already told the agency we only want green [employees]. Additional interview with the Administrator on 07/18/22 at 6:00 PM revealed that CNA3 had not originally been scheduled to work on 07/18/22 but had picked up a shift for another employee. She stated that, our standard was that only employees who had an exemption or were fully vaccination were to be supplied by the agency or scheduled by the facility. She showed the computer app which she had previously referenced, and observation revealed that the code by CNA3's name was an orange half-circle, rather than a green circle which indicated that the staff met all requirements and could be scheduled. The Administrator stated that, It looks like the scheduler didn't catch it. The Administrator reviewed her records and stated that in addition to the day of the survey, CNA3 also worked on 07/07/22, 07/11/22, 07/14/22, 07/15/22 and 07/16/22. The Administrator stated that she would be calling the agency to discuss the issue and also noted that, Our scheduler [whom the Administrator stated was not in the facility/available for interview] definitely had the opportunity to have seen that CNA3 was not fully vaccinated or exempted. Further interview with the Administrator confirmed that the facility's policy did not describe the specific procedures to be used, including reviewing the staffing agency's app to verify vaccination status to assure compliance with the vaccine mandate.

Based on observations, staff interviews and facility record review, the facility failed to maintain resident spaces to include three of six units (LS1 Lifestyles, LS1 East, and LS1 West) in a clean and sanitary manner during four of four days observed (6/27/2022, 6/28/2022, 6/29/2022, and 6/30/2022). Spaces were observed with but not limited to soiled floors, walls, and resident equipment, resident bathrooms had non cleanable surfaces, non-maintained toilet seats and biogrowth on surface, resident rooms air/conditioning and heating units were observed with biogrowth and dust debris caked on the vents and filters. Findings included: During facility-wide tours on 6/27/2022 at 10:50 a.m.; 6/26/2022 at 7:20 a.m., and 1:00 p.m.; 6/29/2022 at 7:45 a.m., and 1:45 p.m., and on 6/30/2022 at 8:00 a.m., 1:30 p.m. the following was observed: LS1 EAST 1. Resident room 118 was observed with a wall dresser with the facing of the bottom drawer torn off and lying on the floor next to the bed. The floor was heavily sticky with black color matter. The indoor metal door frame in the bathroom was observed heavily rusted and leaving no cleanable surface. The bathroom toilet seat was loose and not tightly secured to the base. The ceiling was observed with heavy water staining with water dripping onto the floor. An area of brown and black biogrowth was observed to size approximately ten by ten inches. The wall framing surrounding the air conditioner/heating unit was observed torn off the wall, in disrepair and leaving holes leading to the outside elements. Further, the wall plaster and wall paper was observed peeling off surround the entire unit, and not leaving a cleanable surface. The air conditioner/heating unit filter and plastic vents were full of dust and debris and spotted with black biogrowth. 2. Resident room 112 window wall was soiled with black grime from foot and hand prints, the bathroom floor was sticky and soiled with debris. The room floor was heavily soiled with sticky debris, and the floor area under all three beds were heavily sticky with debris. 3. Resident room 111-bathroom toilet seat was loose and not tightly secured to the base, the paper towel holder secured to the wall was missing the entire front housing, 11 wall tiles across from the sink were observed loose and in disrepair and pushed into the inside wall space, and the inside bathroom door frame was observed with heavy rusting with paint bubbled and cracked, leaving a non-cleanable surface. The bathroom floor was observed sticky and soiled with debris. The privacy curtains were heavily stained with red, orange, and black biogrowth and matter. 4. Resident room 114-bathroom toilet seat was loose and not secured to the base, an unbagged toilet plunger was placed next to the toilet. There were cracked and missing tiles that were also in disrepair and not cleanable, the inside bathroom door frame observed with heavy rusting with paint bubbled and cracked and leaving a non-cleanable surface, the bathroom ceiling was observed with approximately five inch by five-inch area with black biogrowth, the room air conditioning/heating unit filter and plastic vents were full of caked on dust/debris and with yellow and black biogrowth. 5. Resident room 102 air conditioning/heating wall unit filter was caked with dust/debris and with the plastic vents of the unit spotted heavily with black biogrowth. The bathroom floor was observed sticky and soiled with debris 6. Resident room 103 air conditioning/heating wall unit filter was caked with dust/debris and with the plastic vents of the unit spotted heavily with black biogrowth. 7. Resident room 115 was observed with a hole in the wall, what appeared to be a missing wall outlet. There was debris to include plastic hydration cup lids, and other various crumpled up paper/debris in it. 8. Resident room 110 main inside door, door handle was observed with a broken door handle that was popped off the door itself. Photographic evidence was taken with relation to above areas listed. LS1 LIFESTYLE 9. Resident room 125-bathroom floor was observed sticky and soiled with debris. The privacy curtains were heavily stained with red, orange, and black biogrowth and matter. 10. Resident room 103-bathroom sink was observed backed up with over six inches of water. The toilet did not flush all the way when lever was pulled, and the bathroom floor was sticky and soiled with debris. LS1 WEST SECURED UNIT 11. Resident room 109 was observed with the window wall just above the C bed with grime and soiling. It appeared as if the wall had foot prints and grime from resident's feet and hands. The floors in the room were sticky with debris, the bathroom toilet seat was loose and not secured tightly to the base, the sink was observed heavily soiled with brown matter, the toilet floor behind the toilet base was observed with brown matter and there was no toilet paper in the bathroom. The privacy curtains were heavily stained with red, orange, and black biogrowth and matter. 12. Resident room 110 was observed with all four beds with ripped and torn blanket/linen. The floors under all beds were sticky and soiled debris matter. The bathroom toilet seat was loose and not tightly secured to the base, and the floors in the bathroom were sticky with brown and black matter. The privacy curtains were heavily stained with red, orange, and black biogrowth and matter. 13. Resident room 102 was observed with heavily sticky floors in the room and in the bathroom. Also, there was brown matter all over the right-side base of the toilet. The privacy curtains were heavily stained with red, orange, and black biogrowth and matter. Photographic evidence was taken with regards to the above listed observations. On 6/28/2022 at 10:00 a.m. an interview with the Housekeeping Director revealed he just took this facility on and was still trying to learn what is needed as far as deep cleaning schedules. He did not have any current cleaning sheets or documentation to show what resident rooms were scheduled for entire room cleaning. He did confirm the daily expectations for his staff were to empty trash cans, sweep, mop room and bathroom floors and clean any staining and matter as needed. On 6/29/2022 at 1:00 p.m. an interview with the Maintenance Director confirmed he did not have any work orders with relation to the above listed areas. He revealed it is the job of floor staff to put in work orders so he can get to the concerns as quick as possible. He further indicated he does make rounds but had no documentation to support the last time he made entire facility rounds to look at general maintenance and cleanliness of rooms and equipment. On 6/30/2022 at 1:30 p.m. an interview with the Nursing Home Administrator revealed she has had to change housekeeping staff several times recently and did not have any documentation to show what rooms were on schedule to be deep cleaned. The Administrator was not able to provide an equipment maintenance, or daily cleaning policy and procedure for review.

Based on observations, interviews, and record reviews the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and the Ombudsman for five residents (#24, #161, #188, #221, and #95) of five residents sampled for hospitalization . Findings included: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer that resident had loose stools. Resident was sitting in bed, alert and responsive, right then resident started vomiting clear liquids, VS [vital signs] 106/58, p [pulse] 62, r [respirations] 24, O2 [oxygen saturation] sat 88% RA [room air], placed on oxygen, notified [doctor name] with new order to send resident to ER [emergency room ] to treat and eval [evaluate], 911 [emergency medical system] notified, resident transferred to [local hospital] via stretcher, left message for responsible to call back facility when available. A review of the Nursing Home Transfer and Discharge Notice dated 6/4/22 revealed Resident #24 was sent to the hospital due to needs cannot be met and a Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was dated for 6/4/22. On 6/27/22 at 12:46 p.m. Resident #161 was observed lying in bed with a sitter at the bedside. The resident was sleeping. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #161 was most recently admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated ,d+[DATE] 22 revealed a BIMS score was unable to be completed for the resident due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the nursing progress notes revealed the following entry: 5/6/2022 at 9:27 a.m. Patient observed by staff demonstrating unsafe acts to herself and destroying items in facility. Patient observed by staff tying her wrist in the blinds, patient wrist removed from blinds. Risk manager, unit manager, and nurse practitioner notified in facility. 911 called for transport to emergency room for increased AMS [altered mental status]. A review of the Nursing Home Transfer and Discharge Notice dated 5/6/22 revealed Resident #161 was sent to the hospital with no reason for discharge or transfer marked. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was blank. On 6/27/22 at 12:30 p.m. Resident #188 was observed seated in a wheelchair by the nurse's station. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #188 was most recently admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed Resident #188 had a BIMS score of 99 indicating the resident was unable to complete the interview due to moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/20/22 10:52 a.m. Resident was noted to have a change of condition during medication rounds. He was less responsive, skin was cold and clammy, decreased respirations. His urinary output was minimal at 25 cc [cubic centimeters]. BP 98/61 O2 92 P65 R14. Per the paramedics his blood sugar 56. Spoke with doctor gave order to send the resident to hospital for evaluation. POA [power of attorney] was notified of the change of condition and the order to sent for evaluation. A review of the Nursing Home Transfer and Discharge Notice dated 6/18/22 revealed Resident #188 was sent to the hospital due to cannot met needs at facility. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was blank. A review of the medical record for Resident #221 revealed the resident was most recently admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed Resident #221 had BIMS score of 12 indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/8/2022 10:16 p.m. Resident found with shortness of breath, labored breathing, O2 80-86% on oxygen at 2 liters per nasal cannula, diminished lung sounds, with eyes closed and difficult ot arouse. Primary doctor notified with order to send to emergency room for evaluation and treatment. Message left with representative. A review of the Nursing Home Transfer and Discharge Notice dated 5/8/22 revealed Resident #221 was sent to the hospital due to cannot met needs at facility. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was filled in with 5/8/22. On 6/29/22 at 3:53 p.m. an interview was conducted with the Social Services Director (SSD) and the Director of Nursing (DON). The SSD stated the transfer and bed hold policy forms are given to him once nursing has completed the forms and sent the resident out of the facility. He stated he does not send any written notices to the Resident Representative or the Ombudsman. He stated he was not aware he needed to do this because he had misinterpreted the regulation. He stated he was aware now that he needs to do this and he will correct his practice. He stated he stopped sending notifications to the Ombudsman three months ago because he did not believe he needed to anymore. He stated the only time he sends out a written notification is when a resident is being given a 30-day notice of discharge. The DON verified his current practice and his misinterpretation of the regulation. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM). Staff A, LPN UM stated the nurses are responsible for completing all paperwork for a transfer to the hospital for a resident. This includes the transfer form and the bed hold policy form. The Resident Representative is notified by telephone only by the nurse. The nurses do not send any paperwork in writing to the Representatives or the Ombudsman. The paperwork is sent to the medical records department for follow-up once the resident is out of the facility. A review of the facility policy entitled Transfer and Discharge (including AMA), undated and presented by the DON for review, indicated the following: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Policy explanation and compliance guidelines: .3 The facility may initiate transfers or discharges in the following limited circumstances: a The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. .c The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. .7 Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b Notify resident and/or resident representative. c Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. d Complete and send with the resident (or provide as soon as practicable) a Transfer Form . .f the original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. .i Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. j Provide transfer notice as soon as practicable to resident and representative. k Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 2. A review of the Admission Record for Resident #95 revealed that she was readmitted into the facility on [DATE]. The Nursing Home Transfer and Discharge Notice with an effective date of 03/31/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Resident, Legal Guardian or Representative on 03/31/22, Local Long Term Care Ombudsman Council on 03/31/22, and Resident Clinical Record on 03/31/22. A review of the Order Summary Report dated 05/01/22 - 05/31/22 revealed the following order: Send to emergency room to evaluate and treat 05/27/22. The Nursing Home Transfer and Discharge Notice with an effective date of 05/27/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Local Long Term Care Ombudsman Council on 05/27/22 and Resident Clinical Record on 05/27/22. A review of the order details dated 06/01/22 indicated the following order: send to emergency room . The Nursing Home Transfer and Discharge Notice with an effective date of 06/01/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Local Long Term Care Ombudsman Council on 06/01/22 and Resident Clinical Record on 06/01/22.

Based on interviews and record reviews the facility failed to provide written notification of Bed Hold Policy to Resident/Resident Representatives for five residents (#188, #24, #221, #161, and #95) of five residents sampled for hospitalization . Findings include: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer that resident had loose stools. Resident was sitting in bed, alert and responsive, right then resident started vomiting clear liquids, VS [vital signs] 106/58, p [pulse] 62, r [respirations] 24, O2sat [oxygen saturation] 88% RA [room air], placed on oxygen, notified [doctor name] with new order to send resident to ER [emergency room ] to treat and eval [evaluate], 911 [emergency medical system] notified, resident transferred to [local hospital] via stretcher, left message for responsible to call back facility when available. A review of the Bed Hold and In-house Transfer Policy dated 6/4/22 revealed listed in Signature-Resident area res [resident] unable to sign and date of 6/4/22. Under Signature-Family Member or Legal Representative there was a nurse signature and written was [power of attorney] verbally with a date of 6/4/22. On 6/27/22 at 12:46 p.m. Resident #161 was observed lying in bed with a sitter at the bedside. The resident was sleeping. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #161 was most recently admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated ,d+[DATE] 22 revealed a BIMS score was unable to be completed for the resident due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the nursing progress notes revealed the following entry: 5/6/2022 at 9:27 a.m. Patient observed by staff demonstrating unsafe acts to herself and destroying items in facility. Patient observed by staff tying her wrist in the blinds, patient wrist removed from blinds. Risk manager, unit manager, and nurse practitioner notified in facility. 911 called for transport to emergency room for increased AMS [altered mental status]. A review of the Bed Hold and In-house Transfer Policy dated 5/6/22 revealed listed in Signature-Resident area Resident unable to sign and date of 5/6/22. Under Signature-Family Member or Legal Representative written was [power of attorney] verbal with a date of 5/6/22. On 6/27/22 at 12:30 p.m. Resident #188 was observed seated in a wheelchair by the nurse's station. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #188 was most recently admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed Resident #188 had a BIMS score of 99 indicating the resident was unable to complete the interview due to moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/20/22 10:52 a.m. Resident was noted to have a change of condition during medication rounds. He was less responsive, skin was cold and clammy, decreased respirations. His urinary output was minimal at 25 cc [cubic centimeters]. BP 98/61 O2 92 P65 R14. Per the paramedics his blood sugar 56. Spoke with doctor gave order to send the resident to hospital for evaluation. POA [power of attorney] was notified of the change of condition and the order to send for evaluation. A review of the Bed Hold and In-house Transfer Policy dated 6/18/22 revealed listed in Signature-Resident area Resident unable to sign and date of 6/18/22. Under Signature-Family Member or Legal Representative written was [POA] verbal with a date of 6/18/22. A review of the medical record for Resident #221 revealed the resident was most recently admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed Resident #221 had BIMS score of 12 indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/8/2022 10:16 p.m. Resident found with shortness of breath, labored breathing, O2 80-86% on oxygen at 2 liters per nasal cannula, diminished lung sounds, with eyes closed and difficult ot arouse. Primary doctor notified with order to send to emergency room for evaluation and treatment. Message left with representative. A review of the Bed Hold and In-house Transfer Policy dated 5/8/22revealed listed in Signature-Resident area Resident wasn't able to sign and date of 5/822. Under Signature-Family Member or Legal Representative written was [POA] verbal with a date of 5/8/22. On 6/29/22 at 3:53 p.m. an interview was conducted with the Social Services Director (SSD) and the DON. The SSD stated the transfer and bed hold policy forms are given to him once nursing has completed the forms and sent the resident out of the facility. He stated he does not send any written notices to the Resident Representative or the Ombudsman. He stated he was not aware he needed to do this because he had misinterpreted the regulation. He stated he is aware now that he needs to do this and he will correct his practice. He stated he stopped sending notifications to the Ombudsman three months ago because he did not believe he needed to anymore. He stated the only time he sends out a written notification is when a resident is being given a 30-day notice of discharge. The DON verified his current practice and his misinterpretation of the regulation. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM). Staff A, LPN UM stated the nurses are responsible for completing all paperwork for a transfer to the hospital for a resident. This includes the transfer form and the bed hold policy form. The Resident Representative is notified by telephone only by the nurse. The nurses do not send any paperwork in writing to the Representatives or the Ombudsman. The paperwork is sent to the medical records department for follow-up once the resident is out of the facility. A review of the facility policy entitled Transfer and Discharge (including AMA), undated and presented by the DON for review, indicated the following: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Policy explanation and compliance guidelines: .3 The facility may initiate transfers or discharges in the following limited circumstances: a The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. .c The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. .7 Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b Notify resident and/or resident representative. c Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. d Complete and send with the resident (or provide as soon as practicable) a Transfer Form . .f The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. .i Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. j Provide transfer notice as soon as practicable to resident and representative. k Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 2. A review of the Admission Record for Resident #95 revealed that she was readmitted into the facility on [DATE]. The Nursing Home Transfer and Discharge Notice with an effective date of 03/31/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 03/31/22. A review of the Order Summary Report dated 05/01/22 - 05/31/22 revealed the following order: Send to emergency room to evaluate and treat 05/27/22. The Nursing Home Transfer and Discharge Notice with an effective date of 05/27/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 05/27/22. A review of the order details dated 06/01/22 indicated the following order: send to emergency room . The Nursing Home Transfer and Discharge Notice with an effective date of 06/01/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 06/01/22.

Based on observation, record review, interviews and facility policy review, the facility failed to ensure that one (#1) of seventeen sampled residents was free from abuse. Findings included: A review of Resident #1's clinical record face sheet documented an initial admission of 08/04/20 with a recent readmission of 12/22/21. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's clinical progress notes reflected the following entries: -12/21/21, 23:00: Writer was informed by Staff D, Certified Nursing Assistant (CNA), that she had witnessed another CNA punching the resident several times in the face. I immediately got up to check on the resident's safety and placed a call to the Director of Nursing (DON) and Administrator to notify of the situation. Resident stated that the CNA was in his room providing care when she punched him 4-5 times in the face with a closed fist. Writer made sure that the CNA was placed in the nursing office with another staff member to monitor her and that a staff member was placed with the resident as well. Writer placed a call to 911, the resident's POA (Power of Attorney), and his primary physician. The resident was transferred to [local hospital emergency room ] for evaluation. -12/22/21, 00:26: Resident sent out to hospital as the result of being involved in an incident. -12/22/21, 05:13: Resident returned from [local hospital] at approximately 05:15. He was transported by 2 EMTs (Emergency Medical Technicians) and assisted to his previous room and transferred into bed. He denies any pain, distress, or discomfort and does not present with any via assessment. Skin remains intact, [MEDICATION(S)] membranes moist and intact. Medical Doctor (MD) is aware of resident concern and agrees with the plan of care. -12/22/21, 20:45, e-interact SBAR Summary for providers: Situation: .Change in skin color or condition Nursing Observations, evaluation .: Discoloration noted with small abrasions right upper arm. -12/23/21, 01:38: The resident received from last shift resting in bed with call light in reach and eyes closed, resp (responses) wnl (within normal limits) and unlabored, resident with multiple bruises around the body, resident with s/s (signs or symptoms) for pain at this time will continue to monitor. A review of a weekly skin assessment dated [DATE], 00:33, documented that Resident #1 has a bruise on his face. The description stated: forehead and L (left) eye bruising. A review of Resident #1's care plan revealed: Focus area Resident #1 may suffer from [CONDITION(S)] (Post Traumatic Stress Disorder) related to recent incident with staff member, initiated 12/22/21. Goal: Resident will suffer no new behaviors related to incident through next review date. Interventions, initiated 12/22/21: -Administer medication as prescribed. -Allow resident to express his feelings -Encourage to attend activities -Notify Physician/Psych (psychiatry) of any new behaviors that may be related to recent incident. -Psych Consult as needed/as ordered. A review of Resident #1's Care Coordination Note, (Psychiatry note), dated 12/08/21, documented Resident #1 was discussed in a [CONDITION(S)] meeting on 12/08/21 and that the Chief Complaint was listed to be, Dementia, depression, anxiety and mood disorder. Further review of the notes reflected: As per collected information, patient is stable. Patient has no behaviors. Patient is yelling out less. No other psychiatric symptoms observed. Dementia is persisting but no other behaviors noted Assessment and Plan .Patient is at baseline. No GDR (gradual dose reduction): As per collected information and interview, it appears that patient is doing well overall . A review of Resident #1's Psychiatry Subsequent Note, dated 12/23/21, documented the reason for today's encounter: Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. Due to acuity of the situation, I saw patient using Telepsych .I am seeing the patient today via telepsych due to nursing reports that patient was involved in a physical altercation with a staff member. At last visit, no medication changes were made. Resident #1 was interviewed at bedside where patient is alert and oriented x 1. He reports that his is doing well, and mood is stated as okay. Resident #1 was recently involved in an altercation where patient was physically assaulted. Resident #1 denies any trauma or trauma related symptoms as a result of the attack. He reports that he had to defend himself by squeezing the attacker's fingers. His NSESSS (National Stressful Events Survey [CONDITION(S)] Short Scale) score for [CONDITION(S)] was 9, which indicates minimal trauma associated with the event. Symptoms are stable causing no level of distress. On 01/07/22 at 2:31 p.m.an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the following regarding the event which occurred with Resident #1. The event occurred on 12/21/21, at approximately 10:30 p.m. She stated, I got a call, from the Staff F, Registered Nurse (RN), he told me the allegation of what Staff D, CNA saw. Reading the statement from Staff D, CNA, the NHA stated, Nurse told me resident was giving another CNA hard time. I went to help her-opened door-saw her holding his hands with left hand & punching resident with right hand in head and face. I went & notified supervisor immediately. I don't know if she saw me. The NHA said Staff D, CNA was extremely upset, stating, we got the statement at 11:53 p.m. The aid that was assigned to the resident was Staff E, CNA. She was agency. The nurse for the resident was Staff G (Agency nurse). Staff F, RN called me and called to 911. I told Staff F, RN to keep Staff E, CNA separate, and she was brought into this room with another staff member. The NHA further stated, the resident was assessed, and the Paramedics came. Myself and the DON, we got here at 11:00 p.m. (Resident #1) had notable bruising on the left eye within 15 minutes. The paramedics wanted him to go to the hospital. They just wanted him to be safe. Initially he refused. The NHA further explained, Staff E, CNA, she was with agency. She had been here for 3 weeks, and I do not know if she was working anywhere else. We talked to the staff, and Staff F, RN conducted a skin assessment on all the residents that were on Staff E's set (assignment). The assessments were completed on 12/22/21 (right after midnight after 12/21). There was no evidence of any other bruising on the staff member's set. In addition, we looked at the skin checks in the whole building, to make sure of any bruises; additional bruises that we were unaware of. There were people that had some bruises, that were correlated to a fall event. The NHA said she did not have a mechanism to have knowledge of how many hours the staff member worked outside of the facility. The NHA said Staff E, CNA started back in January 2021, and she was at the facility 'on and off.' In the weeks preceding the event, the staff member had been working consistently. The NHA provided documentation Staff E, CNA, had completed abuse and neglect training in 10/2021. On 01/07/22 at 4:25 p.m., an observation was conducted of Resident #1. He was observed on his bed and dressed in seasonally appropriate clothing. An attempt to interview the resident was conducted; he stated he felt safe, and he did not recall the altercation with the staff member. At the time of observation, the resident's face had no bruising present or noticeable swelling. A review of the facility's Abuse, Neglect and Exploitation policy and procedures, copyright 2020, the compliance store, LLC., documented the Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s) . Mistreatment means inappropriate treatment or exploitation of a resident . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI program. 2. The facility will designate an Abuse Coordinator . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: I. Screening: . II. Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1.Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2.Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3.Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5.Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; . F. -G H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.

Based on observations, administrative and direct care staff interviews, resident representative interview, resident medical record review, policy and procedure review, and job description review, the facility neglected to provide the care and services to ensure a resident received meals, received medications, received CNA (certified nursing assistant) care and neglected to prevent and identify an unwitnessed exit from the facility for one (Resident #1) of six sampled residents resulting in neglect. The facility staff neglected to locate the resident during change of shift rounds between the day and evening shift on 9/7/2021. They failed to locate him during mealtime and during medication administration on the evening shift of 9/7/2021. The staff documented that the resident's wander guard (an electronic monitoring device used to help prevent elopement) was checked while the resident was not in the building during the afternoon of 9/7/2021. The facility failed to ensure that the CNA assigned to care for Resident #1 on 9/7/2021 during the evening shift was working on the unit where the resident resided and aware of the assignment. Resident #1 was assessed to be at high-risk for elopement and had disorganized thinking and inattention which fluctuated in severity, short-term and long-term memory problems, difficulty with speech and swallowing, abnormalities of gait and mobility and a history of seizures. On 09/07/21 Resident #1 independently ambulated an estimated 1.7 miles next to both a six-lane (66th Street North) highly traveled road and a two-lane (46th Avenue North) road. Resident #1 was last seen in the facility at approximately 2:00 p.m. The assigned care providers for Resident #1 were unaware of his absence until approximately 8:35 p.m., an estimated 6 hours and 35 minutes later. Resident #1 was seen by a bystander lying in the grass roadside and subsequently taken by Emergency Medical Services to the hospital for admission. This resulted in the findings of Immediate Jeopardy occurring on 09/07/21 and after verification of immediacy removal action was removed on 9/23/2021, with the scope and severity reduced to a D. Findings included: 1. A review of Resident #1's Facesheet, revealed an initial admitted [DATE] with a Responsible Party designee. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 resided on the second floor of the building. Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], revealed he had behaviors of disorganized thinking and inattention which fluctuated in severity, along with a short-term and long-term memory problem. Continued review of the MDS revealed Resident #1 was independent in locomotion on and off the unit and required the daily placement of a wander/elopement alarm. Review of Resident #1's Care Plan revealed a focus area, initiated on 08/14/20, of [Resident #1] is at risk for wandering/eloping related to: independently mobile Exit seeking behaviors Verbalized desire to leave Tailgating staff and visitors at exit doors. Interventions for this focus area included initiate facility's elopement protocol if resident's whereabout are unknown, monitor for fatigue and weight loss, monitor resident for tailgating when visitors are in the building, and restorative to check wander guard functionality daily, wander guard to right ankle due to confusion, and wander guard check placement each shift. Further review of the Care Plan revealed additional focus areas and interventions related to Resident #1's care requirements. These included: [Resident #1] has the following behavior problems: Has history of Physically abusive when agitated . Places self on floor, will lay down . at times, puts cigarette butts in his mouth and chews on them . Non compliant with thickened liquids/takes fluids from other residents . History of removing wander guard ., date initiated 11/09/20, with included interventions of providing medications as ordered, and intervening as necessary to protect the rights and safety of others. [Resident #1] has potential for difficulty breathing related to chronic condition of [CONDITION(S)], date initiated on 08/14/20, with included interventions of avoiding extremes of hot and cold, monitoring for signs and symptoms of breathing difficulty, observing for increased wheezing and/or lower activity intolerance. [Resident #1] has potential for impaired vision secondary to bilateral [CONDITION(S)] ., date initiated 08/14/20, with included interventions of maintaining a clutter free environment, and orienting [Resident #1] to surroundings. [Resident #1] if at risk for fluid volume deficit related to thickened liquids. Due to impaired cognition and mental illness. [Resident #1] does not understand the importance of adequate fluid intake, date initiated on 08/14/20, with included interventions of observing for signs and symptoms of dehydration, providing and monitoring intake of food and fluids. [Resident #1] has potential for injury related to history of [CONDITION(S)] activity, date initiated 08/14/20, with interventions of administering anti-convulsant medication as ordered, monitoring for [CONDITION(S)] activity, and not leaving Resident #1 alone during a [CONDITION(S)]. [Resident #1] is at risk for falls/injuries related to poor safety awareness, [CONDITION(S)] disorder and use of [CONDITION(S)] medications. [Resident #1] is impulsive and will sit or sleep on the floor, date initiated 08/14/20, with included interventions of The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls . [Resident #1] is at risk for skin impairment related to episodes of incontinence, impaired cognition with poor hygiene habits. [Resident #1] is unaware of the importance of daily skin care, date initiated 08/14/20, with included interventions of encourage good nutrition and hydration, and assist as needed with episodes of incontinence. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's . Elopement Evaluation, dated 12/11/20, revealed Resident #1 had a score of 14, indicating a high risk of eloping, due to a history of wandering, was ambulatory, could not communicate, had medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/20/21 at 11:13 a.m., Resident #1 was observed outside in the smoking patio area with a smoking apron on. An attempt to interview Resident #1 revealed he responded to simple questions with incoherent speech that could not be understood. After he finished his cigarette, the Resident stood up and began walking away from the area with a slightly hunched back. He shuffled his feet as he ambulated without fully lifting them off the ground. Resident #1 was followed by his aide assigned to provide 1:1 supervision. On 09/20/21 at 11:56 a.m., Staff D, Certified Nursing Assistant (CNA) stated she worked on 09/07/21, the day Resident #1 eloped, during the 7:00 a.m. to 3:00 p.m. shift. While not his assigned aide on 09/07/21, Staff D, CNA was familiar with Resident #1. Staff D, CNA stated Resident #1 had behaviors of lying-in front of the front exit door and by the elevator door. Staff D said, . [Resident #1] normally does need help getting back up if he sits down because he is pretty thin and frail . I have seen him stumble when walking but he walks at a normal pace, not very fast. The day of 09/07/21, Staff D, CNA remembers seeing Resident #1 on the second floor around 12:00 p.m. waiting for coffee. Staff D left the facility around 3:08 p.m. and at that time there had been no overhead alert related to a missing resident. Staff D stated nobody knew anything. During a follow-up interview with Staff D, CNA on 09/20/21 at 1:47 p.m., it was revealed the facility procedure was to round at the beginning and end of the shift to visually see your assigned resident with the off-going shift, however, sometimes the on-coming shift will arrive late and so staff do not always round together. An interview on 09/20/21 at 2:10 p.m. with Staff O, Licensed Practical Nurse (LPN)/Unit Manager revealed on 09/07/21 she had seen Resident #1 walking the hallways in the morning time. Staff O, LPN was performing COVID-19 testing that day and conducted Resident #1's test around 2:00 p.m. Staff O, LPN stated she did not see Resident #1 again after this and exited the building at 5:00 p.m. Staff O did not hear an elopement overhead alarm sound related to a missing resident prior to her leaving the building. She was first notified that Resident #1 was missing from the building around 9:45 p.m. the night of 09/07/21. The procedures have been that if no one had seen Resident #1 in a while then the building should be checked and if unable to locate him then the elopement procedure should be initiated. Staff O, LPN stated nurses have the responsibility to check the functionality and placement of a resident's wander guard, however, . that's the problem, nurses didn't have the functionality guns on the carts. Restorative aides said they were checking the wander guards on the 3:00 p.m. to 11:00 p.m. shift, however, Staff O, LPN/Unit Manager was not sure where they were documenting this function nor how the staff were communicating between each other that the service was completed. During a follow-up interview on 09/21/21 at 9:00 a.m., Staff O, LPN stated staff are supposed to round and visually see the residents at the start of a shift and end of shift to see if they needed any care or services. On 09/20/21 at 3:38 p.m., Staff G, Restorative Aide/CNA revealed she normally worked the second shift from 3:00 p.m. to 11:00 p.m. Staff G stated it has never been the responsibilities of the restorative aides to check the functionality of a resident's wander guard, nor has she . ever seen what the wander guard functionality checker looks like. During this interview, Staff G stated she arrived at the facility on 09/07/21 at 2:45 p.m. and was assigned to restorative duties on the 3:00 p.m. to 11:00 p.m. shift. She was not assigned to any specific resident room set. She had not seen Resident #1 during her shift. Staff G stated during the evening she was called to the second floor between 7:30 p.m. to 8:00 p.m. because, . it seemed like that floor was short . and they didn't have anyone on his [Resident #1's] side [room assignment]. Staff G, Restorative Aide/CNA stated dinner was normally served on the second floor around 5:45 p.m. Another aide (Staff L, CNA) went up to the second floor to assist with picking up dinner trays as well and said when she picked up Resident #1's dinner tray it had been untouched. Another aide (Staff C, CNA) said when she passed out the dinner trays, Resident #1 still had his lunch tray in his room which had also been untouched. Staff G stated the elopement protocol for a missing resident was not initiated until after 9:00 p.m. on 09/07/21. On 09/20/21 at 4:24 p.m., an interview with Staff M, Personal Care Assistant (PCA) revealed she was Resident #1's assigned aide during the 7:00 a.m. to 3:00 p.m. shift on 09/07/21. Staff M, PCA stated she does not have a CNA license but is allowed to provide care to residents except assisting with eating and transfers. Staff M stated her duties included rounding and visually seeing the residents at the start and end of shift. Staff M stated while staff should be rounding at the end of their shift with the on-coming shift, many times the on-coming shift arrives late. On 09/07/21, Staff M, PCA stated she left her shift at 3:10 p.m. but she does not remember seeing Resident #1 at the end of her shift as she had not done her rounding. Staff M, PCA stated she remembered seeing Resident #1 during lunch as she passed his lunch tray. Staff M, PCA stated she saw Resident #1 20 minutes prior to the end of her shift, at approximately 2:40 p.m. This timeframe conflicted with the local county's Emergency Medical Services (EMS) Patient Care Report, which indicated a 3rd party call was received by EMS related to Resident #1 being observed lying roadside at 2:41 p.m. Further review indicated Resident #1 was found by EMS and transported at 3:02 p.m. to the hospital. An observation of the receptionist office and interview on 09/21/21 at 10:38 a.m. with Staff H, Receptionist revealed the receptionist office was located directly next to the main front entrance. The front entrance door could be seen from the receptionist office. Staff H stated her duties included accepting packages, answering calls, getting the mail, and assisting with screening staff. Staff H confirmed she was working on 09/07/21. Her shift normally starts at 8:00 a.m. and she leaves at 4:30 p.m. Staff H last remembered seeing Resident #1 lying underneath the handicap button directly next to the front main door around 12:00 p.m. before he went back upstairs. She did not see him again that day. Staff H stated on 09/07/21 she was busy accepting resident food orders and was handing out money to the food vendors who were coming in and out during the morning time, however, she reported that she was in the office around 2:00 p.m. and would have seen Resident #1 attempting to leave. Record review of Withdrawal Transactions receipts for 09/07/21 revealed between the hours of 11:20 a.m. and 2:45 p.m. 12 residents' outside food orders were requested and delivered by outside vendors. 2. During a phone interview on 09/21/21 at 2:23 p.m., Staff N, LPN confirmed he was Resident #1's assigned nurse on 09/07/21 on the 7:00 a.m. to 3:00 p.m. shift. Staff N, LPN stated he ended his shift after 3:00 p.m. and the last time he remembered seeing Resident #1 was around 2:00 p.m., after which time he did not see Resident #1 again. Staff N, LPN stated it was normal for Resident #1 to wander around the facility. Staff N stated that at no point from 2:00 p.m. to the end of his shift did someone report that Resident #1 was missing. Staff N reported that if a resident had not been seen for a certain amount of time, about one and a half to two hours, then staff were to ask around to see where the resident was. Staff N, LPN stated that checking a resident's wander guard was scheduled to be checked for functionality and placement once a shift. Staff N, LPN stated he was aware he should be visually checking Resident #1's wander guard once a shift, however, he was unsure of whose responsibility it was to check the functionality of the wander guard. A record review of Resident #1's Medication Admin [administration] Audit Report, schedule date 09/07/21, revealed Staff N, LPN signed as verifying the functionality of Resident #1's wander guard at 7:31 a.m. An interview on 09/21/21 at 3:52 p.m. with Staff C, CNA revealed she did not remember seeing Resident #1 at the start of shift on 09/07/21; however, she normally sees the resident wandering around the building and sitting on the floor. Sometimes at the start of her shift, the previous aide will provide a report but if there was no one to give a report she will just start her rounding for to visually see her assigned residents. Staff C, CNA confirmed she was the CNA who passed out Resident #1's dinner tray on 09/07/21 around 5:30 p.m. When she delivered the meal tray, Resident #1's lunch tray was still in the room. Staff C reported that when she lifted the lunch tray meal lid, she saw nothing had been consumed. Staff C said, [Resident #1] is a messy eater . so you can tell when he ate. At that point she left Resident #1's dinner tray in the room along with his lunch tray because it was not uncommon for the resident to be wandering so staff will leave things in his room for him. Staff C, CNA stated after she left Resident #1's room, after delivering the dinner tray, she mentioned to another CNA on the floor where is [Resident #1]? He didn't touch lunch. Staff C, CNA stated it was not uncommon for the second-floor unit to be short-staff during the evening and she cannot remember if Resident #1's room had an assigned aide, so, she continued on her assignment of meal tray passing. Staff C, CNA stated she did not inform the nurse on duty about Resident #1's untouched lunch tray, and just left the dinner tray unattended in the resident's room because she was already assisting other residents with eating and assisting with residents that were not on her assignment. Staff C, CNA stated she finished assisting residents with eating and began collecting meal trays between 6:30 p.m. and 7:00 p.m. on 09/07/21. An interview on 09/21/21 at 4:12 p.m. with Staff B, CNA revealed she did not remember seeing Resident #1 on 09/07/21. Staff B, CNA stated that evening it seemed like Resident #1's room assignment did not have an assigned aide because they were instructed to split up the room set assignment amongst herself and the two other CNAs on that floor. It was not until about 7:30 p.m. that evening that another aide (Staff G, Restorative Aide/CNA) was called to the unit to assist with resident care. Staff B, CNA stated that it was Resident #1's normal behavior to wait by the elevators at the start of the 3:00 p.m. to 11:00 p.m. shift and ask for ice cream, however, he was not there on 09/07/21. Around dinner time that evening, about 5:30 p.m., Staff C, CNA came to her and said where's [Resident #1]? He hasn't touched his lunch tray. She and Staff C, CNA walked into the Resident's room. Staff C, CNA lifted Resident #1's lunch tray lid in front of her and she saw that Resident #1 had not consumed his meal. Staff C, CNA left Resident #1's dinner tray in his room along with the untouched lunch tray. Staff B, CNA stated she did not report the untouched lunch tray because lunch was served around 11:30 a.m., and she felt that whoever delivered the meal tray should have re-collected it. At that point, the other aides on the unit were assisting residents outside of their assignment set with eating and still had to pass more dinner trays due to being short an aide. A record review of meal intake for Resident #1 revealed the last meal percentage logged for Resident #1 on 09/07/21 was timed at 1:51 p.m. at 51-75% consumed. During an interview on 09/21/21 at 12:55 p.m. the Risk Manager stated the expectation for resident meal refusal was for staff to report it to the nurse on duty, and if a resident meal tray was picked up and had not been touched, the resident should be found to determine why they had not eaten anything. During this interview, Staff O, Unit Manager confirmed these expectations. A record review of the Assignment Sheet, dated 09/07/21, for the 3:00 p.m. to 11:00 p.m. revealed Resident #1's listed assigned CNA was Staff L, and his listed assigned nurse was Staff A, LPN. Two other CNAs (Staff B and Staff C) were also listed as working on the second floor. A phone interview on 09/23/21 at 11:52 a.m. with Staff L, CNA revealed on 09/07/21 she had worked two shifts, both the morning and evening shift. During the morning shift, she was assigned resident rooms located on the first floor. Once the morning shift ended, at the start of the 3:00 p.m. to 11:00 p.m. shift she was assigned to work the front desk on the first floor to conduct COVID-19 screenings. Staff L, CNA stated she did not go to the second floor until after 5:00 p.m. to assist with collecting dinner trays; therefore, she did not do any visual rounding checks of residents residing on the second floor (Resident #1's unit). Staff L, CNA stated that she did not have any resident assigned rooms to her care during the evening shift and once she was done assisting with dinner tray collection, she returned to the first floor again to man the front door. Once she left, another aide (Staff G, Restorative Aide/CNA) went to the unit to assist with resident care. During this interview on 09/23/21 at 11:52 a.m. Staff L, CNA stated while working the front desk in the evening, she answered a phone call inquiring about Resident #1, so she attempted to transfer the call to the second-floor nurse (Staff A, LPN) but no one was answering so she began overhead paging, however, no one answered the page. Another nurse came over to the desk and went up to the second floor to talk to Staff A, LPN and apparently told the nurse to answer the phone. After this incident, Staff L, CNA stated she did not get any other calls related to Resident #1. On 09/23/21 at 12:05 p.m. an interview with Staff A, LPN, Resident #1's assigned nurse during the 3:00 p.m. to 11:00 p.m. shift, revealed she did not visually verify or see Resident #1 for the entirety of her shift. Staff A, LPN stated that at the start of her shift, she did not conduct her walking rounds to visually verify the presence of her assigned residents. Staff A, LPN stated she did walk around to see all the residents under her assigned care later and remembered seeing someone in Resident #1's bed, however, apparently it was the roommate that was lying in the bed. Staff A, LPN confirmed she did not verify the presence or functionality of Resident #1's wander guard per his physician order. Staff A, LPN confirmed she did not provide Resident #1 with his physician ordered medications during her assigned shift. Staff A, LPN stated she checked the medications out . set them aside with the intention of going to find [Resident #1] but wanted to complete the medication pass to the other residents . A review of Resident #1's Medication Admin Audit Report, schedule date 09/07/21, revealed Wanderguard-Check placement . and Wanderguard -Check function . was documented by Staff A, LPN as completed with a timestamp of 3:33 p.m. Further review of the Medication Admin Audit Report, revealed Resident #1 was ordered for additional treatments and medications to be administered at 3:00 p.m. by Staff A, LPN. 1. [MEDICATION(S)] Tablet 10 milligram (MG) related to paranoid [CONDITION(S)]. Administration time was documented at 5:00 p.m., Chart Code . 9 2. [MEDICATION(S)] Tablet 10 MG related to dementia. Administration time was documented at 5:00 p.m., Chart Code . 9 3. [MEDICATION(S)] Tablet 300 MG related to [CONDITION(S)] disorder. Administration time was documented at 5:00 p.m., Chart Code . 9 The Medication Admin Audit Report legend, Chart Code . 9 indicated 9=Other/ See Progress Notes. A review of Resident #1's Progress Notes, dated 09/07/21, note type Orders- Administration Note, revealed Staff A, LPN did not provide the above listed medications due to Resident off unit. During the interview on 09/23/21 at 12:05 p.m. Staff A, LPN stated on 09/07/21 the second floor, where Resident #1 resided, only had three assigned CNAs instead of four due to one CNA not arriving for their shift. Staff A, LPN stated an aide (Staff L, CNA) arrived at the unit later into the shift to assist in dinner tray pick up, but after assisting with picking up the trays, the aide . went back down to her assignment and then later in the evening after 7:00 p.m. another CNA [Staff G, CNA] did come up to assist [with resident care]. Staff A, LPN stated it was . around bedtime med [medication] pass . that she was notified Resident #1 was in the hospital. Staff A, LPN stated she received a call from Resident #1's Health Representative the evening of 09/07/21. The Health Representative was upset and asked Staff A to call the hospital where Resident #1 was admitted . Staff A, LPN said, There were so many small things that happened that led to this event. Staff A, LPN stated the normal procedure should a resident be found missing was to notify the supervisors, however, she did not know where to find the contact phone numbers. Staff A, LPN said, It was multiple failures all rolled in to one. Staff A, LPN said she . only knew for certain it was before 10:00 p.m . that she was notified Resident #1 was in the hospital and not in the facility. Review of the Medication Admin Audit Report revealed Staff A, LPN selected Chart Code . 6 at 9:24 p.m. on 09/07/21 for not providing Resident #1's physician ordered medications of [MEDICATION(S)] for [CONDITION(S)], [MEDICATION(S)] for depression, [MEDICATION(S)] for seizures, and [MEDICATION(S)] for hypertension. The Medication Admin Audit Report legend, Chart Code . 6 indicated 6=hospitalized . An interview on 09/23/21 at 11:12 a.m. with Staff K, Registered Nurse (RN)/Previous Staff Development Coordinator/Assistant Director of Nursing revealed the role of the Staff Development Coordinator was to provide education to staff on the facility procedures. Staff K, RN stated the expectation for nurses when medications were not provided as scheduled was to report this to the doctor. If attempting to provide the medications and the resident was not present, then the nurse should find the resident. If they are not able to be found, then the elopement procedure should be initiated. The expectation is that nursing staff should be accurately documenting the services they provide, such as checking a resident's wander guard. An interview on 09/22/21 at 2:17 p.m. with the Social Services Director (SSD) revealed on 09/07/21 she received a call from Resident #1's Health Representative. The SSD reviewed her telephone call log to confirm the call was received at 9:47 p.m. on 09/07/21. The SSD stated the Health Representative called her because they had been attempting to speak with someone at the facility regarding Resident #1 but were unable to get relevant information. The Health Representative informed the SSD that Resident #1 was in the hospital due to exiting the facility. The SSD then called the Nursing Home Administrator (NHA) and reported what the Health Representative had told her. The SSD said, It appears that way, related to being the first person to notify the NHA regarding Resident #1's elopement status. The SSD stated Resident #1 has a Health Representative because he was considered to be incapacitated. A record review of the Assignment Sheet, dated 09/07/21, for the 3:00 p.m. to 11:00 p.m. revealed Resident #1's listed assigned CNA was Staff L, and his listed assigned nurse was Staff A, LPN. Two other CNAs (Staff B and Staff C) were also listed as working on the second floor. An interview on 09/23/21 at 2:02 p.m. was conducted with the Risk Manager, Administrator-in-Training (AIT), NHA, and DON. The Risk Manager stated the purpose of the assignment sheet was for CNAs to know which residents they were responsible for during their shift. On 09/23/21 at 12:41 p.m., an interview with the Staffing Coordinator revealed the assignment sheet indicated which aide and nurse were assigned to which residents. Those CNAs assigned to the resident rooms were responsible for providing care and oversight to the resident. If a CNA did not show up for their assignment, then the staff should contact her or the DON. The Staffing Coordinator was not aware of any staffing shortages for the evening of 09/07/21. On 09/23/21 at 1:17 p.m. an interview with the DON revealed that on 09/07/21 she received a call related to there being an emergency on the evening shift and Staff L, CNA needing to be moved from the second-floor assignment to the first-floor front desk. At which time Staff G, CNA was moved to the second floor to assist with resident care. The DON was unable to provide times for when this staffing adjustment was made, however, it was after she had already exited the building. The DON stated it was her expectation for aides on the assignment sheet to go to their assigned unit and complete their resident rounding, unless, prior to the start of their shift assignments were adjusted. The direct care staff that were assigned to a resident were responsible for providing care, making sure the resident was safe, and monitoring the resident. The DON stated it was the expectation that the Risk Manager would be aware of who worked the night of 09/07/21 and what their assignment was as part of their incident investigation. An interview on 09/23/21 at 1:33 p.m. with the Risk Manager revealed for the evening shift on 09/07/21 Staff L, CNA was assigned to provide care to Resident #1. The Risk Manager stated the expectation would be that those aides coming onto a shift would complete the visual rounding on their assigned residents to ensure they were being provided with care. The Risk Manager stated if Resident #1 did not have a CNA assigned, she would want to be notified .because that could be neglect. An interview was conducted on 09/21/21 at 12:55 p.m. with the Risk Manager, DON, NHA, AIT, and Staff O, LPN. The NHA stated that on 09/07/21 at about 9:48 p.m. she received a call from the SSD. The SSD told her Resident #1's Health Representative called her and informed her that Resident #1 was picked up by EMS off 46th Ave N, outside of the facility, and transported to the hospital for admission. After the NHA was notified, she contacted the hospital where Resident #1 was admitted verifying it was him and then called the Risk Manager and the DON. At this point, the DON called the facility around 10:00 p.m. and instructed that a 100% head count of all residents be completed to ensure all other residents were safe and accounted for. During the interview on 09/23/21 at 2:02 p.m., Staff A, LPN's witness statement was reviewed. All staff members in the interview confirmed Staff A, LPN reported receiving a call from Resident #1's Health Representative at about 8:35 p.m. reporting Resident #1 was not in the facility and had been admitted to the hospital. The Risk Manager, DON, and NHA confirmed that upon this notification, Staff A, LPN should have immediately contacted the Risk Manager, who was also the acting Abuse Coordinator. All facility staff members present in the interview confirmed they did not receive a call from the facility about Resident #1's absence. The NHA confirmed it was the SSD who first notified her of Resident #1 eloping from the facility at around 9:48 p.m. the night of 09/07/21. The DON stated when she called the facility around 10:00 p.m. for a 100% audit of the residents was when the first elopement procedure requirements were started. The Risk Manager, NHA, and DON confirmed that immediately upon Staff A, LPN's notification at 8:35 p.m. that Resident #1 was not present in the facility without staff knowledge of his exit, the elopement procedure should have been initiated. None of the staff members present were able to state why Staff A, LPN did not notify the appropriate parties once she was notified Resident #1 was not in the facility. The Risk Manager stated during the interview on 09/23/21 at 2:02 p.m. that staff witness statements were reviewed as part of the incident investigation. Upon a review of Staff B, CNA's witness statement it was revealed under the section why did this event occur? Staff B, CNA wrote No Staff. The Risk Manager, DON, and NHA reviewed the witness statement and revealed none of them were aware that Staff B wrote this as a reason as to why the event occurred. During this interview, the assignment sheet was reviewed for the evening shift of 09/07/21, which indicated Staff L, CNA was assigned to Resident #1. The Risk Manager stated if a CNA was assigned to that floor on that shift, then the expectation was that the aide will be present at that location. All the present facility staff members were unaware that Staff L, CNA started her evening shift at the front desk and did not go to the second floor to conduct resident visual checks or provide care as listed on the assignment sheet. 3. A review of Resident #1's Progress Notes, revealed a COMMUNICATION- with Family . note dated 09/09/21, written by the Nursing Home Administrator (NHA). The note stated . Advised responsible party that facility has contacted [a State Agency Department] and filed allegation of neglect . [TRUNCATED]

Based on observations, facility staff and resident representative interviews, medical record review, and policy and procedure review the facility failed to provide supervision to one (Resident #1) of six sampled residents to prevent and identify and act on an unwitnessed exit from the facility. Resident #1 was assessed to be at high-risk for elopement and had disorganized thinking and inattention which fluctuated in severity, short-term and long-term memory problems, difficulty with speech and swallowing, abnormalities of gait and mobility and a history of seizures. On 09/07/21, Resident #1 was last seen in the facility at approximately 2:00 p.m. Resident #1 exited from the facility and was located 1.7 miles away lying in the grass beside a road. Resident #1 traveled along a six-lane (66th Street North) road and a two-lane (46th Avenue North) road each with a steady flow of traffic. He was observed by a bystander and transported by Emergency Medical Services to the hospital. The assigned care providers for Resident #1 were unaware of his absence until an estimated 6 hours and 35 minutes later at approximately 8:35 p.m. Facility staff missed multiple supervision opportunities that placed Resident #1 at risk for elopement. Facility staff failed to identify that the resident was present on change of shift report rounds and facility staff failed to complete two hour checks on Resident #1 in accordance with industry standards of practice. Facility staff failed to ensure the procedure for wanderguard checks of placement and functionality was reliable. The facility failed to ensure that the CNA (certified nurse's aide) assigned to care for Resident #1 on 9/7/2021 during the evening shift was working on the unit where the resident resided and aware of the assignment. Facility staff also did not [MEDICATION(S)] when the resident was not observed during meal pass or medication administration during the evening shift of 9/7/2021. Staff A, Licensed Practical Nurse (LPN) received direct notification of the elopement from the Resident's Health Representative at approximately 8:35 p.m. and failed to notify the facility administration or immediately ensure the safety/presence of other facility residents until approximately 10:00 p.m. that night. This resulted in the findings of Immediate Jeopardy occurring on 09/07/21 and removed on 9/23/2021, with the scope and severity reduced to a D. Findings included: 1. On 09/20/21 at 2:41 p.m., Resident #1's Health Representative was interviewed and said that Resident #1 has behaviors of wandering around the facility building. The Health Representative stated on 09/07/21 around 9:15 p.m. she received a call from the hospital informing her Resident #1 had been admitted after being found outside of the facility off 46th Ave North wearing a wrist band with his name on it. The Health Representative said, it was . very weird, that she got a call from the hospital before the facility and so she called the facility to . find out what was going on, that is when they [the facility] realized he [Resident #1] wasn't there. The facility staff then thought that maybe someone transferred Resident #1 to the hospital, so, the Health Representative had to re-tell them, No, he eloped from the facility. The Health Representative said Resident #1 was found without his wander guard present due to him cutting it off at the facility. A review of Resident #1's Facesheet, revealed an initial admitted [DATE] with a Responsible Party designee. His medical diagnoses included paranoid [CONDITION(S)], abnormalities of gait and mobility, mood disorder due to known physiological condition with depressive features, dysphagia (difficulty swallowing foods or liquids), other seizures, [CONDITION(S)] ([CONDITION(S)]), and dementia. Further review revealed Resident #1 resided on the second floor of the building. Resident #1's annual Minimum Data Set (MDS) dated [DATE], revealed he had short term and long term memory impairment, behaviors of disorganized thinking and inattention which fluctuated in severity. Further review revealed Resident #1 was independent in locomotion on and off the unit and required the daily placement of a wander/elopement alarm. A review of Resident #1's . Elopement Evaluation, dated 12/11/20, revealed Resident #1 had a score of 14, indicating a high risk of eloping, due to a history of wandering, was ambulatory, could not communicate, had medical diagnosis of dementia/cognitive impairment, and had diagnosis impacting gait/mobility or strength. Review of Resident #1's Care Plan revealed a focus area, initiated on 08/14/20, of [Resident #1] is at risk for wandering/eloping related to: independently mobile Exit seeking behaviors Verbalized desire to leave Tailgating staff and visitors at exit doors. Interventions for this focus area included initiate facility's elopement protocol if resident's whereabout are unknown, monitor for fatigue and weight loss, monitor resident for tailgating when visitors are in the building, and restorative to check wander guard functionality daily, wander guard to right ankle due to confusion, and wander guard check placement each shift. Further review of the Care Plan revealed additional focus areas and interventions related to Resident #1's care requirements. These included: [Resident #1] has the following behavior problems: Has history of Physically abusive when agitated . Places self on floor, will lay down . at times, puts cigarette butts in his mouth and chews on them . Non compliant with thickened liquids/takes fluids from other residents . History of removing wander guard ., date initiated 11/09/20, with included interventions of providing medications as ordered, and intervening as necessary to protect the rights and safety of others. [Resident #1] has potential for difficulty breathing related to chronic condition of [CONDITION(S)], date initiated on 08/14/20, with included interventions of avoiding extremes of hot and cold, monitoring for signs and symptoms of breathing difficulty, observing for increased wheezing and/or lower activity intolerance. [Resident #1] has potential for impaired vision secondary to bilateral [CONDITION(S)] ., date initiated 08/14/20, with included interventions of maintaining a clutter free environment, and orienting [Resident #1] to surroundings. [Resident #1] if at risk for fluid volume deficit related to thickened liquids. Due to impaired cognition and mental illness. [Resident #1] does not understand the importance of adequate fluid intake, date initiated on 08/14/20, with included interventions of observing for signs and symptoms of dehydration, providing and monitoring intake of food and fluids. [Resident #1] has potential for injury related to history of [CONDITION(S)] activity, date initiated 08/14/20, with interventions of administering anti-convulsant medication as ordered, monitoring for [CONDITION(S)] activity, and not leaving Resident #1 alone during a [CONDITION(S)]. [Resident #1] is at risk for falls/injuries related to poor safety awareness, [CONDITION(S)] disorder and use of [CONDITION(S)] medications. [Resident #1] is impulsive and will sit or sleep on the floor, date initiated 08/14/20, with included interventions of The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls . [Resident #1] is at risk for skin impairment related to episodes of incontinence, impaired cognition with poor hygiene habits. [Resident #1] is unaware of the importance of daily skin care, date initiated 08/14/20, with included interventions of encourage good nutrition and hydration, and assist as needed with episodes of incontinence. Review of Resident #1's Order Summary Report revealed active orders to check the wander guard functionality every shift, ordered on 05/28/21, and check wander guard placement every shift, ordered on 02/19/21. A review of Resident #1's Progress Notes, revealed a COMMUNICATION- with Family . note dated 09/09/21, written by the Nursing Home Administrator (NHA). The note stated . Advised responsible party that facility has contacted [a State Agency Department] . resident's wander guard was located in his night stand and appeared to have been cut off . [Resident #1] will be placed on a 1:1 supervision in an abundance of caution . 2. On 09/20/21 at 11:13 a.m., Resident #1 was observed walking away from the smoking patio area with a slightly hunched back. He shuffled his feet as he ambulated without fully lifting his feet off the ground. An attempt was made to interview the resident, but his speech was incoherent. A review of the Emergency Medical Services Patient Care Report, dated 09/07/21, revealed under section Narrative that 3rd party caller for unknown medical male [Resident #1] lying in grass roadside . found alert and responding, 70 y/o [year-old], male sitting upright in grass . Difficulty obtaining pt [patient] information due to pt having poor enunciation with speech, able to determine pt is possibly homeless male or missing person . pt is unable to ambulate away from current location with unsteady gait .Transported nonemergency to [Hospital Name] . Continued review of the report revealed under section TIMES the 3rd party call was received at 2:41 p.m. Resident #1 was found located at 8151 46th Ave N and transported at 3:02 p.m. to the hospital. Under section SCENE INFORMATION, it was revealed . Patient Found: On Ground . Can Patient get up w/o [without] assit [assistance]? No . Can PT Ambulate? No . A review of [Hospital Name] EMERGENCY PROVIDER REPORT, dated 09/07/21 with a timestamp of 4:56 p.m., revealed on page 1 Patient [Resident #1] . presents via EMS [emergency medical services] by a bystander in which EMS was called. When EMS arrived they said that he had unintelligible speech and he was non compliant with coming with them and sat down on the ground. Patient has been here walking around and difficulty understanding his speech therefore is a poor historian . Note: the last time patient was here he was coming from an ALF [Assisted Living Facility]. Patient tries to say where he is from but we are unable to understand him. We are unsure if he escaped from a facility or if he is just homeless. A review of [Hospital Name] History & [and] Physical . dated 09/07/21 with a time stamp of 10:07 p.m. revealed on page 1, [Resident #1] is a 70 y.o. M [Male] with an extensive medical history . was brought by EMS after being found wandering the streets seemingly confused by a bystander . When asked about family members, he gave his brothers name . however, that phone number has been disconnected . Further review of this document revealed on page 8, . patient arrived at the ED [emergency department] . {Facility Name] was notified of this, and was unaware that the patient had left their facility. As of writing, they are investigating how this could have happened . The facility is now aware of the patient's status A Google map review revealed the distance from the facility to the location where Resident #1 was found was an estimated 1.7 miles and would require an estimated 35 minutes to walk. A route observation from the entrance of the facility to the location where Resident #1 was located by EMS was conducted on 09/23/21 at 9:00 a.m. In front of the facility was a heavily traveled, 6-lane road divided by a median, 66th Street North, with a posted speed limit of 45 miles per hour (mph). Fourth Six Avenue North was a 2-lane road, with cement sidewalks on either side of the road and a speed limit of 35 mph. During the observation of 46th Avenue, the road had a constant flow of traffic in both directions. While traveling the route of 46th Avenue North, the road crossed over a bridge, a water stream, and passed by a lake. In addition, the street address where Resident #1 was found was an odd number, which indicates he crossed 46th Avenue North prior to sitting on the ground. Observation of the cement sidewalks by the location Resident #1 was found revealed cracks, uneven surfaces, and raised cement pieces. Photographic evidence obtained of the location and sidewalk. A review of the weather for 09/07/21 for the city location Resident #1 resided in, found at https://www.timeanddate.com/weather/usa/st-petersburg/historic?month=9&year=2021, revealed between the hours of 1:53 p.m. to 3:53 p.m., the times at which Resident #1 would have been ambulating outside alone, the weather was sunny with an average temperature of 85.7 degrees Fahrenheit with an average humidity of 70.3%. Using the Heat Index Calculator from the National Weather Service, found at https://www.weather.gov/epz/wxcalc_heatindex, the above listed temperature and humidity would indicate a heat index of 94.3 degrees Fahrenheit. According to the National Weather Service, https://www.weather.gov/ama/heatindex, .The heat index, also known as the apparent temperature, is what the temperature feels like to the human body when relative humidity is combined with the air temperature. This has important considerations for the human body's comfort . Per the National Weather Service, a heat index between 90 to 103 degrees Fahrenheit is classified as Extreme Caution due to placing individuals at risk for . heat stroke, heat cramps, or heat exhaustion possible with prolonged exposure and/or physical activity . 3. On 09/20/21 at 11:56 a.m., Staff D, Certified Nursing Assistant (CNA) stated she worked on 09/07/21, the day Resident #1 eloped, during the 7:00 a.m. to 3:00 p.m. shift. While not his assigned aide on 09/07/21, Staff D, CNA was familiar with Resident #1. Staff D, CNA stated Resident #1 had behaviors of lying-in front of the front exit door and by the elevator door. Staff D, stated she was the aide who found Resident #1's cut wander guard in his night stand during the morning time on 09/08/21 after being reassigned to his room. After finding the cut wander guard, she gave it to the Nursing Home Administrator (NHA). Staff D said, . [Resident #1] normally does need help getting back up if he sits down because he is pretty thin and frail . I have seen him stumble when walking but he walks at a normal pace, not very fast. The day of 09/07/21, Staff D, CNA remembers seeing Resident #1 on the second floor around 12:00 p.m. waiting for coffee. Staff D left the facility around 3:08 p.m. and at that time there had been no overhead alert related to a missing resident. Staff D stated nobody knew anything. During a follow-up interview with Staff D, CNA on 09/20/21 at 1:47 p.m., it was revealed the facility procedure required rounds at the beginning and end of the shift to visually see your assigned resident with the off-going shift, however, sometimes the on-coming shift arrive late and staff do not always round together. An interview on 09/20/21 at 2:10 p.m. with Staff O, Licensed Practical Nurse (LPN)/Unit Manager revealed on 09/07/21 she had seen Resident #1 walking the hallways in the morning time. Staff O, LPN was performing COVID-19 testing that day and conducted Resident #1's test around 2:00 p.m. Staff O, LPN stated she did not see Resident #1 again after this and exited the building at 5:00 p.m. Staff O, LPN stated nurses have the responsibility to check the functionality and placement of a resident's wander guard, however, . that's the problem, nurses didn't have the functionality guns on the carts. Restorative aides said they were checking the wander guards on the 3:00 p.m. to 11:00 p.m. shift, however, Staff O, LPN/Unit Manager was not sure where they were documenting this function or how the staff were communicating between each other that the service was completed. Staff O was first notified that Resident #1 was missing from the building around 9:45 p.m. the night of 09/07/21. What should have happened if no one had seen Resident #1 in a while then the building should be checked and if unable to locate him then the elopement procedure should be initiated. An interview on 09/20/21 at 3:38 p.m. with Staff G, Restorative Aide/CNA revealed she normally works the second shift from 3:00 p.m. to 11:00 p.m. Staff G stated it has never been the responsibility of the restorative aides to check the functionality of a resident's wander guard, nor has she . ever seen what the wander guard functionality checker looks like. During this interview, Staff G stated she arrived at the facility on 09/07/21 at 2:45 p.m. and was assigned to restorative duties on the 3:00 p.m. to 11:00 p.m. shift, so, she was not assigned to any specific resident room set. She had not seen Resident #1 during her shift. Staff G stated during the evening she was called to the second floor between 7:30 p.m. to 8:00 p.m. because, . it seemed like that floor was short . and they didn't have anyone on his [Resident #1's] side [room assignment]. Staff G, Restorative Aide/CNA stated dinner is normally served on the second floor around 5:45 p.m. Another aide (Staff L, CNA) went up to the second floor to assist with picking up dinner trays as well and said when she picked up Resident #1's dinner tray it had been untouched. Another aide (Staff C, CNA) said when she passed out the dinner trays, Resident #1 still had his lunch tray in his room which had also been untouched. Staff G stated the elopement protocol for a missing resident was not initiated until after 9:00 p.m. On 09/20/21 at 1:25 p.m. Staff P, Registered Nurse (RN) revealed he was not working on 09/07/21. However, prior to Resident #1's unwitnessed exit on 09/07/21, if an elopement risk resident was missing their wander guard, . the aides [certified nursing assistants] would notice it missing if they were providing them [ a resident] a shower [or other forms of care]. Staff P, RN stated nurses only had the responsibility to check a wander guards' placement, not its functionality. On 09/20/21 at 4:24 p.m., an interview with Staff M, Personal Care Assistant (PCA) revealed she was Resident #1's assigned aide on 09/07/21 from 7:00 a.m. to 3:00 p.m. Staff M, PCA stated she does not have a CNA license but was allowed to provide care to residents except assisting with eating and transfers. Staff M stated part of her duties do include rounding and visually seeing the residents at the start and end of shift. She did not remember seeing Resident #1 with a wander guard during her shift, however, she . did not look for one. Staff M stated while staff should be rounding at the end of their shift with the on-coming shift, many times the on-coming shift arrives late. On 09/07/21, Staff M, PCA stated she left her shift at 3:10 p.m. but she does not remember seeing Resident #1 at the end of her shift as she had not done her rounding. Staff M, PCA stated she remembered seeing Resident #1 during lunch as she passed his lunch tray. Staff M, PCA stated she saw Resident #1 20 minutes prior to the end of her shift; however, this information conflicted with the EMS Report which indicated that a bystander called to report the resident lying in the grass along the roadside at 2:41 p.m. The report also indicated that the resident was transported to the local hospital at 3:02 p.m. An observation of the receptionist office and interview on 09/21/21 at 10:38 a.m. with Staff H, Receptionist revealed the receptionist office was located directly next to the main front entrance. The front entrance door could be seen from the receptionist office. Staff H stated her duties included accepting packages, answering calls, getting the mail, and assisting with screening staff. Staff H confirmed she was working on 09/07/21 and she generally works from 8:00 a.m. to 4:30 p.m. Staff H last remembered seeing Resident #1 lying underneath the handicap button directly next to the front main door around 12:00 p.m. before he went back upstairs. She did not see him again that day. Staff H stated on 09/07/21 she was busy accepting resident food orders and was handing out money to the food vendors who were coming in and out during the morning time, however, she reported that she was in the office around 2:00 p.m. and would have seen Resident #1 attempting to leave. Staff H said the front door wander guard alarm was not properly reading the wander guard bracelets, so the monitoring box had to be lowered. Staff H was unsure when this repair was completed. Record review of Withdrawal Transactions receipts for 09/07/21 revealed between the hours of 11:20 a.m. and 2:45 p.m. 12 residents' outside food orders were requested and delivered by outside vendors. On 09/21/21 at 12: 55 p.m., the NHA stated during their event investigation, Resident #1 would only tell them that . he went through the front door. On 09/21/21 at 11:37 p.m., the Maintenance Director stated the wander guard alarm will alert staff once a resident walked through the door. He stated at no point did he have issues with the elopement box alarming or sensing elopement bracelets. He had no need to adjust the box. The Maintenance Director stated he would follow up with his other technicians to double check if they had to make any adjustments to the alarm box prior to 09/07/21. However, the door was checked on 09/07/21 and there were no issues with the front door alarm. On 09/21/21 at 12:00 p.m. Staff J, Maintenance Staff stated after Resident #1 eloped, the facility checked all the doors and when he tested the front door by putting an elopement alarm on his ankle, he found that the alarm would only sometimes sound if he walked through the door and sometimes it did not sound. Staff J found that by lowering the alarm box the alarm would sound consistently when the wander guard was on the right ankle. However, the alarm box was still having issues when sounding if the wander guard was placed on the left ankle. The door push bar still sounds if you hold it for 15 seconds. He indicated that he verbally reported this to the Maintenance Director the following day (09/08/21) who then would have reported it to the NHA (Nursing Home Administrator). During a phone interview on 09/21/21 at 2:23 p.m., Staff N, LPN confirmed he was Resident #1's assigned nurse on 09/07/21 on the 7:00 a.m. to 3:00 p.m. shift. Staff N, LPN stated he ended his shift after 3:00 p.m. and the last time he remembered seeing Resident #1 was around 2:00 p.m., after which time he did not see Resident #1 again. Staff N, LPN stated it was normal for Resident #1 to wander around the facility. Staff N stated that at no point from 2:00 p.m. to the end of his shift did someone report that Resident #1 was missing. Staff N reported that if a resident had not been seen for a certain amount of time, about one and a half to two hours, then staff were to ask around to see where the resident was. Staff N, LPN stated that resident wander guards were scheduled to be checked for functionality and placement once a shift. Staff N, LPN stated he was aware he should be visually checking Resident #1's wander guard once a shift, however, he was unsure of whose responsibility it was to check the functionality of the wander guard. A record review of Resident #1's Medication Admin [administration] Audit Report, schedule date 09/07/21, revealed Staff N, LPN signed as verifying the functionality of Resident #1's wander guard at 7:31 a.m. 4. A review of Resident #1's Medication Admin Audit Report, schedule date 09/07/21, revealed Wanderguard-Check placement . and Wanderguard -Check function . was documented by Staff A, LPN as completed with a timestamp of 3:33 p.m. Further review of the Medication Admin Audit Report, revealed Resident #1 had orders for treatments and medications to be administered at 3:00 p.m. by Staff A, LPN. 1. [MEDICATION(S)] Tablet 10 milligram (MG) related to paranoid [CONDITION(S)]. Administration time was documented at 5:00 p.m., Chart Code . 9 2. [MEDICATION(S)] Tablet 10 MG related to dementia. Administration time was documented at 5:00 p.m., Chart Code . 9 3. [MEDICATION(S)] Tablet 300 MG related to [CONDITION(S)] disorder. Administration time was documented at 5:00 p.m., Chart Code . 9 A review of the chart code legend revealed, Chart Code . 9 indicated Other/ See Progress Notes. A review of Resident #1's Progress Notes, dated 09/07/21, note type Orders- Administration Note, revealed Staff A, LPN did not provide the above listed medications due to Resident off unit. Review of the Medication Admin Audit Report revealed Staff A, LPN selected Chart Code . 6 at 9:24 p.m. on 09/07/21 for not providing Resident #1's physician ordered medications of [MEDICATION(S)] for [CONDITION(S)], [MEDICATION(S)] for depression, [MEDICATION(S)] for seizures, and [MEDICATION(S)] for hypertension. The chart code legend indicated 6 meant hospitalized . On 09/23/21 at 12:05 p.m., an interview with Staff A, LPN, Resident #1's assigned nurse during the 3:00 p.m. to 11:00 p.m. shift, revealed she did not visually verify or see Resident #1 for the entirety of her shift. Staff A, LPN stated that at the start of her shift, she did not conduct her walking rounds to visually verify the presence of her assigned residents. Staff A, LPN stated she did walk around to see all the residents under her assigned care later and remembered seeing someone in Resident #1's bed, however, apparently it was the roommate that was lying in the bed. Staff A, LPN confirmed she did not verify the presence or functionality of Resident #1's wander guard according to his physician order. Staff A, LPN confirmed she did not provide Resident #1 with his physician ordered medications during her assigned shift. Staff A, LPN stated she checked the medications out . set them aside with the intention of going to find [Resident #1] but wanted to complete the medication pass to the other residents . An interview on 09/23/21 at 11:12 a.m. with Staff K, Registered Nurse (RN)/Previous Staff Development Coordinator/Assistant Director of Nursing revealed the role of the Staff Development Coordinator was to provide education to staff on the facility procedures. Staff K, RN stated the expectation for nurses when medications were not provided as scheduled was to report this to the doctor. If attempting to provide the medications and the resident was not present, then the nurse should find the resident. If they are not able to be found, then the elopement procedure should be initiated. The expectation is that nursing staff should be accurately documenting the services they provide, such as checking a resident's wander guard. A record review of meal intake for Resident #1 revealed the last meal percentage logged for Resident #1 on 09/07/21 was timed at 1:51 p.m. at 51-75% consumed. During an interview 09/21/21 at 12:55 p.m. the Risk Manager stated the expectation for resident meal refusal was for staff to report it to the nurse on duty, and if a resident meal tray was picked up and had not been touched, the resident should be found to determine why they had not eaten anything. During this interview, Staff O, Unit Manager confirmed these expectations. An interview on 09/21/21 at 3:52 p.m. with Staff C, CNA revealed she did not remember seeing Resident #1 at the start of the 3 p.m. to 11 p.m. shift on 09/07/21; however, she normally sees the resident wandering around the building and sitting on the floor. Sometimes at the start of her shift, the previous aide will provide a report but if there was no one to give a report she will just start her rounding for to visually see her assigned residents. Staff C, CNA confirmed she was the CNA who delivered Resident #1's dinner tray on 09/07/21 around 5:30 p.m. When she delivered the meal tray, Resident #1's lunch tray was still in the room. Staff C reported that when she lifted the lunch tray meal lid, she saw nothing had been consumed. Staff C said, [Resident #1] is a messy eater . so you can tell when he ate. At that point she left Resident #1's dinner tray in the room along with his lunch tray because it was not uncommon for the resident to be wandering so staff will leave things in his room for him. Staff C, CNA stated after she left Resident #1's room, after delivering the dinner tray, she mentioned to another CNA on the floor where is [Resident #1]? He didn't touch lunch. Staff C, CNA stated it was not uncommon for the second-floor unit to be short-staff during the evening and she cannot remember if Resident #1's room had an assigned aide, so, she continued on her assignment of delivering meal trays. Staff C, CNA stated she did not inform the nurse on duty about Resident #1's untouched lunch tray, and left the dinner tray unattended in the resident's room because she was already assisting other residents with eating and assisting with residents that were not on her assignment. Staff C, CNA stated she finished assisting residents with meals and began collecting meal trays between 6:30 p.m. and 7:00 p.m. on 09/07/21. An interview on 09/21/21 at 4:12 p.m. with Staff B, CNA revealed she did not remember seeing Resident #1 on 09/07/21. Staff B, CNA stated that evening it seemed like Resident #1's room assignment did not have an assigned aide because they were instructed to split up the room set assignment amongst herself and the two other CNAs on that floor. It was not until about 7:30 p.m. that evening that another aide (Staff G, Restorative Aide/CNA) was called to the unit to assist with resident care. Staff B, CNA stated that it was Resident #1's normal behavior to wait by the elevators at the start of the 3:00 p.m. to 11:00 p.m. shift and ask for ice cream, however, he was not there on 09/07/21. Around dinner time that evening, about 5:30 p.m., Staff C, CNA came to her and said where's [Resident #1]? He hasn't touched his lunch tray. She and Staff C, CNA walked into the Resident's room. Staff C, CNA lifted Resident #1's lunch tray lid in front of her and she saw that Resident #1 had not consumed his meal. Staff C, CNA left Resident #1's dinner tray in his room along with the untouched lunch tray. Staff B, CNA stated she did not report the untouched lunch tray because lunch was served around 11:30 a.m., and she felt that whoever delivered the meal tray should have re-collected it. At that point, the other aides on the unit were assisting residents outside of their assignment set with eating and still had to pass more dinner trays due to being short an aide. A record review of the Assignment Sheet, dated 09/07/21, for the 3:00 p.m. to 11:00 p.m. revealed Resident #1's listed assigned CNA was Staff L, and his listed assigned nurse was Staff A, LPN. Two other CNAs (Staff B and Staff C) were also listed as working on the second floor that evening. A phone interview on 09/23/21 at 11:52 a.m. with Staff L, CNA revealed on 09/07/21 she had worked two shifts, both the morning and evening shift. During the morning shift, she was assigned resident rooms located on the first floor. Once the morning shift ended, at the start of the 3:00 p.m. to 11:00 p.m. shift she was assigned to work the front desk on the first floor to conduct COVID-19 screenings. Staff L, CNA stated she did not go to the second floor until after 5:00 p.m. to assist with collecting dinner trays; therefore, she did not do any visual rounding checks of residents residing on the second floor (Resident #1's unit). Staff L, CNA stated that she did not have any resident assigned rooms to her care during the evening shift and once she was done assisting with dinner tray collection, she returned to the first floor again to man the front door. Once she left, another aide (Staff G, Restorative Aide/CNA) went to the unit to assist with resident care. During this interview on 09/23/21 at 11:52 a.m. Staff L, CNA stated while working the front desk in the evening, she answered a phone call inquiring about Resident #1, so she attempted to transfer the call to the second-floor nurse (Staff A, LPN) but no one was answering so she began overhead paging, however, no one answered the page. Another nurse came over to the desk and went up to the second floor to talk to Staff A, LPN and apparently told the nurse to answer the phone. After this incide [TRUNCATED]

Based on interviews and clinical record review, the facility failed to ensure that it was free from significant medication errors related to one (Resident #1) of four residents sampled. Resident #1 received an overdose of diabetic medication due to an error in transcription, and this resulted in extreme [DIAGNOSES REDACTED] (low blood sugar), while Resident #1 was being transferred to the hospital. A clinical record review revealed a face sheet that indicated Resident #1 was an [AGE] year old female originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. Further review revealed a pharmacy form dated 2/21/14 that stated that stated, " URGENT-Non-covered Medication. " The form indicated that the medication " [MEDICATION NAME] 2.5 mg three tablets (7.5mg) by mouth every morning for Diabetes Mellitus, " was no longer a covered expense. The " Rx Option " was listed as " [MEDICATION NAME] 10 mg one tablet by mouth every morning for Diabetes Melllitus. " An authorization was signed for this medication to be swapped as indicated, as per the option, by Resident #1 ' s Advanced Registered Nurse Practitioner, (ARNP), who worked under the supervision of Resident #1 ' s physician. A review of the Medication Administration Record [REDACTED]. On April 1, 2014 the new medication, [MEDICATION NAME] 10 mg was to begin, in place of the [MEDICATION NAME]. However, further review revealed that the dosage for the [MEDICATION NAME] was recorded as the same dosage as the [MEDICATION NAME], " three tablets (7.5mg) once daily, " instead of " 10 mg one tablet once daily, " as originally indicated. A closer review of the April 2014 MAR indicated [REDACTED]. A review of the Ambulance run report revealed an entry dated 4/2/14 and timed 12:08 p.m. that stated, " Patient is an [AGE] year old female found sitting in a wheelchair at nursing home. Complaint of fever and UTI. Upon evaluating treating patient in ambulance, her blood glucose is noted at 43mg/dl with known history of diabetes. 25 grams [MEDICATION NAME] is administered, patient becomes more aroused shortly after. A review of the hospital ' s History and Physical dated 4/2/14 stated under Reason for Admission, " Hypoxic [MEDICAL CONDITION], [DIAGNOSES REDACTED]. " Under History of Present Illness, it was stated, " Unable to get any history from the patient. History obtained from the medical record. The patient is an [AGE] year old white female resident from Jacaranda, brought to the hospital with shortness of breath and [MEDICAL CONDITION], She was also treated at a nursing home for UTI. Urine culture as an outpatient grew [DIAGNOSES REDACTED] and Proteus. She had been on [MEDICATION NAME] and [MEDICATION NAME]. She was not getting any better. In the ER chest x ray revealed pneumonia, she was hypoxic. Her blood sugars were low also. She was given D50 and her glucose came up, but again dropped. " On 4/15/14 at approximately 2:30 p.m., Employee C confirmed that she was the licensed practical nurse that was assigned to Resident #1 on 4/2/14, the day that she was transferred to the hospital. She stated that she had given Resident #1 her medications that morning, and " she wasn ' t herself. " She confirmed that the resident had a change in mental status, and had also developed a fever. She stated that she spoke to the physician and also to Resident #1 ' s daughter that morning, who indicated that she was coming in to the facility. Employee C stated that when Resident #1 ' s daughter arrived, she wanted her transported to the hospital, so an ambulance was called and she left around noon. She confirmed that Resident #1 had taken her medications that morning. Employee C was given the April, 2014 MAR indicated [REDACTED]. She confirmed that it stated that the tablets were 10 mg each, to give three tabs, and the total dosage was listed as 7.5 mg, but three tablets would have far exceeded that amount. She confirmed that she administered three tablets for a total of 30 mg on 4/1/14 and again on 4/2/14. She stated, " I should have gotten clarification. " On 4/15/14 at approximately 2:50 p.m. an interview was conducted with the general manager of the pharmacy. He confirmed that the dosage of [MEDICATION NAME] 10mg three tablets (7.5mg) once by mouth daily was in error, and the order should have read " [MEDICATION NAME] 10 mg one tablet by mouth daily. " He stated that he thought it was a computer generated error. He stated that it is nursing ' s responsibility to ensure that new orders are reviewed and accurate each month. He stated that giving three tablets of [MEDICATION NAME] exceeded the recommended dosage, and was triple the current physician's order [REDACTED]. On 4/15/14 at approximately 3:00 p.m. the Director of Nursing (DON) confirmed that the order for the dosage of [MEDICATION NAME] was in error. She confirmed that this should have been noted and corrected as the new monthly orders and MAR ' s were checked. On 4/15/14 at approximately 3:20 p.m. an interview was conducted with Resident #1 ' s physician. He confirmed that Resident #1 should only have received [MEDICATION NAME] 10 mg one tablet in the morning, and not three tablets on 4/1/14 and 4/2/14. He confirmed that this could likely contribute to low blood sugar, or [DIAGNOSES REDACTED].

Based on interviews with the facility's nursing and administrative staff, a legally appointed guardian, the attending physician/Medical Director, and review of clinical records and facility policies, it was determined that the facility failed to protect the rights of residents to refuse Cardio-Pulmonary Resuscitation (CPR) consistent with their end of life wishes, for one (#24) of 25 sampled residents and one of 85 residents identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. The facility initiated CPR on Resident #24, a [AGE] year old man with multiple comorbidities. This resident had a signed Do Not Resuscitate (DNR) order completed by his legally appointed guardian on [DATE] and signed by his physician on [DATE]. The facility failed to honor Resident #24's advanced directives and denied the resident/guardian the opportunity to refuse treatment. The facility initiated CPR for Resident #24 without checking his code status using the systems in place by the facility. The facility called 911 for the resident who was at the mercy of the staff and provided with unwanted treatments of cardiac compressions, artificial ventilation, defibrillation and a chest tube to prolong life. The facility violated this resident's rights by failing to honor the resident/guardian's wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at their last moments of life. Failure of the facility staff to ensure the right to formulate an advance directive of DNR was honored in accordance with the resident's/guardian's expressed wishes to withhold the treatment and service of CPR, resulted in findings of immediate jeopardy which was removed on [DATE] at 5:50 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the facility's admission agreement with an effective date of [DATE] revealed the following relevant information related to Advanced Directives: "1.4 Legal Representative for Healthcare. ("Legal Representative for Healthcare") refers to an individual who a resident or court has designated to have the legal authority to act on behalf of the Resident with regard to healthcare decisions. A document that evidences this legal authority must be provided to must be provided to the Center. Documents that demonstrate such legal authority are called different names, as determined by State or Commonwealth ...An individual who is appointed by a court to act as a resident's Legal Representative for Healthcare may be referred to by different names, as determined by State law, including guardian ... 2.2 Nursing. The center is required to meet applicable State and Federal nurses staffing requirements. The Center does not provide 24-hour, one-to-one nurse to resident care. While residing in the Center, the Resident will receive medically necessary routine nursing services and, as applicable, emergency care. 3.2 Resident Right to Participate in Treatment Decisions. The Resident has the right to consent to or refuse and treatment or procedure, and, at any time, to revoke previously provided consent for a treatment or procedure ... If the Resident lacks the capacity to make healthcare decisions ...or is deemed incompetent by a court of law ...the Resident's Legal Representative for Healthcare will act on the Resident ' s behalf with regard to healthcare decision-making. 3.4 Advance Directives. In accordance with applicable Federal and State laws and regulations, the Resident has a right to accept or refuse treatment and, at the Resident's option, formulate advance directives. The Center will not discriminate against or condition the admission or provision of care to the Resident based on whether the Resident has or has not elected to execute advance directives. The Center shall act in accordance with a resident's advance directives, if the advance directives were executed in accordance with applicable State law ... 8. The Center must comply with the requirements relating to maintaining written policies and procedures regarding advance directives ...This includes a written description of the Center's policies to implement advance directives and applicable State law. If an adult individual is incapacitated at the time of admission and is unable to receive information ...or articulate whether or not he or she has executed advance directives, the Center [MEDICAL CONDITION].advance directives information to the individual's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual ... Attachment A - Consent to Admission and Treatment ...B. Medical Treatment: ...The Resident consents to admission to the Center, and, pursuant to the Resident's Attending physician's orders [REDACTED]. The Resident, however, has the legal right to refuse at any time any treatment and to be informed of the consequences of refusing such treatment ... Attachment B - Resident Rights - Federal ...4. The resident has the right to refuse treatment ...and formulate an advance directive ... Attachment C - Advance Directive Acknowledgement ...4. I understand that the terms of any Advance Directive that I have executed will be followed by the health care facility and my caregivers to the extent permitted by law." 2. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). 3. A review of the advanced directives section of the clinical record revealed the following relevant documents: Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's legal guardian on [DATE] and the attending physician on [DATE]. 4. A review of the resident's individualized plan of care revealed the following relevant information dated [DATE]: "Problem or Strength: Resident #24 has the following Advance Directives on record: Living Will, Guardianship, Durable Power of Attorney, Do Not Resuscitate (DNR), and a physician's orders [REDACTED]. Goal: Advance Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Guardian's wishes will be honored. Interventions: Discuss Advanced Directives with the resident and or appointed health care representative. The appointed health care representative will make all health care decisions if the resident is incapacitated. Resident #24's legal guardian's name and phone number is then listed. Notify physician of resident's wishes regarding life prolonging procedures. An Advance Directive can be revoked or changed if the resident and or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and or appointed health care rep to provide copies to the facility of any updated Advanced Directives. For DNR status: Verify presence of yellow DNR form on resident's chart Verify presence of physician's orders [REDACTED]. 5. The resident had the following relevant [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Disease, Dysphagia, [MEDICAL CONDITIONS], [MEDICAL CONDITION] Reflux, Chronic Kidney Disorder, Benign Prostatic Hypertrophy without obstruction, [MEDICAL CONDITION], Arthropathy, Muscle Weakness, and [DIAGNOSES REDACTED]. 6. Review of the Nurses Notes revealed the following relevant entries: [DATE] 7:42 p.m. "This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident then was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m. and paramedics arrived at scene at 6:57 p.m. and took over resident ' s state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident's state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]. [DATE] 9:18 p.m. "Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. 7. Hospital record review revealed the following relevant information: [DATE] 7:18 p.m. "Rapid initial assessment from ER: Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival." [DATE] Internal medicine progress note: "Foley catheter inserted." History and Physical [DATE] 9:11 a.m. "Reason for admission: Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia, status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment." Pulmonary Consult Note [DATE] at 9:10 a.m. ... "per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, patient is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR) revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Patient currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved status [REDACTED]. Questionable concomitant Community Acquired Pneumonia (CAP) versus aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR." [DATE] Critical Care Progress Note: "Assessment: Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudative/infectious etiology." [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: "Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function." [DATE] ST : "Video swallow eval Comments: intermittently delayed bolus propulsion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials." Critical Care Progress Note [DATE]: "Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor." Pulmonary Progress Note from [DATE]: "Chest X-ray [DATE] 2:37 a.m. Impression: stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]." Pulmonary Progress Note: [DATE] 7:04 a.m. "Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%." Pulmonary Progress Notes on [DATE] and [DATE] indicate: "Respiratory/Chest Assessment : Rales, wheezing, paradoxical breathing, palpable rales on right anterior chest. Pectus Excavatum." [DATE] Cardiology Consult: "Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient's hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care." 8. Interview with the facility's Administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed an incident occurred on [DATE] around 6:30 p.m. involving Resident #24 for which the facility had conducted a review of the circumstances. Resident #24 was in the dining room at the time of the event and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B) who was present in the dining room to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was now at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night of the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B is a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete a report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B reported back to the DON that the guardian said she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B was currently in nursing school and she started thinking about what would happen if the resident's brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place the staff do not resuscitate. The staff is trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked, it was human error. Thirty seconds must have seemed like 10 minutes." Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take ownership. The DON figured that if Employee B was tasked with having to reiterate the correct process repeatedly then it would stick. The administrator stated she asked the DON the same question and when the DON explained this to her it made sense. 9. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he had been a CNA at the facility for the past [AGE] years. He worked in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled, that on [DATE], he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24 he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and, again, said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down. They put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given, but, stated "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated, "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away." 10. Interview on [DATE] at 2:43 p.m. with Employee B, revealed she had been a LPN for the past [AGE] years and has worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor, but, at the time of the event he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 ate in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to the resident and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lives downstairs and she called out for somebody to go get the chart and to call downstairs so they could find out his code status. She was unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response, she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from the patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the resident's chart but she could not recall who this was. They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started "you do not stop." An ambu-bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed. "It seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 11. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident was still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he had been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 had become unresponsive in the past and he usually comes right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 12. Telephone interview on [DATE] at 4:37 p.m. with the Medical Director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence. He stated they have a team of 11 physicians and practitioners who provide coverage. The physician said that he was certain the facility called them as "they call us like clockwork." The Medical Director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately." The Medical Director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done, then, we would follow protocol for a DNR. 13. Review of the facility's undated "Code Arrest - Procedure and Protocol," which was in effect at the time of the [DATE] incident revealed the following relevant information: "Policy: Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. "Code 99" - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code Call Code "99" Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident's chart and code cart to the resident's room ..." 14. Review of Employee B's personnel file confirmed that she had current CPR certification by the American Heart Association with an issue date of [DATE] and an expiration date of [DATE]. Review of the Personnel Consultation Form with a date of counseling of [DATE] for a date of occurrence on [DATE] revealed the following: "Final Written Warning for a description of occurrence as follows: As per employment handbook page #25, line #9 stipulated unsatisfactory or careless work; page #25 line #13 stipulated violating facility rules or safety practices. Employee enacted code 99 protocol and started CPR and directed staff to do so prior to verifying actual code status of a resident. Corrective Action Taken: Employee was re-educated on the appropriate protocol and process to carryout Code 99 in the facility. Employee was re-educated on Emergency Response, verifying code status, and documentation components. Any further discrepancies/issues regarding this will result in immediate termination. The document was signed and dated by Employee B and the DON on [DATE]." 15. Interview with the NHA, DON and RM on [DATE] at 10:48 a.m. revealed the facility began education with the staff on the Code 99 process immediately after being informed of the event on [DATE] by Employee B. The following morning, [DATE], the interdisciplinary team met and developed a Quality Assurance (QA) Action Plan. Review of the QA Action Plan for an area identified as "Staff not verifying code status prior to initiating CPR" revealed the following actions to be taken (Process Change/Education): a. 100% education for all licensed nurses and C.N.A.'s regarding the Code 99 Policy and how to verify code status. Review of a list of all current licensed nurses and C.N.A.'s revealed a total of 286 employees would need to receive this education. As of [DATE], 266 employees had signed in-service records indicating they have received this training. Interview with the DON and Staff Development Coordinator on [DATE] at 5:29 p.m. revealed the 20 remaining employees have not worked in the facility since the event due to various reasons to include scheduled vacation, medical leave, call in's, not scheduled, and PRN. The DON stated we have been calling them and leaving messages on their phones to inform them they need to come in to receive training. In some cases, we can't get a hold of the people as the phone numbers are no longer working. If they have not worked in the past

Based on facility policy review, review of advance directive information included in the admission packet, review of staff education records, clinical record review, and interviews with nursing and administrative staff, the Medical Director/attending physician, and a resident ' s legal guardian, it was determined that the facility failed to ensure staff were knowledgeable of facility policies and procedures for advance directives, and could identify end of life wishes regarding resuscitation for one (#24) of 25 samples residents of 85 total identified as having do not resuscitate orders (DNR), according to the [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. The facility failed to implement their own policies for Code Arrest and the execution of Advanced Directives in accordance with their Admission Agreement. The facility initiated CPR on Resident #24, a [AGE] year old man with multiple comorbidities. This resident had a signed Do Not Resuscitate (DNR) order completed by his legally appointed guardian on [DATE] and signed by his physician on [DATE]. The facility failed to honor Resident #24's advanced directives and denied the resident/guardian the opportunity to refuse treatment. The facility initiated CPR for Resident #24 without checking his code status using the systems in place by the facility. The facility called 911 for the resident who was at the mercy of the staff and provided with unwanted treatments of cardiac compressions, artificial ventilation, defibrillation and a chest tube to prolong life. The facility violated this resident's rights by failing to honor the resident/guardian's wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at their last moments of life. Failure to protect the rights of residents to ensure facility staff correctly implemented advanced directives resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to a D. Findings include: 1. Interview on [DATE] at 2:43 p.m. with Employee B, revealed she had been a LPN for the past [AGE] years and has worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor, but, at the time of a [DATE] event, he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 ate in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to Resident #24 and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lived downstairs and she called out for somebody to go get the chart and to call downstairs so they could find out his code status. She was unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from the patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the resident's chart but she could not recall who this was. They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started, "you do not stop." An ambu-bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed. "It seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 2. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he had been a CNA at the facility for the past [AGE] years. He worked in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled that, on [DATE] he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24 he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and, again, said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down. They put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given but stated "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away." 3. Review of the facility's training materials for Resident Rights, End of Life, and Advanced Directives revealed the facility utilized the Silver Chair computer based learning system. The content details for Resident Rights revealed the following relevant information: "Resident in long term care facilities have certain rights under state and federal law. This course helps employees better understand these rights and describes ways they can protect and promote resident rights." "As a result of completing this course, the learner will be able to: Describe the purpose of the Residents' Rights document List four residents' rights Describe four ways to protect residents rights." Employee B was listed as having last completed this course on [DATE]. The content details for Advanced Directives/Ethical Issues at the End of Life revealed the flowing relevant information: "A person can decide what kind of treatment he wants at the end of life. He may choose aggressive treatment which may prolong life or he may choose to stop treatment, which could mean dying earlier but more comfortably. Even if you know his decisions about end-of-life care, caring for a dying loved one is not easy. If these decisions have not been made ahead of time, ethical and legal standards may determine the dying person's treatment. This course discusses the ethical and legal issues and standards concerning the end of life. After completing this course, you will be able to understand the options available at the end of life as well as the decisions you or a loved one will have to make." The following relevant course objectives were listed as follows: "Describe the different types of advance directives Describe ethical dilemmas that can occur at the end of life Identify the best way to help the patient or caregiver make such ethical decisions Discuss how advance directives apply to emergency situations Describe the communication process at the end of life Identify the ethical issues surrounding end-of-life decisions Identify the physical process of dying." Employee B was listed as having last completed this course on [DATE]. 4. Review of the facility's admission agreement with an effective date of [DATE] revealed the following relevant information related to Advanced Directives: "4.4 Legal Representative for Healthcare. ("Legal Representative for Healthcare") refers to an individual who a resident or court has designated to have the legal authority to act on behalf of the Resident with regard to healthcare decisions. A document that evidences this legal authority must be provided to must be provided to the Center. Documents that demonstrate such legal authority are called different names, as determined by State or Commonwealth ...An individual who is appointed by a court to act as a resident's Legal Representative for Healthcare may be referred to by different names, as determined by State law, including guardian ... 2.2 Nursing. The center is required to meet applicable State and Federal nurses staffing requirements. The Center does not provide 24-hour, one-to-one nurse to resident care. While residing in the Center, the Resident will receive medically necessary routine nursing services and, as applicable, emergency care. 3.2 Resident Right to Participate in Treatment Decisions. The Resident has the right to consent to or refuse and treatment or procedure, and, at any time, to revoke previously provided consent for a treatment or procedure ... If the Resident lacks the capacity to make healthcare decisions ...or is deemed incompetent by a court of law ...the Resident's Legal Representative for Healthcare will act on the Resident ' s behalf with regard to healthcare decision-making. 3.4 Advance Directives. In accordance with applicable Federal and State laws and regulations, the Resident has a right to accept or refuse treatment and, at the Resident option, formulate advance directives. The Center will not discriminate against or condition the admission or provision of care to the Resident based on whether the Resident has or has not elected to execute advance directives. The Center shall act in accordance with a resident's advance directives, if the advance directives were executed in accordance with applicable State law ..." "The Center must comply with the requirements relating to maintaining written policies and procedures regarding advance directives ...This includes a written description of the Center's policies to implement advance directives and applicable State law. If an adult individual is incapacitated at the time of admission and is unable to receive information ...or articulate whether or not he or she has executed advance directives, the Center may give advance directives information to the individual's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual ..." "Attachment A - Consent to Admission and Treatment ...B. Medical Treatment: ...The Resident consents to admission to the Center, and, pursuant to the Resident's Attending physician's orders [REDACTED]. The Resident, however, has the legal right to refuse at any time any treatment and to be informed of the consequences of refusing such treatment ..." "Attachment B - Resident Rights - Federal ...4. The resident has the right to refuse treatment ...and formulate an advance directive ..." "Attachment C - Advance Directive Acknowledgement ...4. I understand that the terms of any Advance Directive that I have executed will be followed by the health care facility and my caregivers to the extent permitted by law." 5. Review of the facility's undated "Code Arrest" - Procedure and Protocol which was in effect at the time of the [DATE] incident revealed the following relevant information: "Policy: Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. "Code 99" - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code Call Code "99" Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident's chart and code cart to the resident's room ..." 6. Interview with the facility's Administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed that an incident occurred on [DATE] around 6:30 p.m. involving Resident #24 for which the facility had conducted a review of the circumstances. Resident #24 was in the dining room at the time of the event and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B), who was present in the dining room, to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was now at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night of the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B was a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete a report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B reported back to the DON that the guardian said she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. 7. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). A review of the advanced directives section of the clinical record revealed the following relevant documents: Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's legal guardian on [DATE] and the attending physician on [DATE]. This document included a "Statement that the Court appointed guardian based upon informed consent, hereby directs that CPR be withheld or withdrawn." In addition, this document included a physician statement documenting that the physician of Resident #24 hereby "directs the withholding of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest." A review of the resident's individualized plan of care revealed the following relevant information, dated [DATE]: "Problem or Strength: Resident #24 has the following Advance Directives on record: Living Will, Guardianship, Durable Power of Attorney, Do Not Resuscitate (DNR), and a physician's orders [REDACTED]. Goal: Advance Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Guardian's wishes will be honored. Interventions: Discuss Advanced Directives with the resident and or appointed health care representative. The appointed health care representative will make all health care decisions if the resident is incapacitated. Resident #24's legal guardian's name and phone number is then listed. Notify physician of resident's wishes regarding life prolonging procedures. An Advance Directive can be revoked or changed if the resident and or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and or appointed health care rep to provide copies to the facility of any updated Advanced Directives. For DNR status: Verify presence of yellow DNR form on resident's chart Verify presence of physician's orders [REDACTED]. The resident had the following relevant [DIAGNOSES REDACTED]. 8. Review of the Nurses Notes revealed the following relevant entries: [DATE] 7:42 p.m. "This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident than was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m. and paramedics arrived at scene at 6:57 p.m. and took over resident's state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident's state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]." [DATE] 9:18 p.m. "Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. 9. Hospital record review revealed the following relevant information: [DATE] 7:18 p.m. "Rapid initial assessment from ER: Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival." [DATE] Internal medicine progress note: "Foley catheter inserted." History and Physical [DATE] 9:11 a.m. "Reason for admission: Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia, status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment." Pulmonary Consult Note [DATE] at 9:10 a.m. "... per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, patient is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR) revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Patient currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved status [REDACTED]. Questionable concomitant Community Acquired Pneumonia (CAP) versus aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR." [DATE] Critical Care Progress Note: "Assessment: Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudative/infectious etiology." [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: "Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function." [DATE] ST: "Video swallow eval Comments: intermittently delayed bolus propulsion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials." Critical Care Progress Note [DATE]: "Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor." Pulmonary Progress Note from [DATE]: Chest X-ray [DATE] 2:37 a.m. Impression: "stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]." Pulmonary Progress Note: [DATE] 7:04 a.m. "Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%." Pulmonary Progress Notes on [DATE] and [DATE] indicate: "Respiratory/Chest Assessment : Rales, wheezing, paradoxical breathing, palpable rales on right anterior chest. Pectus Excavatum." [DATE] Cardiology Consult: "Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient's hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care." 10. Telephone interview on [DATE] at 4:37 p.m. with the Medical Director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence. He stated they have a team of 11 physicians and practitioners who provide coverage. The physician said that he was certain the facility called them as "they call us like clockwork." The Medical Director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately." The Medical Director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done then we would follow protocol for a DNR. 11. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident was still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he had been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 had become unresponsive in the past and he usually came right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 11. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but, by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B was currently in nursing school and she started thinking about what would happen if the resident's brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place, the staff do not resuscitate. The staff is trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked, it was human error. Thirty seconds must have seemed like 10 minutes." Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take owners

Based on interview with facility staff and a resident's legal guardian, review of the resident's medical record, facility policies, and personnel consultation form, it was determined that the facility failed to honor the advanced directives for one (#24) of 85 residents identified as having do not resuscitate orders (DNR), according to the [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. The facility initiated Cardio-Pulmonary Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility staff did not properly implement their corporate policy and procedure entitled Code Arrest (undated) and the Abuse Prevention Policy and Procedure dated [DATE]. The staff did not fulfill a care taking obligation to provide goods or services necessary to avoid physical harm and mental anguish consistent with the resident ' s signed do not resuscitate order dated [DATE]. The facility did not honor the expressed wishes of the legal ly appointed guardian of an incapacitated resident. Failure of the facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy which was removed on [DATE] at 5:50 p.m. and the severity and scope was reduced to a D. Findings include: 1. Initial interview with the facility's administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed an incident occurred on [DATE] around 6:30 p.m. involving Resident #24. Resident #24 was in the dining room at the time and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B) who was present in the dining room to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was not at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B is a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete an incident report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B told the DON that the guardian that she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. 2. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident is still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he has been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 has become unresponsive in the past and he usually comes right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 3. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he has been a CNA at the facility for the past [AGE] years. He works in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled that on [DATE] he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24 he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and again said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down and they put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given but stated "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away." 4. Interview on [DATE] at 2:43 p.m. with Employee B, the nurse directly involved in the occurrence with Resident #24 on [DATE], revealed she has been a LPN for the past [AGE] years and has worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor but at the time of the event he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses ' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 eats in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to the resident and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lives downstairs and she called out for somebody go get the chart and to call downstairs so they could find out his code status. She is unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the chart (unknown who). They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started "you do not stop." An ambu bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed but "it seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 5. Telephone interview on [DATE] at 4:37 p.m. with the medical director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence, as they have a team of 11 physicians and practitioners who provide coverage. The physician stated that he was certain that the facility called them as "they call us like clockwork." The medical director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately." The medical director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done then we would follow protocol for a DNR. 6. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). A review of the advanced directives section of the clinical record revealed the following relevant documents: Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. A State of Florida Do NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident ' s legal guardian on [DATE] and the attending physician on [DATE]. The resident had the following [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed the following relevant entries: [DATE] 7:42 p.m. This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident than was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m and paramedics arrived at scene at 6:57 p.m. and took over resident's state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident's state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]. [DATE] 9:18 p.m. Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. Hospital record review revealed the following relevant information: [DATE] 7:18 p.m. Rapid initial assessment from ER: Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival. [DATE] Internal medicine progress note: Foley catheter inserted. History and Physical [DATE] 9:11 a.m. Reason for admission : Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia , status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment. Pulmonary Consult Note [DATE] at 9:10 a.m. ... per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, pt is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR)revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Pt currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved s/p bedside chest tube insertion with remaining left sided pneumothorax, likely from traumatic chest compressions. Questionable concomitant Community Acquired Pneumonia (CAP) vs aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR. [DATE] Critical Care Progress Note: Assessment: Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudiative/infectious etiology. [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function. [DATE] ST: video swallow eval Comments: intermittently delayed bolus propultion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials. Critical Care Progress Note [DATE]: Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor. Pulmonary Progress Note from [DATE]: Chest X-ray [DATE] 2:37 a.m. Impression: stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]. Pulmonary Progress Note: [DATE] 7:04 a.m. Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%. Pulmonary Progress Notes on [DATE] and [DATE] indicate Respiratory/Chest Assessment : Rales, wheezing, parodixical breathing, palpable rales on right anterior chest. Pectus Excavatum. [DATE] Cardiology Consult: Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient's hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care. 7. Review of the facility's undated "Code Arrest" - Procedure and Protocol which was in effect at the time of the [DATE] incident revealed the following relevant information: Policy: Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. "Code 99" - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code 3. Call Code "99" Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident's chart and code cart to the resident's room ... Review of the facility's "Abuse Prevention Policy & Procedure" dated [DATE] revealed the following relevant information: Purpose: The purpose of this written Resident Abuse, Neglect, and Misappropriation Prevention Program is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff ... 1. Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse ...by any facility staff member ... 2. Definitions: The most common forms of abuse include: Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness; e.g., denial of food or health-related services, abandonment. 6. Reporting/Investigation/Response Policy: Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. Procedures: Immediate Response: (2) Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation ... (7) Prevention Through QA Policy: Reviewing and Disciplining - This facility will conduct a comprehensive review of any employee suspected of abuse, neglect or mistreatment of [REDACTED]. Any employee, who is accused or resident abuse ...will be suspended pending further investigation. Discipline: 1. Any employee suspected of abuse, neglect or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation. Do not wait for the State Department of Human Services to investigate. 8. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B is currently in nursing school and she started thinking about what would happen if the resident's brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place the staff do not resuscitate. The staff are trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect on Day 1 when they submitted their initial federal report to the Agency for Health Care Administration. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked it was human error. Thirty seconds must have seemed like 10 minutes." Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take ownership. The DON figured that if Employee B was tasked with having to reiterate the correct process repeatedly then it would stick. The administrator stated she asked the DON the same question and when the DON explained this to her it made sense. 9. Review of Employee B's personnel file confirmed that she had current CPR certification by the American Heart Association with an issue date of [DATE] and an expiration date of [DATE]. Review of the Personnel Consultation Form with a date of counseling of [DATE] for a date of occurrence on [DATE] revealed the following: Final Written Warning for a description of occurrence as follows: As per employment handbook page #25, line #9 stipulated unsatisfactory or careless work; page #25 line #13 stipulated violating facility rules or safety practices. Employee enacted code 99 protocol and started CPR and directed staff to do so prior to verifying actual code status of a resident. Corrective Action Taken: Employee was re-educated on the appropriate protocol and process to carryout Code 99 in the facility. Employee was re-educated on Emergency Response, verifying code status, and documentation components. Any further discrepancies/issues regarding this will result in immediate termination. The document was signed and dated by Employee B and the DON on [DATE]. 10. Interview with the NHA, DON and RM on [DATE] at 10:48 a.m. revealed the facility began education with the staff on the Code 99 process immediately after being informed of the event on [DATE] by Employee B. The following morning, [DATE], the interdisciplinary team met and developed a Quality Assurance (QA) Action Plan. Review of the QA Action Plan for an area identified as "Staff not verifying code status prior to initiating CPR" revealed the following actions to be taken (Process Change/Education): 1. 100% education for all licensed nurses and C.N.A.'s regarding the Code 99 Policy and how to verify code status. (Review of a list of all current licensed nurses and C.N.A.'s revealed a total of 286 employees would need to receive this education. As of [DATE] 266 employees have signed in-service records indicating they have received this training. Interview with the DON and Staff Development Coordinator on [DATE] at 5:29 p.m. revealed the 20 remaining employees have not worked in the facility since the event due to various reasons to include scheduled vacation, medical leave, call in's, not scheduled, and PRN. The DON stated we have been calling them and leaving messages on their phones to inform them they need to come in to receive training. In some cases, we can't get a hold of the people as the phone numbers are no longer working. If they have not worked in the past 60 days we are going to terminate them from the system. Some work weekends only and have been on the schedule but called off this past weekend. We will be giving the staffing coordinator a list of the 20 employees so she knows that they cannot be scheduled until they come in, receive the training, and sign off on it. The facility does not use agency staff. The DON will hold ultimate responsibility to ensure that these 20 employees will not be scheduled to work until the training has been received. 2. Validate Quality Education by interviewing randomly selected Nurses and C.N.A.s using the post education questionnaire. 8 nurses and 8 C.N.A.'s per shift/100% review of these will be completed by the NHA. This will be done daily for 5 days and then weekly until 100% accurate responses are provided to interviewer. This will continue for 5 days then weekly until 100% accurate responses are received for 4 consecutive weeks. Review of the facility's corrective action plan notebook revealed well over 100 questionnaires had been completed by nurses and C.N.A.'s. In-depth validation interviews were conducted by the survey team with thirty employees representing all shifts as well as weekend staff with no negative results received. 3. Conduct Mock Code 99 drills once per shift for one week. The administrator will audit Code 99 drill participation sign in sheets. This will continue one time each week then once per week on each shift until the QA/PI Committee determines future duration. Review of the facility's corrective action notebook revealed that the facility has far exceeded their stated number of mock drills for QA. Random interviews with the licensed nurses and C.N.A.'s revealed they have been participating in the drills where random scenarios are being utilized such as choking, diabetic, unresponsive, and [MEDICAL CONDITION] residents. The staff indicated that they are benefiting from the hands-on training and find it to be an effective educational tool. 4. Conduct 100% audit of all resident records including Kiosk, Physician Orders, Goldenrod/DNR forms and Care Plans on [DATE] by Social Service staff. Post [DATE] SS will do an additional audit of 10 per week for 4 weeks on those residents with DNR status. On [DATE] Medical Records will conduct a 2nd 100% audit to verify accuracy of any corrections. The weekly audits of 10 will continue until 100% compliance is achieved for 3 consecutive months. The survey team reconciled the code status on the physician orders, goldenrod DNR forms, and the computerized/kiosk system for 60 randomly selected residents from 6 of 6 facility units. A slight discrepancy was found on one resident's record but it was quickly clarified and corrected. 5. Ensure all Nursing Staff involved in [DATE] Code 99 had valid CPR Certificate. In addition, 15 of all nursing staff will by audited for CPR certification monthly for three months. This will be on-going until 100% compliance is reported for 3 consecutive months. The survey team reviewed 31 licensed nurses and C.N.A. personnel files. This review revealed all had current CPR cards on hand, however, five were on-line courses with no return demonstration requirement. This information was reported to the administrator on [DATE] at approximately 10:30 a.m. As a result of this information the facility developed a second QA Action plan on [DATE] for an area identified as "On-line C.P.R. class verified 5 of 31 Personnel Files checked for Licensed and Certified S

Based on review of the Florida Nurse Practice Act, clinical record review, staff interviews, facility policy review and job description reviews for the Director of Nursing (DON)and Licensed Practical Nurse (LPN), revised ,[DATE] it was determined that the facility did not ensure physician orders [REDACTED].#24) of 25 sampled residents of 85 identified as having a Do Not Resuscitate order (DNR), according to the [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. The Licensed Practical Nurse did not withhold Cardio-Pulmonary Resuscitation for a DNR resident after identifying the resident to be without pulse or respirations. In addition, the Director of Nursing failed to provide supervision and direction in accordance with her job description and facility's policies and procedures when she was notified that resident #2 4 was absent of vital signs. Failure of the facility to ensure nurses meet professional standards and act in accordance with the Nurse Practice Act as defined in the Florida Statutes, Chapter 464, resulted in findings of immediate jeopardy which was removed on [DATE] at 5:50 p.m. and the severity and scope was reduced to a D. Findings include: 1. The Florida Nurse Practice Act includes: 3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. Review of the Licensed Practical Nurse (LPN) job description with a revised date of ,[DATE] revealed this position reports to the Director of Nursing (DON). This job description contained the following relevant information: "General Purpose: Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern our facility, and as may be required by the DON to maintain the highest degree of quality care at all times. Administrative Functions: Cooperate with other resident services when coordinating nursing services be certain that the resident's total regimen of care is maintained. Charting and Documentation: Write nurses' notes to reflect that the care plan is being followed when administering nursing care or treatment. Nursing Care Functions: Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. Administer professional services such as: ...care for the dead/dying, etc., as required. Review care plans daily to confirm that appropriate care is being rendered. Other Duties: Protect residents from neglect, mistreatment, and abuse. Minimum Qualifications: Comply with the Resident Rights and Facility Policies and Procedures." 3. Review of the Director of Nursing (DON) job description with a revised date of ,[DATE] revealed the following relevant information: "General Purpose: To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs. Administrative Functions: Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Personnel Functions: Interview, orient, train, evaluate and supervise nursing department personnel. Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines. Nursing Care Functions: Perform nursing services and deliver resident care services in compliance with Corporate policies and State and Federal regulations. Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations. Safety and Sanitation: Monitor nursing service personnel to verify that they are following established safety regulations in the use of equipment and supplies. Provide that all nursing service personnel follow established departmental policies and procedures, ... Assure residents a comfortable, clean, orderly and safe environment Care Plan and Assessment Functions, Documentation: Verify that medical and nursing care is administered in accordance with the resident ' s wishes, including the implementation of advance directives. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes." 4. Interview with the facility's Administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed an incident occurred on [DATE] around 6:30 p.m. involving Resident #24. Resident #24 was in the dining room at the time and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B) who was present in the dining room to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was now at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night of the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B is a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete an incident report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B reported back to the DON that the guardian said she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. 5. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident was still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he had been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 had become unresponsive in the past and he usually comes right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 6. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). A review of the advanced directives section of the clinical record revealed the following relevant documents: a. Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. b. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's legal guardian on [DATE] and the attending physician on [DATE]. The resident had the following relevant [DIAGNOSES REDACTED]. Review of the Nurses' Notes revealed the following relevant entries: [DATE] 7:42 p.m. "This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident than was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m and paramedics arrived at scene at 6:57 p.m. and took over resident's state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident ' s state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]. [DATE] 9:18 p.m. Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. 7. Hospital record review revealed the following relevant information: "[DATE] 7:18 p.m. Rapid initial assessment from ER: Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival." "[DATE] Internal medicine progress note: "Foley catheter inserted." History and Physical [DATE] 9:11 a.m. Reason for admission: "Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia, status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment." Pulmonary Consult Note [DATE] at 9:10 a.m. " ... per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, patient is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR) revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Patient currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved status [REDACTED]. Questionable concomitant Community Acquired Pneumonia (CAP) versus aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR." [DATE] Critical Care Progress Note: "Assessment: Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudiative/infectious etiology." [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: "Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function." [DATE] ST: "Video swallow eval Comments: intermittently delayed bolus propultion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials." Critical Care Progress Note [DATE]: "Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor." Pulmonary Progress Note from [DATE]: "Chest X-ray [DATE] 2:37 a.m. Impression: stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]." Pulmonary Progress Note: [DATE] 7:04 a.m. "Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%." Pulmonary Progress Notes on [DATE] and [DATE] indicated Respiratory/Chest Assessment: "Rales, wheezing, parodixical breathing, palpable rales on right anterior chest. Pectus Excavatum." [DATE] Cardiology Consult: "Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient ' s hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care." 8. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he had been a CNA at the facility for the past [AGE] years. He worked in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled that, on [DATE], he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24 he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and, again, said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down. They put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given but stated, "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away." 9. Interview on [DATE] at 2:43 p.m. with Employee B, revealed she had been a LPN for the past [AGE] years and worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor but, at the time of the event, he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 ate in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to the resident and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lived downstairs and she called out for somebody to go get the chart and to call downstairs so they could find out his code status. She was unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response, she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from the patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the resident's chart but she could not recall who this was. They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started "you do not stop." An ambu bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed. "It seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 10. Telephone interview on [DATE] at 4:37 p.m. with the Medical Director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence. He stated they have a team of 11 physicians and practitioners who provide coverage. The physician said that he was certain the facility called them as "they call us like clockwork." The Medical Director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately." The Medical Director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done then we would follow protocol for a DNR. 11. Review of the facility's undated "Code Arrest" - Procedure and Protocol which was in effect at the time of the [DATE] incident revealed the following relevant information: Policy: "Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. " Code 99 " - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code 3. Call Code " 99 " Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident ' s chart and code cart to the resident's room ..." Review of the facility's "Abuse Prevention Policy & Procedure," dated [DATE], revealed the following relevant information: "Purpose: The purpose of this written Resident Abuse, Neglect, and Misappropriation Prevention Program is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff ... 1. Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse ...by any facility staff member ... 2. Definitions: The most common forms of abuse include: Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness; e.g., denial of food or health-related services, abandonment. 6. Reporting/Investigation/Response Policy: Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. Procedures: Immediate Response: (2) Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation ... (7) Prevention Through QA Policy: Reviewing and Disciplining - This facility will conduct a comprehensive review of any employee suspected of abuse, neglect or mistreatment of [REDACTED]. Any employee, who is accused or resident abuse ...will be suspended pending further investigation. Discipline: 1. Any employee suspected of abuse, neglect or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation. Do not wait for the State Department of Human Services to investigate." 12. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B was currently in nursing school and she started thinking about what would happen if the resident's brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place the staff do not resuscitate. The staff are trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect on Day 1. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked, it was human error. Thirty seconds must have seemed like 10 minutes." Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take ownership. The DON figured that if Employee B was tasked with having to reiterate the correct process repeatedly then it would stick. The administrator stated she asked the DON the same question and when the DON explained this to her it made sense. 13. Review of Employee B's personnel file confirmed that she had current CPR certification by the American Heart Association with an issue date of [DATE] and an expiration date of [DATE]. Review of the Personnel Consultation Form with a date of counseling of [DATE] for a date of occurrence on [DATE] revealed the following: Final Written Warning for a description of occurrence as follows: As per employment handbook page #25, line #9 stipulated unsatisfactory or careless work; page #25 line #13 stipulated violating facility rules or safety practices. Employee enacted code 99 protocol and started CPR and directed staff to do so prior to verifying actual code status of

Based on interviews with facility staff and a resident's legal guardian, review of the resident's clinical record, facility's policy and procedures, and a personnel consultation form, it was determined that the facility failed to implement the individualized care plan for advanced directives for one (#24) of 25 sampled residents of 85 identified as having do not resuscitate orders (DNR), according to the [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. Facility personnel performed Cardio-Pulmonary Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility staff did not ensure advance directives, which were in effect for DNR, were carried out in accordance with the resident's plan of care. The facility personnel did not ensure that, in the event the resident's heart stopped or breath ceased, that CPR would not be initiated to honor the resident's DNR wishes. In addition, the facility did not ensure that the legally appointed guardian's wishes for a DNR order were honored. Failure of the facility staff to correctly implement the plan of care for advanced directives for Resident #24 resulted in findings of immediate jeopardy which was removed on [DATE] at 5:50 p.m. and the severity and scope was reduced to a D. Findings include: 1. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). A review of the advanced directives section of the clinical record revealed the following relevant documents: Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's legal guardian on [DATE] and the attending physician on [DATE]. 2. A review of the resident's individualized plan of care revealed the following relevant information, dated [DATE]: "Problem or Strength: Resident #24 has the following Advance Directives on record: Living Will, Guardianship, Durable Power of Attorney, Do Not Resuscitate (DNR), and a physician's orders [REDACTED]. Goal: Advance Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Guardian's wishes will be honored. Interventions: Discuss Advanced Directives with the resident and or appointed health care representative. The appointed health care representative will make all hearth care decisions if the resident is incapacitated. Resident #24's legal guardian's name and phone number is then listed. Notify physician of resident's wishes regarding life prolonging procedures. An Advance Directive can be revoked or changed if the resident and or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and or appointed health care rep to provide copies to the facility of any updated Advanced Directives. For DNR status: Verify presence of yellow DNR form on resident's chart Verify presence of physician's orders [REDACTED]. 3. Resident #24 had the following relevant [DIAGNOSES REDACTED]. 4. Review of the Nurses Notes revealed the following relevant entries: [DATE] 7:42 p.m. "This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident than was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m. and paramedics arrived at scene at 6:57 p.m. and took over resident's state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident's state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]." [DATE] 9:18 p.m. Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. 5. Hospital record review revealed the following relevant information: [DATE] 7:18 p.m. Rapid initial assessment from ER: "Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival." [DATE] Internal medicine progress note: "Foley catheter inserted." History and Physical [DATE] 9:11 a.m. Reason for admission: "Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia, status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment." Pulmonary Consult Note [DATE] at 9:10 a.m. " ... per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, patient is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR) revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Patient currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved status [REDACTED]. Questionable concomitant Community Acquired Pneumonia (CAP) versus aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR." [DATE] Critical Care Progress Note: Assessment: "Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudiative/infectious etiology." [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: "Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function." [DATE] ST: "Video swallow eval Comments: intermittently delayed bolus propultion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials." Critical Care Progress Note [DATE]: "Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor." Pulmonary Progress Note from [DATE]: "Chest X-ray [DATE] 2:37 a.m. Impression: stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]." Pulmonary Progress Note: [DATE] 7:04 a.m.: "Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%." Pulmonary Progress Notes on [DATE] and [DATE] indicated: "Respiratory/Chest Assessment : Rales, wheezing, parodixical breathing, palpable rales on right anterior chest. Pectus Excavatum." [DATE] Cardiology Consult: "Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient's hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care." 6. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he has been a CNA at the facility for the past [AGE] years. He works in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled that on [DATE] he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24, he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and again said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down. They put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given but stated "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away. " 7. Interview on [DATE] at 2:43 p.m. with Employee B, revealed she has been a LPN for the past [AGE] years and has worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor but at the time of the event he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 eats in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to the resident and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lives downstairs and she called out for somebody to go get the chart and to call downstairs so they could find out his code status. She was unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from the patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the resident's chart but she could not recall who this was. They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started "you do not stop." An ambu bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed. "It seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 8. Review of the facility's undated "Code Arrest" - Procedure and Protocol which was in effect at the time of the [DATE] incident revealed the following relevant information: Policy: "Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. " Code 99 " - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code 3. Call Code "99" Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident's chart and code cart to the resident's room ..." 9. Interview with the facility's Administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed an incident occurred on [DATE] around 6:30 p.m. involving Resident #24 for which the facility had reviewed the circumstances of the event. Resident #24 was in the dining room at the time of the event and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B) who was present in the dining room to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was now at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night of the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B is a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete an incident report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B reported back to the DON that the guardian said she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. 10. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident was still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he has been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 had become unresponsive in the past and he usually comes right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 11. Telephone interview on [DATE] at 4:37 p.m. with the Medical Director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence. He stated they have a team of 11 physicians and practitioners who provide coverage. The physician said that he was certain the facility called them as "they call us like clockwork." The Medical Director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately. " The Medical Director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done then we would follow protocol for a DNR. 12. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B was currently in nursing school and she started thinking about what would happen if the resident's brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place the staff do not resuscitate. The staff are trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect on Day 1 when they submitted their initial federal report to the Agency for Health Care Administration. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked it was human error. Thirty seconds must have seemed like 10 minutes." Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take ownership. The DON figured that if Employee B was tasked with having to reiterate the correct process repeatedly then it would stick. The administrator stated she asked the DON the same question and when the DON explained this to her it made sense. 13. Review of Employee B's personnel file confirmed that she had current CPR certification by the American Heart Association with an issue date of [DATE] and an expiration date of [DATE]. Review of the Personnel Consultation Form with a date of counseling of [DATE] for a date of occurrence on [DATE] revealed the following: Final Written Warning for a description of occurrence as follows: As per employment handbook page #25, line #9 stipulated unsatisfactory or careless work; page #25 line #13 stipulated violating facility rules or safety practices. Employee enacted code 99 protocol and started CPR and directed staff to do so prior to verifying actual code status of a resident. Corrective Action Taken: Employee was re-educated on the appropriate protocol and process to carryout Code 99 in the facility. Employee was re-educated on Emergency Response, verifying code status, and documentation components. Any further discrepancies/issues regarding this will result in immediate termination. The document was signed and dated by Employee B and the DON on [DATE]. 14. Interview with the NHA, DON and RM on [DATE] at 10:48 a.m. revealed the facility began education with the staff on the Code 99 process immediately after being informed of the event on [DATE] by Employee B. The following morning, [DATE], the interdisciplinary team met and developed a Quality Assurance (QA) Action Plan. Review of the QA Action Plan for an area identified as "Staff not verifying code status prior to initiating CPR" revealed the following actions to be taken (Process Change/Education): a. 100% education for all licensed nurses and C.N.A.'s regarding the Code 99 Policy and how to verify code status. Review of a list of all current licensed nurses and C.N.A.'s revealed a total of 286 employees would need to receive this education. As of [DATE] 266 employees have signed in-service records indicating they have received this training. Interview with the DON and Staff Development Coordinator on [DATE] at 5:29 p.m. revealed the 20 remaining employees have not worked in the facility since the event due to various reasons to include scheduled vacation, medical leave, call in's, not scheduled, and PRN. The DON stated we have been calling them and leaving messages on their phones to inform them they need to come in to receive training. In some cases, we can't get a hold of the people as the phone numbers are no longer working. If they have not worked in the past 60 days we are going to terminate them from the system. Some work weekends only and have been on the schedule but called off this past weekend. We will be giving the staffing coordinator a list of the 20 employees so she knows that they cannot be scheduled until they come in, receive the training, and sign off on it. The facility does not use agency staff. The DON will hold ultimate responsibility to ensure that these 20 employees will not be scheduled to work until the training has been received. b. Validate Quality Education by interviewing randomly selected Nurses and C.N.A.s using the post education questionnaire. 8 nurses and 8 C.N.A.'s per shift/100% review of these will be completed by the NHA. This will be done daily for 5 days and then weekly until 100% accurate responses are provided to interviewer. This will continue for 5 days then weekly until 100% accurate responses are received for 4 consecutive weeks. Review of the facility's corrective action plan notebook revealed well over 100 questionnaires had been completed by nurses and C.N.A.'s. In-depth validation interviews were conducted by the survey team with thirty employees representing all shifts, as well as weekend staff, with no negative results received. c. Conduct Mock Code 99 drills once per shift for one week. The administrator will audit Code 99 drill participation sign in sheets. This will continue one time each week then once per week on each shift until the QA/PI Committee determines future duration. Review of the facility's corrective action notebook revealed that the facility has far exceeded their stated number of mock drills for QA. Random interviews with the licensed nurses and C.N.A.'s revealed they have been participating in the drills where random scenarios are being utilized such as choking, diabetic, unresponsive, and [MEDICAL CONDITION] residents. The staff indicated that they are benefiting from the hands-on training and find it to be an effective educational tool. d. Conduct 100% audit of all resident records including Kiosk, Physician Orders, Goldenrod/DNR forms and Care Plans on [DATE] by Social Service (SS) staff. After [DATE] SS will do an additional audit of 10 per week for 4 weeks on those residents with DNR status. On [DATE] Medical Records will conduct a 2nd 100% audit to verify accuracy of any corrections. The weekly audits of 10 will continue until 100% compliance is achieved for 3 consecutive months. The survey team reconciled the code status on the physician orders, goldenrod DNR forms, and the computerized/kiosk system for 60 randomly selected residents from 6 of 6 facility units. A slight discrepancy was found on one resident's record but it was quickly clarified and corrected. e. Ensure all Nursing Staff involved in [DATE] Code 99 had valid CPR Certificate. In addition, 15 of all nursing staff will by audited for CPR certification monthly for three months. This will be on-going until 100% compliance is reported for 3 consecutive months. The survey team reviewed 31 licensed nurses and C.N.A. personnel files. This review revealed all had current CPR cards on hand, however, five were on-line courses with no return demonstration requirement. This information was reported to the administrator on [DATE] at approximately 10:30 a.m. As a result of this information the facility developed a second QA Action plan on [DATE] for an area identified as "On-line C.P.R. class verified 5 of 31 Personnel Files checked for Licensed and Certified Staff." The 5 staff members who only had documentation of on-line CPR training in their personnel file were immediately suspended. A 100% audit will be conducted of Personnel Files to determine if other staff members have inadequate documentation of their C.P.R. Training. This may involve calling the numbers on the copies of the cards to verify a return demonstration of skills was conducted at the said class. HR Director will immediately communicate names of Staff who are verified through the above audit to not have had a return demonstration performed during C.P.R. Training to the Director of Nursing so that they may be removed from the schedule immediately. I

Based on clinical record review, policy and procedure review for Code Arrest and Abuse Prevention Policy and Procedure, Nursing Home Administrator (NHA) job description review, and interviews with the facility's nursing and administrative staff, a legally appointed resident's guardian, and the attending physician/Medical Director, it was determined that administration failed to provide resource management to ensure the right to refuse treatment and formulate advanced directives related to end of life decisions were protected for one (#24) of 25 residents identified as having a Do Not Resuscitate order (DNR), of 85 residents identified as D.N.R. according to the [DATE] facility audit of all current resident records and review of resident #24's clinical record on [DATE]. Administration did not ensure the direct functions and operations of the facility, including the right to be free from neglect, were in accordance with current regulations governing long term care facilities related to implementing policies and procedures for code arrest and abuse prevention. The facility failed to ensure that Resident #24's Advance Directive of DNR was properly carried out as facility personnel administered Cardio-Pulmonary Resuscitation (CPR) when the resident was found to be without pulse or respirations. The administration ' s failure to ensure that the resident's expressed wishes related to advance directives and the right to refuse treatment were honored and protected led to findings of Immediate Jeopardy which was removed on [DATE] at 5:50 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the job description for the Nursing Home Administrator with a revised date of ,[DATE] revealed the following relevant information: "General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Facility Management: Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in conjunction with facility's operational budget and state and federal regulations. Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed. Compliance Management: Maintain a working knowledge of and confirm compliance with all governmental regulations. Monitor Human Resources practices to verify compliance with employment laws and company policies, and to confirm practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, proactive supervisory practices and maintaining a proactive work environment. Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Other duties: Protect residents from neglect, mistreatment, and abuse. Minimum Qualifications: Comply with the Residents' Rights and Facility Policies and Procedures." 2. Clinical record review for Resident #24 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The face sheet also documented that Resident #24 was a widow who had previously worked as a Registered Nurse (RN). A review of the advanced directives section of the clinical record revealed the following relevant documents: Legal guardianship court documents for Resident #24, an incapacitated person, dated [DATE]th, 2008. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's legal guardian on [DATE] and the attending physician on [DATE]. 3. A review of the resident's individualized plan of care revealed the following relevant information dated [DATE]: Problem or Strength: Resident #24 has the following Advance Directives on record: Living Will, Guardianship, Durable Power of Attorney, Do Not Resuscitate (DNR), and a physician's orders [REDACTED]. Goal: Advance Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Guardian's wishes will be honored. Interventions: Discuss Advanced Directives with the resident and or appointed health care representative. The appointed health care representative will make all hearth care decisions if the resident is incapacitated. Resident #24's legal guardian's name and phone number is then listed. Notify physician of resident's wishes regarding life prolonging procedures. An Advance Directive can be revoked or changed if the resident and or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and or appointed health care rep to provide copies to the facility of any updated Advanced Directives. For DNR status: Verify presence of yellow DNR form on resident's chart Verify presence of physician's orders [REDACTED]. 4. The resident had the following relevant [DIAGNOSES REDACTED]. 5. Review of the Nurses Notes revealed the following relevant entries: [DATE] 7:42 p.m. "This writer was in the lifestyle 2 dining room at 6:45 p.m. when notified by staff member that something was wrong with the resident. Attended to resident at once who was sitting up in the chair with head leaning forward, skin color pale and not responsive to sternal rubs or to name calling. No coughing noted. Mouth sweep done and no food or foreign objects obtained. Unable to obtain a pulse. Resident than was placed on the floor. Code 99 was activated at 6:50 p.m. AED applied to chest and CPR was initiated at 6:54 p.m. 911 activated at 6:50 p.m. and paramedics arrived at scene at 6:57 p.m. and took over resident's state. Ok to send to hospital. Call placed to resident's responsible party at 7:13 p.m. and left message to call back at facility's number. Responsible party returned call at 7:30 p.m. and spoke with this writer who notified her of resident's state. She was made aware that resident was DNR and CPR was initiated. Responsible party stated that initiating CPR was fine that it was ok and that she did not have a problem with that. She also thanked writer for calling. Call placed to hospital at 8:25 p.m. regarding resident ' s state and spoke with staff member who stated that resident was stable, labs were pending and that he will be admitted . No [DIAGNOSES REDACTED]." [DATE] 9:18 p.m. Call placed to emergency room at 9:15 p.m., resident admitted with [DIAGNOSES REDACTED]. 6. Hospital record review revealed the following relevant information: [DATE] 7:18 p.m. Rapid initial assessment from ER: "Nursing home reports patient turned blue while eating dinner and began having respiratory distress but did not appear to be choking. CPR was performed at nursing home prior to EMS arrival." [DATE] Internal medicine progress note: "Foley catheter inserted." History and Physical [DATE] 9:11 a.m. Reason for admission: "Respiratory distress, right sided pneumothorax. History of present illness: resident from a nursing home brought to hospital with respiratory distress. The patient had a cardio-pulmonary arrest and had CPR. Chest x-ray revealed aspiration pneumonia and right side pneumothorax. Chest tube placed in ER and admitted to ICU. Assessment and Plan: 1. aspiration pneumonia, status [REDACTED]. Plan: Admit to ICU, will get in touch with Power of Attorney to find out how far one should be aggressive in the treatment." Pulmonary Consult Note [DATE] at 9:10 a.m. "... per records the patient ambulated to the dining hall and had an unknown event for which CPR was begun. Of note, patient is a DNR, but per records CPR was done at the nursing home. Per records, CPR was then completed with return of spontaneous circulation (ROSC) on this patient. Of great significance it is incredibly difficult to discern the actual occurrence of events prior to arrival in the ED: at this point it is unclear if the patient actually arrested at all. Patient had pulses when Emergency Medical Services (EMS) arrived, and he was subsequently brought to the hospital where significant subcutaneous of [MEDICAL CONDITION] was noted on physical exam in the upper torso and Upper Extremities (UE ' s) and Chest X-Ray (CXR) revealed pneumothorax with subq air for which a chest tube was subsequently placed on the right. Patient currently on [MEDICAL CONDITION] chest tube was not seen in thorax on CXR this a.m. For this we replaced this right sided chest tube with a larger caliber ...Diagnosis, Assessment, and Plan: Acute [MEDICAL CONDITION]-stable right pneumothorax resolved status [REDACTED]. Questionable concomitant Community Acquired Pneumonia (CAP) versus aspiration pneumonia. Questionable out of hospital cardiorespiratory arrest with CPR. Given patients guarded condition will place left sided chest tube tomorrow as doing two procedures in the same day could significantly worsen prognosis. Will continue broad spectrum antibiotic (ABT) coverage, check PCT with AM labs. Will monitor on [MEDICAL CONDITION] and do all we can without intubation as patient is DNR." [DATE] Critical Care Progress Note: "Assessment: Acute [MEDICAL CONDITION] right pneumothorax stable at 25%. ...Elevate PCT this a.m. consistent with concomitant health care acquired pneumonia vs. aspiration pneumonia. Will update ABT regimen to add [MEDICATION NAME], and Discontinue [MEDICATION NAME] and [MEDICATION NAME]. Pleural fluid consistent with exudiative/infectious etiology." [DATE] Speech Therapy (ST) Clinical Dysphagia Eval: "Pt had increase work of breathing, mild decrease in oxygen sat, and mild increase in heart rate after by mouth (PO) trials. Pt had delayed cough after thin liquids. Recommend video swallow study to further assess swallow function." [DATE] ST: "Video swallow eval Comments: intermittently delayed bolus propultion ... Summary: Pt had pharyngeal stasis after all trials. Majority of pharyngeal stasis cleared with repeat swallow or liquid wash. No aspiration or penetration noted with any tested consistency. Chewing was mildly prolonged but adequate for mechanical soft trials." Critical Care Progress Note [DATE]: "Acute [MEDICAL CONDITION] - improving. Chest tube out yesterday. CXR stable this am. Will continue on current ABT, keep on ventimask. ...From [MEDICAL CONDITION] standpoint, pt is stable to transfer to the floor." Pulmonary Progress Note from [DATE]: "Chest X-ray [DATE] 2:37 a.m. Impression: stable bilateral air space disease and enlargement cardiac silhouette suggesting [DIAGNOSES REDACTED]." Pulmonary Progress Note: [DATE] 7:04 a.m.: "Pt remains nonverbal but does not appear in distress other than his paradoxical breathing. Nurse notes his oxygen sat has continued to drop overnight and increasing amount of oxygen was required to keep sat above 90%." Pulmonary Progress Notes on [DATE] and [DATE] indicated: "Respiratory/Chest Assessment : Rales, wheezing, parodixical breathing, palpable rales on right anterior chest. Pectus Excavatum." [DATE] Cardiology Consult: "Cardiology consult requested which I assume is to eval for possible [MEDICAL CONDITION] given patient's hypoxemia. The patient is DNR and with overall multiple comorbidities and very poor functional status. Therefore at first glance cardiology management will be conservative. Plan: ECHO and conservative care." 7. Interview with the facility's Administrator (NHA), Director of Nursing (DON), and Risk Manager (RM) on [DATE] at 10:48 a.m. revealed an incident occurred on [DATE] around 6:30 p.m. involving Resident #24 for which the facility had reviewed the circumstances of the event. Resident #24 was in the dining room at the time of the event and was not responsive. A certified nursing assistant (CNA/Employee A) was sitting at the dinner table with Resident #24 and feeding another resident. Employee A noticed that Resident #24 wasn't eating and shook him to get him to respond. Employee A found that the resident was unresponsive and he called for the licensed practical nurse (LPN/Employee B) who was present in the dining room to assist. Employee B quickly assessed the resident who was pale, had no response to sternal rub, and no pulse. A mouth sweep was done with nothing found and CPR was initiated. Paramedics arrived and took Resident #24 to the hospital. The resident was discovered to be a DNR. The administrative staff described this resident as being alert with confusion, able to follow simple commands, and would ambulate throughout the facility using a merry walker. The resident was now at the local hospital in stable condition where he was found to have a pneumothorax with the insertion of a chest tube. The DON stated she received a phone call from Employee B on the night of the incident to inform her that Resident #24 was found unresponsive in the dining room. Employee B is a weekend supervisor for the 2nd floor of the facility. They started CPR and he was doing well when he left. Employee B told her the code went well and when he left the building he had a pulse. Employee B later discovered that the resident was a DNR. The DON advised her to complete a report and to contact the resident's responsible party and tell them exactly what was done and then report back. The DON also explained to Employee B that she needed to notify the RM. The DON stated that Employee B informed her that she immediately felt compelled to do CPR and "to do the right thing." Employee B called the resident's guardian and explained in detail what had occurred three times. Employee B reported back to the DON that the guardian said she understood that the resident received CPR and was okay with it. The doctor was also made aware. The DON then instructed Employee B to go ahead and start education with the other staff in the facility along with the nursing supervisor on the first floor of the facility. The education consisted of verifying whether a resident was a DNR status or a full code. The RM stated she was also called by Employee B on the night of the incident and informed of the events which took place in regards to Resident #24. The RM told Employee B to go ahead and start the education as directed by the DON. The administrator, DON, and Risk manager indicated that they did not come in on the night of the incident. 8. Telephone interview on [DATE] at 4:26 p.m. with Resident #24's legal guardian revealed the resident was still in the Intensive Care Unit (ICU) at the hospital with chest tubes in both lungs. She stated that he has been kept in ICU because he still had fluid on his lungs. The guardian remembered receiving a phone call to tell her that Resident #24 was in the dining room and became unresponsive. They told me they performed CPR and that he had a pulse when he left. They obviously did not have the chart with them when this happened. Resident #24 has become unresponsive in the past and he usually comes right back. They did explain to me that they did not know he was a DNR at the time and I didn't have a problem with what they did because they didn't know at the time. 9. Review of the facility's undated "Code Arrest" - Procedure and Protocol which was in effect at the time of the [DATE] incident revealed the following relevant information: Policy: "Code protocol is established so that all residents will receive prompt specialized care in life threatening situations. Purpose: Guidelines for code protocol to ensure that all residents receive prompt specialized care in life threatening situations. General Guidelines: I. SUPPORTIVE DATA: A. Definitions: 1. " Code 99 " - Cardiac and/or respiratory arrest has occurred on an adult age 12 or above. It will be announced over facility intercom system. This will call all necessary members of the health care team to respond immediately to designated area and assist with resuscitation. B. Initial Response: 1. Assess the resident for signs and symptoms of cardiopulmonary arrest: a. Unconscious state b. Pulselesness c. Dilated Pupils d. Absent Respirations 2. Assess need to call a code 3. Call Code " 99 " Room ___ three times in succession on the intercom, nurse in charge of resident and other nursing unit staff will provide CPR, start IV's (per physician order) and bring resident ' s chart and code cart to the resident's room ..." 10. Review of the facility's "Abuse Prevention Policy & Procedure," dated [DATE], revealed the following relevant information: Purpose: "The purpose of this written Resident Abuse, Neglect, and Misappropriation Prevention Program is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff ... 1. Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse ...by any facility staff member ... 2. Definitions: The most common forms of abuse include: Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness; e.g., denial of food or health-related services, abandonment. 6. Reporting/Investigation/Response Policy: Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. Procedures: Immediate Response: (2) Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation ... (7) Prevention Through QA Policy: Reviewing and Disciplining - This facility will conduct a comprehensive review of any employee suspected of abuse, neglect or mistreatment of [REDACTED]. Any employee, who is accused or resident abuse ...will be suspended pending further investigation. Discipline: 1. Any employee suspected of abuse, neglect or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation. Do not wait for the State Department of Human Services to investigate." 11. Telephone interview with Employee A on [DATE] at 1:14 p.m. revealed he had been a CNA at the facility for the past [AGE] years. He worked in the restorative department on the weekends from 7:00 a.m. - 11:00 p.m. Employee A was familiar with Resident #24 and stated he was always walking around in a merry walker, was not very talkative, but he liked to read things like your name tag and things like that. Employee A recalled that on [DATE] he was sitting next to Resident #24 at the table in the 2nd floor dining room. Employee A stated everyone was eating at the table and when he looked back at Resident #24 he noticed he wasn't eating. He called out the resident's name and said "it's time to eat." He then touched the resident's arm and again said the resident's name and told him to eat. The resident did not respond. Employee A noticed the resident was not breathing right. "Like it wasn't regular it wasn't normal. I don't know if he was hardly breathing but it just didn't look right so I called the nurse over." The nurse, Employee B, was in the dining room and came over and looked at him. She said call 911 and page code 99. At that point Employee A started moving other residents out of the way because he knew the ambulance was coming. Employee A then came back over to the resident and awaited further instructions on what to do. Employee A stated other staff were present but he could not recall exactly who. Employee B said let's lay him down. They put the gait belt around him and lowered him to the floor. Employee A stated he stood there and was trying to keep the other residents out of the way while Employee B started doing CPR. He recalled Employee B performing chest compressions and using the AED (automated external defibrillator) machine. Employee A did not recall the resident receiving a shock from the AED machine and also could not recall any breaths being given but stated "they probably did, but I don't recall that." Employee A also could not recall if anyone looked for the resident's code status in the resident's chart or in the computer kiosk located in the dining room. He stated, "I don't recall if anyone did. I just know what I was doing at the time and that was keeping the patients away." 12. Interview on [DATE] at 2:43 p.m. with Employee B, revealed she has been a LPN for the past [AGE] years and has worked in the facility for [AGE] years (first starting out as a CNA). Her assigned position at the time of the event was second floor weekend supervisor on Saturday and Sunday from 7:00 a.m. - 11:00 p.m. She stated she used to take care of Resident #24 when he lived on the second floor but at the time of the event he was living downstairs. She stated she would recognize the resident if she saw him but was not familiar with him hands on. She recalled Resident #24 walking all over the building in a merry walker. He also liked to read and write, would hang out by the nurses' stations, and would pick up a book if it was sitting there and read it. He did not speak much. Employee B stated that Resident #24 ate in the restorative program which was held in the 2nd floor dining room. On [DATE] at dinner time she was present in the 2nd floor dining room and remembered being called over by Employee A who said the patient does not look right. She went over to the resident and saw that his head was down and he was pale. She did a sternum rub and talked to him. He did not respond. She checked his radial pulse and found that he had no pulse and no respirations. "His chest wasn't rising." Employee B stated she did not know him well because he lived downstairs and she called out for somebody to go get the chart and to call downstairs so they could find out his code status. She was unsure who she gave those instructions to and what other staff members were present in the dining room with the exception of Employee A. Employee B said after that it seemed like too much time was going by so we placed him on the floor. She did a mouth sweep with no findings and no coughing. When she wasn't receiving a response she started CPR. She put the AED machine on the resident and followed the directions given by the machine. She placed the two pads on to the resident. The machine says to stay away from the patient because it will deliver a shock. She could not recall if the AED shocked Resident #24 but did remember the message coming up. She then did chest compressions. The machine also gave messages to let her know if more pressure was needed with the compressions. During this process, someone came up with the resident's chart but she could not recall who this was. They said he was a DNR and she continued CPR. Employee B stated the reason she continued was because once CPR was started "you do not stop." An ambu bag was used during the code and the crash cart was brought in. Employee B stated one of the CNA's used the ambu bag which was hooked up to oxygen. She could not recall who the CNA was. Employee B stated another unknown employee, possibly a nurse, had called 911 and when the paramedics arrived, they took over the situation. Employee B stated the code status can also be checked using the computer kiosk and one of the CNA's checked the kiosk (unknown who), but she felt too much time was passing so she used nursing judgment and started CPR. Employee B stated she could not recall exactly how much time had passed. "It seemed like a lot of time passed by but I can't say if it was one minute or 5 minutes." After the event, Employee B called the resident's guardian and told her what had happened. She told her he was a DNR and she did start CPR. She also called the on call doctor, not sure exactly who, and informed him that the resident was a DNR and "we 911'd him and sent him out." Employee B also called the DON and RM and told them exactly what had happened. The DON in-serviced her over the phone on checking the residents' code status and instructed her to do an in-service with staff on code status, full code versus DNR. Employee B then in-serviced the nurses showing them to look on the chart or in the kiosk for the information. 13. Telephone interview on [DATE] at 4:37 p.m. with the Medical Director for the facility, who also served as the attending physician for Resident #24, revealed he was unsure who was on call on [DATE], the night of this occurrence. He stated they have a team of 11 physicians and practitioners who provide coverage. The physician said that he was certain the facility called them as "they call us like clockwork." The Medical Director said he had a meeting on Monday, [DATE], with the NHA and was informed that they had instituted CPR on Resident #24 and he was a DNR. The doctor said he had been taking care of Resident #24 for a long time and "unfortunately, I think they started CPR. We can't change what happened unfortunately." The Medical Director stated it was his expectation that if a resident was a full DNR then they should just contact the physician and contact the family. If the family doesn't want anything done then we would follow protocol for a DNR. 14. Continued investigation and interview on [DATE] at 11:22 a.m. with the NHA, DON, ADON (assistant director of nursing), Staff Development Coordinator and RM revealed the facility conducted a root cause analysis for the [DATE] event involving Resident #24. They determined that CPR was started without the code status having been verified. They could not find any breakdown in the system at this time. After speaking to the nurse involved (Employee B) she verified that she did not check the code status. She panicked and didn't want to lose valuable time waiting. She took action in case he was a full code. Based on multiple interviews with staff, they were able to get the information on the resident's code status quickly, but by that time Employee B had already started CPR. "It was a nursing judgment call." Employee B never expressed concern that it was taking too long to get the information. Employee B is currently in nursing school and she started thinking about what would happen if the resident ' s brain went too long without oxygen. "She basically said one minute could have been five minutes." We honor advanced directives here. It is our expectation that if a resident experiences [MEDICAL CONDITION] and had a DNR in place the staff do not resuscitate. The staff are trained according to the facility's philosophy to honor DNR's and it is incorporated into the code 99 process to check the resident's code status. Resident #24's code status of DNR was determined very shortly after CPR was started. It was prior to the paramedics arrival. The facility's investigation was still on-going as [DATE] was Day 5. The facility had determined that this was an allegation of neglect on Day 1. We did consider timeliness in the investigation. We made sure all the information was at the front of chart to include the physician's telephone order with the goldenrod DNR form. The staff can check the chart, the computer, or the kiosk for the residents' code status. Employee B "panicked, it was human error. Thirty seconds must have seemed like 10 minutes." 15. Employee B had actually received training several hours before the incident with Resident #24. The staff development coordinator had come in over the weekend to do pre-survey education. The staff development coordinator covered a list of items to include Code 99 at 2:00 p.m. on [DATE] and this incident happened around 6:00 p.m. 16. Employee B received disciplinary action of a final written warning about a day or so after the event for not checking the DNR status. This was not in the employee's personnel file which was reviewed on [DATE] because it was still awaiting review by the NHA. The survey team asked why Employee B, the individual who failed to honor the resident's DNR, was selected as the person to begin training other staff members on-site that night. The DON replied that because Employee B was the one who was incorrect in her response, she felt as though she should take ownership. The DON figured that if Employee B was tasked with having to reiterate the correct process repeatedly then it would stick. The administrator stated she asked the DON the same question and when the DON explained this to her it made sense. 17. Review of Employee B's personnel file confirmed that she had current CPR certification by the American Heart Association with an issue date of [DATE] and an expiration date of [DATE]. Review of the Personnel Consultation Form with a date of counseling of [DATE] for a date of occurrence on [DATE] revealed the following: Final Written Warning for a description of occurrence as follows: As per employment handbook page #25, line #9 stipulated unsatisfactory or careless work; page #25 line #13 stipulated violating facility rules or safety practices. Employee enacted code 99 protocol and started CPR and directed staff to do so prior to verifying actual code status of a resident. Corrective Action Taken: Employee was re-educated on the appropriate protocol and process to carryout Code 99 in the facility. Employee was re-educated on Emergency Response, verifying code status, and documentation components. Any further discrepancies/issues regarding this will result in immediate termination. The document was signed and dated by Employee B and the DON on [DATE]. 18. Interview with the NHA, DON and RM on [DATE] at 10:48 a.m. revealed the facility began education with the staff on the Code 99 process immediately after being informed of the event on [DATE] by Employee B. The following morning, [DATE], the interdisciplinary team met and developed a Quality Assurance (QA) Action Plan. Review of the QA Action Plan for an area identified as "Staff not verifying code status prior to initiating CPR" revealed the following actions to be taken (Process Change/Education): a. 100% education for all licensed nurses and C.N.A.'s regarding the Code 99 Policy and how to verify code status. Review of a list of all current licensed nurses and C.N.A.'s revealed a total of 286 employees would need to receive this education. As of [DATE] 266 employees have signed in-service records indicating they have received this training. Interview with the DON and Staff Development Coordinator on [DATE] at 5:29 p.m. revealed the 20 remaining employees have not worked in the facility since the event due to various reasons to include scheduled vacation, medical leave, call in's, not scheduled, and PRN. The DON stated we have been calling them and leaving messages on their phones to inform them they need to come in to receive training. In some cases, we can't get a hold of the people as the phone numbers are no longer working. If they have not worked in the past 60