Every finding on record at Boca Ciega Center

Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent resident to resident altercation for two (#5 & #6) of thirteen sampled residents. Findings included: A review of Resident #6's admission record showed an admission in 02/2020. The diagnosis information included: chronic pain syndrome; neuromuscular dysfunction of bladder; muscle wasting and atrophy not elsewhere classified; idiopathic progressive neuropathy; generalized anxiety disorder; bipolar disorder; type 2 diabetes; atherosclerotic heart disease of native coronary artery without angina pectoris; . A review of Resident #6's BIMS, dated 02/03/2026, documented a score of 14, which indicated cognitively intact. A review of Resident #5's admission record showed an admission of 01/05/2026. The diagnosis included: cerebral infarction; dysarthria following cerebral infarction; encephalopathy; difficulty in walking; unspecified dementia without behavioral disturbance; psychotic disturbance, mood disturbance and anxiety; cognitive communication deficit; . A review of Resident #5's Brief Interview for Mental Status (BIMS), dated 01/06/2026, documented a score of 00, which indicated severe cognitive impairment. A review of Resident #5's progress note dated 03/05/2026 showed an Interdisciplinary team (IDT) meeting held to discuss Resident #5 for elopement risk. Resident #5 with diagnosis of Dementia, able to self-propel in wheelchair. BIMS 0. IDT agrees to continue with wanderguard. Wanderguard in place and functional. Care plan reviewed. A review of Resident #5's Progress notes, dated 03/18/2026 at 3:12 p.m., documented by the Social Service Director: Staff observed an altercation between two residents on 400 hall. The conflict began after resident was in another resident room touching their property. [sic] coming into room putting on the resident shoes. Verbal escalation occurred, followed by punches being thrown by both residents. Resident was crying stating he was punching and punching. [sic] . Evaluation completed, resident was observed with an injury in the area of their eye and side of their face. Resident appeared crying, shaken up following the incident. A review of Resident #5's nursing skin check dated 03/18/2026 at 4:12 p.m., revealed Resident #5 had three new skin impairments found: left eyebrow cut, left temple hematoma, and below left temple abrasion. A review of Resident #5's Progress notes, dated 03/20/2026 at 2:38 p.m., revealed a follow up with Resident #5 related to the incident. Resident #5 was asked if he was in pain and resident pointed to his face above eye and said ouch, something there. Resident observed in no emotional or psychological distress or anxiousness. Will continue to monitor. An interview conducted on 03/24/2026 at 11:21 a.m. with the Social Service Director (SSD), she stated she was familiar with Resident #5, prior to coming to this facility, he had been in another facility, he has a guardian. Yes, he goes into other peoples' rooms. He is not interviewable. He is in a wheelchair (w/c). On 03/24/2026 at 11:15 a.m., an observation of the location of Residents #5 and #6's rooms. Their rooms were separated by fifteen other resident rooms and the nurses' station. On 03/24/2026 at 11:24 a.m., an observation of Resident #5, in the dining room, sitting with a Speech Therapist. Resident #5 was observed dressed in seasonally appropriate clothing, bruising on the left outer eye area. On 03/24/2026 at 11:40 a.m., an interview was conducted with the Speech Therapist. The Speech Therapist stated currently working with Resident #5. She said, Resident #5 has documented to dementia prior to admission to this facility. He is oriented towards himself. He does not know where his room is. Resident #5 is a busy body. He will spend all day looking for his room. He likes reading. The speech therapist explained Resident #5 has aphasia, meaning he has difficulty in naming objects. The speech therapist stated, Resident #5 knows something happened to him. The speech therapist stated Resident #5 suffered from significant bruising right after the event, as the bruising was much worse than it is now. She said Resident #5 points to the bruise at sometimes. The speech therapist stated Resident #5 does wander although easily re-directed. On 03/24/2026 at 2:00 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she had been working on the day of the altercation, 03/18/2026, between Resident #5 and #6. She stated she did not see it. I was at the nurses' station. The oncoming nurse (Staff B, LPN), came up the hall with (Resident #5). Staff A was observed to motion towards the end of the hall where Resident #6's room was located. She stated, (Resident #5) had blood on his face and eye. I asked him what happened. (Staff B) said Resident #6 hit Resident #5. I grabbed the Business Office Manager and went to Resident #6's room. I asked Resident #6 what happened. He said they were fighting. Staff A stated, Resident #5, he does not understand. I said to Resident #6, if he was doing something, why not just call? When Staff A was asked if she could recall the last time she had seen Resident #5 prior to the event on 03/18, she said, The last time. At this time, Staff A was observed to look down the hall, and she stopped what she was saying. An observation was conducted of Resident #5 in his (w/c), at the end of the hall next to the exit doors outside of Resident #6's room. Staff A was observed to run down the hall, observed to re-direct Resident #5, back towards the nursing station. He was observed to self-propel his w/c towards the nursing station. Staff A continued the interview, she stated, that day, she had seen Resident #5 after lunch. I don't think he knows what room is his. He needs to be re-directed. On 03/24/2026 at 2:18 p.m., an interview was conducted with The Minimum Data Set (MDS) Coordinator, Registered Nurse (RN). The MDS/RN stated being responsible for completing the care plan for Resident #5. The MDS/RN was asked about Resident #5's wandering behavior and stated knowing about the behavior. The MDS/RN stated a behavior care plan was developed for Resident #5's wandering into other residents' rooms. The MDS/RN stated, I do not believe he knows where his room is. A review of Resident #5's Care Plan was conducted with the MDS coordinator. The Care Plan documented a focus: Behavioral: The resident has a behavior problem r/t (related to) wandering into other residents' room, rummaging, initiated 03/17/2026. The goal of the plan: The resident will have few episodes. The interventions listed were:Document behaviors, and resident response to interventions, initiated 03/17/2026.Intervene as necessary to protect the rights and safety of others. Approach/ speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated 03/17/2026.Praise the resident for appropriate behavior as indicated, initiated 03/17/2026.Consider location, time of day, persons involved, and situations. Document behavior and potential causes, initiated 03/24/2026.Anticipate and meet the resident needs, initiated 03/24/2026. On 03/24/2026 at 2:30 p.m., an interview with Staff C, Certified Nursing Assistant (CNA). She stated she was familiar with Resident #5, she had him on and off. She stated he was ambulatory with a w/c. Yes, he goes into other peoples' rooms, he has been doing it since he has been here. On 03/24/2026 at 2:37 p.m., an interview was conducted with Staff D, CNA. She stated she was assigned Resident #5 on a regular basis. She stated, since he has been here, he has self-propelled in the w/c; he will follow simple instructions. His room, he does not remember, he goes into every room; he has dementia. She confirmed she had worked on 03/18. She stated she normally changes her assigned residents after lunch, she had changed him and saw him wandering. She stated, when we see him going into other residents' rooms, I re-direct. I do not document going into rooms. On 03/24/2026 at 3:08 p.m., an interview was conducted with the Director of Nursing (DON). She stated a BIMS was conducted for Resident #5 on 01/06/2026, the score was 0, which indicated the resident was cognitively impaired'. She stated Resident #5 does have the behavior of wandering into rooms. He has only done it a couple of times per my knowledge, that was reported to me. Normally CNAs or nurses report to the unit manager and it is communicated to us in the clinical stand down meeting, daily at 3:15 p.m. On 03/25/2026 at 12:30 p.m., the 03/18 event between Resident #5 and #6 was reviewed with the Nursing Home Administrator (NHA) and the DON. The NHA stated the event occurred on 03/18/2026 at approximately 3:00 p.m. in Resident #6's room. It was unwitnessed. The NHA stated Resident #6 came back from a leave of absence to his room and saw Resident #5 in the room with Resident #6's shoe on. The NHA said, Resident #6 stated he went to take the shoe off of Resident #5 and their heads bumped, he said it was an accident. Resident #5 was unable to provide details. Resident #5 had redness and swelling to his left eye. When the NHA and the DON were asked if they had been aware of Resident #5's behavior of wandering into residents' rooms, both stated, they were unaware of Resident #5's behavior of entering other persons rooms until this event. They said, we should have been made aware of it. We were aware that (Resident #5) moved around the facility freely. On 03/25/2026 at 2:13 p.m., the NHA was asked if she had reviewed the camera footage for the date, 03/18/2026. The NHA confirmed video footage was available for the hall in front of Resident #6's room since it was near an exit door. The NHA stated, we are looking at it today. On 03/25/2026 at 2:45 p.m., the NHA provided the available video recording. She stated the time indicated on the video record was one hour and 3 minutes off, behind due to daylight savings time. i.e. 13:39 would mean 14:39 +3 min, =2:42 p.m. A review of the footage was conducted with the NHA. The view of the video footage, the camera was directed at the exit door, which Resident #6's bedroom door could be observed. The following was observed: 13:39 (2:42 p.m.), Resident #5 was observed in front of the exit doors in the hall, outside of Resident #6's room. Resident #5 was in a w/c, he was looking and touching the wall in the hall. 13:40 (2:43 p.m.), Resident #5 self-propelled into Resident #6's room. 13:50 (2:53 p.m.), Resident #6 was observed to come into view. He was on a motorized w/c. He entered the room; the door closed to leave an approximate one-foot opening. 13:52 (2:55 p.m.), Resident #5, was observed self-propelling out of the room, in his w/c, a stream of blood could be seen from his eye, down his cheek to his mouth. He had two different shoes on. The NHA confirmed she observed blood on Resident #5's face; she stated Resident #5 was headed towards the nursing station. 13:52.39 (2:55.39 p.m.), Staff B, LPN, was observed coming into view, walking towards Resident #6's room, he turned and entered the room across the hall from Resident #6's room. 13:52:55 (2:55.55 p.m.), Staff B, LPN, was observed coming out of the room from across the hall, leaving the view of the camera towards the nurses' station. 13:53:06 (2:56.06 p.m.), Resident #6 is observed exiting his room on his motorized w/c; no blood is observed on his person. Staff B, LPN was observed to come into view and interact with Resident #6. The NHA stated Staff B, LPN, was talking to Resident #6, keeping him at the one end of the hall. End observation. A review of the facility's Abuse Prevention Program policy and procedure, last revised 03/2022, documented the policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. The Procedure: The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. Prevention .Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation may be more likely to occur, such as: Residents with needs/ behaviors which might lead to conflict or abuse/ neglect.

Based on interview, observation, and record review, the facility did not ensure timely Activities of Daily Living (ADL) related to incontinence care for two (#1 and #2) of three residents. Findings include: On 8/08/2024 at 10:30 a.m., an interview and observation were conducted with Resident #2 in his room. Resident #2 was in his bed and when asked when was the last time his incontinence needs were addressed, he stated last night and agreed no one had come in this morning to change him. Resident #2 agreed he needed incontinence care now. On 8/08/2024 at 11:00 a.m., an interview and observation were conducted with Resident #1 in her room. She stated the last time she had her incontinence care addressed was 3:30 a.m. and currently was waiting for her morning needs to be met. Resident #1 agreed she was wet and in need of incontinence care stating, they will get around to it eventually, they are so busy. Resident #1 agreed she felt uncomfortable in her briefs but stated, there is nothing I can do about it. On 8/08/2024 at 11:15 a.m., an interview was conducted with Staff E, Certified Nursing Assistant (CNA). Staff E was unable to give a number of residents assigned to her but stated she had four residents requiring total care. Staff F, CNA refused to be interviewed. At some point, Staff F was replaced by Staff I, CNA after two days of orientation stating this was day three of her orientation. Staff E stated she would be assisting Staff I but was unable to give a number of the newly assigned residents requiring total care, stating, Some days I am able to get my work done and sometimes depending on who you work with it's a struggle. On 8/08/2024 at 11:50 a.m., an interview was conducted with Staff C, CNA and Staff D, CNA. Staff C stated she had eleven residents and of those eleven residents, five were dependent for total care. Staff D stated she had ten residents but could not state how many were total dependent but stated she had 4 more residents to take care of. A record review of Resident #1's Admission Record showed an admitted [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. Secondary diagnoses included but were not limited to adult failure to thrive, muscle wasting and atrophy not elsewhere specified, need for assistance with personal care, other reduced mobility, and history of falling. A review of Resident #1's Minimum Data Set (MDS) dated [DATE], for Section C-Cognitive Patterns showed Resident #1 did not require further mental status assessment based on the resident was able to complete Brief Interview for Mental Status. Section GG GG0130 self -care-Functional Abilities and Goals showed Resident #1 as Dependent for toileting /hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear and substantial/maximal assistance with upper body dressing, and personal hygiene. Section GG0170- Functional Abilities and Goals showed Resident #1 as Dependent for roll left to right, the ability to roll from lying on back to left and right side and return to lying on back on the bed. In Section H-Bladder and Bowel, H0300 and H0400 urinary incontinence and bowel continence showed Resident #1 as always incontinent of bladder and bowel. A review of Resident #1's care plan revised on 3/14/2024 showed a focus area of incontinence of bladder/bowel related to immobility, involuntary or unpredictable bladder and bowel elimination, intolerance of using toilet, bedside commode or urinal, refusal or resistance to participation in any kind of programs. The goal for this focus area included maintain dignity, minimize the risk of infection, and minimize the risk of skin breakdown. The Interventions/Tasks for this focus area included but were not limited to check for incontinence frequently and provide incontinence care as indicated, provide perineal care and apply barrier cream after incontinent episodes and as needed, and observe condition of skin with each incontinent episode. A focus area of ADL Self-Care performance deficit cannot complete ADL tasks independently related to impaired mobility, resident declines to get out of bed routinely. The goal for this focus area included maintaining current level of self-performance with ADLs through the next review. The interventions/Tasks for this focus area included but were not limited to two person staff when providing care, bladder and bowel incontinent and assist of one for bathing in bed. A review of the daily tasks documented by the CNAs shows on 8/08/2024 Resident #1 received toileting care at 1:10 a.m. and no further entries were documented [photographic evidence obtained]. A record review of Resident #2's Admission Record showed an admitted [DATE] with a readmitted [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Secondary diagnoses included but were not limited to dysphagia following cerebral infarction, muscle wasting and atrophy not elsewhere classified left lower leg, and need for assistance with personal care. A review of Resident #2's Minimum Data Set (MDS) dated [DATE], for Section C-Cognitive Patterns showed Resident #2 had a Brief Interview for Mental Status of four which indicated severe cognitive impairment. Section GG GG0130 self-care Functional Abilities and Goals showed Resident #2 as substantial maximal assistance for toileting /hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, eating, oral hygiene, upper body dressing and personal hygiene. Section GG0170- Functional Abilities and Goals showed Resident #2 was Dependent for toilet transfer, tub shower transfer, sit to stand, chair/bed-to-chair transfer, and Substantial/maximal assistance for roll left and right, sit to lying, and lying to sitting on side of bed. In Section H-Bladder and Bowel, H0300 and H0400 urinary incontinence and bowel continence showed Resident #2 as always incontinent of bladder and bowel. A review of Resident #2's care plan revised on 5/28/2024 showed a focus area for incontinence of bladder/bowel and was not a candidate for a toileting program related to involuntary or unpredictable bladder and bowel elimination, decreased cognition. The goal for this focus area was to maintain dignity through next review, minimize the risk for infection and the risk for skin breakdown. Interventions included but were not limited to check for incontinence frequently and provide care as indicated and observe for foul smelling, cloudy urine, change in urinary output, mental status change, changes in bowel pattern and report as needed. The care plan showed a focus area of ADL Self-Care performance deficit related to impaired mobility related to cerebral vascular accident with left-sided weakness and decreased cognitive status. The goal for this focus area would be to maintain current level of self -performance with ADLs through next review. Interventions included but were not limited to personal hygiene, bladder (incontinent) and bowel (incontinent), eating, bed mobility with assist of one. A review of the daily tasks documented by the CNAs shows on 8/08/2024 Resident #2 received toileting care on 8/07/2024 at 7:13 p.m. and 8/08/2024 at 2:59 p.m. and 4:36 p.m. [photographic evidence obtained]. On 8/08/2024 at 5:10 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated staffing was based on the census, and we go above and beyond our numbers, we have an expectation of every two hours to check on residents and to document incontinence care. On 8/08/2024 at 10:40 a.m., an interview was conducted with Staff A, CNA and Staff B, CNA. Staff A stated her current assignment was twelve residents and of those twelve, nine were dependent for total care. Staff B stated her assignment was twelve and of those twelve, nine were dependent for total care. Both CNAs stated the night shift did not get residents up before they started their shift but stated they were fine with this because they both knew they did a good job in ensuring their residents were properly cleaned and groomed. Staff A stated, I have to rotate my residents when I get them up because it is too much, I try to get my residents up at least twice a week by a rotation process. Staff A and Staff B both agreed they worked well together but still had more residents to attend to and stated it's just too much. Staff A stated, I have to prioritize my morning but I am always in and out of my residents' rooms checking in on them. On 8/08/2024 at 11:30 a.m., an interview was conducted with Staff G, CNA and Staff H, CNA. Staff G stated she had fourteen residents and of those fourteen, eight were dependent for total care. Staff H stated she had thirteen residents and of those thirteen, nine required total care. Both stated they were still trying to complete their assignments for their residents. Both CNAs stated they worked well together but one sick call could mess up the whole day. On 8/08/2024 at 12:30 p.m., a third tour was conducted. Staff G, CNA stated a CNA was pulled from each hallway to assist in the main dining area. When the CNA returned to their assigned hallway, the remainder of trays that were served to residents in their room was completed and then the CNAs would assist those residents that required assistance. Staff G stated she had one more resident to attend to for ADL care. Staff H, CNA returned to her assigned hallway and stated she was able to complete her care of dependent residents right before she had to go to the main dining. Both CNAs stated it put a lot of stress on the CNAs to have one taken away from the hallway to assist in the main dining. On 8/08/2024 at 12: 50 p.m., Staff A, CNA and Staff B, CNA stated having a CNA pulled to the main dining area during mealtime placed a great deal of stress on the CNA left in the hallways. Staff C and Staff D stated there were two residents that required assistance with feeding in their hallway and when a CNA was pulled to the main dining there was a delay in feeding those residents. On 8/08/2024 at 4:45 p.m., an interview was conducted with the Staff J, CNA /Staffing Coordinator and Central Supply in her office. Staff J stated staffing assignments were based on the census but acuity was considered as well. Staff J stated sick calls were covered by their own staff and the facility did not use agency nurses. Staff J stated telephone calls were made or group texts were posted for coverage requests. Staff J stated Staff C was just suspended a few hours ago as well as Staff F from this morning. Staff J stated Staff C's CNA assignment was covered by Staff I, CNA. Staff J stated this was Staff I's third day of orientation but I was watching and assisting her all day. Staff J stated the Activities Director, Medical Records Director and herself were CNAs. They would cover assignments if there was a last-minute sick call until they could be replaced to then return to their job duties. Staff J stated she was currently covering a CNA who had overslept but would be in later today. A request for policies were requested for ADL care and/or incontinence care but the facility did not have such policies.

Based on observations, interviews and policy review the facility failed to ensure a clean and sanitary kitchen on three of three observations regarding areas that were not clean or were in disrepair. Finding included During an observation on 4/29/2024 at 11:00 a.m. showed on an initial tour in the kitchen a dirty trash can next to the hand washing station. Food trays were observed piled up on kitchen sink, next to the hand washing station during meal preparation. Dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up kitchen visit on 04/31/2024 at 11:00 a.m., showed the kitchen stove dirty with grease stuck on the side of the stove and missing stove knobs covers. An open garbage can was observed next to cooked food on the stove. The kitchen floor was observed dirty multiple times throughout the survey. During an interview on 5/3/2024 at 2:00 p.m., with the Certified Dietary Manager, CDM. She stated that there are areas in the kitchen that need to be cleaned up. She has tried to clean the walk-in refrigerator floor, but it is very hard to clean that type of floor. She agrees that the stove should be cleaner than what it looks like right now. During an interview on 5/3/2024 at 2:00 p.m., with the Nursing Home Administrator. She stated she has spoken with CDM multiple times about the cleanliness of the kitchen. The way the kitchen was presented is not acceptable and her expectations are that her kitchen remains clean. Review of the facility policy titled, Cleaning and Sanitation Effective date September 2012, showed the facility promotes a clean and sanitary environment for its employees, residents, and visitors. The entire Food and Nutrition Service team maintains clean and sanitary kitchen facilities and equipment walls, floors, ceiling, equipment, and utensils are clean, sanitized and in good working order. 7. Follow appropriate procedures for washing and sanitizing kitchen equipment. 12. Cover trash cans with lids while in the kitchen and/or when taken out to dumpster. Photographic evidence obtained.

Based on observations, interviews, and record review, the facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms, during four days (4/29, 4/30, 5/01, and 5/02/24) of four days observed, in three of four hallways observed. Findings included: 1) On 4/29/2024 at 9:53 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the middle drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the bottom drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:00 AM the door to the bathroom in the occupied room [ROOM NUMBER] was observed with a cylindrical metal piece protruding from where the doorknob should be. No doorknob was found. (Photographic Evidence Obtained). On 4/29/2024 at 10:08 AM the wall behind the occupied bed of 415 A was observed with a deep gouge in the drywall, leaving a hole in the wall behind the bed. The head of the bed was resting on the wall and floor, not attached to the bed. (Photographic Evidence Obtained). On 4/29/2024 at 10:11 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the top drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the middle drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:12 AM the wall behind the occupied bed of 415 C was observed with a gouge in the drywall, behind the bed. (Photographic Evidence Obtained). On 4/30/2024 at 10:11 AM and 10:13 AM the sinks in the occupied resident rooms of 415 and 413 respectively, were observed with cracks in the base of the sinks around the drains. The cracks traveled up the sink base to approximately the middle of the bowl. The cracks were visible with brownish/black substance in the cracks. (Photographic Evidence Obtained). An interview was conducted with the Maintenance Director on 5/2/2024 at 3:52 PM. The Maintenance Director observed the vent cover in room [ROOM NUMBER] and stated, Oh Goodness, that is not acceptable, the vent absolutely needs to be cleaned. The Maintenance Director continued to tour the facility and confirmed the areas were not acceptable and needed repair and painting. The Maintenance Director stated, The entire building needs to be audited and repaired. An interview was conducted with the Nursing Home Administrator (NHA) on 5/2/2024 at 3:50 PM. The NHA reviewed the photographic evidence and confirmed the environment needs repair/replacement/cleaning. 37999 2) On 4/29/24 at 11:11 a.m., an observation was made of the bathroom in room [ROOM NUMBER]. The bathroom did have a shower in the room which had eleven tile transition tiles missing, the floor of the shower and the shower wall grout was discolored black, the shower floor tiles were discolored with a black substance, the caulking around the toilet base was discolored black, and the white shower curtain had black spots of biogrowth. (Photographic evidence was obtained). On 4/30/24 at 8:54 a.m., an observation was made of the bathroom in room [ROOM NUMBER]. The shower curtain in the bathroom was discolored with an unknown black substance and along the bottom edge was tan-colored. The observation revealed the vinyl cove base was pulled away from the wall leaving a gap between the base and tile of a few inches. (Photographic evidence was obtained). On 5/2/24 at 8:47 a.m., an observation of room [ROOM NUMBER]'s bathroom revealed the shower curtain had black spots of unknown substance attached to it and the vinyl cove base was pulled away from the tiled wall next to the toilet. On 5/2/24 at 8:50 a.m., an observation of room [ROOM NUMBER]'s bathroom revealed the shower curtain had black spots of an unknown substance, the showers wall grout and floor tile was discolored with a black unknown substance, and the two safety handles beside and behind the toilet was rusty, therefore uncleanable. On 5/2/24 at 10:20 a.m., observations of room [ROOM NUMBER] and 206's bathrooms were conducted with the Housekeeping Manager and the Environmental District Manager (EDM). The EDM stated they could take money out of petty cash to replace the shower curtain in room [ROOM NUMBER] and the resident reported seeing palmetto bugs/roaches coming out of the cove base about every other day. The EDM stated the floor in room [ROOM NUMBER]'s shower could be cleaned and the shower curtain should have been changed. The EDM stated the handrails were not cleanable and the Housekeeping manager stated the safety handles are cleaned then a hour later the rust was back. 46498 3) During an observation made on 04/29/2024 at 12:00 p.m., rooms [ROOM NUMBERS] had paint missing off the doors. room [ROOM NUMBER]'s sink inside the room was observed with a black like substance stuck inside the sink. room [ROOM NUMBER] was observed with a dirty privacy curtain hanging up in the room. (Photographic evidence obtained). Review of the facility policy titled, Physical Environment, Effective date January 1, 2020, revealed the following: Policy: A safe, clean, comfortable, and home -life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition throughout the facility's Preventative Maintenance Program. 4. Assure resident/patient care equipment is clean, properly stored, and identified. 5. Assure an applicable working system is in place and within reach for the resident/patient to summon assistance, including, but not limited to: Typical call light with cord, Manual call bell, Specialty call bell as needed.

Based on observations, record reviews, and interviews, the facility 1) failed to revise and review one resident (#60) care plan with the appropriate staff/professionals and resident out of forty-one sampled residents, 2) failed to review and revise the care plan for four residents (#55, #1, #47, and #85) related to psychotropic medications, falls, activities of daily living (ADL), and range of motion (ROM) out of forty-one sampled residents. Findings included: 1. Review of Resident #60's Admission Record revealed the resident was initially admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, unspecified peripheral vascular disease, and unspecified sequelae of cerebral infarction. During an interview on 4/30/24 at 9:46 a.m., Resident #60 reported no participation in care planning meetings and stated, They're supposed to do all that?, then began chuckling and clapping hands. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's Brief Interview of Mental Status (BIMS) score was 13 out of 15, indicating an intact cognition. Review of Resident #60's care plan revealed the goals for the resident's focuses had been revised on 1/15/24 with a target date of 6/20/24. A focus regarding the resident being a smoker had been initiated 4/11/24. Review of Resident #60's progress notes revealed there was no progress note on 4/11/24 regarding a care plan meeting. Review of the resident's progress notes from 12/30/23 to 1/29/24 did not reveal a care plan meeting had been held. An interview was conducted on 5/1/24 at 9:29 a.m. with Staff G, Registered Nurse/Unit Manager (RN/UM). The staff member reported being unaware of the location of Resident #60's care plan. An interview was conducted on 5/1/24 at 9:45 a.m., with Staff L, Senior Clinical Reimbursement Director. The staff member stated the CRD was in charge of scheduling and notifying residents and representatives of care plan meetings. The staff member reported doing an electronic progress note and at minimum the note contained what was discussed. Staff L reported the invitation (to resident) was used to record the attendees at the time of the care plan meeting. An interview was conducted on 5/1/24 at 11:11 a.m., with Staff L, the staff member reported finding one progress note for Resident #60 regarding a care plan meeting, dated 4/14/23, revealing a meeting was scheduled for 1 p.m. on 4/19/23. The staff member confirmed there was no note revealing what was discussed and being unable to locate a care plan invitation for the period between December 2023 and January 2024. Staff L confirmed the invitation for the care plan meeting on 4/11/24 at 1:45 p.m. for Resident #60 was blank. An interview was conducted on 5/2/24 at 9:58 a.m. with the Social Service Director (SSD), the SSD stated the attendees at the care plan meetings were a Certified Nursing Assistant, Activities, the Unit Manager or nurse or the MDS Coordinator has already spoken with the nurse regarding meds, (and/or) therapy. Review of Resident #60's care plan meeting invitations for 7/12/23 and 9/21/23 revealed the attendees were the resident, the CRD and the SSD. 2. On 4/30/24 at 8:16 a.m., Resident #55 was observed sitting in wheelchair, appropriately dressed, and the resident's bed was made. On 5/1/24 at 12:48 p.m., Resident #55 was observed lying in bed, eyes closed, with audible rhythmic breathing. Review of Resident #55's Admission Record showed an admitted [DATE] and diagnoses including but not limited to other encephalopathy, unspecified depression, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #55's care plan revealed Psychotropic Med: The resident uses psychotropic medications related to (r/t) antidepressant to manage: depression, initiated and revised 4/4/23. The goals initiated 4/4/23, revealed Resident will be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum functional ability both mentally and physically through the next review and Will have no side effects of psychotropic medications. The goals were initiated on 4/4/23, revised on 4/22/24, and had a target date of 7/6/24. Review of Resident #55's active physician orders did not reveal the resident was to receive either a scheduled or as needed psychotropic medication. Review of Resident #55's current and discontinued medications revealed the resident did not have a current order for any psychotropic medication and the discontinued medications showed the last psychotropic order was Trazodone 50 milligram - Give 1 tablet via gastrostomy (G-tube) at bedtime for insomnia. The resident's order for Trazodone was started on 4/3/23 and discontinued on 10/30/23. An interview was conducted with Staff L, Clinical Reimbursement Director (CRD) on 5/2/24 at 3:44 p.m., the CRD reviewed Resident #55's care plan and confirmed it revealed the resident was receiving antidepressant medications. The CRD reviewed the current and discontinued medications, revealing the resident had not been receiving any psychotropic medications since Trazodone, confirming the care plan should have been resolved when the resident's antidepressant, Trazodone had been discontinued in October 2023. The facility did not provide any other discontinued psychotropic orders from the time frame of October 2023 to May 2, 2024. 48223 2. On 4/29/2024 at 10:08 AM Resident #1 was observed sitting on the edge of the bed, feet on the floor, bed in the low position. Resident #1 was observed leaning forward reaching for the floor, then sitting up and laying back on the bed, rolling back and forth. On 4/29/2024 at 11:30 AM Resident #1 was observed on the floor outside of room [ROOM NUMBER], wheelchair nearby, and staff attending. Resident #1 was returned to the wheelchair by the staff. Review of Resident #1's Admission Record showed a readmitted [DATE] and original admitted [DATE] with diagnoses including but not limited to: cerebral infarction, abnormalities of gait and mobility, reduced mobility, muscle wasting and atrophy, spinal stenosis, lack of coordination, pulmonary edema, heart failure, anxiety disorder, and schizophrenia. Review of Resident #1's care plan revealed the following: Focus: Fall: Resident #1 is at risk for falls or fall related injury related to unsteady gait, history of falls, decreased safety awareness secondary to impaired cognition and psychotropic and narcotic medication use. Resident #1 is very impulsive, difficult to redirect, also very independent minded, no awareness of abilities or lack thereof - date initiated: 6/28/2021, revision date on 4/15/2024. Goal: Will minimize the risk of injury - date initiated: 1/26/2023, revised on 3/8/2024. Will have no untreated fall related injury - date initiated 3/8/2024. Interventions/tasks: Encourage and try to assist resident with toileting before meals and at bedtime - date initiated 9/20/2023. 4/23 prompted toileting, before and after meals, and at bedtime -date initiated 4/30/2024. Focus: Incontinence: Resident #1 is incontinent of bladder/bowel related to severely impaired cognition with impaired awareness of need to void an unpredictable pattern - date Initiated: 7/16/2021, revised on 10/6/2023. Goal: Will maintain dignity - date initiated 7/16/2021 revised on 10/11/2023. Will minimize the risk of infection - date initiated 7/16/2021 revised on 10/11/2023. Will minimize the risk of skin breakdown - date initiated 7/16/2021 revised on 10/11/2023. Interventions/Tasks: check for incontinence frequently and provide incontinence care is indicated - date initiated 7/16/2021, revised on 1/26/2023. Provide perineal care and apply barrier cream after incontinent episodes as needed - date initiated 7/16/2021. Utilizing continent products as needed to provide dignity - date initiated 7/16/2021. Observe condition of skin with each incontinent episode - date initiated 1/26/2023. Observe for foul smelling, cloudy urine, change in urinary output, mental status change, changes in bowel pattern and report as needed - date initiated 1/26/2023. An interview was conducted with Staff L, CRD on 5/1/24 at 3:18 PM. Staff L, CRD reviewed Resident #1's care plan and confirmed the care plan interventions under the Fall Care Plan were redundant in regards to the encourage toileting. Staff L, CRD stated the resident's entire care plan should have been reviewed and an intervention placed after the root cause for the fall ascertained. Staff L, CRD continued to state the toileting intervention was not appropriate if the Incontinence Care Plan was accurate. On 4/29/2024 at 10:13 AM Resident #47 was observed sitting upright in bed. Resident #47 had an enteral tube feeding hanging on a pole next to the bed. The enteral feeding was dated 4/28/2024 not timed and half of the bottle was gone. The pump was not on and the tubing was not connected to Resident #47. On 4/30/2024 at 9:11 AM Resident #47 was observed sitting upright in bed, an over the bed table next to the bed with a carton of milk. Review of Resident #47's Admission Record showed a readmitted [DATE] and original admitted [DATE] with diagnoses including but not limited to: encephalopathy, vascular dementia, abnormalities of gait and mobility, dysphagia, acute kidney failure, a transient cerebral schematic attack (TIA), depressive disorder, hypertensive heart disease, and anxiety. Review of Resident #47's Physician Order Summary Report showed: Regular Diet Mechanical soft/soft and bite sized SB6 texture, Regular (Thin) consistency for diet, with an order date of 4/23/2024. Urinary Catheter for obstructive uropathy with urinary catheter size #16FR with 10cc balloon. Observe every shift with an order start date of 3/29/2024. Review of Resident #47's care plan revealed: Focus: Nutritional: the resident has a nutritional problem or potential nutritional problem related to advanced age, depression, hypertension, Benign prostatic hyperplasia (BPH), anxiety, Depression, hyperlipidemia, dementia and muscle wasting . date initiated: 10/11/23 and revised on 11/29/2023. Goal: Maintain nutritional and hydration status via by mouth (PO) intake to avoid significant weight changes, while honoring resident's food preferences - date initiated 10/11/23 and revised on 10/24/23. Interventions/Tasks: Resident is nothing by mouth (NPO)- do not provide food or fluids by mouth. See nurse. - date initiated: 3/1/2024. Focus: activities of daily living (ADL): the resident has an ADL self-care performance deficit related to recent hospitalization , dementia, history of TIA. date initiated: 1/5/2024 and revised on 3/20/2024. Interventions/Tasks: Resolved: Eating: Independent - resolved 3/1/2024. Eat nothing by mouth - date initiated 3/1/2024. Bladder: Incontinent - date initiated 3/1/2024. Focus: Behavioral: the resident is noted with the following behaviors: urinating on the floor - date initiated 11/17/2023. Goal: risk for complications related to behavior will be minimized through review date - date initiated 11/28/2023. Interventions/Tasks: administer psychotropic medications as ordered. Report missed or refused medications to physician - date initiated: 11/28/2023. Medications as ordered, report missed or refused meds to physician, discuss possible alternatives with MD and resident - date initiated 11/28/2023. Praise the resident will behavior is appropriate - date initiated 11/28/2023. Observe for changes in behavior and report to physician for example insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements etc. - date initiated 11/28/2023. Do not Corner if agitated. Provides space, remove other residents, remain calm and call for assistance - date initiated 11/28/2023. Psychiatry services as needed - date initiated 11/28/2023. Psychological services as needed - date initiated 11/28/2023. During an interview on 5/2/2024 at 9:15 AM Staff L, CRD reviewed Resident #47's care plan with focus areas of Nutritional, Tube Feeding and ADLs. Staff L, CRD stated Resident #47's care plan is not updated. Staff L, CRD stated when the order was received for the catheter the behavior and ADL care plan should have been updated to reflect resident's current status. Staff L, CRD continued to state, The same should have been done with the diet order. If the Care Plan is not updated the CNAs, Kardex does not get updated. The Kardex is what tells the CNAs what care to provide for the residents. On 4/29/2024 at 9:58 AM and 4/30/2024 at 9:15 AM Resident #85 was observed in bed, with arms crossed at the waste and hands bent with fingers touching both palms. Resident #85 was not able to open fingers or extend either arm out from the elbow. Review of Resident #85's Admission Record showed a readmitted [DATE] and original admitted [DATE] with diagnoses including but not limited to: encephalopathy, abnormalities of gait and mobility, dysphagia, depressive disorder, hypertensive, anxiety, and paranoid schizophrenia. Review of Resident #85's care plan revealed the ADL care plan had been resolved on 3/25/2024. During an interview on 5/2/2024 at 10:15 AM Staff L, CRD reviewed Resident #85's care plan and stated an ADL care plan should be in place. During an interview on 05/2/2024 at 12:40 PM the Director of Nursing (DON) stated the expectation is to update the residents care plans as changes occur. Review of the facility's policy and procedure topic, Care Plan - Interdisciplinary (IDT) Plan of Care from Interim to Meeting, dated effective February 2024 showed: Policy The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring residents condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situations, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions. a. Addressing ways to try to preserve and build upon a residence's strengths, needs, personal, and cultural preferences. b. Applying current standards of practice in the care planning process. c. Evaluating treatment of measurable objectives, timetables, and outcomes of care. d. Respecting the residents right to choose to decline treatment, request treatment, or discontinue treatment. e. Offering alternative treatments, as applicable. 2. Using appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. a. Involving the resident to have a role in care planning even if a judged incompetent, and the resident's family and/or other resident representatives as appropriate to participate in the development and implementation of his or her person-centered plan of care. b. Assessing and planning for care to meet the residents medical, nursing, mental, and psychosocial needs. c. Involving the direct care staff with the care planning process relating to the resident's expected outcomes. d. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. Procedure 2. Update to Care Plans - a. Ongoing updates to care plans are added by a member of the IDT, as needed. 3. Dates and Documentation on the Care Plan a. New, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made. b. Problems and goals have IDT approaches and interventions to assist the resident in their goal attainment. 5. Comprehensive Plan of Care a. The comprehensive care plan is developed by members of the IDT and the resident, resident's family, or representative, as appropriate, in conjunction with the completion of the Admission, Annual, Significant Change in Assessment or other comprehensive assessment, and associated Care Area Assessments. b. The comprehensive care plan describes or includes: i. The services that are to be furnished and goals that reflect the resident's wishes, choices, and exercise of rights. ii. Any services that would normally be provided but are not provided due to the residents exercise of rights, include the right to refuse treatment, or any alternative means or options to address the problem. iii. The needs, strengths, and preferences identified in the comprehensive resident assessment. iv. Prevention of avoidable declines in functioning or functional levels v. Standards of current professional practice vi. Adequate information provided to make informed choices regarding treatment. c. The comprehensive care plan is completed within regulated time frames. 6. Quarterly Update of the Plan of Care a. The comprehensive care plan is reviewed and revised by members of the IDT and the resident, resident's family, or representative, as appropriate, in consultation with completion of the Quarterly Assessment. b. The IDT members make a quarterly care plan review note within the designated discipline's progress notes which include: i. If goals are met or unmet ii. If care plan will remain in effect for resident 7. Care Plan Meeting Invitation a. The facility assists residents or their representatives to participate in and understand the assessment and care planning process, when feasible, holding care planning meetings at the time of day when a resident is functioning best, planning enough time for information exchange and decision making; Encouraging a residence representative to attend (e.g., family member, friend), if desired by the resident, and/or Hospice representative. b. The clinical reimbursement director (CRD) and/or clinical reimbursement specialist (CRS) facilitate the care plan schedules and letters to be delivered to the resident or their representative prior to the care plan meeting. i. A copy of the letter is retained by the facility and is filled into the medical record upon completion of the care plan meeting. Ii. When feasible, CRD, CRS, or designee calls or visits resident or their representative prior to meeting if no response has been received for confirmation of attendance. Call or visit is recorded on copy of letter. 8. Care Plan Meeting a. All team members are to report promptly at time indicated on weekly schedule. b. Care plan meetings are held in an uncluttered, confidential setting with all team members able to sit as well as resident and/or representative. c. All care plan updates, revisions, and evaluations are completed prior to the meeting. d. IDT Meats regardless of resident and/or resident representative ability to attend. e. Care plans are discussed allowed, to include discussion goals, interventions, and evaluations. f. CRD, CRS, unit manager (UM) or other designee in absence of, facilitates and explains the purpose and length of the meeting: i. Purpose: to communicate the medical, psychosocial, recreational and nutritional condition and discuss the approaches being taken to attain goals. ii. Time time allotted for meeting: 15 minutes per resident or private meeting after with appropriate department team members. iii. Introduction to team members and their titles. g. Nursing i. Review current diagnosis, tests, or procedures, treatments (wounds, rashes, etc.), discuss current interventions and risk of further breakdown, if applicable, recent, or pending referrals, physician consults, restorative, medications, pain management plan, behavioral management plan, special needs, risks of falls and current interventions, and recent falls or other issues (informed consents, isolation, etc.) ii. Clinical representative will be UM we're charged nurse familiar with the care of the resident. Assigned CNA also attends or provides input to IDT regarding care provided and resident response. Absence of UM or charge nurse should be by exception. h. Dietary/nutritional status i. Current weight, loss or gain, appetite, supplements, food likes/dislikes, and confirm history of allergies. i. Social Services i. Review any changes needed to face sheet information, advanced directive status, review code status to include do not resuscitate (DNR) and presence of state required documents. Discuss living will, ethical concerns, competency/capacity (surrogate, DPOA, guardian status), ancillary, services/pending referrals - dental, Podiatry, vision, hearing, mental health, recent changes in cognition, behaviors, and socialization and approaches, any discharge planning or any needed assistance with Medicaid application process or grievances that may need to be addressed. j. Recreation i. Update on customers participation in, and response to, activities. k. Therapy i. Physical, occupational, and/or speech therapy goals and progress. l. Position i. New orders, disease progression, discharge planning or advanced care planning needs may be addressed, as examples. m. CRD, CRS, UM, or designee to review/summarize any action steps or follow up needed. n. Questions o. Adjournment 9. Care plan meeting participation record a. The copy of the care plan meeting invitation letter is also the participation record. Attendee sign names, indicate relationship, or title and date of attendance at care plan meeting. b. If the resident or resident representative cannot participate in the care plan meeting, the reason is documented on the copy of the letter in the indicated section. c. The completed care plan meeting invitation/participation record is then maintained in the medical record under the 'Care Plan' tab.

Based on record review, observations and interviews the facility failed to provide restorative therapy related to applying splints for Resident #30 and did not prevent the further decrease in range of motion for Resident #85 out of twelve residents. Findings included: On 04/29/24 at 10:25 a.m., an observation was made of Resident #30 in his room with his eyes closed. Resident #30 had a blanket covering his body from chest to feet with his arms on top of the blanket. Resident #30's hands were in a curled loose fist bilaterally on top of his chest. Record review of Resident #30's Admission Record had an original admitted [DATE] with a readmitted [DATE]. Resident #30 has a primary diagnosis of Multiple Sclerosis (MS) with secondary diagnoses to include but not limited to aphasia and dysphagia following nontraumatic subarachnoid hemorrhage, major depression, and contracture of muscle multiple sites. A record review of Resident #30 physician orders shows orders for Physical/Occupational and Speech Therapy to evaluate and treat as needed and Restorative Nursing as needed with a revision date of 4/15/2024. A review of Resident #30 care plan has a focus area of Range of Motion (ROM) actual limitations in range of motion, and remains at risk related to diagnosis of MS as evidence by contracture bilateral lower extremities initiated on 02/16/2023 and revised 02/11/2024. The goal for this focus area will be to maintain range of motion and remain free of injuries or complications related to limitations of range of motion with a target date of 05/17/2024. Interventions for this focus area include: to encourage/assist the resident to change position for comfort and to observe and report decline in range of motion. On 5/01/24 at 12:10 p.m., an interview was conducted with the Program Manager for the therapy department. The facility's restorative therapy program is formally called Functional Maintenance program and it is nurse driven. The therapy department will determine if a resident is appropriate for the Functional Maintenance program after the initial acute therapy regimen is completed or if the resident has reached their goals and /or not progressing. The therapy department will design the program which includes but not limited to donning and doffing splints, active and/or passive range of motion, and eating assistance or devices for eating. The therapy department will train the nursing staff to the designed therapy specifically made for a resident in this program. The Program Manager will hand a paper form to the unit managers for each hallway which consists of the therapy designed for the resident, actual pictures of the splint and how it looks on a resident and an education sign in sheet of the staff in-service. The Program Manager stated the nursing staff will have to place this into the electronic medical records as well so it will show up as a task for the certified nursing assistants (CNAs) to implement. The Program Manager was unaware of a new order for Resident #30 for PT/OT/Speech therapy to evaluate and treat dated 4/15/24. On 5/01/24 at 12:35 p.m., an interview was conducted with the facility's two-unit managers (UM), Staff A, Registered Nurse and Staff G, Registered Nurse (RN). Both agreed there is a notebook which contains the information for restorative therapy but where not sure of its location. On 5/01/24 at 1:05 p.m., the Program Manager was observed in Resident #30's room doffing isolation personal protective equipment (PPE) stating the evaluation was completed. On 5/01/24 at 1:15 p.m., an interview was conducted with Staff C, CNA and Staff D, CNA. Both staff members stated they are familiar with Resident #30 and they have seen him in splints but stated they do not see any splints in his room currently. Both staff members agreed the restorative therapy is done by the smoking aid CNA when she comes in at 11:00 a.m., in between the smoking periods, she will take care of the residents in the program. Both staff members, added Staff B, CNA will assist with the restorative therapy program as well. Neither staff member knew of the formal name for the restorative therapy as the Functional Maintenance program. On 5/01/24 at 1:38 p.m., incontinence care was observed for Resident #30 with Staff C, CNA and Staff D, CNA. Resident #30 had bilateral feet and toes in a stiff pointing position. Both staff members stated he has splints for his feet and hands but were unable to locate in the resident's drawers or closet. On 5/01/24 at 1:44 p.m., an interview was conducted with Staff B, CNA regarding her role in the restorative therapy program. Staff B, CNA stated she oversaw all the residents assigned to restorative therapy and stated most of her job duties included donning and sometimes doffing of splints, range of motion either Active or Passive. She would get the instructions from the physical therapy team but the nurses would put the plan into the electronic chart so the tasks could be viewed and charted by the CNAs. She would also assist in the dining area for residents in need of assistance or for queuing and/or observation while eating and assist with weighing residents as ordered. Ever since Covid she no longer oversees the restorative program and stated, I miss it quite a lot. Staff B, CNA recalled Resident #30 wearing splints at some point in the past but is rarely assigned to his area. Currently, Staff B, CNA did not know anything about the smoking CNA assisting in restorative therapy. On 5/01/24 at 2:20 p.m., the Program Manager showed the process of a current resident getting ready to complete her acute therapy program and transition to the Functional Maintenance program (restorative therapy). In the packet was the written plan of therapy, pictures of the splint to be placed in various stages of donning and a blank sign in sheet for the CNAs to sign once they have been educated. On 5/01/24 at 3:30 p.m., two unlabeled notebooks were provided of the current residents for their Functional Maintenance program (Restorative Therapy). Upon review, Resident #30 had programs in both notebooks {photographic evidence}. A list of residents for splints/braces was provided by the facility for a total of four residents. Upon further investigation of these two notebooks, other residents were listed as well as residents no longer in the facility. On 5/02/24 at 11:20 a.m., an interview was conducted with Staff C, CNA, Staff N, CNA and Staff R, CNA. All three agreed to not be part of the restorative therapy program. All three stated they do not place splints/braces on residents and the smoking aid/CNA oversees the splints/braces when she arrives at 11:00 a.m. On 5/02/24 at 11:50 a.m., an interview was conducted with Staff I, CNA. Staff I, CNA stated if she sees on her task list a resident for splints, she will follow the task and place it on the resident and complete it in her task. Staff I, CNA stated physical therapy is good for educating the nursing staff but if she had a question, she knows therapy would assist her with her concerns. A review of Resident #30's Task Description for CNAs has under Nursing Rehab: Assistance with splint bilateral lower ankle foot orthotics (AFOs) for up to six hours as tolerated , may remove to check skin integrity and for hygiene care. On 5/02/24 at 12:29 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The newly hired ADON stated she is aware of the lack of ownership for the restorative therapy program and stated this will be addressed from the bottom up stating this is a nursing issue and all need to take responsibility for this project. The ADON was not aware of the smoking CNA responsible for the restorative therapy and stated it was inappropriate. On 5/02/24 at 12:29 p.m., an interview was conducted with Staff T, CNA. Staff T, CNA was feeding a resident in his room. Staff T, CNA stated she will do the restorative therapy in between smoking times, feeding residents, answering the phone in the front when the receptionist takes a break and whatever activities I need to do, I just go where they tell me. 48223 On 4/29/2024 at 9:58 AM and 4/30/2024 at 9:15 AM Resident #85 was observed in bed, with arms crossed at the waste and hands bent with fingers touching both palms. Resident #85 was not able to open fingers or extend either arm out from the elbow. Review of Resident #85's Admission Record showed a readmitted [DATE] and original admitted [DATE] with diagnoses including but not limited to: encephalopathy, abnormalities of gait and mobility, dysphagia, depressive disorder, hypertensive, anxiety, and paranoid schizophrenia. Review of Resident #85's Minimum Data Set (MDS) dated [DATE] revealed Section GG - Functional Abilities and Goals no upper or lower extremity impairments. Review of Resident #85's care plan revealed the Activity of Daily Living (ADL) care plan had been resolved on 3/25/2024. During an interview on 5/2/2024 at 10:15 AM Staff L, Clinical Reimbursement Director (CRD) reviewed Resident #85's care plan and stated an ADL care plan should be in place. An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 4/30/2024 at 10:01 AM stated I only provide care, not Range of Motion (ROM). ROM is provided by someone else but I don't know who. Staff D, CNA continued to state noticing some tightness in the Resident's upper and lower extremities when trying to dress Resident #85. An interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 4/30/2024 at 10:05 AM. Staff S, LPN stated she was unaware of who provided ROM to the residents. Staff S, LPN continued to state noticing Resident #85's fingers and elbows beginning to tighten, but did not think much of it. An interview was conducted with the Director of Rehabilitation (DOR) on 5/2/2024 at 10:56 AM. The DOR stated residents are screened based on referrals from nursing and the therapist are knowledgeable of the residents. The DOR went on to say screens might also be completed on a resident when readmitted from the hospital or if the resident has a functional decline. On 5/2/2024 at 11:05 AM an observation and interview were conducted with Resident #85 and the DOR. Resident #85 was lying face up in bed, arms were crossed at the waist and fingers were touching the palms. Resident #85 was not able to open her fingers on either hand when requested by the DOR. Nor was she able to extend her arms. The DOR asked Resident #85 if she could massage her hands. Resident #85 granted permission. The DOR massaged the Resident's hands for a few minutes then tried to open the palm of the hand (one hand at a time) the Resident grimaced and pulled away, bilaterally. The DOR stated the resident is in need of an evaluation and would request an order from the physician. During an interview on 05/2/2024 at 12:40 PM the Director of Nursing (DON) stated the expectation is for all CNAs to complete ROM and a referral to therapy be made if a staff member notices a decrease in any flexibility of a resident. Review of the facility's Restorative Nursing Programs dated revision October 2017 showed: Topic Restorative Nursing Programs and Guidelines Overview The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The interdisciplinary team (IDT), resident and, or family identify the needs of the resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: *Contracture Management and Prevention- This program includes the provision of active and/ or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. * Mobility- This program improves or maintains self-performance in bed mobility, transfers, wheelchair mobility and walking. * Activities of daily Living-This program involves improvement or maintenance of the resident's self-performance in dressing (including prosthetic care), grooming and bathing. * Bowel and Bladder Continence- This program involves facilitating a resident in regaining or preserving continence to their maximal functional potential. * Restorative Dining- This program improves or maintains the resident's self-performance and self-feeding which may involve compensatory/adaptive strategies, positioning, and assistance/cues. * Communication- This program involves activities to improve or maintain the resident's self-performance and expressive and receptive communication. This may involve adaptive techniques, compensatory strategies, and adaptive devices. These programs can be combined based on the person-centered goals of each resident. The varied combinations can promote the highest functional level of each resident as well as enhance the restorative process. Refer to the following potential combinations that may be beneficial to the resident's needs. Combinations to consider that may enhance the restorative nursing process: *Passive Range of Motion (PROM) + Splint/Brace Assist *PROM/AROM (Active Range of Motion) + Splint/Brace Assist *AROM plus dressing/grooming *Bed Mobility + Transfer *Eating/Swallowing + Splint/Brace Assist *Bed Mobility/Walking + Transfer *Amputation/Prosthesis Care + Dressing/Grooming *Transfer + Amputation/Prosthesis Care *Transfer + Walking + Bowel/Bladder *Transfer + Walking *Communication + Dining + Walking *Communication + ADL (grooming/dressing) + Transfers

Based on observations, interviews and record review the facility failed to ensure medication was administered in a clean manner, ensure staff doffed PPE (personal protective equipment) appropriately, and residents were offered hand hygiene prior to meals. Findings included: On 4/30/24 at 11:00 a.m., an observation was made of the main dining area prior to lunch service of residents self-propelling with their arms to dining tables. Staff were present waiting for lunch tray delivery and/or bringing residents to the dining area. Residents were not offered hand hygiene prior to the delivery of lunch. The Activities Director was witnessed washing a resident's hands with a wet paper towel and then sitting next to this resident to assist with feeding. On 5/01/23 at 1:38 p.m., an observation was made during incontinence care of two Certified Nursing Assistants (CNAs) and a resident on Enhanced Precaution Isolation. Both CNAs were wearing appropriate personal protective equipment (PPE) during the care provided to the resident. The resident was turned to his left side with the assistance of Staff C, CNA while Staff D, CNA was in the process of cleaning the resident and changing the linen. Staff D, CNA with the same PPE still on rummaged through the resident's closet stating she was looking for a sheet. Unable to locate what she was looking for, Staff D, CNA walked out of the room with the same gloves and gown used while providing care and walked across the hallway to the locked linen closet pressing numbers on the code box to obtain access into the closet. Numerous attempts were made at accessing the linen closet via the locked keypad system. Unable to access the closest, Staff D, CNA returned to the resident's room. Staff C, CNA rolled the resident to his back, removed the PPE appropriately and gathered the sheet in the linen closest. Staff C, CNA donned new PPE and returned to assist Staff D, CNA to complete the care provided to the resident. Staff D, CNA removed the PPE she was wearing and left the room with dirty linen in a bag. Staff A, Registered Nurse/Unit Manager was notified of the incident and stated, She knows better than that, I will talk to her. Staff A, RN/UM was seen cleaning the keypad to the linen closest. On 5/01/24 at 9:30 a.m., an observation was made of Staff E, RN during medication administration. Staff E, RN was observed pulling medication administration cards for the resident but did not punch the tablet into a medicine cup but instead popped the medication in his hand to then dropped the pill into the cup. When questioned regarding the cleanliness of this process, Staff E, RN stated he uses the alcohol based hand rub (ABHR ) in between each medication. This process was not witnessed consistently and Staff E, RN was witnessed opening and closing medication drawers as well as touching medication cards. On 5/02/24 at 8:18 a.m., an observation was made of Staff F, RN during medication administration. Staff F, RN was observed dropping a pill onto the medication cart and placed it back into the medicine cup. During medication administration of a resident, Staff F, RN attempted to give all eleven pills at once to a resident. Resident was unable to take all at once and pills were witnessed dropping down the side to the resident onto her side by her hip in the bed. Staff F, RN rummaged through the bed, picked up loose pills with his ungloved hand and placed them in the resident's mouth to complete the medication administration for this resident. On 5/02/24 at 10:30 a.m., the Director of Nursing was aware of the infection control during medication administration. A review of the facility's policy titled: Medication Administration General Guidelines, Section 7.1 dated 09/18 shows their policy as: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. . 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, optic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: soap and water should always be used after contact with residents with Clostridium difficile (C. Diff) as antimicrobial sanitizer does not kill the spores produced by C. Diff., which may result in the spread of the infection. 37999 An observation was conducted of meal service on 5/1/24 at 8:12 a.m., with Staff H and Staff I, Certified Nursing Assistant's (CNAs). The observation revealed the breakfast meal cart was delivered on 5/1/24 at 8:16 a.m. to hallway. The following was observed: - 8:16 a.m., the breakfast cart arrived to the unit. - Staff H delivered a tray to room [ROOM NUMBER] A-bed without offering hand hygiene; - Staff H delivered a tray to room [ROOM NUMBER] A-bed, leaving the room without offering hand hygiene; - 8:22 a.m., Staff I delivered tray to Resident #60, who opened eyes and stretched, the staff member encouraged the resident to open eyes and not close eyes, leaving the room without offering hand hygiene. During an interview with Resident #60 on 4/30/24 at 9:47 a.m., the resident stated the facility did not ask residents to wash hands before meals. Resident #60 was observed during the survey period eating meals in room and in the main Dining Room. Review of the facility's policy and procedure titled with the Topic Hand Hygiene dated Effective February 2021 showed: Policy The facility considers hand hygiene the primary means to prevent the spread of infections Procedure: . 2. Personal shall follow the handwashing/hand hygiene guidelines to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. No other policy and procedure were received from the facility in regards to resident hand hygiene.

Based on observations, interviews, and record review, the facility failed to accommodate the needs for one resident (#85) related to placing the call light within the resident's reach out of six residents sampled for environmental concerns. Findings included: On 4/29/2024 at 9:58 AM Resident #85 was observed in the bed, facing the ceiling, arms crossed at the waist. The call light was around the bed rail on the left side near the head of the bed. Resident #85 was on an air mattress with a perimeter cover, in front of the bed rail. Resident #85 was not able to reach the call light when requested. An interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 4/29/2024 at 10:00 AM. Staff S, LPN confirmed Resident #85 uses the call light and call lights should be within the resident's reach. Staff S, LPN confirmed Resident #85's call light was not within reach. Staff S, LPN assisted resident and placed the call light within the resident's reach. On 4/29/2024 at 3:15 PM Resident #85 was observed in the bed facing the door, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. An interview was conducted with Staff R, CNA on 4/29/2024 at 3:17 PM. Staff R, CNA confirmed Resident #85 uses the call light and call lights should always be within the resident's reach. Staff R, CNA observed the call light and stated, [Resident #85] would not be able to utilize the call in that position. Staff R, CNA moved the call light into the resident's reach. On 4/30/2024 at 9:15 AM Resident #85 was observed in the bed, facing the ceiling, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. Resident #85 stated, Happens all of the time. On 4/30/2024 at 10:00 AM Resident #85 was calling out for assistance. Resident #85 was observed lying in bed, facing the ceiling, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. Staff S, LPN was informed Resident #85 was calling out for assistance. Staff S, LPN confirmed the call light was not within Resident #85's reach. Review of Resident #85's Admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses encephalopathy, abnormalities of gait and mobility, lack of coordination, reduced mobility, and muscle wasting and atrophy. During an interview on 5/1/2024 at 3:40 PM the Director of Nursing (DON) stated Resident #85 was able to use her call light, and residents should be able to access the call light when needed. During an interview on 5/1/2024 at 4:00 PM the Nursing Home Administrator (NHA) stated the facility does not have a policy and procedure for call lights.

Based on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#81 and #13), were provided with Activity of Daily Living(ADL) assistance related to hair and fingernail care out of forty one sampled residents. Finding Included: 1. During an observation on 04/29/2024 at 11:00 a.m., Resident # 81 was observed laying down in bed dressed in his nightgown with his call light within reach. Resident # 81 fingernails were observed long and dirty and he had thick facial hair. Resident # 81 stated he has asked staff to cut his hair and his fingernails, but they will not assist him. During an observation on 04/30 /24 at 02:24 PM Resident #81 was observed laying down in bed with his call light in reach, dressed in his nightgown. Resident # 81 said he has asked his aide to cut his facial hair and his fingernail, but she did not assist him with his care. Review of an Admission Record, dated 05/02/2024, showed Resident #81 was admitted initially on 06/17/2023 and readmitted on [DATE] with diagnoses to include but not limited to non-Pressure chronic ulcer of unspecified part of left lower leg with unspecified severity, adjustment disorder with anxiety, and Pressure Ulcer of Sacral Region, Stage 4. Review of a Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status, (BIMS) score of 14 to indicated Resident #81 was cognitively intact. Further review of the MDS showed in section GG, for Functional Abilities and Goals, Resident #81 was dependent for his personal hygiene. Review of a care plan focusing on ADL's showed: Resident #81 has an ADL self-care performance deficit related to paraplegia status post Motor Vehicle Accident. Date initiated: 01/03/2024 and revised on 01/03/2024. Interventions: Dependent for personal hygiene. Date initiated 09/06/2023 and revised on 01/03/2024. During an interview on 05/01/2024 at 12:00 p.m., with Staff Q, a Certified Nursing Assistant, CNA, she stated she provides all of Resident #81's ADL care because he is a total dependent resident. She said the first thing she does is empty his colostomy and catheter bag in the morning. She said Resident #81 asked her to shave him yesterday, but she was not able to do it because she was too busy. During an interview on 05/01/2024 at 12:15 p.m., with Staff E, a Registered Nurse, RN, He said his expectation is if staff are having problems with completing their ADL task, they should report it to him and document the reason why they could not complete the task. For example, if resident refuses care the aide needs to report the situation to their nurse and document the concern. His expectation are staff should follow out the residents ADL's according to the resident's plan of care. During an interview on 05/01/2024 at 1:00 p.m., with the Director of Nurses, DON, the DON said her expectation was that every resident should be provided with ADL care. If for some reason they are not able to complete the task, then they should report the issue to their nurse and they should follow up with documentation regarding the resident's refusal of care. 50434 2. During an observation on 04/29/2024 at 10:30 a.m. Resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During an observation on 04/30/24 10:00 a.m. Resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During the observation she was yelling out. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/01/2024 at 11:00 a.m. Resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed hair was noted to have been brushed and resident was clean looking in appearance. Resident was happy in demeanor. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/02/2024 at 9:45 a.m. Resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed to be disheveled in appearance with her hair knotted. Resident was not observed to be engaged in any activities throughout the observation. Review of Resident #13's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of reduced mobility, need for assistance with personal care, other chronic pancreatitis, adjustment disorders with anxiety, major depressive disorder, and anxiety disorder. Review of Resident #13's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Section GG revealed Resident #13 was dependent for Toileting hygiene, and Shower/bathe care. Resident requires substantial/maximal assistance for Oral hygiene, upper body dressing and lower body dressing. During an interview on 05/01/2024 at 10:30 a.m. with Staff N, Certified Nursing Assistant (CNA), she stated she is typically assigned to another part of the building and used to be on this hall. She stated Resident #13 is a fully dependent resident who requires full assistance with all of her care. She stated she helps with oral care, dressing for the day, bathing and with meals daily. She stated Resident #13 prefers to have a bath over a shower so she is sure to give her a bed bath daily. She stated Activities of Daily Life (ADL) care are supposed to be completed every shift and she cannot speak for other shifts or staff but when she is working, she ensures the Resident #13 gets her ADL care. She repositions the resident every 2 hours and uses a pillow to keep her comfortable, since the resident prefers to stay in bed most of the time. She stated the resident prefers to do activities in her room and she had brought her an audio book to listen to during the day before and she really enjoyed it. During an interview on 05/02/2024 at 10:30 a.m. with Staff O, CNA she stated she is supposed to provide ADL care to the residents daily. ADL care consists of oral care, daily bathing, and dressing for the day. She also assists the residents out of bed if they wish. Staff O, CNA stated Resident #13 prefers to stay in bed most days and often refuses her help with ADL care. She stated she does not force the resident to let her help them with care or out of bed. If the resident refuses, she takes no as the answer and does not encourage the resident any longer. She stated she does not provide any activities for the residents to do in their rooms because the facility has an activities director who goes to residents rooms and offers them things to do like coloring or a word search puzzle. Staff O, CNA stated she does not document when residents refuse showers, or not wanting to get out of bed or the behavior of the residents because she does not have access to do so. Staff O, CNA stated she reports to the nurse on duty when residents do not want to get out of bed or refuse their showers. During an interview on 05/02/2024 at 11:15 a.m. with the DON she stated they have residents who refuse care and when residents continue to refuse care, they update the care plan. CNA's do not have access to documents when residents refuse care. DON reviewed Resident #13's care plan, dated 03/03/2024, and noted the resident was not care planned to refuse ADL care. Her expectation for activities for residents who are dependent is for the activities director to visit the rooms of those residents and provide them with activities. The facility was asked to provide a policy regarding their ADL care and stated they do not have a Policy for ADL Care.

Based on observations, record reviews, and interviews the failed to ensure two residents (# 68, 13) residing on the same hall were provided with activities out of eight residents sampled. Finding Include: 1.During an observation made on 04/29/2024 at 10:00 a.m., 11:30 a.m., and again at 3:00p.m., Resident# 68 was observed in bed, leaning off the side of her bed. Resident # 68 was dressed in her nightgown, with her call light out of her reach. During an observation made on 04/30/24 at 9:00 a.m. and 11:30 a.m., Resident # 68 was observed in bed, dressed in a nightgown with her call light out of reach. Resident # 68 was observed leaning to the side. Review of an Admission Record dated 05/02/2024 showed Resident # 68 was admitted on [DATE] with diagnoses to include but not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Cognitive Communication Deficit, Need for assistance with Personal Care Review of a Minimum Data Set, MDS dated [DATE] showed a Brief Interview for Mental Status, BIMS showed a score of 05 to indicated Resident # 68 is severely impaired. Review of a care plan focusing on Activities showed Resident # 68 requires staff assistance with involvement of activities related to cognitive deficits. Date initiated 04/04/2023.Further review of the care plan interventions showed to encourage Resident # 68 to participate with activities of choice. Date initiated: 04/04/2023. During an interview on 05/02/2024 at 2: 00 p.m., with Staff P, the Activities Director. She stated she conducts room visits for dependent residents. She asked the residents in their rooms if they would like to do a word search, or color. She said she even does nail care as an activity for some residents in their rooms. She was not able to conduct activities this week for the dependent residents residing on the 100 halls because she was too busy. During an interview on 05/02/2024 at 2:30 p.m., with the Director of Nursing. She stated her expectation is that residents have activities according to their plan of care. 50434 2. During an observation on 04/29/2024 at 10:30a resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During an observation on 04/30/24 10:00 AM resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During the observation she was yelling out. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/01/2024 at 11:00 am resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed hair was noted to have been brushed and resident was clean looking in appearance. Resident was happy in demeanor. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/02/2024 at 9:45 am resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed to be disheveled in appearance with her hair knotted. Resident was not observed to be engaged in any activities throughout the observation. Review of Resident #13's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of reduced mobility, need for assistance with personal care, other chronic pancreatitis, adjustment disorders with anxiety, major depressive disorder, and anxiety disorder. Review of Resident #13's Quarterly Minimum Data Set (MDS) dated [DATE] Section C, Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 10 out of 15. Section GG revealed Resident #13 is dependent for Toileting hygiene, and Shower/bathe care. Resident requires substantial/maximal assistance for Oral hygiene, upper body dressing and lower body dressing. According to the Self-Care Coding dependent means helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Substantial/maximal means helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort. During an interview on 05/01/2024 at 10:30a with Staff N, Certified Nursing Assistant (CNA), she stated she is typically assigned to another part of the building and used to be on this hall. She stated resident #13 is a fully dependent resident who requires full assistance with all of her care. She stated that she helps with oral care, dressing for the day, bathing and with meals daily. She stated resident #13 prefers to have a bath over a shower so she is sure to give her a bed bath daily. She stated ADL care is supposed to be completed every shift and she cannot speak for other shifts or staff but when she is working, she ensures the resident #13 gets her ADL care. She repositions the resident every 2 hours and uses a pillow to keep her comfortable, since the resident prefers to stay in bed most of the time. She stated the resident prefers to do activities in her room and that she has brought her an audio book to listen to during the day before and she really enjoyed it. During an interview on 05/02/2024 at 10:30 am with Staff O, CNA she stated that she is supposed to provide ADL care to the residents daily. ADL care consists of oral care, daily bathing, and dressing for the day. She also assists the residents out of bed if they wish. Staff O, CNA stated that resident #13 prefers to stay in bed most days and often refuses her help with ADL care. She stated that she does not force the resident to let her help them with care or out of bed. If the resident refuses, she takes no as the answer and does not encourage the resident any longer. She stated that she does not provide any activities for the residents to do in their rooms because the facility has an activities director who goes to residents rooms and offers them things to do like coloring or a word search puzzle. Staff O, CNA stated that she does not document when residents refuse showers, or not wanting to get out of bed or the behavior of the residents because she does not have access to do so. Staff O, CNA stated she reports to the nurse on duty when residents do not want to get out of bed or refuse their showers. During an interview on 05/02/2024 at 11:15 am, with the DON she stated they have residents who refuse care and when residents continue to refuse care, they update the care plan. CNA's do not have access to documents when residents refuse care. DON reviewed resident #13's care plan dated 03/03/2024 and noted that the resident was not care planned to refuse ADL care. Her expectation for activities for residents who are dependent is for the activities director to visit the rooms of those residents and provide them with activities. During an interview on 05/02/2024 at 11:30 am, with Staff P, Activities director, she stated she is responsible for activities for the entire resident population. She visits residents who are dependent on Mondays, Wednesdays, and Fridays. She offers the residents word searches, coloring pages, and sits with the resident to provide companionship. She stated that she has not been able to visit the dependent residents recently because she has been busy with her other tasks. She stated this is a frequent occurrence because of everything she does with in the facility she is not able to do her one on one with all the residents because she is the only one who does activities. The facility was asked to provide their activities policy and the facility did not provide this policy.

Based on observations, record reviews, and interviews the facility failed to assess and obtain physician orders for the wounds of two (#60 and #45) out of three residents sampled for skin conditions. Findings included: 1. On 4/30/24 at 9:51 a.m., Resident #60 was observed lying in bed and a tan-colored foam dressing was observed covering the left below the knee amputation (LBKA), the dressing was dated 4/28 11-7 and initialed, EC, with a pencil eraser-sized discoloration. Photographic evidence was obtained. On 5/1/24 at 2:22 p.m., Resident #60 was observed sitting in wheelchair and stated the dressing (to LBKA) had not been changed. The resident reported yesterday's nurse stated the 11 p.m. - 7 a.m. (11-7) shift nurse was going to change it. The dressing was observed and continued to be dated 4/28 11-7 EC with a pencil eraser-sized discoloration. Photographic evidence was obtained. Review of Resident #60's evaluations did not show a Change of Condition or Wound evaluation had been completed on 4/28 in regards to the skin condition covered by the dressing covering the LBKA. Review of Resident #60's April Medication and Treatment Administration Records (MAR/TAR), printed on 5/2/24 at 3:50 p.m., did not reveal a physician order for the dressing applied to the resident's LBKA, which was dated 4/28. Review of the facility provided list of wounds revealed Resident #60 was included with others with pressure, surgical, venous, arterial, diabetic, and moisture-associated skin damaged condition. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM) on 5/1/24 at 2:26 p.m., the staff member reported the resident had redness to the perineal area, reviewed Resident #60's record, and confirmed there was no order for a LBKA dressing. An unsuccessful attempt was made with Staff G to observe the resident's dressing. The photo evidence of the resident's LBKA dressing was reviewed with the staff member, who stated oh no and confirmed there should have been a change in condition and assessment done for the area. The staff member asked writer if knowing what was under the dressing. On 5/1/24 at 2:47 p.m., the Director of Nursing (DON) was informed by the staff member of Resident #60's unassessed and unordered dressing. Review of Resident #60's care plan revealed the following: - Wound Risk: The resident is at risk of developing a wound related to (r/t)decreased mobility and multiple co-morbidities. The interventions instructed staff to observe for any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; report to nurse if noted, Nurse will report to MD if noted. - Preference/Choice: Resident has indicated the following preferences and/or has made the following choice regarding their health care: Resident chooses to decline recommended or ordered health care interventions of: Resident may decline to be weighed at times; to attend scheduled medical appointments. The interventions should staff were to encourage resident involvement in plan of care. - Behavioral: The resident is noted with the following behaviors: intermittently confabulates information regarding staff and/or other residents; occasionally buys sodas or snacks for other residents (without them requesting such) and will later charge them for the soda and/or snack; will, at times, ask assistance from another resident and/or staff member to look for something she is missing and then report the item missing or taken. 2. On 4/30/24 at 5:17 p.m., an observation was made with Staff J, Registered Nurse (RN) of Resident #45's bilateral lower extremities. The observation revealed no open areas to the resident's lower extremities. The staff member stated the area heals then reoccurs, and right now the staff are just putting cream on it. On 5/1/24 at 12:49 p.m., an observation was made of Resident #45 raising the head of bed as a meal tray was on the over-bed table in front of the resident. Review of Resident #45's Admission Record revealed an admitted [DATE] and diagnoses not limited to not elsewhere classified senile degeneration of brain, contracture of left knee, contracture of left ankle, and muscle wasting and atrophy not elsewhere classified unspecified site. Review of Resident #45's Skin Check Weekly and as needed (PRN), dated 1/26/24 revealed No New Areas of Skin Impairment. The document revealed staff also had New Areas of Skin Impairment Found, See Skin Grid (paper version or PCC Skin & Wound Module), See Skin/wound Note, Care Plan Reviewed & Current, and Resident Refused Skin Evaluation available to document any findings. Review of Resident #45's Skin Check Weekly and PRN, dated 2/2/24, revealed No New Areas Of Skin Improvements. Review of Resident #45's progress notes, dated 12/31/23 to 1/30/24, did not reveal the staff had documented any skin condition or change in condition for the resident. Review of Resident #45's progress notes revealed a note, dated 2/5/24, Resident noted with skin impairment to anterior bilateral lower extremities. MD notified with orders and Healthcare Proxy (HCP) called. Review of Resident #45's progress notes revealed the resident was seen by the facility wound care provider on 2/6/24 and an order for a vascular consult was obtained with the primary physician and Power of Attorney updated. Review of Resident #45's Infection Note, dated 2/7/24 showed the resident continued on oral antibiotic for cellulitis. The note on 2/15/24 revealed the resident continued on doxycycline for cellulitis to bilateral lower extremities. Review of Resident #45's January Medication and Treatment Records (MAR/TAR) did not reveal any order for a dressing change or an order for an antibiotic related to any infection. Review of Resident #45's February MAR/TAR's revealed the resident was ordered: - Doxycycline Hyclate Oral Tablet 100 milligram (mg) - Give 1 tablet by mouth two times a day for cellulitis to right (rt) leg for 10 days. The MAR showed the antibiotic was administered on 2/5-2/10, evening shift on 2/13, both times on 2/14 and not administered on morning shift of 2/15/24. - Cleanse area to left anterior lower leg with normal saline (NS), skin preop wound edges, apply Xeroform, and cover with dry dressing daily and PRN every day shift, ordered 2/6 and discontinued on 2/13/24. - Cleanse area to right posterior knee with NS, skin prep wound edges, apply Xeroform, and cover with dry dressing daily and PRN every day shift, ordered 2/6 and discontinued 2/13/24. - Cleanse area to right upper shin with NS, skin prep wound edges, apply Xeroform and cover with dry dressing, and daily and PRN every day shift, ordered 2/6 and discontinued 2/13/24. An interview was conducted on 5/1/24 at 5:31 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding an incident of a CNA reporting a 7-day old dressing that the facility reported to the state agency. The NHA reported a Certified Nursing Assistant (CNA) had reported on 2/5/24 at 8:15 a.m. of observing a dressing to Resident #45's right lower extremity dated 1/27/24. The DON reported the resident has skin alterations of dry and crusty patches and one of the flakes had probably popped off. The NHA reported the investigation into the issue revealed a Registered Nurse (RN) had applied a dressing to the anterior right leg on 1/27/24 however did not follow wound protocol - did not put order in and did not document if an assessment had been done on the wound. The NHA stated the CNA had informed the nurse on 2/5/24 (different than the one on 1/27/24) and the nurse had not looked for a physician order but had just put the same type of dressing (dated 1/27/24) on the wound. The NHA reported Doppler studies were done on the lower extremity of Resident #45 and showed significant stenosis of the right popliteal artery. The wound provider diagnoses the resident with venous insufficiency and cellulitis and the antibiotic Doxycycline was started. At the time of the incident on 2/5/24, the DON assessed the wound and reported it hadn't changed in status and reported currently the resident had crusty scaly areas on legs. The NHA stated on 2/5/24 a physician order was obtained, a dressing was applied and the NHA started a Quality Assurance Performance Improvement plan. The NHA reported the roster of nurses who care from Resident #45 during the period of time were interviewed. The DON stated there was a piece of scale that was there, hadn't come off but did have some drainage. The NHA stated the root cause of the incident was that the nurse on 1/27/24 did not follow the facility's wound protocol. The NHA reported the incident was not substantiated because the wound had not worsened. The NHA stated the facility had completed audits of wound care dressings and labeling and the facility was no longer auditing due to the issue was resolved. The DON confirmed Resident #45's dressing (1/27-2/5/24) had been in place for 7 days, stating some dressings could be left on for 7 days. The facility education on 2/5/24 presented by the previous Assistant Director of Nursing (ADON) instructed staff when a new skin issue was found, a risk management assessment needs to be completed, a change of condition completed, report to the physician, get treatment orders, and notify the responsible party and DON. Review of Resident #45's care plan revealed the resident was at risk for developing a wound related to (r/t) decreased mobility and incontinent of bowel and bladder and multiple co-morbidities. The goal was to minimize wounds from developing. The interventions included Observe for any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; report to nurse if noted, Nurse will report to MD if noted. The facility failed to provide any skin/wound notes for January 2023, any evaluation for 1/26, 1/27, and 1/28/23. Review of the facility policy - Wound Prevention & Treatment Overview, effective October 2021, revealed The facility strives to ensure that a Resident/Patient entering the facility without Ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. A resident with ulcers will receive continued preventative interventions & necessary treatment & services to promote healing & prevent infection. Wound characteristics will be documented by measuring length, width & depth in centimeters. Additional documentation shall also include: - Color of drainage - Wound Bed Color - Odor - Amount of Drainage - Wound Bed Tissue Type - Tunneling/undermining with depth if applicable. Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition.

Based on observations, interviews and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (#53) out of eight residents related to timely assessment and vital signs post dialysis. Findings included: A record review of Resident #53's Admission Record has an original admitted [DATE] with a readmitted [DATE]. Resident #53 has a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Secondary diagnoses include but are not limited to end stage renal disease requiring dialysis, Type 1 diabetes mellitus with diabetic autoimmune polyneuropathy and personal history of other venous thrombosis and embolism. A review of physician orders for Resident #53 include resident to have dialysis on days: Monday, Wednesday, Friday dialysis center, document vital signs upon resident returning from dialysis every Monday, Wednesday and Friday, monitor for signs and symptoms of bleeding, notify MD (physician) of bleeding, monitor for bruit and thrill AV (Arteriovenous) shunt located at left lower extremity (upper leg) and may remove compression dressing post dialysis per MD orders instructions one time a day every Monday, Wednesday and Friday for treatment follow physician instructions when to remove dressing. On 4/30/24 at 11:00 a.m., a review of Resident #53's dialysis communication binder had one day of communication between the facility and the dialysis center, dated 4/29/24. Post vital signs and assessment of AV fistula were not entered from the facility upon return to the facility post dialysis. There was no post dialysis report from the dialysis center either on the communication sheet or on a separate report. An interview was conducted with Staff A, Registered Nurse/Unit Manager (RN/UM) who stated the reports may be faxed over later today but if there was a concern the facility would notify us via telephone conversation. A request was made for Resident #53's dialysis communication tools for the month of April 2024. Later that afternoon on 4/30/24, the facility provided copies of the resident's dialysis communication tools for the month of April with the following dates: 4/05, 4/09,4/10, 4/12, 4/13, 4/15, 4/17, 4/19, 4/22, 4/24, and 4/26. Upon further review, three of the communication tools had vital signs and post assessment of the AV fistula documented. All the communication tools for the month of April lacked timely communication from the dialysis center either in writing or fax. On 5/01/24 at 08:30 a.m., an interview was conducted with Resident #53. Resident #53 was in the main lobby sitting in his wheelchair waiting for transport to take him to his dialysis center. Resident had a binder in the back of his wheelchair with his name on it and the word dialysis. A packed lunch was made for the resident and packed in an insulated lunch bag. Resident #53 confirmed the location of his AV fistula was in his left upper thigh, stating he has had AV fistulas before in his arms but they did not do well due to small vessels. On 5/01/24 at 5:43 p.m., an observation and interview were conducted with Resident #53 post dialysis. In the 300 hallways at the nurse's station, Staff A, RN/UM confirmed Resident #53 was back from dialysis. Resident #53 was in his wheelchair in his room. Resident #53 stated he got back about forty-five minutes ago. He stated he had issues today at the dialysis center when they removed his needle from his AV fistula. Resident #53 stated he bled more than usual from his fistula and required longer direct pressure time to stop the bleeding at the dialysis center. The resident stated blood was all over the place and seeped into his shorts. Resident #53 stated the nursing staff have not come into his room to take vital signs or assess his AV fistula site, stating, they never come and check on it. He stated he did not eat his lunch today because he did not feel good. A request was made for Resident #53's dialysis communication binder from Staff A, RN/UM. Staff A, RN/UM stated she did not have the communication binder and sent a certified nurse assistant to locate the binder. Resident #53's dialysis communication binder was with the resident behind his wheelchair. The CNA gave the binder to a nurse staff member in the process of medication administration. Staff A, RN/UM stated no changes in dialysis were reported to her from the dialysis center. Review of the facility's policy entitled, Dialysis Management (Hemodialysis) dated October 2021 With the following guidelines: 1. Obtain A physician's order to include but not limited to: Name and address of the dialysis center Scheduled days and times of dialysis treatment Fluid management /restrictions -fluids will be coordinated and provided by nursing and dietary Lab values Medication administration terms on dialysis days Blood pressure or blood draw in arm with the shunt or access (error) Site signs and symptoms to monitor such as pain infection or bleeding period . 8. Complete the dialysis communication tool before and after dialysis and following up on any special instructions from the dialysis center. . 10. Evaluate for and manage post dialysis complication which may include, but are not limited to, the following: confusion fever pruritus anaphylaxis seizures hypertension muscle cramps cardiac arrhythmia restlessness air embolus insomnia hemorrhage

Based on observations, record reviews, and interviews the facility failed to obtain blood pressures for one (#60) out of 5 residents sampled for unnecessary medications related to the physician ordered vasodilator, Hydralazine. Findings included: On 05/1/24 at 8:06 AM, Resident #60 was observed lying in bed with eyes closed. Review of Resident #60's Admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to essential (primary) hypertension and unspecified sequelae of cerebral infarction. Review of Resident #60's March Medication Administration Record (MAR) revealed the following physician orders related to the resident's diagnosis of hypertension: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23. - BP and pulse weekly every evening shift every Sunday (Sun) for preventative measure. - Hydrochlorothiazide 25 mg - give one tablet by mouth one time a day for HTN. - Metoprolol Tartrate 25 mg - Give 1 tablet by mouth two times a day for HTN. Review of Resident #60's March MAR revealed the staff had obtained a blood pressure and pulse one time a week, on Sunday. The MAR did not reveal a blood pressure had been taken every 8 hours to ensure the resident's ordered Hydralazine was not required. The MAR showed a blood pressure was not ordered to be obtained prior to administering the resident's Hydrochlorothiazide and Metoprolol. Review of Resident #60's Blood Pressure Summary report revealed documented blood pressures on 3/3, 3/10 (twice), 3/17, 3/24, and 3/31/24. Review of Resident #60's April MAR revealed the following physician orders related to the resident's diagnosis of hypertension: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23. - BP and pulse weekly every evening shift every Sunday (Sun) for preventative measure. - Hydrochlorothiazide 25 mg - give 1 tablet by mouth one time a day for HTN. - Metoprolol Tartrate 25 mg - Give 1 tablet by mouth two times a day for HTN. Review of Resident #60's April MAR revealed the staff had obtained a blood pressure and pulse one time a week, on Sunday. The MAR did not reveal a blood pressure had been taken every 8 hours to ensure the resident's ordered Hydralazine was not required. The MAR showed a blood pressure was not ordered to be obtained prior to administering the resident's Hydrochlorothiazide and Metoprolol. Review of Resident #60's Blood Pressure Summary report revealed documented blood pressures one time daily on 4/7, 4/14, 4/21, and 4/28/24. Review of Resident #60's care plan showed the resident had a cardiovascular problem related to (r/t) hypertension (HTN), A-fib, (and) history (hx) of cardiovascular accident (CVA). The goal was for the resident to be free from complications of cardiac problems through the review date. The interventions r/t this focus included Vital signs ordered and Administer medications as ordered. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM), on 5/1/24 at 2:47 p.m., the staff member stated if the resident (#60) had an as needed (PRN) blood pressure medication with parameters and scheduled for every 8 hours (PRN), (the resident) should have blood pressures taken every 8 hours. The staff member reviewed Resident #60's Hydralazine order and stated yes staff should be taking blood pressures every 8 hours. Review of Resident #60's May MAR revealed the following order: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23 and discontinued on 5/1/24 at 4:01 p.m. Review of the policy - Physician Orders, effective October 2021, revealed At the time each resident is admitted , the facility will have physician orders for their immediate care. physician orders will be dated and signed at next physician visit. The policy instructed staff to Confirm the accuracy of orders. Review orders daily in the Clinical meeting to confirm accuracy in transcription and identify errors of omission. The Regional Nurse Consultant reported the facility did not have a policy related to nursing documentation.

Based on observations, record reviews, and interviews the facility failed to ensure medications were stored in a safe and secure manner and failed to ensure medications were discarded after manufacturer expiration date and failed to label medications with shortened shelf lifes with open dates. Findings included: On 4/29/24 at 11:45 a.m., Resident #29 was observed with a bottle of eye drops, for the relief of redness of the eye due to minor eye irritant, on the over-bed table next to the resident's bed and on the bedside dresser was a bottle of nasal spray with a large green top. The resident stated the nasal spray did not work. Review of Resident #29's physician orders revealed an order for Fluticasone Propionate Nasal Suspension 50 microgram (mcg/act) - 1 spray in both nostrils one time a day for allergic rhinitis. The review did not reveal an order for any eye drops. Photographic evidence was obtained. On 4/30/24 at 9:51 a.m., Resident #60 was observed and interviewed in the resident room. The observation revealed on top of the bedside dresser was a large jar of 1% Silver Sulfadiazine cream with a medication on top of it containing a white cream. The Silver Sulfadiazine was labeled Prescription (RX) only. The resident reported not being able to say if (they) put the cream on rash by self. Review of Resident #60's April Medication Administration Record (MAR) revealed an order for Silvadene External Cream 1% - Apply to perineal area topically every shift for rash until resolved, ordered 4/6/24 and discontinued 4/26/24. Review of Resident #60's April Treatment Administration Record (TAR) revealed an order for Silvadene External Cream 1% - Apply to bilateral buttocks topically every shift for redness bilateral buttocks, ordered 12/12/22. The TAR showed Silvadene was applied to the resident's buttocks three times a day during April. On 5/2/24 at 10:02 a.m., the 200-hall medication cart was observed with Staff G, Registered Nurse/Unit Manager. The observation revealed the following: - One round white tablet and one round pink tablet lying on the bottom of a drawer with boxes of eye drops. - Bottle of undated Latanoprost (Xalatan) 0.005% eye drops. The bottle has label to document open date. (According to https://medlineplus.gov/druginfo/meds/a697003.html#storage-conditions, accessed on 5/7/24 at 8:01 p.m., once opened Xalatan can be kept at room temperature for 6 weeks). - A container of disinfecting wipes stored in the same compartment of the bottom drawer as a bottle of Sodium Bicarbonate tablets which was sitting on top of a box of topical pain patches. - A Insulin Lispro Kwikpen labeled with no open date. - Novolog insulin pen labeled with no open date. - Levemir vial, not labeled with an open date. Pharmacy label showed the vial should be discarded in 42 days. Staff G observed the findings. On 5/2/24 at 10:38 a.m., the 400-hall medication cart was observed with Staff K, Licensed Practical Nurse. The observation revealed the following: - An undated open bottle of Liquid Protein. The label showed the bottle was to discarded 3 months after opening. - A vial of Novolog insulin, opened on 3/16/24. The pharmacy label instructed Discard after 28 days. Review of calendar revealed the vial should have been discarded 4/13/24, 19 days prior to the observation. - A vial of Insulin Glargine, opened on 3/21/24. The pharmacy label instructed Discard after 28 days. Review of calendar revealed the vial should have been discarded 4/18/24, 14 days prior to the observation. - An undated open vial of Lantus insulin. The pharmacy label instructed Discard after 28 days. Staff K confirmed the findings. Photographic evidence was obtained of the medication carts and resident findings. The policy - Medication Storage, effective 09/18, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel ,or staff members lawfully authorized to administer medications. 4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin file may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature. Do not freeze insulin. If insulin has been frozen, do not use. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according two procedures for medication disposal and reordered from the pharmacy, if a current order exists. 16. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.

Based on observations, interviews, and record review the facility failed to provide monitoring and care according to professional standards of practice related to urinary catheter care for one resident (#1) out of 3 residents sampled for catheter care. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a hospitalization . Resident #1 diagnoses include but are not limited to, Bacteremia, Stage 3 Chronic Kidney Disease, candidiasis, need for assistance with personal care, obstructive and reflux uropathy, dementia without behavioral disturbances, and dysphagia. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed in Section H: Bladder and Bowel, Resident #1 had a urinary catheter. Section C: Cognitive Patterns, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. A review of Resident #1's Certified Nursing Assistant (CNA) documentation from 7/3/23-7/12/23 revealed documentation that identified Resident #1 as having an indwelling urinary catheter. An observation was conducted of Resident #1 on 7/12/23 at 3:00 p.m. The resident was observed to be in bed sitting upright with the head of the bed elevated, watching television. A urinary catheter bag was observed to be hanging on her bed frame, empty and off of the floor. A review of Resident #1's Physician orders did not reveal any orders related to Resident #1 having a urinary catheter, care of a urinary catheter, or monitoring of a urinary catheter. A review of Resident #1's July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal any documentation a urinary catheter was being monitored or cared for by nursing. A further MAR and TAR review from June 2023, revealed Resident #1 had not had a urinary catheter monitored or cared for by nursing since June 12th, 2023. An interview was conducted on 7/12/23 at 2:00 p.m. with the facility's Director of Nursing (DON). She confirmed there were no urinary catheter orders in place for Resident #1 and she stated, The resident has been in and out of the hospital so the orders must not have been reordered when she came back. On 7/12/23 at 2:35 p.m. The DON stated the facility does not have a urinary catheter policy for review, they only have a catheter competency list.

Based on observations, record review, interviews, and policy on medication administration, the facility failed to ensure sufficient nursing staff to meet the needs of residents as evidenced by 1.) Untimely medication administration for eight (#1, #9, #10, #11, #12, #13, #14, #15) of fifteen residents; and 2.) Untimely Speech Therapy Evaluation for one (#3) of fifteen sampled residents. Findings Include: 1. On 11/02/2022 at 10:10 a.m. an interview was conducted with Resident #1. The resident stated, I'm not getting my medications on time. Their late every day. I won't take them after 11:00 a.m. I have things I have to do, and it doesn't make any sense why I have to wait so long. On 11/02/2022 at 10:15 a.m. Staff Member A, Licensed Practical Nurse (LPN) was observed on the 200 unit in a resident bedroom administering medications. She confirmed she was administering medication to the 200 unit and part of the 400 unit. The LPN said she would start administering medications on the 400 unit in approximately half an hour. Staff A said her normal routine was to start on the 200 unit but today a certified nursing assistant (CNA) did not show up for work and that had left the residents on the unit with one nursing assistant. Staff A said she had assisted the residents which caused the medication pass to be delayed. She then added even if she had started the medication pass on time (8:00 a.m.) she was not unable to administer 31 resident's medications timely. When asked if she had informed anyone about her concern about not having sufficient time allowed to provide the necessary medications she stated, I told the Unit Manager, the Director of Nursing, and the Nursing Home Administrator. On 11/02/2022 at 10:50 a.m. Staff Member A confirmed she finished the 200 unit and was preparing medication for Resident #1. The following medications were prepared and administered at 10:56 a.m.: -[MEDICATION(S)] oral tablet 400 milligrams (mg) -loratadine 10 mg -[MEDICATION(S)] 500 mg give one two times a day -[MEDICATION(S)] tablet 40 mg one time a day -[MEDICATION(S)] tablet 25 mg two times a day -potassium tablet 10 milliequivalents (meq) one time a day. Review of Resident #1 Medication Admin Audit Report revealed her medications were due at 9:00 a.m., indicating the medications were delayed by one hour and fifty-six minutes. Further review of the audit reflected on 11/01/2022 the resident's medications were administered at 10:20a.m., and on 10/31/2022 at 10:28a.m. At 11:00 Staff A, LPN confirmed Residents #9, #10, #11, #12, #13, #14, and #15 had not received their medications, which were due at 9:00a.m. Review of Resident #9 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -[MEDICATION(S)] 10 mg -[MEDICATION(S)] HCI 50 mg tablet three times a day -aspirin 81 tablet one time a day -[MEDICATION(S)] 10 mg tablet one time a day -[MEDICATION(S)] 0.5 mg tablet three times a day -[MEDICATION(S)] 40 mg tablet one time a day. The audit did not reflect an administration time for the day. Review of resident #10 Medication Admin Audit Report revealed his scheduled 9:00 a.m. medications listed: -[MEDICATION(S)] 800 micrograms (mcg) give one tablet time a day -vitamin B-12 1000 MCG one tablet one time a day -[MEDICATION(S)] 100 mg one time a day -[MEDICATION(S)] 12.5 mg tablet give one two times a day -[MEDICATION(S)] HCL tablet give 2.5 mg two times a day -[MEDICATION(S)] suspension 1-0.2% instill one drop in both eye three times a day. The audit reflected the administered time at 11:17 a.m. Further review of the audit reflected on 11/01/2022 the 9:00 a.m. scheduled medications were administered at 10:34 a.m., on 10/31/2022 at 10:50 a.m., and on 10/30/2022 at 10:25 a.m. Review of resident #11 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -[MEDICATION(S)] 5 mg one time a day -[MEDICATION(S)] 500 mg tablet two times a day -[MEDICATION(S)] 25 mg two times a day -[MEDICATION(S)] HCL 225 mg one time a day -aspirin 81 mg one time a day -[MEDICATION(S)] 500 mg give two times a day -famotidine 20 mg two times a day. The audit did not reflect an administration time for the day. Further review of the audit reflected on 11/01/2022 scheduled 9:00 a.m. medications were administered at 10:36 a.m. and on 10/28/2022 at 12:34 p.m. Review of resident #12 Medication Admin Audit Report revealed his scheduled 9:00 a.m. medications listed: -[MEDICATION(S)] NCL 20 mg one time a day -[MEDICATION(S)] sulfate 325 mg one time a day -[MEDICATION(S)] 500 mg one tablet three times a day -[MEDICATION(S)] 12.5 mg tablet two times a day -[MEDICATION(S)] 30 gram three times a day -[MEDICATION(S)] HCL 1000 mg two times a day -[MEDICATION(S)] 75 mg one time a day -[MEDICATION(S)] 10 mg one time a day The audit reflected the administered time at 11:11 a.m. Further review of the audit reflected on 11/01/2022 the scheduled 9:00 a.m. medications were administered at 10:48 a.m. Review of resident #13 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -[MEDICATION(S)] 100 mg give 2 capsules two times a day -[MEDICATION(S)] 5 mg two times a day -[MEDICATION(S)] bisulfate 75 mg one time a day -Tylenol extra strength 500 mg two tablets two times a day. The audit did not reflect an administration time for the day. Further review of the audit reflected on 11/01/2022 the 9:00 a.m. medications were administered at 10:43 a.m., on 10/31/2022 at 11:15 a.m., and on 10/30/2022 at 10:31 a.m. Review of resident #14 Medication Admin Audit Report revealed she had medications scheduled 8:00 a.m. and 9:00 a.m. The 8:00a.m. medications listed: -omeprazole delayed release 40 mg every morning and at bedtime -fish oil 1000 mg every morning and at bedtime -[MEDICATION(S)] one every morning and at bedtime -[MEDICATION(S)] 40 mg one every morning and at bedtime. The 9:00 a.m. scheduled medications listed: -potassium 20 [NAME] one a day -[MEDICATION(S)] 1000 mcg one time a day -multivitamin one time a day -[MEDICATION(S)] 6.25 mg two times a day -[MEDICATION(S)] 1 mg one time a day -[MEDICATION(S)] sulfate two puffs two times a day -[MEDICATION(S)] 200 mg one time a day -budesonide -[MEDICATION(S)] two puffs two times a day -[MEDICATION(S)] 100 mg one time a day. The audit reflected on 11/02/2022 the 8:00a.m. and 9:00a.m. medications were administered at 11:08 a.m. Further review of the audit reflected on 11/01/2022 the morning medications were administered at 10:24 a.m., on 10/31/2022 at 10:32 a.m., and on 10/29/2022 at 1:08 p.m. (13:08). Review of resident #15 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. listed: -[MEDICATION(S)] HCL 5 mg one time a day -[MEDICATION(S)] 25 mg one tablet two times a day -[MEDICATION(S)] XL 25 mg give one two times a day -[MEDICATION(S)] 10 mg one time a day -aspirin 81 mg one time a day [MEDICATION(S)] 10 mg one time a day [MEDICATION(S)] HCL ER give one tablet two times a day. The audit did not reflect an administration time for the day. Further review of the audit revealed on 11/01/2022 the morning medication were administered at 10:31 a.m., on 10/31/2022 at 10:51 a.m., and on 10/30/2022 at 10:33 a.m. On 11/02/2022 at 1:09 p.m. during an interview with the NHA, she stated, we started an ad hoc training on medications given on time, lacking organization skills, and less distractions. It is being provided by the Staff Development Coordinator at this time. She said we have unit managers (UM) that help the nurses during the day and perform treatments. The NHA confirmed it is her expectation the staff would deliver the residents with their medications timely. On 11/02/2022 at 1:18 p.m. an interview was conducted with the Director of Nursing (DON) related to the residents on the 400 unit not being provided their medications in a timely manner. She stated, will call the Physician and inform them. She said normally I would have two-unit managers on the units. One is out today and the second one is working a unit. She said she was unaware a nursing assistant did not show up today. Review of the policy titled Medication Administration dated 2007. General Guidelines Policy Medications are administered as prescribed in accordance with manufactures specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. PROCEDURES Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered in according to the established medication administered schedule for the nursing center. 2. Review of Resident #3 Admission Record form revealed the resident had resided at the facility for over a year. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Dysarthria - difficulty speaking caused by brain damage, which results in an inability to control the muscles used in speech. Dysphagia - difficulty swallowing, which can be a symptom of dysarthria). A review of progress notes dated on 09/27/2022 at 10:28 a.m. reflected a Therapy Referral was made for Speech (ST) consult for evaluation (eval) and treatment (tx) for dysphagia and increased difficulty swallowing. At 1:43 p.m. (13:43) Therapy referral received. Signed by the Speech Therapist. A continued review of progress notes dated 10/06/2022 at 1:01 p.m. (13:01) revealed a Therapy Referral The following were noted: Difficulty feeding self. While: not eating Referral was made to speech (SP) Further review of progress notes dated 10/12/2022 08:33 revealed Therapy Referral Received. Signed by the Director of Therapy Services. At 10:34 a.m. resident reports difficulty with eating utensils. She is requiring increased assistance with meals. Therapy referral noted. On 11/02/2022 at 3:55 p.m. an interview was conducted with the Speech Therapist (ST). She said she knew Resident #4 and had worked with her in the past. The ST said Resident #4 was able to understand when she was spoken to. She had dysarthria and mild cognitive impairments but not significant. Her primarily goals were dysphagia and speech. She was cooperative and receptive to the therapy. She said she additionally had worked with the resident the day (10/13/2022) prior to being discharged to the hospital. The ST said her first treatment was 10/05/2022. The ST confirmed there had been an eight-day delay. She stated, sometimes when the nursing referral goes into [name of the computer system] there is a breakdown in communication. On 11/02/2022 at 4:10 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated, The Therapy Department is responsible for running their daily reports. On 11/03/2022 at 10:10 p.m. an interview was conducted with the Rehabilitation Director and the NHA. The Director said she had received a speech evaluation recommendation for Resident #4 on 09/27/2022. She confirmed the resident was not seen until 10/05/2022. The Director said she has one speech therapist. She continued, saying, if necessary, a sister facility therapist can come over and help. The Director stated, the Speech therapist was off on 09/30, (Friday), 10/01, 10/02, and returned on 10/03/2022. She further said she was off on 10/02/2022. The Director said when she returned on 10/03/2022, she went through the box of paperwork and assigned the evaluation to start on 10/05/2022. She added, that was the soonest it could be done. When asked if she had asked for assistance to get the evaluation (speech) done, she said she had not. The Director said normally evaluations are completed within three days of the referral. She confirmed the evaluation took nine days to implement care after receiving.

Based on observation, record review and interviews, the facility failed to comprehensively implement the facility Grievance policy and procedures for four (#8, #2, #3, and #4) of fifteen sampled residents. Findings include: A review of the facility policy and procedure, Grievance/ Concern Management, effective February 2021, documented the policy: Residents/representatives have the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing and the reporter may request to remain anonymous . These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. The Procedure included: .4. The NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. 6. The department involved will document the concern and record the resident/resident representative's satisfaction with the resolution to the concern . 10. Concerns are tracked, trended, and reported in monthly QAPI Committee Meeting. 1. On 11/02/2022 at 9:35 a.m., Resident #8 was observed in her bed in her room. She agreed to an interview, and stated, the staff member with the orange jacket, who was working today, her language is not appropriate, and she followed with explicative comments, which she reported the staff member used. Resident #8 said she had told someone two days ago. Resident #8 stated, they put a stop to it. Now she does not say anything at all. She is rough. She throws my legs out of the bed. I cannot lift them because they are so filled with fluid. It is painful when she cares for me. She roughs me up. Some people are really nice, and they take care to be sensitive and move you gently. Not her. The Certified Nursing Assistant (CNA) with the orange jacket was observed in the hallway outside of Resident #8's room, and she was identified to be Staff C. A review of the facility grievance log for the date of 05/01/2022 through the date of survey, 11/02/2022 reflected no grievances from Resident #8. An interview was conducted on 11/02/2022 at 10:00 a.m. with the Social Service Director (SSD). He stated Resident #8 had not complained or filed a grievance. An interview was conducted on 11/02/2022 at 4:40 p.m. with the Payroll Specialist. She confirmed she had access to the personnel files and reported there were no reports or disciplinary action for Staff C, for use of inappropriate language that she was aware of. She said, if so, it should have gone to social services. On 11/03/2022 at 9:57 a.m., during an interview with the Nursing Home Administrator (NHA), she stated she had gone and talked to Resident #8 yesterday after the Payroll Specialist had told her about the surveyor asking if there were any disciplinary or counseling for Staff C, CNA. The NHA stated she had suspended Staff C yesterday, and she file a reportable event form. 2. A review of Resident #2's clinical chart, the face sheet, reflected an admission of 03/02/2022, and a subsequent discharge of 07/08/2022. A phone interview was conducted on 11/03/2022 at 11:25 a.m. with Resident #2's family member. The family member stated, she had visited her mother in July, and she mentioned to her she was missing $95.00. The family member reported she had given her the $95.00 with her identification at admission. The daughter stated, they said they would look for it. Never heard anything else. A review of the facility Grievance log reflected no grievances for missing money for Resident #2. On 11/03/2022 at 11:35 a.m., the SSD was interviewed. He stated he was not aware of $95.00 missing for Resident #2. 3. On 11/01/2022 at 1:58 p.m. a phone interview was conducted with Resident #3 family member, who confirmed she felt like someone was taking her mother's money. She said staff were probably changing her mother money to get things for her. She stated, how else would $10.00 be gone in 2 days? The family member said she had told a staff member about the missing money. She indicated she could not recall the staff member name. Review of the facility provided Grievance Log did not reveal an entry for Resident #3 related to missing money. On 11/03/2022 at 11:35 a.m. interview was conducted with the SSD, who said he was not aware of any missing money for Resident #3. 4. On 11/02/2022 at 9:25 a.m. Resident #4 was observed in his bed and when approached he was receptive to an interview. He appeared comfortable and answered questions appropriately. Resident #4 said he was missing a [sports team] T-shirt and it was blue in color. He stated, it was brand new, and I had only worn it one time. He further stated, I told the social worker about it. He said it was a couple of months ago, and denied the social worker followed-up with him. Review of the facility provided Grievance Log did not reveal an entry for Resident #4 for the prior five months. On 11/03/2022 at 10:30 a.m. an interview was conducted with the Nursing Home Administrator (NHA), who stated, I am unaware he had a missing [sports team] T-[NAME].t The NHA confirmed if a resident had a concern with a missing item, there should be an entry in the grievance log. On 11/03/2022 at 10:19 a.m. an interview was conducted with the SSD, who confirmed he knew Resident #4. When asked about his concern related to a missing [sports team] T-shirt, he stated I remember him telling me about it. I don't recall when it was. I can't recall if it was last month, I really can't recall how long it had been. The SSD said when a resident is missing something he would normally write it down in the Grievance Log. He reviewed the log that was provided by the facility and confirmed that the log did not reflect a grievance for the missing shirt for Resident #4.

Based on record review, and interviews, the facility failed to ensure it implemented the facility Abuse Prevention Program related to the absence of Abuse and Neglect training for one (Staff B, Certified Nursing Assistant) of five direct care staff members reviewed. Findings include: On 11/02/2022 at 2:20 p.m. the Nursing Home Administrator (NHA) was asked to provide Level II background screenings, most recent Abuse & Neglect training, and license information for five direct care staff members, which included Staff B, Certified Nursing Assistant (CNA). A review of Staff B's Certified Nursing Assistant (CNA) personnel file reflected a hire date of 10/10/2022. The facility did not provide evidence Staff B, CNA had received Abuse and Neglect training. Further review of Staff B's personnel file reflected she had formerly terminated employment from the facility on the date of 04/28/2022. An interview was conducted on 11/03/2022 at 11:47 a.m. with the NHA. She confirmed Staff B, CNA, had been hired on 10/10/2022 and Staff B, CNA was a rehired employee. The NHA reported Staff B had received a copy of the employee handbook, which she stated the employee had signed receipt of, and in that handbook on page 34, she said the handbook covered Abuse and Neglect training. A review of the handbook reflected a risk management paragraph, and under this paragraph, the handbook briefly outlined abuse reporting. On 11/03/2022 at 12;07 p.m. an interview was conducted with the Staff Educator, Registered Nurse (SERN). She confirmed she normally would provide education to employees. She stated Staff B, CNA was a rehire, so, she only signed the employee handbook. The SERN said, Staff B did not have the Abuse and Neglect training with the new hired employees, because she was a rehire. On 11/03/2022 at 12:54 p.m., an interview was conducted with the Regional Nurse Consultant (RNC). She provided the facility Day 1 Agenda Checklist New Employee Orientation summary list which listed the orientation curriculum. Included in the curriculum was a 1-hour long session, which included Risk Management and Events Reporting; Abuse/Neglect/ Exploitation/Mistreatment and Misappropriation-Immediate Reporting; Compliance Hotline; Leave of Absence/Elopement/Missing Residents; Quality Assurance; Smoking and Designated Areas; and Elder Justice Act. The RNC reported the Risk Designee was to provide the training. The RNC further reported that at this time, the Risk Designee was the NHA. The facility did not provide any documentation that would indicate Staff B, CNA, had received the facility orientation. On 11/03/2022 at 1:35 p.m., the NHA provided a Post Test Abuse, Neglect and Exploitation document, dated 10/12/2021 (over one year old), that had Staff B's name printed on the cover. A review of the second page, the line that the employee would sign, was blank. A review of the facility's Abuse Prevention program policy and procedures, effective date January 2012, last reviewed October 2022, documented the policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. Included in procedures: Training: Facility orientation program & ongoing training programs will include, but may not be limited to: 483.95 (c): Freedom from abuse, neglect, & exploitation requirements in 483.13. 483.95 (c): Activities that constitute abuse, neglect, exploitation, & misappropriation of resident property as set forth in 483.12. 483.95 (c): procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. 483.95 (c): Dementia management & resident abuse prevention. Elder Justice Act. Identification of abuse, neglect, mistreatment, exploitation, and misappropriation. Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. Refer to Behavior Management program and Code CAT process for further information. How staff should report their knowledge related to allegations without fear of reprisal. How to provide protection for residents. Components of a complete and through investigation. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques. Refer to HR Manual for identifying and managing staff burnout, and [NAME] (Employee Assistance Program) availability. Staff training will be documented and maintained with facility education records.

Based on interviews and policy review, the facility did not ensure residents could voice grievances in a safe manner and did not respond to grievances in a timely manner regarding concerns expressed by 8 named residents (Resident #79, #1, #6, #22, #302, #46, #71 and #76) out of 50 sampled residents, and additional unnamed residents. Findings include: On 02/14/22 at 12:44 p.m., an interview was conducted with Resident #6. Resident #6 stated her sister filed a grievance on her behalf related to a staff member in the kitchen who was rude and mean. Resident #6 stated a meeting was held with herself, her sister the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Resident #6 stated she was not provided any feedback related to that grievance and the staff member treated her worse after she reported. On 02/16/22 at 4:09 p.m., an interview was conducted with the DON related to Resident #6's grievance meeting. The DON stated she remembers having a meeting with the sister and the NHA. The DON said, Honestly I can't remember what it was about. The grievance form and notes related to that meeting were requested but not provided. An interview was conducted with the NHA on 02/16/22 at 5:45 p.m., related to Resident #6's grievance meeting. The NHA stated they had a meeting with the DON and her sister but, he could not remember what it was about. The NHA stated he could not say if it was about an employee interaction. The NHA further stated the same employee had a negative interaction with a resident this week, and that she had been suspended pending the investigation. The NHA stated Resident #6 had stopped him and stated that she heard the same kitchen employee raising her voice to a resident who wanted a cup of hot water. The NHA stated he went to the kitchen and got the resident the hot water he needed. The NHA stated he spoke to the employee's manager. When asked if he had filed a grievance for this resident. The NHA said, No, but I have started the process. When asked if he had notified the Social Services Director (SSD) about the grievance, the NHA said, No, but I have started the process. The NHA denied remembering any grievances related to the employee. An interview was conducted with Resident #71 on 02/14/22 at 12:47 p.m. Resident #71 stated there is a staff member in the kitchen who is very rude. Resident #71 said, If you report her, I know she will retaliate and not put something on your tray or who knows what else she could do. Resident #71 stated the NHA knows about it. Resident #71 stated the residents have complained about this employee's behavior. During observation of a Resident Council meeting on 02/16/22 at 2:30 p.m., sixteen residents who attended the meeting expressed fear of retaliation related to reporting or filing grievances. The residents said in regard to staff, They get back at you, They sweep things under the rug, No point reporting, Don't know where to find forms, They never acknowledge what is going on, No point submitting a grievance, Don't write down our names, and We don't want to cause trouble. The residents reported they had not filed grievances related to staff who they said were mean stating, Can't say their names, and Don't want to pay the price. On 02/14/22 at 3:04 p.m., an interview was conducted with Resident #76, Resident Council President. Resident #76 stated she had received residents' grievances related to cold food, missing laundry and call lights not answered in a timely manner. Resident #76 stated she handed them over to the Social Services Director (SSD). Resident #76 said, The problem is that they don't report the resolution. The residents are not heard. Resident #76 stated sometimes the residents don't say anything at all because the administration will not respond. Resident #76 stated residents fear some of the certified nurse's aides (CNAs). On 02/14/22 at 12:57 p.m., a brief interview was conducted with Resident #46. Resident #46 expressed fearing to report his concerns. During the interview, Resident #46 avoided eye contact and stopped talking as a staff member passed by. Resident #46 stated some of the staff are rude, and the management does not do anything about it. Resident #46 discontinued the interview as a staff member walked into the room. On 02/15/22 at 3:00 p.m., a second interview was conducted with Resident #46. Resident #46 stated the facility has gone down. Resident #46 stated there was no safe forum to voice grievances. Resident #46 stated it did not matter if he filed a grievance or not. Resident #46 stated he felt the administration did not care. On 02/14/22 at 12:57 p.m., an interview was conducted with Resident #1. Resident #1 reported he had concerns that he could not express to the management. Resident # 1 said, They don't respond to grievances. Resident #1 reported being fearful of retaliation for reporting his concerns. Resident #1 stated he did not want to continue the interview and was observed constantly looking at the doorway during the interview. On 02/15/22 at 9:11 a.m., Resident #1 was observed in his room after breakfast. Resident #1 stated he would like to speak with the surveyor some more today. Resident #1 stated he does not want staff to see him talk to the surveyor for fear of someone getting back at him. An interview was conducted with Resident #1 on 02/15/22 at 2:45 p.m Resident #1 reported his main concerns was there was no respect for privacy. Resident #1 stated he had not filed a grievance because there was no safe forum. Resident #1 stated the facility does not respond to complaints related to staff behavior. In an interview with the SSD on 02/16/22 at 11:28 a.m., The SSD stated Resident #302 had filed a complaint a year ago related to customer service. The SSD stated the grievance related to making sure the resident's needs were met prior to leaving the room. Review of the grievance document showed check marks that indicated completion of the investigation were not checked. The SSD stated he was not at the facility at the time. The SSD stated he could not tell the specifics of the complaint, but it was documented that the resident had concerns related to staff interaction. The SSD stated he could not confirm if the grievance was resolved due to lack of documentation. The SSD stated the previous SSD should have gotten specifics related to the fear of retaliation and followed up with the administration. An interview was conducted on 02/14/22 at 10:00 a.m., with Resident #22. Resident #22 expressed concerns related to dietary and care. Resident #22 stated she has not filed a written grievance related to her concerns. Resident #22 said, I haven't filed because, they get back at you. Resident #22 said, They are watching even now to see which rooms you go to and listen to what you ask. Resident #22 stated the residents at the facility are fearful. When asked who they were fearful of, Resident #22 said, Both staff and administration. Resident #22 said, They make you pay. Resident #22 stated staff retaliate by things like delaying your care or sabotaging your meal. Resident #22 asked the surveyor to leave the room and return later because staff were lingering at the door. On 02/14/22 at 11:58 a.m., Resident #22 stated there is a staff member in the kitchen who is not nice and is rude. Her name is [staff name]. Resident #22 stated she had filed a grievance with the DON. Resident #22 stated she had not received a response related to this grievance. Resident #22 stated she did not fill out a form but spoke to the DON in person. An interview was conducted with Resident #79 on 02/15/22 at 2:31 p.m Residents #79 stated some residents would not know how to file a grievance and did not have the contact number of the local ombudsman. Resident #79 stated she was a short-term resident and did not fear speaking up. Resident #79 said, Most residents don't know how to speak up. When asked if she had filed a grievance, Resident #79 said, What good is filing a grievance if no one is going to respond. An interview was conducted on 02/16/22 at 11:28 a.m. with the SSD related to the residents' concerns with retaliation and lack of follow-up with grievances. The SSD stated when he investigates customer service complaints, the residents speak in general terms. The SSD stated they don't speak of a specific person involved or a direct incident. When asked why the residents spoke in general terms, the SSD said, I just wonder that maybe they do fear of retaliation. The SSD stated he reassures the residents their grievance is confidential. The SSD stated he has been trying to educate the residents. The SSD stated the NHA is aware of the fear concerns as expressed by the residents. The SSD said, We brought this up to him in one of our morning or afternoon meetings. The SSD said, It's unfortunate the residents are fearful. When asked if he had filed a grievance related to residents' fear of filing grievances, the SSD stated he had filed the grievance by talking to the NHA. The SSD said, I never filed it specifically, like filling out a paper form. I was trying to address the concerns. The SSD said the administration said they would do in-services. On 02/16/22 at 12:51 p.m., an interview was conducted with the NHA related to the residents' fear of retaliation. The NHA stated he had not heard of this concern. The NHA said, I am surprised that this is the culture. I am not aware that residents are afraid of voicing concerns. My door is always open. The NHA stated he did not know residents were afraid of filing grievances regarding staff. Review of a facility policy titled, Grievance / Concern Management, dated February 2021, showed the residents/representatives have the right to present concerns on behalf of themselves and/or others to the staff and administrator of the facility, to government officials, or any other person. The concern may be filed verbally or in writing and the reporter may request to remain anonymous. Residents/representatives have the right to be free from restraint, interference, coercion, discrimination or reprisal. The right includes access to ombudsman and advocates. The right also includes prompt efforts by the facility to resolve resident concerns. Review of an undated job description titled, Social Services Director, stated the SSD is responsible for identifying and providing for each resident's social emotional and psychological needs, and to continuing development of the resident's full potential during their stay at the facility.

Based on observations, staff/resident interviews and record review, the facility failed to treat residents with respect and dignity as evidenced by five staff members (A, B, D, E, F) failing to knock or announce themselves prior to entering occupied resident rooms in two halls (300 and 400) of four halls for four of four days observed (2/14/2022, 2/15/2022, 2/16/2022, and 2/17/2022). Findings include: During the days from 2/14/2022 to 2/17/2022 staff were observed to not consistently knock, announce or identify themselves prior to entering occupied resident rooms. The observations were as follows: - On 2/14/2022 at 10:08 a.m., Staff A, Certified Nursing Assistant (CNA) was observed to walk in resident room [ROOM NUMBER] and did not first knock and or announce herself. There were two residents in the room at the time. - On 2/14/2022 at 10:14 a.m. Staff B, CNA was observed to walk in resident room [ROOM NUMBER] without first knocking or announcing herself. There were two residents in the room at the time. - On 2/14/2022 at 10:16 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident in the room at the time. - On 2/15/2022 at 6:33 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two resident in the room at the time. - On 2/15/2022 at 6:37 a.m. Staff D, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident observed in the room at the time. - On 2/15/2022 at 6:42 a.m. Staff E, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two residents in the room at the time. - On 2/16/2022 at 7:50 a.m. Staff F, Licensed Practical Nurse (LPN) was observed to carry medications into resident room [ROOM NUMBER] and did not first knock or announce herself prior to entering. There was one resident in the room at the time. - On 2/17/2022 7:34 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] and did not first knock and or announce herself prior to entering. There was one resident in the room at the time. - On 2/17/2022 8:22 a.m. Staff F, LPN was observed to walk into resident room [ROOM NUMBER] and did not knock or announce herself prior to entering. There was one resident in the room at the time. Random resident interviews revealed: On 2/14/2022 at 11:45 a.m. Resident #87 revealed staff always and continually walk into his room at all times of the day and most do not knock or announce themselves. He indicated he does like his privacy and would like for them to knock. He spoke to management before with no resolution. He has stopped complaining because nothing ever gets better. On 2/14/2022 at 2:00 p.m. Resident #53 confirmed staff routinely just walk in the room and don't knock before answering. While interviewing her, an aide was observed to walk in the room and only motioned to knock on the door as she was walking in. The resident indicated this happens at times and she does not like it. She further revealed she does not like confrontation, so she has not verbally complained to anyone about it. On 2/15/2022 at 2:15 p.m. Resident #62 revealed he has had it with staff just walking in the room and they don't say anything or knock before coming in. He has complained in the past but nothing ever gets better. He would like his privacy. On 2/14/2022 at 1:30 p.m. Resident #76 confirmed staff walk in her room all the time and don't say anything or knock. She felt staff should at least announce themselves before coming in the room. Sometimes she does not even know why staff come in her room, and they don't tell her why. She has reported it to management in the past but did not remember when or who she spoke with. On 2/17/2022 at 1:30 p.m. an interview with Staff T, Registered Nurse (RN)/300/400 Unit Manager revealed it is the facility's policy for all staff to either knock or announce themselves prior to going into resident rooms, no matter what. She did not have any documented information to show she audits staff knocking and announcing prior to going in rooms. She was also unaware that residents were not comfortable with staff just walking into the rooms unannounced. On 2/17/2022 at 2:00 p.m. an interview with the Director of Nursing (DON) confirmed staff should always knock and/or announce themselves prior to going into occupied rooms and they (staff) are trained and inserviced on that matter. There was no documented evidence to show staff were trained on this area. A review of the policy and procedure titled, Personnel Policies & Employee Conduct, with an effective date of April 2017, documented the policy as: To provide guidelines and standards pertaining to Environmental Management Services Sanitation Section job-related issues. The Manner section of the policy read: Be alert, courteous, helpful and brief. Employees should report any problems or issues to their immediate supervisor. Avoid showing irritation with residents and staff members. Show job interest and willingness to learn. Take pride in job. Be considerate of residents and the staff responsible for their care. Always knock, Announce, Identify, Duration, Engage, and Thank when entering and working in a Resident's room.

Based on interviews with the facility's nursing and administrative staff, the appointed POA, the attending physician and medical director, and review of clinical records and facility policies, it was determined that the facility failed to protect the rights of resident's to refuse Cardio-Pulmonary Resuscitation (CPR) consistent with their end of life wishes for one (#4) of 28 residents identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of all current resident records and review of Resident #4 ' s clinical record on [DATE]. The facility initiated CPR on Resident #4, a [AGE] year old man with multiple co-morbidities and was admitted for End of Life Care due to a terminal [DIAGNOSES REDACTED]. Resident #4 had a signed DO NOT RESUSCITATE ORDER (DNR) completed by his appointed Power of Attorney (POA) and close friend and signed by a hospital physician on [DATE]. The facility was unable to locate Resident #4's clinical record to verify his code status when he was found unresponsive. The facility failed to honor Resident #4's advanced directives and denied the resident and the POA the opportunity to refuse treatment. The facility initiated CPR for Resident #4 without checking his code status using the system in place by the facility. The facility called 911 for the resident who was at the mercy of the staff who provided unwanted treatments of cardiac compressions and artificial ventilation to prolong life. The facility violated this resident's and the POA and close friend's wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at the last moments of his life. Failure of the facility staff to ensure the right to formulate an advance directive of DNR was honored in accordance with the resident and POA's expressed wishes to withhold the treatment and interventions of CPR, resulted in findings of immediate jeopardy which was removed on [DATE] at 12:45 p.m., and the severity and scope was reduced to a D. Findings Include: 1. A review of the medical record for Resident #4 revealed an admission record sheet with a date of birth of [DATE], ([AGE] years old) and an original date of admission to the facility of [DATE]. The admission record notated that the resident had never been married and listed himself as his own responsible party and listed the contact person as his POA and close friend. The admission record also notated an Advanced Directive of DNR. The physician orders [REDACTED]. The Advanced Directive Status was marked, "current and verified." The medical record revealed the resident had the following [DIAGNOSES REDACTED]. The advanced directives section of the clinical record revealed the following relevant documents: a. Durable Power of Attorney document signed by the Resident and the POA and close friend dated [DATE]. b. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the Resident ' s POA/close friend and hospital physician on [DATE]. c. An " ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES " form signed by the facility ' s Administrative Assistant and POA and close friend dated [DATE]. d. A review of the Advance Directives Policy and Record dated and initialed by the Administrative Assistant on [DATE] revealed: It is the facility ' s policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. 1. Decisions Concerning Medical Care and Valid Advance Directives. Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. b. Valid Advance Directives made in accordance with state law. The making of Advance Directives by the resident is not a precondition to; nor does the facility otherwise discriminate against a resident based on whether or not Advance Directives have been made. 2. Invalid Advance Directives or No Advance Directive. If the resident has an invalid Advance Directive or no Advance Directive and the resident or the representative wishes to refuse, withhold, or withdraw life sustaining medical treatment, such decision, such decision shall be made consistent with state law and in conjunction with the facility staff, management staff and the attending physician. Full consideration shall be given to the applicable law as interpreted by the Legal Department. E. An Authorization to Use and/or Disclose Health information signed and dated by the POA and close friend on [DATE]. F. A Review of the facility's "Consent to Treatment" form dated [DATE], signed by the POA and close friend revealed, "The resident and/or legal representative hereby authorizes the appropriate staff of this facility to perform such functions as are necessary to maintain the well-being of the resident, including, but not limited to bathing and hygiene, dressing, toiletry-daily activities-assistance with general nursing care, the administration of medications and treatments, the performance of therapies, as prescribed by the resident ' s physician and the resident's plan of care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the resident by federal or state law. The undersigned legal representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the resident, that documents supporting such authority have been delivered to this facility, and that such representative hereby consents on behalf of the resident to the treatment described above." The name of the authority listed at the bottom of the "Consent to Treatment" form is checked off as the Durable Power of Attorney for Health Care. A review of the physician's assessment note dated [DATE] revealed a history of present illness of a [AGE] year old with metastatic [MEDICAL CONDITIONS] resistant staph aureus (MRSA) of a urinary tract infection [MEDICAL CONDITION], cervical cord compressions, a [MEDICAL CONDITION] after a fall and stroke before Christmas. The resident had surgery for [REDACTED]. "Cardiac problems unclear of type with recent hospitalization ." There is a "large left lung mass with biopsy and then transferred from the hospital to hospice for end of life care. He then transferred to the facility with a reason for admission listed as End of Life Care. History a little unclear came from his POA and friend, major weight loss, mental decline, no improvement." The assessment noted the resident was a DNR. The review of systems noted mental impairment, wasting, clubbing and muscle wasting of the joints and extremities, heart rate very irregular, no longer able to recognize the POA and friend of 5 years, left [MEDICAL CONDITION], and questionable eroded metastatic deposit of the right scapular area. The physician's [DIAGNOSES REDACTED]. "Plan: palliative comfort care. Diagnosis: [REDACTED]. Plan: palliative comfort care; only comfort meds. Diagnosis: [REDACTED]." A review of the admission Minimum Data Set assessment (MDS) with an assessment reference date of [DATE] revealed a Brief Interview of Mental Status (BIMS) was conducted with a score of 3, which indicated severe impairment. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment." Review of the care plan initiated [DATE] revealed: Resident Advance Directives is as follows: Resident/authorized responsible party request DNR wish to be honored. Durable Power of Attorney for health care decisions, Durable Power of Attorney for financial decisions. Goal: Resident's Advance Directives will be honored. Interventions: Inform residents that Advance Directive can be revoked or changed if resident and/or appointed health care representative changes their mind about the medical care they want delivered. Verify presence of physicians order for DNR. Review DNR status and orders quarterly and PRN. Review of the care plan initiated [DATE] revealed: The resident had impaired cognitive function/dementia or impaired thought processes related to severely impaired: BIMS score ,[DATE], short term memory loss, long term memory loss. A review of the Nurse's Progress Notes revealed the following relevant entries: On [DATE], at 5:38 p.m., the Director of Nurses (DON) documented the patient was found unresponsive in his bed. No pulse and no respirations. A Code was called, and 911 were also notified. CPR was initiated. When the Paramedics arrived, they phoned their Medical Director, who pronounced the resident. On [DATE], at 5:46 p.m., the DON documented that the POA, physician, and the National Cremation were notified. The note documents that the POA came in to sit with the resident. National Cremation arrived at 2:00 p.m. The POA was notified that they had arrived to transport the Resident. A review of the complete medical record for Resident #4 revealed no Social Service or Nursing documentation was present to indicate that Advance Directive decisions had been discussed and reviewed with the resident or the POA and close friend. In fact, no Social Service notes were present in the record. 2. Review of the Resident Admission Agreement revealed: A. Facility agrees: To provide basic room and board, general nursing care, social services, dietary services, and activities as required by law. To assist, provide or obtain, as required by law, the services of providers of Resident ' s choice for necessary care. B. Consent to Treatment: The Resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident ' s physician in the Resident ' s Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided the Resident by federal and state law. C. The following provisions are applicable to all residents. The Resident and/or Legal Representative agree: To the administration of such services as are required to carry out the Resident's plan of care as Resident, Facility, and the Resident's attending physician deem appropriate, except where the Resident has indicated in writing to the Facility and Resident's physician that a particular service is refused to the extent permitted by law. To abide by all rules, regulations, policies and procedures as are from time to time established by Facility. To provide Facility with a copy of any written document indicating the Resident's choices for treatment of [REDACTED]. Our facility will protect and promote each of the following rights: Exercise of Rights: If you are not adjudged incompetent by a state court, any legal surrogate designated according to state law may exercise your rights, to the extent provided by state law. Notice of Rights and Services: You have the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive such as a living will or a durable power of attorney for health care, recognized under state law relating to the provision of health care when you are no longer able to make decisions. Free Choice: You have the right to be fully informed in advance about care and treatment and of any changes in the care or treatment that may affect your well-being and to participate in planning care and treatment or changes in care and treatment, unless you have been adjudged incompetent or found to be incapacitated under state law. Quality of Life: Dignity/Self Determination and Participation. You have the right to receive care from the facility in a manner and in an environment that promotes, maintain, or enhances your dignity and respect in full recognition of your individuality. You have the right to: (a) Choose activities, schedules, and health care consistent with your interests, assessments, and plans of care. (b) Interact with members of the community both inside and outside the nursing facility. (c) Make choices about aspects of your life in the nursing facility that are significant to you. Review of the Resident Handbook (page 13 Effective Date February 1, 2014) revealed the following relevant information: When it comes to your health information, you have certain rights. You have the right to: Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. (Page 14 Effective Date February 1, 2014) revealed the following relevant information: Your choices If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. 3. An interview was conducted on [DATE] at 3:00 p.m. with Employee F, Administrative Assistant, who confirmed that she assists admissions by going over the admission paperwork with new, admits. I just help out the admission director with admission packs and what to go over with the new admissions. Employee F confirmed that she had not received any training on the admission packs or what to look at when getting advanced directives from residents or their family member. " I often initial the receipt of advanced directives without seeing them based on the Social Services Director telling me she has them. " Employee F agreed by signing the Consent Received Form, it appeared she had received them, reviewed them, and that they were valid. Employee F could not recall if she had actually received Resident #4's Advanced Directives or if she just initialed that she had received them. 4. An interview was conducted on [DATE] at 3:43 p.m. with the NHA who confirmed that the Social Services Director failed to review and meet with the resident and the POA to discuss the Advanced Directives. 5. An interview was conducted on [DATE] at 3:51 p.m., with the Medical Director who confirmed that he had been notified on [DATE] of the event. The staff should have followed the facility's policy for responding to a code. We are taking this very seriously and are working on this currently in the quality meetings and I am very involved in our quality initiatives." 6. A review of the facility ' s " Code Status Orders and Response " - Policy and Procedure which was in effect at the time of the [DATE] event revealed the following information: Policy: "The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support (BLS) CPR only. No Advanced Life Support services are offered in the facility by facility staff. DNR ORDER- The resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN, and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 (DNR) document should not be placed in the resident's chart as the DNR order is not valid. The patient or authorized designee may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. Procedure for Admission: 1. Review Advance Directive acknowledgement with the Resident and the family. 2. Obtain all Advance Directive decision making documents at the time of admission when available. If not available, request the family to bring copies to the facility as soon as possible. Educate the Resident and the family of the requirement for the forms to be available and complete in order for staff to execute and Advance Directives. 3. Social Services or Nursing should discuss Advance Directive decisions with the patient and or family. Ascertain that the patient/responsible party understands the decision. 4. Notify the attending physician of the patients request for DNR status. 5. If a 1896 Florida DNR order did not accompany the Resident upon transfer, request from the attending physician, a completed 1896 DNR order (State of Florida). Assure the form is copied on yellow paper with multiple copies placed on the front of the chart. Assure the form is completed by the patient or patient representative and signed by the physician. The form must be completed with both signatures and copied on yellow paper to be valid. 6. Obtain a written physician order [REDACTED]. 7. Scan the DNR form into the electronic medical record system (where scanning is available). 8. Update the care plan and kardex system. 9. Notify all staff members of the code status. Procedure for Changing Code Status: 1. The physician and/or social services/clinical team will review the resident/patient or authorized responsible party wishes regarding code status as it relates to the current clinical condition. This discussion will include an explanation of "DNR "Do Not Resuscitate" and/or "Full Code ." If the resident/patient is a minor that has not been emancipated, the physician shall also give such explanation to the resident/patient's parents or legal guardian. 2. Obtain a completed 1896 form (State of Florida DO NOT RESUSCITATE ORDER) completed by the patient or health care representative and signed by the physician. The form must be copied on yellow paper and signed by the physician and resident/health care representative to be valid. 3. Obtain a written MD order for the patient's medical record. This can be written on a telephone order if the order is obtained in the presence of two nurses. Transcribe the order into the facility's electronic medical record system. Code status is either-full code or DNR. 4. Update the resident care plan and nursing kardex system. 5. Scan the form 1896 into electronic medical record system (where scanning is available). 6. Place the code order and the 1896 form in the front of the medical record. 7. Review in the next clinical meeting, any changes to code status or advance directives. 8. The patient retains the right to withdraw or change any type of advance directive including code status at any time. Procedure for Initiating CPR: Once CPR is started, CPR will continue until: 1. Relieved by emergency medical services, 2. Relieved by another staff member who will take over CPR, 3. Physician orders [REDACTED]. 4. Resident pulse and respirations are palpable/observable. First nurse on the scene 1. Confirms cardiac or respiratory arrest. (Point of Emphasis: CODE status must be confirmed by checking the medical record). 2. Calls for HELP. 3. Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR if appropriate based on previously expressed advanced directives. 6. Continues CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. The role of the second responder is to assist the first responder as necessary and be the coordinator of the event. The second responder will assure someone: 1. Immediately brings code cart and medical record to the patient ' s location. 2. Calls a code blue and the location over the PA system. 3. Assures that assignments are made for: a. Notifying 911. b. Notifying family and physician. c. Completing paperwork for impending transfer to the hospital. d. Waiting for emergency medical services personnel to arrive and escort them to code site. e. Designate a scribe to record activity related to the " code Blue worksheet " provided on the emergency cart. The second person should be available at all times to assist the first responder as necessary with CPR. First nurse responder at the end of the event: 1. Assures code blue worksheet is reviewed with the team and code critique is completed 2. Assures all documentation is completed in the medical record/24 hour report and DON/Administrator are notified 3. Assures code cart is replenished with used supplies. 7. A review of the facility's Policy & Procedure effective [DATE] for Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Policy: The facility has designated and implemented processes which strive to ensure the prevention and reporting of suspected, or alleged, abuse, neglect, exploitation, mistreatment and exploitation of residents/patients and their property. The facility acknowledges the following definitions: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Training: Facility orientation program and on-going training programs will include, but may not be limited to:- Definitions of abuse, neglect, mistreatment, exploitation and misappropriation. Identification of abuse, neglect, mistreatment, exploitation and misappropriation. Utilization of appropriate interventions to deal with resident behaviors that might result in harm to the resident or staff. How to provide protection for residents/patients. Components of a complete and thorough investigation. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation, that may include, but may not be limited to, recognizing signs of burnout, frustration and stress; stress management and relaxation techniques. Staff training will be documented and maintained with facility educational records. 8. A telephone interview was conducted on [DATE] at 4:13 p.m. with the resident's Power of Attorney (POA) and close friend. The POA and close friend stated, "he told me right out of his mouth (Resident #4), that he did not want to be resuscitated. This was back when he was able to talk before he had a stroke and then was diagnosed with [REDACTED].? He told me that if anything happened to him, for me to call his daughter and that, when I go I just want to go. " The POA and close friend stated the resident told her, "I can't walk, I can't talk right and I can't hear. "The POA and close friend confirmed that the resident had never been married and had a daughter who had not been in contact with him in years. The POA confirmed they were longtime friends and there was no family involvement so "I carried out his wishes". I called his daughter when that man was sick on his bed and his daughter sent me a text back stating "that man does not exist. " I made sure I let his daughter know everything, but she did not want to have anything to do with him. "I knew he wanted to be cremated and so that is what I did." The POA and close friend confirmed that the facility had called her on [DATE] at around 10:00 a.m. "They told me he had died . They did not tell me anything else. I went to the facility and sat with his body for two hours." 9. An interview was conducted on [DATE], at 10:54 a.m., with the resident ' s primary physician at the facility who confirmed he was notified immediately on [DATE] when the Resident expired. "I did not know about the facility initiating CPR until yesterday ([DATE]) when the NHA gave me a call." The resident's primary physician stated, "As I recall, this resident had been in and out of the hospital a couple of times, then went to hospice where he lived longer than expected so hospice transferred him to the facility for end of life care with advanced directives already in place. I would have honored the DNR as I would have not had a reason to think it was erroneous. " The physician confirmed that the resident was a DNR stating, "Oh, my gosh, yes he was a DNR. The resident initially had a stroke and has been going downhill for the past 5 months. The resident had lost weight, had no appetite and was recently diagnosed with [REDACTED]. "The POA clearly was invested in doing the right thing for her friend. When I assessed him he was totally death and his cognition was clearly not there. He just stared off into space." The physician confirmed that he got more of a history from the POA than the information he had received from hospice. "I admitted this resident for end of life care. The resident had [MEDICAL CONDITION] and now it had metastasized through to his right shoulder. The resident also had rapid fire [MEDICAL CONDITION], and was cachectic (wasting away). I saw him a total of three times while he was in the facility. The resident had been sick for several months and the POA confirmed that. I discussed with the POA what the resident's wishes were and I wrote them down. The resident could not hear, his cognition was minimal, his wishes had been expressed." I gave an order for [REDACTED]. But, to me his end of life wishes had been expressed and his wishes were not to be resuscitated. The facility's little glitch caused a non-productive outcome and a non-productive outcome for the resident. It would have all fallen on the POA anyway since there was no one else. There is a real difficulty here, we as physicians get DNR's all of the time, in every health care setting and we do everything we can to ensure they are correct. This DNR was initiated in the hospital, accepted in hospice and accepted by this facility when the Resident was admitted . The resident was admitted by me for end of life care and there should have been no question about his code status. " 10. An interview on [DATE] at 1:48 p.m. with Employee A revealed she was the assigned Certified Nursing Assistant for Resident #4 on [DATE]. She recalled feeding the resident breakfast that morning and he began coughing. Employee A went and got Employee B, Resident #4's assigned nurse, who checked his throat and elevated the head of the resident ' s bed. Employee A stated she then left Resident #4 in the care of his nurse and began caring for other residents. The next thing, Employee A recalled was coming back in to check on Resident #4 who was found to be alone, with the head of the bed still elevated, but he was slumped over and looked yellow and was cold to the touch. She could not recall how much time had elapsed between the time in which she had left the resident with the nurse and returned to find him in this state. Employee A stated she then went and got Employee B again. When Employee B observed the resident, she (Employee B) called a Code Blue and instructed Employee A to go get the resident's chart. Employee A did not make an attempt to retrieve the chart as she thought someone else had. The last thing Employee A recalled was someone coming down the hall with the crash cart. Employee A stated she heard the Director of Nursing (DON) arrive at the room and state " You have started CPR, keep going. " Employee A did not have any further involvement in the event. 11. An interview was conducted on [DATE] at 1:30 p.m. with the Risk Manager, R.N., who confirmed that she heard the overhead page on [DATE] for the code blue and she responded. "When I got to the resident's room, I saw the resident in bed and assessed the resident. There was no pulse. I initiated CPR because Employee B, who was the resident ' s nurse that day, confirmed to me three (3) times that she was sure that the resident was a full code. I started CPR. We did not look in the chart because the chart could not be located by anyone. In fact, the record was not found and brought into the resident ' s room until the paramedics arrived. They took one look at the DNR and had me stop CPR." A follow-up interview with the Risk Manager on [DATE] at 2:10 p.m. revealed "I should not have accepted the word of Employee B telling me the esident was a full code. I should have waited on the medical record." If I had seen the medical record when the code was called and was presented with the goldenrod DNR I would not have started CPR. I should have looked for the code status in the computer, "it would have been quicker." The Risk Manager stated this incident was "majorly investigated" by our corporate nurse. The Risk Manager stated this was "definitely, a system breakdown." The Risk Manager was unsure if the Power of Attorney was notified of the CPR which was provided to Resident #4. 12. A telephone interview was conducted on [DATE] at 2:30 p.m., with Employee B who confirmed she was the nurse for Resident #4 on [DATE]. "I made my rounds on the 200 hall around 8:45 a.m., the resident had a choking spell, and I raised the head of his bed up." She could not recall who called the code that day but stated she never left the resident's side. Employee B stated she thought the resident was a full code, but I could not confirm the resident's code status since no one could find the medical record. Employee B confirmed that the DNR order would have also been in their electronic medical record system, "but I want to see the actual copy for myself. I do not trust the computer." When the paramedics arrived the medical record was brought in and the paramedics looked at the goldenrod DNR form on the medical record and instructed us to stop CPR. Employee B confirmed that later she checked the resident's code status in their electronic medical record system and that there was an order for [REDACTED]. I still do not understand was the Resident a DNR or not? Since the goldenrod DNR status was in the clinical record at the time of the event, I thought he was a DNR." Employee B stated that Resident #4 was confused and would not have been able to make his wishes known. 13. An interview was conducted on [DATE] at 1:52 p.m., with Employee C, R.N., who confirmed that a code blue was called for Resident #4 and she observed the

Based on facility policy review, review of advance directive information included in the admission packet, review of the clinical record, and interviews with facility staff, the attending physician, and the resident's close friend and Power of Attorney, it was determined that the facility failed to implement the policies and procedures for advance directives and failed to readily identify and carry out the end of life wishes regarding resuscitation for one (#4) of 28 residents identified as having Do Not Resuscitate orders (DNR), according to the [DATE] facility audit tool on all current resident records, and review of Resident #4's clinical record on [DATE]. The facility failed to implement their own policies for Code Status and Response (undated) and the execution of Advanced Directives in accordance with their Admission Agreement. The facility initiated CPR on Resident #4, a [AGE] year old man with metastatic [MEDICAL CONDITION]. This resident had a signed State of Florida do not resuscitate order (DNR) dated [DATE] by the hospital physician and power of attorney and close friend as well as a DNR order issued by the facility's attending primary care physician dated [DATE]. Both of these documents had been filed in the facility's clinical record without any further review by facility staff. The facility's systems reflected that this was a valid DNR and failed to honor it during the event as the resident's clinical record could not be located when he was found absent of pulse and respirations. The facility's system break down began at the time of admission. The facility failed to follow their procedure for admission in accordance with their Code Status Orders & Response Policy & Procedure. The facility failed to honor Resident #4's DNR order and allow him and his close friend and POA the opportunity to refuse treatment. The facility called 911 for the resident who was at the mercy of the staff and provided him with unwanted treatments of cardiac compressions and artificial ventilation to prolong 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. Review of the Resident Admission Agreement revealed A. Facility agrees: 1. To provide basic room and board, general nursing care, social services, dietary services, and activities as required by law. 2. To assist, provide or obtain, as required by law, the services of providers of Resident's choice for necessary care. B. Consent to Treatment: The Resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided the Resident by federal and state law. C. The following provisions are applicable to all residents. The Resident and/or Legal Representative agree: To the administration of such services as are required to carry out the Resident's plan of care as Resident, Facility, and the Resident's attending physician deem appropriate, except where the resident has indicated in writing to the Facility and Resident's physician that a particular service is refused to the extent permitted by law. To abide by all rules, regulations, policies and procedures as are from time to time established by Facility. To provide Facility with a copy of any written document indicating the resident's choices for treatment of [REDACTED]. Our facility will protect and promote each of the following rights: Exercise of Rights: If you are not adjudged incompetent by a state court, any legal surrogate designated according to state law may exercise your rights, to the extent provided by state law. Notice of Rights and Services: You have the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive such as a living will or a durable power of attorney for health care, recognized under state law relating to the provision of health care when you are no longer able to make decisions. Free Choice: You have the right to be fully informed in advance about care and treatment and of any changes in the care or treatment that may affect your well-being and to participate in planning care and treatment or changes in care and treatment, unless you have been adjudged incompetent or found to be incapacitated under state law. Quality of Life: Dignity/Self Determination and Participation. You have the right to receive care from the facility in a manner and in an environment that promotes, maintains, or enhances your dignity and respect in full recognition of you r individuality. You have the right to: (a) Choose activities, schedules, and health care consistent with your interests, assessments, and plans of care. (b) Interact with members of the community both inside and outside the nursing facility. (c) Make choices about aspects of your life in the nursing facility that are significant to you. Review of the Resident Handbook (page 13 Effective Date February 1, 2014) revealed the following relevant information: When it comes to your health information, you have certain rights. You have the right to: Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. (Page 14 Effective Date February 1, 2014) revealed the following relevant information: Your choices If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. 2. A review of the facility's "Code Status Orders and Response" - Policy and Procedure which was in effect on [DATE] revealed the following relevant information: Policy: "The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support (BLS) CPR only. No Advanced Life Support services are offered in the facility by facility staff. DNR ORDER- The resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN, and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 (DNR) document should not be placed in the Resident's chart as the DNR order is not valid. The patient or authorized designee may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. Procedure for Admission: 1. Review Advance Directive acknowledgement with the Resident and the family. 2. Obtain all Advance Directive decision making documents at the time of admission when available. If not available, request the family to bring copies to the facility as soon as possible. Educate the Resident and the family of the requirement for the forms to be available and complete in order for staff to execute and Advance Directives. 3. Social Services or Nursing should discuss Advance Directive decisions with the patient and or family. Ascertain that the patient/responsible party understands the decision. 4. Notify the attending physician of the patients request for DNR status. 5. If a 1896 Florida DNR order did not accompany the Resident upon transfer, request from the attending physician, a completed 1896 DNR order (State of Florida). Assure the form is copied on yellow paper with multiple copies placed on the front of the chart. Assure the form is completed by the patient or patient representative and signed by the physician. The form must be completed with both signatures and copied on yellow paper to be valid. 6. Obtain a written physician order [REDACTED]. 7. Scan the DNR form into the electronic medical record system (where scanning is available). 8. Update the care plan and kardex system. 9. Notify all staff members of the code status. Procedure for Changing Code Status: 1. The physician and/or social services/clinical team will review the resident/patient or authorized responsible party wishes regarding code status as it relates to the current clinical condition. This discussion will include an explanation of DNR "Do Not Resuscitate" and/or "Full Code". If the resident/patient is a minor that has not been emancipated, the physician shall also give such explanation to the resident/patient's parents or legal guardian. 2. Obtain a completed 1896 form (State of Florida DO NOT RESUSCITATE ORDER) completed by the patient or health care representative and signed by the physician. The form must be copied on yellow paper and signed by the physician and resident/health care representative to be valid. 3. Obtain a written MD order for the patient's medical record. This can be written on a telephone order if the order is obtained in the presence of two nurses. Transcribe the order into the facility's electronic medical record system. Code status is either-full code or DNR. 4. Update the resident care plan and nursing kardex system. 5. Scan the form 1896 into electronic medical record system (where scanning is available). 6. Place the code order and the 1896 form in the front of the medical record. 7. Review in the next clinical meeting, any changes to code status or advance directives. 8. The patient retains the right to withdraw or change any type of advance directive including code status at any time. Procedure for Initiating CPR: Once CPR is started, CPR will continue until: 1. Relieved by emergency medical services, 2. Relieved by another staff member who will take over CPR, 3. Physician orders [REDACTED]. 4. Resident pulse and respirations are palpable/observable. First nurse on the scene 1. Confirms cardiac or respiratory arrest. (Point of Emphasis: CODE status must be confirmed by checking the medical record.) 2. Calls for HELP. 3. Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR if appropriate based on previously expressed advanced directives. 6. Continues CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. The role of the second responder is to assist the first responder as necessary and be the coordinator of the event. The second responder will assure someone: 1. Immediately brings code cart and medical record to the patient's location. 2. Calls a code blue and the location over the PA system. 3. Assures that assignments are made for: a. Notifying 911. b. Notifying family and physician. c. Completing paperwork for impending transfer to the hospital. d. Waiting for emergency medical services personnel to arrive and escort them to code site. e. Designate a scribe to record activity related to the "code Blue worksheet" provided on the emergency cart. The second person should be available at all times to assist the first responder as necessary with CPR. First nurse responder at the end of the event: 1. Assures code blue worksheet is reviewed with the team and code critique is completed 2. Assures all documentation is completed in the medical record/24hour report and DON/Administrator are notified. 3. Assures code cart is replenished with used supplies. 3. A review of the facility's Policy & Procedure effective [DATE] for Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Policy: The facility has designated and implemented processes which strive to ensure the prevention and reporting of suspected, or alleged, abuse, neglect, exploitation, mistreatment and exploitation of residents/patients and their property. The facility acknowledges the following definitions: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Training: Facility orientation program and on-going training programs will include, but may not be limited to:- Definitions of abuse, neglect, mistreatment, exploitation and misappropriation. Identification of abuse, neglect, mistreatment, exploitation and misappropriation. Utilization of appropriate interventions to deal with resident behaviors that might result in harm to the resident or staff. How to provide protection for residents/patients. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation, that may include, but may not be limited to, recognizing signs of burnout, frustration and stress; stress management and relaxation techniques. Staff training will be documented and maintained with facility educational records. 4. A Review of the facility's policy and procedure for Core Principles for End of Life Care with an effective date of [DATE] revealed the following relevant information "The interdisciplinary team will comfort the residents/patients and their families when end-of-life is near by following the Core Principles. Clinical Policy of care at the end-of-life and the professional practice it guides should: 1. Respect the dignity of both resident/patient and caregivers. 2. Be sensitive to and respectful of the resident/patient's and family's wishes. 3. Use the most appropriate measures that are consistent with resident/patient choices. 4. Encompass alleviation of pain and other physical symptoms. 9. Respect the right to refuse treatment." 5. A telephone interview was conducted on [DATE] at 4:13 p.m. with the resident's Power of Attorney (POA) and close friend. The POA and close friend stated, "he told me right out of his mouth (Resident #4,) that he did not want to be resuscitated. This was back when he was able to talk before he had a stroke and then was diagnosed with [REDACTED].? He told me that if anything happened to him, for me to call his daughter and that, when I go I just want to go." The POA and close friend stated the Resident told her, "I can't walk, I can't talk right and I can't hear. " The POA and close friend confirmed that the Resident had never been married and had a daughter who had not been in contact with him in years. The POA confirmed they were longtime friends and there was no family involvement so "I carried out his wishes." I called his daughter when that man was sick on his bed and his daughter sent me a text back stating "that man does not exist." I made sure I let his daughter know everything, but she did not want to have anything to do with him. "I knew he wanted to be cremated and so that is what I did" The POA and close friend confirmed that the facility had called her on [DATE] at around 10:00 a.m. "They told me he had died . They did not tell me anything else. I went to the facility and sat with his body for two hours." 6. An interview on [DATE] at 1:48 p.m. with Employee A revealed she was the assigned Certified Nursing Assistant for Resident #4 on [DATE]. She recalled feeding the resident breakfast that morning and he began coughing. Employee A went and got Employee B, Resident #4's assigned nurse, who checked his throat and elevated the head of the resident's bed. Employee A stated she then left Resident #4 in the care of his nurse and began caring for other residents. The next thing, Employee A recalled was coming back in to check on Resident #4 who was found to be alone, with the head of the bed still elevated, but he was slumped over and looked yellow and was cold to the touch. She could not recall how much time had elapsed between the time in which she had left the resident with the nurse and returned to find him in this state. Employee A stated she then went and got Employee B again. When Employee B observed the Resident, she (Employee B) called a Code Blue and instructed Employee A to go get the resident's chart. Employee A did not make an attempt to retrieve the chart as she thought someone else had. The last thing Employee A recalled was someone coming down the hall with the crash cart. Employee A stated she heard the Director of Nursing (DON) arrive at the room and state "You have started CPR, keep going." Employee A did not have any further involvement in the event. 7. A telephone interview was conducted on [DATE] at 2:30 p.m., with Employee B who confirmed she was the nurse for Resident #4 on [DATE]. "I made my rounds on the 200 hall around 8:45 a.m., the Resident had a choking spell, and I raised the head of his bed up." She could not recall who called the code that day but stated she never left the resident's side. Employee B stated she thought the resident was a full code, but I could not confirm the resident's code status since no one could find the medical record. Employee B confirmed that the DNR order would have also been in their electronic medical record system, "but I want to see the actual copy for myself. I do not trust the computer." When the paramedics arrived the medical record was brought in and the paramedics looked at the goldenrod DNR form on the medical record and instructed us to stop CPR. Employee B confirmed that later she checked the resident's code status in their electronic medical record system and that there was an order for [REDACTED]. I still do not understand was the resident a DNR or not? Since the goldenrod DNR status was in the clinical record at the time of the event, I thought he was a DNR." Employee B stated that Resident #4 was confused and would not have been able to make his wishes known. 8. An interview was conducted on [DATE] at 1:30 p.m. with the Risk Manager, R.N., who confirmed that she heard the overhead page on [DATE] for the code blue and she responded. "When I got to the resident's room, I saw the resident in bed and assessed the Resident. There was no pulse. I initiated CPR because Employee B, who was the resident's nurse that day, confirmed to me three (3) times that she was sure that the Resident was a full code. I started CPR. We did not look in the chart because the chart could not be located by anyone. In fact, the record was not found and brought into the resident's room until the paramedics arrived. They took one look at the DNR and had me stop CPR." A follow-up interview with the Risk Manager on [DATE] at 2:10 p.m. revealed "I should not have accepted the word of Employee B telling me the resident was a full code. I should have waited on the medical record." If I had seen the medical record when the code was called and was presented with the goldenrod DNR I would not have started CPR. I should have looked for the code status in the computer, "it would have been quicker." The Risk Manager stated this incident was "majorly investigated" by our corporate nurse. The Risk Manager stated this was "definitely, a system breakdown." The Risk Manager was unsure if the Power of Attorney was notified of the CPR which was provided to Resident #4. 9. An interview was conducted on [DATE] at 1:52 p.m., with Employee C, R.N., who confirmed that a code blue was called for Resident #4 and she observed the crash cart being wheeled down to the resident's room. Employee C, R.N., then stated, "When I arrived to the resident's room, the Risk Manager, R.N., was on the floor and had already initiated CPR. I assumed the resident was a full code since I saw the Risk Manager on the floor doing compressions. I am not sure why my floor nurse, Employee B, thought that Resident #4 was a full code. They know they had to check the medical record first." The Risk Manager was not able to get air movement so I assisted with the respirations while she did compressions. I am not sure how much time had elapsed when the medical record was finally located and brought into the resident's room. I verified the resident had a DNR on the record. We continued CPR since we had already started and continued until the paramedics arrived. We stopped only long enough to check for a pulse, switch off and we continued. When the paramedics arrived, they saw the DNR order on the residen's record and called their boss. The paramedics instructed us to stop and the resident was pronounced dead. If I had seen the DNR on the goldenrod paper in the resident's medical record at the time of the event I would have believed it was valid. "If it was not a valid DNR then why would it be in the medical record?" 10. Further investigation and interview with the NHA on [DATE] at approximately 10:30 a.m. revealed that prior to the event CPR and Advanced Directives were covered as part of staff education on an annual basis using the Code Status and Response policy, End of Life Care Policy, Advance Directives handbook and resident rights handout. After the event on [DATE], he immediately started in-services with the staff and has since added competency testing to ensure licensed staff was knowledgeable and would respond appropriately in the future. 11. A review of in-service records for all licensed nurses involved in the [DATE] performance of CPR on Resident #4 revealed training in the past year entitled Commitment to Honoring Advance Directives. Employees B, C, and the Risk Manager all acknowledged the following: They understood the risk and benefits of a patient forming an Advance Directive. They understood their responsibilities as a nurse and employee of the facility to practice care under an Advance Directive. They had the ability to react in an emergency situation, (where decision making was critical to the outcome of the patient), to assure that the patients previously expressed desires regarding their care (i.e. full code, DNR) under the guidance of physician orders [REDACTED]. They were provided education on the procedures for executing an advance directive in this facility. They were given an opportunity to ask questions and be fully informed of their responsibilities in providing care under an Advance Directive. They did not have ethical, moral or religious philosophies that would in inhibit their ability to provide patient care under an advance directive. 12. A review of the medical record for Resident #4 revealed an Admission Record sheet with a date of birth of [DATE], ([AGE] years old) and an original date of admission to the facility of [DATE]. The Admission Record notated that the resident had never been married and listed himself as his own responsible party and listed the contact person as his POA and close friend. The Admission Record also notated an Advanced Directive of DNR. A review of the physician orders [REDACTED]. The Advanced Directive Status was marked, "current and verified." A review of the [DIAGNOSES REDACTED]. A review of the advanced directives section of the clinical record revealed the following relevant documents: a. A Durable Power of Attorney document signed by the Resident and the POA and close friend dated [DATE]. b. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the Resident's POA/close friend and hospital physician on [DATE]. c. An "ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES" form signed by the facility's Administrative Assistant and POA and close friend dated [DATE]. d. An Authorization to Use and/or Disclose Health information signed and dated by the POA and close friend on [DATE]. e. A review of the Advance Directives Policy and Record dated and initialed by the Administrative Assistant on [DATE] revealed: "It is the facility's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. 1. Decisions Concerning Medical Care and Valid Advance Directives. Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. b. Valid Advance Directives made in accordance with state law. The making of Advance Directives by the resident is not a precondition to; nor does the facility otherwise discriminate against a resident based on whether or not Advance Directives have been made. 2. Invalid Advance Directives or No Advance Directive. If the resident has an invalid Advance Directive or no Advance Directive and the resident or the representative wishes to refuse, withhold, or withdraw life sustaining medical treatment, such decision, such decision shall be made consistent with state law and in conjunction with the facility staff, management staff and the attending physician. Full consideration shall be given to the applicable law as interpreted by the Legal Department." f. A "Consent to Treatment" form dated [DATE], signed by the POA and close friend. Review of this form revealed, "The resident and/or legal representative hereby authorizes the appropriate staff of this facility to perform such functions as are necessary to maintain the well-being of the resident, including, but not limited to bathing and hygiene, dressing, toiletry-daily activities-assistance with general nursing care, the administration of medications and treatments, the performance of therapies, as prescribed by the resident's physician and the resident's plan of care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the resident by federal or state law. The undersigned legal representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the resident, that documents supporting such authority have been delivered to this facility, and that such representative hereby consents on behalf of the resident to the treatment described above." The name of the authority listed at the bottom of the Consent to Treatment form is checked off as the Durable Power of Attorney for Health Care. A review of the physician's assessment note dated [DATE] revealed a history of present illness of a [AGE] year old with metastatic [MEDICAL CONDITIONS] resistant staph aureus (MRSA) of a urinary tract infection [MEDICAL CONDITION], cervical cord compressions, a [MEDICAL CONDITION] after a fall and stroke before Christmas. The resident had surgery for [REDACTED]. "Cardiac problems unclear of type with recent hospitalization ." There is a "large left lung mass with biopsy" and then transferred from the hospital to hospice for end of life care. He then transferred to the facility with a reason for admission listed as "End of Life Care." "History a little unclear came from his POA and friend, major weight loss, mental decline, no improvement." The assessment noted the resident was a DNR. The review of systems noted mental impairment, wasting, clubbing and muscle wasting of the joints and extremities, heart rate very irregular, no longer able to recognize the POA and friend of 5 years, left [MEDICAL CONDITION], and questionable eroded metastatic deposit of the right scapular area. The physician's [DIAGNOSES REDACTED]. "Plan: palliative comfort care. Diagnosis: [REDACTED]. Plan: palliative comfort care; only comfort meds. Diagnosis: [REDACTED]." A review of the admission minimum data set assessment (MDS) with an assessment reference date of [DATE] revealed a Brief Interview of Mental Status (BIMS) was conducted with a score of 3 which indicated severe impairment. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment." Review of the care plan initiated [DATE] revealed: Resident Advance Directives is as follows: Resident/authorized responsible party request DNR wish to be honored. Durable Power of Attorney for health care decisions, Durable Power of Attorney for financial decisions. Goal: Residents Advance Directives will be honored. Interventions: Inform residents that Advance Directive can be revoked or changed if resident and/or appointed health care representative changes their mind about the medical care they want delivered. Verify presence of physicians order for DNR. Review DNR status and orders quarterly and PRN. Review of the care plan initiated [DATE] revealed: The resident had impaired cognitive function/dementia or impaired thought processes related to severely impaired: BIMS score ,[DATE], short term memory loss, long term memory loss. A review of the Nurse's Progress Notes revealed the following relevant entries: On [DATE] at 5:38 p.m., the Director of Nurses (DON) documented the patient was found unresponsive in his bed. No pulse and no respirations. A Code was called, and 911 were also notified. CPR was initiated. When the Paramedics arrived, they phoned their Medical Director, who pronounced the resident. On [DATE], at 5:46 p.m., the DON documented that the POA, physician, and the National Cremation were notified. The note documents that the POA came in to sit with the Resident. National Cremation arrived at 2:00 p.m. The POA was notified that they had arrived to transport the resident. A review of the complete medical record for Resident #4 revealed no Social Service or Nursing documentation was present to indicate that Advance Directive decisions had been discussed and reviewed with the resident or the POA and close friend. In fact, no Social Service notes were present in the record. 13. A telephone interview was conducted on [DATE] at 5:31 p.m. with the previous Director of Nurses (DON) for the facility who confirmed she was working at the facility on the day this event occurred. The DON confirmed that CPR was initiated on Resident #4 without confirming the code status on the medical record. The DON also confirmed that the resident's medical record could not be located and that the facility's policy and procedure stated to view the DNR golden rod form be

Based on an interview with facility staff and a resident's Power of Attorney and close friend, review of a Resident's medical record, and facility policies and procedures, it was determined the facility failed to honor the advanced directives for one (#4) of 28 residents identified as having do not resuscitate orders (DNR), according to the [DATE] facility audit tool on all current resident records, and review of Resident #4'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 was unable to locate Resident #4's clinical record to verify his code status per their policy and procedure entitled Code Status and Response (undated). 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 Abuse Prevention Policy and Procedure effective [DATE], the Code Status and Response policy and procedure (undated), the resident's signed State of Florida do not resuscitate order (DNR) dated [DATE] by the hospital physician, and a DNR order issued by the facility's attending primary care physician dated [DATE]. At the time of Resident #4's admission on [DATE] the facility's Administrative Assistant reviewed, received and accepted Advance Directive documents from the close friend and Power of Attorney on behalf of Resident #4 which included a State of Florida Do Not Resuscitate Order dated [DATE]. This document was placed in Resident #4's clinical record without any further review by facility staff and a physician's orders [REDACTED].#4. The facility's systems reflected that this was a valid DNR and failed to honor it during the event. The facility's system break down began at the time of admission. The facility failed to follow their procedure for admission in accordance with their Code Status Orders & Response Policy & Procedure. The facility staff failed to correctly implement the response policy and procedure resulting in findings of immediate jeopardy which was removed on [DATE] at 12:45 p.m. and the severity and scope was reduced to a D. Findings include: 1. An interview on [DATE] at 1:48 p.m. with Employee A revealed she was the assigned Certified Nursing Assistant for Resident #4 on [DATE]. She recalled feeding the resident breakfast that morning and he began coughing. Employee A went and got Employee B, Resident #4's assigned nurse, who checked his throat and elevated the head of the resident's bed. Employee A stated she then left Resident #4 in the care of his nurse and began caring for other residents. The next thing, Employee A recalled was coming back in to check on Resident #4 who was found to be alone, with the head of the bed still elevated, but he was slumped over and looked yellow and was cold to the touch. She could not recall how much time had elapsed between the time in which she had left the resident with the nurse and returned to find him in this state. Employee A stated she then went and got Employee B again. When Employee B observed the Resident, she (Employee B) called a Code Blue and instructed Employee A to go get the Resident's chart. Employee A did not make an attempt to retrieve the chart as she thought someone else had. The last thing Employee A recalled was someone coming down the hall with the crash cart. Employee A stated she heard the Director of Nursing (DON) arrive at the room and state "You have started CPR, keep going." Employee A did not have any further involvement in the event. 2. A telephone interview was conducted on [DATE] at 2:30 p.m., with Employee B who confirmed she was the nurse for Resident #4 on [DATE]. "I made my rounds on the 200 hall around 8:45 a.m., the Resident had a choking spell, and I raised the head of his bed up." She could not recall who called the code that day but stated she never left the Resident's side. Employee B stated she thought the Resident was a full code, but I could not confirm the Resident's code status since no one could find the medical record. Employee B confirmed that the DNR order would have also been in their electronic medical record system, "but I want to see the actual copy for myself. I do not trust the computer." When the paramedics arrived the medical record was brought in and the paramedics looked at the goldenrod DNR form on the medical record and instructed us to stop CPR. Employee B confirmed that later she checked the Resident's code status in their electronic medical record system and that there was an order for [REDACTED]. I still do not understand was the Resident a DNR or not? Since the goldenrod DNR status was in the clinical record at the time of the event, I thought he was a DNR. " Employee B stated that Resident #4 was confused and would not have been able to make his wishes known. 3. An interview was conducted on [DATE] at 1:30 p.m. with the Risk Manager, R.N., who confirmed that she heard the overhead page on [DATE] for the code blue and she responded. "When I got to the Resident's room, I saw the Resident in bed and assessed the Resident. There was no pulse. I initiated CPR because Employee B, who was the Resident's nurse that day, confirmed to me three (3) times that she was sure that the Resident was a full code. I started CPR. We did not look in the chart because the chart could not be located by anyone. In fact, the record was not found and brought into the Resident's room until the paramedics arrived. They took one look at the DNR and had me stop CPR." A follow-up interview with the Risk Manager on [DATE] at 2:10 p.m. revealed " I should not have accepted the word of Employee B telling me the Resident was a full code. I should have waited on the medical record." If I had seen the medical record when the code was called and was presented with the goldenrod DNR I would not have started CPR. I should have looked for the code status in the computer, "it would have been quicker." The Risk Manager stated this incident was "majorly investigated" by our corporate nurse. The Risk Manager stated this was "definitely, a system breakdown." The Risk Manager was unsure if the Power of Attorney was notified of the CPR which was provided to Resident #4. 4. An interview was conducted on [DATE] at 1:52 p.m., with Employee C, R.N., who confirmed that a code blue was called for Resident #4 and she observed the crash cart being wheeled down to the resident's room. Employee C, R.N., then stated, "When I arrived to the resident's room, the Risk Manager, R.N., was on the floor and had already initiated CPR. I assumed the Resident was a full code since I saw the Risk Manager on the floor doing compressions. I am not sure why my floor nurse, Employee B, thought that Resident #4 was a full code. They know they had to check the medical record first." The Risk Manager was not able to get air movement so I assisted with the respirations while she did compressions. I am not sure how much time had elapsed when the medical record was finally located and brought into the Resident's room. I verified the Resident had a DNR on the record. We continued CPR since we had already started and continued until the paramedics arrived. We stopped only long enough to check for a pulse, switch off and we continued. When the paramedics arrived, they saw the DNR order on the Resident's record and called their boss. The paramedics instructed us to stop and the Resident was pronounced dead. If I had seen the DNR on the goldenrod paper in the resident's medical record at the time of the event I would have believed it was valid. "If it was not a valid DNR then why would it be in the medical record?" 5. A telephone interview was conducted on [DATE] at 5:31 p.m. with the previous Director of Nurses (DON) for the facility who confirmed she was working at the facility on the day this event occurred. The DON confirmed that CPR was initiated on Resident #4 without confirming the code status on the medical record. The DON also confirmed that the Resident's medical record could not be located and that the facility's policy and procedure stated to view the DNR golden rod form before initiating CPR. The DON confirmed that the staff did not look into the facility's electronic medical record system to verify the Resident's code status stating, "There is just too much room for an error." The DON said she had spoken with the Resident ' s POA on [DATE] and informed her of his death. The DON stated, "I did not tell the resident's POA that we had performed CPR. " The DON confirmed that the Social Services Director had not followed the facility's policy and procedure to ensure the resident's advanced directives were complete and valid upon his admission. We started staff education regarding our CPR policy and procedure after this event. There were no changes made to the policy and procedure, we just re-enforced what our procedure was. The DON stated, "This was a very serious mistake. I guess in hindsight, we did not follow our facility policy and procedure on admission to verify the advance directives. We accepted the Resident code status as a DNR." 6. A telephone interview was conducted on [DATE] at 4:13 p.m. with the resident's Power of Attorney (POA) and close friend. The POA and close friend stated, "he told me right out of his mouth (Resident #4,) that he did not want to be resuscitated. This was back when he was able to talk before he had a stroke and then was diagnosed with [REDACTED].? He told me that if anything happened to him, for me to call his daughter and that, when I go I just want to go." The POA and close friend stated the Resident told her, "I can't walk, I can't talk right and I can't hear." The POA and close friend confirmed that the resident had never been married and had a daughter who had not been in contact with him in years. The POA confirmed they were longtime friends and there was no family involvement so " I carried out his wishes. " I called his daughter when that man was sick on his bed and his daughter sent me a text back stating " that man does not exist. " I made sure I let his daughter know everything, but she did not want to have anything to do with him. " I knew he wanted to be cremated and so that is what I did. " The POA and close friend confirmed that the facility had called her on [DATE] at around 10:00 a.m. " They told me he had died . They did not tell me anything else. I went to the facility and sat with his body for two hours. " 7. An interview was conducted on [DATE], at 10:54 a.m., with the resident's primary physician at the facility who confirmed he was notified immediately on [DATE] when the resident expired. " I did not know about the facility initiating CPR until yesterday ([DATE]) when the NHA gave me a call. " The resident's primary physician stated, " As I recall, this resident had been in and out of the hospital a couple of times, then went to hospice where he lived longer than expected so hospice transferred him to the facility for end of life care with advanced directives already in place. I would have honored the DNR as I would have not had a reason to think it was erroneous." The physician confirmed that the resident was a DNR stating, " Oh, my gosh, yes he was a DNR. The resident initially had a stroke and has been going downhill for the past 5 months. The resident had lost weight, had no appetite and was recently diagnosed with [REDACTED]. " The POA clearly was invested in doing the right thing for her friend. When I assessed him he was totally death and his cognition was clearly not there. He just stared off into space. " The physician confirmed that he got more of a history from the POA than the information he had received from hospice. "I admitted this resident for end of life care. The resident had [MEDICAL CONDITION] and now it had metastasized through to his right shoulder. The resident also had rapid fire [MEDICAL CONDITION], and was cachectic (wasting away). I saw him a total of three times while he was in the facility. The resident had been sick for several months and the POA confirmed that. I discussed with the POA what the resident's wishes were and I wrote them down. The resident could not hear, his cognition was minimal, his wishes had been expressed. " I gave an order for [REDACTED]. But, to me his end of life wishes had been expressed and his wishes were not to be resuscitated. The facility's little glitch caused a non-productive outcome and a non-productive outcome for the resident. It would have all fallen on the POA anyway since there was no one else. There is a real difficulty here, we as physicians get DNR's all of the time, in every health care setting and we do everything we can to ensure they are correct. This DNR was initiated in the hospital, accepted in hospice and accepted by this facility when the resident was admitted . The resident was admitted by me for end of life care and there should have been no question about his code status. " 8. A review of the medical record for Resident #4 revealed an Admission Record sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The Admission Record notated that the resident had never been married and listed himself as his own responsible party and listed the contact person as his POA and close friend. The Admission Record also notated an Advanced Directive of DNR. Review of the care plan initiated [DATE] revealed: Resident Advance Directives is as follows: Resident/authorized responsible party request DNR wish to be honored. Durable Power of Attorney for health care decisions, Durable Power of Attorney for financial decisions. Goal: Resident's Advance Directives will be honored. Interventions: Inform resident's that Advance Directive can be revoked or changed if resident and/or appointed health care representative changes their mind about the medical care they want delivered. Verify presence of physicians order for DNR. Review DNR status and orders quarterly and PRN. Review of the care plan initiated [DATE] revealed: The resident had impaired cognitive function/dementia or impaired thought processes related to severely impaired: BIMS score ,[DATE], short term memory loss, long term memory loss. A review of the physician orders [REDACTED]. The Advanced Directive Status was marked, " current and verified. " A review of the medical record revealed the resident had the following [DIAGNOSES REDACTED]. A review of the advanced directives section of the clinical record revealed the following relevant documents: Durable Power of Attorney document signed by the resident and the POA and close friend dated [DATE]. A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's POA/close friend and hospital physician on [DATE]. An " ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES " form signed by the facility's Administrative Assistant and POA and close friend dated [DATE]. An Authorization to Use and/or Disclose Health information signed and dated by the POA and close friend on [DATE]. A facility "Consent to Treatment" form dated [DATE] signed by the POA and close friend. Review of the Consent to Treatment document revealed "The resident and/or legal representative hereby authorizes the appropriate staff of this facility to perform such functions as are necessary to maintain the well-being of the resident, including, but not limited to bathing and hygiene, dressing, toiletry-daily activities-assistance with general nursing care, the administration of medications and treatments, the performance of therapies, as prescribed by the resident's physician and the resident's plan of care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the resident by federal or state law. The undersigned legal representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the resident, that documents supporting such authority have been delivered to this facility, and that such representative hereby consents on behalf of the resident to the treatment described above." The name of the authority listed at the bottom of the Consent to Treatment form is checked off as the Durable Power of Attorney for Health Care. A review of the physician's assessment note dated [DATE] revealed a history of present illness of a [AGE] year old with metastatic [MEDICAL CONDITIONS] resistant staph aureus (MRSA) of a urinary tract infection [MEDICAL CONDITION], cervical cord compressions, a [MEDICAL CONDITION] after a fall and stroke before Christmas. surgery for [REDACTED]. Continued to have falls. Cardiac problems unclear of type with recent hospitalization . There is a large left lung mass with biopsy and then transferred from the hospital to hospice for end of life care. He then transferred to the facility with a reason for admission listed as "End of Life Care." History a little unclear came from his POA and friend. Major weight loss, mental decline, no improvement. The assessment noted the resident was a DNR. The review of systems noted mental impairment, wasting, clubbing and muscle wasting of the joints and extremities, heart rate very irregular, no longer able to recognize the POA and friend of 5 years, left [MEDICAL CONDITION], and questionable eroded metastatic deposit of the right scapular area. The physician's [DIAGNOSES REDACTED]. Plan: palliative comfort care. Diagnosis: [REDACTED]. Plan: palliative comfort care; only comfort meds. Diagnosis: [REDACTED]. A review of the admission minimum data set assessment (MDS) with an assessment reference date of [DATE] revealed a Brief Interview of Mental Status (BIMS) was conducted with a score of 3, which indicated severe impairment. According to the CMS RAI MDS 3.0 Manual: " The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment." A review of the Nurse's Progress Notes revealed the following relevant entries: On [DATE] at 5:38 p.m., The Director of Nurses (DON) documented the patient was found unresponsive in his bed. No pulse and no respirations. A Code was called, and 911 were also notified. CPR was initiated. When the Paramedics arrived, they phoned their Medical Director, who pronounced the Resident. On [DATE], at 5:46 p.m., the DON documented that the POA, physician, and the National Cremation were notified. The note documents that the POA came in to sit with the Resident. National Cremation arrived at 2:00 p.m. The POA was notified that they had arrived to transport the Resident. A review of the complete medical record for Resident #4 revealed no Social Service or Nursing documentation was present to indicate that Advance Directive decisions had been discussed and reviewed with the resident or the responsible party. In fact, no Social Service notes were present in the record. 9. A review of the facility's "Code Status Orders and Response" - Policy and Procedure which was in effect at the time of the [DATE] event revealed the following information: Policy: "The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support (BLS) CPR only. No Advanced Life Support services are offered in the facility by facility staff. DNR ORDER- The resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN, and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 (DNR) document should not be placed in the Resident's chart as the DNR order is not valid. The patient or authorized designee may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. Procedure for Admission: 1. Review Advance Directive acknowledgement with the Resident and the family. 2. Obtain all Advance Directive decision making documents at the time of admission when available. If not available, request the family to bring copies to the facility as soon as possible. Educate the resident and the family of the requirement for the forms to be available and complete in order for staff to execute and Advance Directives. 3. Social Services or Nursing should discuss Advance Directive decisions with the patient and or family. Ascertain that the patient/responsible party understands the decision. 4. Notify the attending physician of the patients request for DNR status. 5. If a DNR order did not accompany the resident upon transfer, request from the attending physician, a completed DNR order (State of Florida). Assure the form is completed by the patient or patient representative and signed by the physician. The form must be completed with both signatures and copied on yellow paper to be valid. 6. Obtain a written physician order [REDACTED]. 7. Scan the DNR form into the electronic medical record system (where scanning is available). 8. Update the care plan and kardex system. 9. Notify all staff members of the code status. Procedure for Changing Code Status: 1. The physician and/or social services/clinical team will review the resident/patient or authorized responsible party wishes regarding code status as it relates to the current clinical condition. This discussion will include an explanation of DNR " Do Not Resuscitate " and/or "Full Code." If the resident/patient is a minor that has not been emancipated, the physician shall also give such explanation to the resident/patient's parents or legal guardian. 2. Obtain a completed 1896 form (State of Florida DO NOT RESUSCITATE ORDER) completed by the patient or health care representative and signed by the physician. The form must be copied on yellow paper and signed by the physician and resident/health care representative to be valid. 3. Obtain a written MD order for the patient's medical record. This can be written on a telephone order if the order is obtained in the presence of two nurses. Transcribe the order into the facility's electronic medical record system. Code status is either-full code or DNR. 4. Update the resident care plan and nursing kardex system. 5. Scan the form 1896 into electronic medical record system (where scanning is available). 6. Place the code order and the 1896 form in the front of the medical record. 7. Review in the next clinical meeting, any changes to code status or advance directives. 8. The patient retains the right to withdraw or change any type of advance directive including code status at any time. Procedure for Initiating CPR: Once CPR is started, CPR will continue until: 1. Relieved by emergency medical services, 2. Relieved by another staff member who will take over CPR, 3. Physician orders [REDACTED]. 4. Resident pulse and respirations are palpable/observable. First nurse on the scene 1. Confirms cardiac or respiratory arrest. (Point of Emphasis: CODE status must be confirmed by checking the medical record.) 2. Calls for HELP. 3. Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR if appropriate based on previously expressed advanced directives. 6. Continues CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. The role of the second responder is to assist the first responder as necessary and be the coordinator of the event. The second responder will assure someone: 1. Immediately brings code cart and medical record to the patient's location. 2. Calls a code blue and the location over the PA system. 3. Assures that assignments are made for: a. Notifying 911. b. Notifying family and physician. c. Completing paperwork for impending transfer to the hospital d. Waiting for emergency medical services personnel to arrive and escort them to code site. e. Designate a scribe to record activity related to the "code Blue worksheet" provided on the emergency cart. The second person should be available at all times to assist the first responder as necessary with CPR. First nurse responder at the end of the event: 1. Assures code blue worksheet is reviewed with the team and code critique is completed. 2. Assures all documentation is completed in the medical record/24hour report and DON/Administrator are notified. 3. Assures code cart is replenished with used supplies. 10. A review of the facility's Policy & Procedure effective [DATE] for Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Policy: The facility has designated and implemented processes which strive to ensure the prevention and reporting of suspected, or alleged, abuse, neglect, exploitation, mistreatment and exploitation of residents/patients and their property. The facility acknowledges the following definitions: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Training: Facility orientation program and on-going training programs will include, but may not be limited to:- Definitions of abuse, neglect, mistreatment, exploitation and misappropriation. Identification of abuse, neglect, mistreatment, exploitation and misappropriation. Utilization of appropriate interventions to deal with resident behaviors that might result in harm to the resident or staff. How to provide protection for residents/patients. Components of a complete and thorough investigation. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation, that may include, but may not be limited to, recognizing signs of burnout, frustration and stress; stress management and relaxation techniques. Staff training will be documented and maintained with facility educational records. 11. An interview was conducted on [DATE] at 3:00 p.m. with Employee F, Administrative Assistant, who confirmed that she assists admissions by going over the admission paperwork with new admits. I just help out the admission director with admission packs and what to go over with the new admissions. Employee F confirmed that she had not received any training on the admission packs or what to look at when getting advanced directives from residents or their family member. "I often initial the receipt of advanced directives without seeing them based on the Social Services Director telling me she has them." Employee F agreed by signing the Consent Received Form, it appeared she had received them, reviewed them, and that they were valid. Employee F could not recall if she had actually received Resident #4's Advanced Directives or if she just initialed that she had received them. 12. An interview was conducted on [DATE] at 9:45 a.m. with the Nursing Home Administrator (NHA) and the facility's Social Services Director. Both confirmed that an event occurred on [DATE] around 8:45 a.m., during which a code blue was called involving Resident #4. The NHA stated, "I remember it well, I was running late that morning and we were to have our stand up meeting at 9:00 a.m. As soon as I got to the facility, I hear a code blue being called overhead." The Social Services Director and NHA- stated that upon admission, " we look at the advanced directives, go through and contact family at admission time to bring them in if necessary and we review the advanced directives for accuracy. With the DNRs, we look at it to make sure the appropriate people have signed them. If a family comes in with a resident that does not have a DNR with health care proxies, we review these at care planning meetings. A DNR signed by the MD is considered an order. We do not trust the accuracy of the information scanned into our electronic medical record system. We feel it is quicker to grab the chart and actually see the DNR order. If the chart cannot be found, we continue to look for the chart." The NHA stated, " we have always had the practice and even with this recent code, the chart has to go to the room." If a staff member cannot locate a resident's medical record, we would then verify a resident's code status by using the electronic medical record to verify the code status. The Social Services Director stated, "With the recent code, Employee D, our medical records person was in the computer at the desk at the nurse's station when the code was called. They have been trained to find the medical record and bring it to the room for the nurses. I don't think she thought to look up the code status in our electronic medical record system." 13. In a follow-up interview with the Social Services Director on [DATE] at 1:15 p.m. she confirmed that there was a breakdown in the process and she had missed reviewing this resident's Advanced Directive documentation upon admission. 14. An interview was conducted on [DATE] at 1:24 p.m., with Employee D, medical records clerk, who confirmed that she remembered the event and hearing the code blue being called on [DATE]. Employee D confirmed that she had been at the nurses' station in the computer system at the time of the event, but did not look up the resident's code status because their process was to get the medical record and take it down to the room so the nurse can visualize the DNR. "I never walked down to the resident's room during the code because I was looking for the resident's medical record. The record was finally found locked in the Minimum Data set (MDS) Coordinator's office. Our business office manager had a master key and went in the MDS office and found the record. I now have to confirm every POA, advanced directive, and health care surrogate to ensure accuracy before I put them on a resident's chart." 15. An interview was conducted on [DATE] at 3:56 p.m. with Employee G, LPN who confirmed that on [DATE], a code blue was called during the standup meeting and she responded to the code. " Once I was in the room everyone was y

Based on interviews, with the facility Social Services Director, Administrative Assistant, facility Administrator, nursing staff, a resident's appointed Power of Attorney (POA) and close friend, the attending physician and medical director, and review of facility policies and procedures and clinical record, it was determined that the facility failed to provide medically related social services and processes to verify, promote, and ensure end of life health care choices were honored for one (#4) of 28 residents identified as having Do Not Resuscitate order (DNR), according to a [DATE] facility audit of all current resident records and review of Resident #4's medical record on [DATE]. At the time of Resident #4's admission on [DATE], the facility's Administrative Assistant reviewed, received and accepted Advance Directive documents from the close friend and Power of Attorney on behalf of Resident #4 which included a State of Florida Do Not Resuscitate Order dated [DATE], signed by the hospital physician. This document was placed in Resident #4's clinical record without any further review by facility staff and a physician's orders [REDACTED].#4. The facility initiated CPR on Resident #4, a [AGE] year old man with multiple co-morbidities who was admitted for End of Life Care due to a terminal [DIAGNOSES REDACTED]. The facility's systems reflected that this was a valid DNR and failed to honor it during the event. The facility's system break down began at the time of admission. The facility failed to follow their procedure for admission in accordance with their Code Status Orders & Response Policy & Procedure, and their Advance Medical Directives policy and procedure effective June, 2013. The facility was unable to locate Resident #4's clinical record to verify his code status when found unresponsive. The facility's Social Services Director failed to follow her job description, (undated) and provide the oversight to assist the resident, POA and close friend and staff with execution of the resident's last wishes and accepted Advance Directives. This contributed to uncertainty among staff as to the resident's intended end of life expectations. The facility's staff failure to follow the duties, policies and procedures related to Advance Directives resulted in findings of immediate jeopardy which was removed on [DATE] at 12:45 p.m. and the severity and scope was reduced to a D. Findings Include: 1. Review of the Social Services Director (undated) job description revealed: The "Social Services Director (SSD) is responsible for initiating and maintaining a comprehensive social services program within the facility. The Social Services Director is responsible for identifying and providing each resident social, emotional, and psychological needs, and to continue the development of the resident's full potential during their stay at the facility and to assist in the planning his/her discharge." Essential Duties and Responsibilities: Counsels perspective residents/patients and families, as needed, for adequate preparation for admission to the facility. Meets with new residents/patients to answer questions. Ensures they have been informed of their personal and property rights and obtains information for a social history and assessment. Ensures that social services are coordinated with other facility services. Provides timely and appropriate psychosocial intervention for residents/patients as required. Documents the intervention. Develops a relationship with each resident/patient by visiting with them regularly. Documents problems and needs. Assesses the social, emotional, spiritual needs of the resident/patients and ensures the social services intervention is a part of the resident's/patients interdisciplinary plan of care (IPOC). Ensures that assessments are initiated and completed according to the resident's/patient's level of care, as required. Ensures that required social services interventions, as identified in each resident/patient (IPOC) are provided either directly though the department or through outside referrals. Explains IPOC process and introduces applicable interdisciplinary team members to the resident's/patient's and /or families. Attends and participates in the IPOC meetings with emphasis on medical related social services including discharge planning. Serves as primary resident/patient/family liaison regarding communication and development of interdisciplinary treatment and/or discharge plan. Assists on execution of Advance Directives, when appropriate. Abilities: Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers, and other facility staff. The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. The ability to plan, organize, develop, implement, and interpret the program goals, objectives, policies and procedures, etc., that are necessary for providing quality consulting services. 2. A review of the Social Services Manual, effective June, 2013, policy and procedure for Advance Medical Directives (S S. 4.10), revealed: Policy: At the time of the admission, the Admissions Coordinator shall furnish residents/patients, family members, and/or the legal representative with information regarding Advance Directives. The resident/patient and/or family/legal representative shall be instructed to provide the facility a copy of any current advance directive to the Director of Social Services for placement in the resident's/patient's medical record. Completion of an advance directive (s) is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further direction (e.g., to a physician) and /or information on Health Care Advance Directives as requires or requested. Procedure: 1. Verify that information on Advance Directives was provided to the resident/patient and/or family/legal representative at the time of admission. 2. Evaluate for factors that may affect the resident/patient capacity to communicate a decision. Notify physician of any concerns. 3. Provide culturally appropriate discussion/education for patient and/or responsible party. 4. Obtain any current Advance Directive from the resident/patient and/or family/legal representative, place in the medical record and update the care plan. 5. Document the Advance Directive that are current and in place on the medical record. 6. Document the Advance Directives/DNR log upon admissions, quarterly, with change in condition, and/or change in Advance Directive Status. 7. Update medical record with new or revised Advance Directives as indicated. 8. Review medical record at least quarterly and document verification of Advance Directive in place in the progress notes. A review of the Social Services Manual effective June, 2013 Guide to Health Care Decision Making Terminology for Advance Medical Directives (S S. 4.11), revealed: Incapacity is a determination by the physician that a resident is unable to make health care decision. If incapacitated, document completed by resident/patient's physician after determination that resident's not able to make his/her own healthcare decisions. Considerations: Requires a signature by one physician that he/she has determined that resident/patient is unable to make medical decisions; does not apply to any decision other than medical. A certificate of terminal illness requires documentation of two physicians' signatures; denotes resident/patient has a terminal illness and allows for initiation of resident's wishes. Considerations: Verify your state requirements prior to discontinuation of feeding tube, or other medical measure. A DNR is implemented through an order by the physician that, should the resident/patient's heart stop, and/or should reparations cease, CPR will not be initiated. Considerations; DNR signed by resident/patient; If incapacitated when DNR status is elected, the DNR is signed by healthcare decision maker; Simply means that CPR will not be initiated: treatable conditions will still be treated; Without a DNR order, CPR will be initiated; Florida requires a yellow form for emergency medical services signed by the physician, resident/patient or authorized health care decision maker. A health care proxy (HCP) is assigned to a resident representative by the facility following a determination of incapacity by the attending or consulting physician. State law may contain provisions for prioritizing who may be assigned. Considerations: Physician must complete the Certificate of Incapacity prior to activation of HCP; Verify resident/patient had not previously assigned a health care decision maker (Surrogate, POA); Proxy must accept designation as health care decision maker. A Health Care Surrogate (HCS) is appointed by resident/patient prior to any incapacity. Requires signature or two witnesses, at least one of which may not be the spouse or blood relative of the resident/patient. May be a part of a living will or POA, or a separate document. Considerations: Physician must complete the Certificate of Incapacity prior to initiation of HCS. A Power of Attorney (POA) is assigned through an attorney, by the resident, prior to any subsequent incapacity. It may be financial, or financial with health care provision. It may be effective from date signed, or with subsequent incapacity. It may be referred to as a Durable Power of Attorney if this terminology is referenced on the document. Consideration: Read the document to determine the provisions; if POA contains only financial provisions, a healthcare decision making entity will be required to identify who is/will make healthcare decisions following the determination of incapacity; If POA includes a healthcare provision, and is effective from date signed, include the resident and POA and in all healthcare decisions; If a Certificate of Incapacity is required to initiate the POA, this must be completed prior to the POA making decisions impacting the resident/patient care e.g. DNR. 3. An interview was conducted on [DATE] at 9:45 a.m. with the Nursing Home Administrator (NHA) and the facility's Social Services Director. Both confirmed that an event occurred on [DATE] around 8:45 a.m., during which a code blue was called involving Resident #4. The NHA stated, "I remember it well, I was running late that morning and we were to have our stand up meeting at 9:00 a.m. As soon as I got to the facility, I hear a code blue being called overhead." The Social Services Director and NHA- stated that upon admission, "we look at the advanced directives, go through and contact family at admission time to bring them in if necessary and we review the advanced directives for accuracy. With the DNRs, we look at it to make sure the appropriate people have signed them. If a family comes in with a resident that does not have a DNR with health care proxies, we review these at care planning meetings. A DNR signed by the MD is considered an order. We do not trust the accuracy of the information scanned into our electronic medical record system. We feel it is quicker to grab the chart and actually see the DNR order. If the chart cannot be found, we continue to look for the chart." The NHA stated, "We have always had the practice and even with this recent code, the chart has to go to the room." If a staff member cannot locate a resident's medical record, we would then verify a resident's code status by using the electronic medical record to verify the code status. The Social Services Director stated, " With the recent code, Employee D, our medical records person was in the computer at the desk at the nurses' station when the code was called. They have been trained to find the medical record and bring it to the room for the nurses. I don't think she thought to look up the code status in our electronic medical record system. 4. An interview was conducted on [DATE] at 3:00 p.m. with Employee F, Administrative Assistant, who confirmed that she assisted admissions by going over the admission paperwork with new, admits. I just help out the admission director with admission packs and what to go over with the new admissions. Employee F confirmed that she had not received any training on the admission packs or what to look at when getting advanced directives from residents or their family member. "I often initial the receipt of advanced directives without seeing them based on the Social Services Director telling me she has them." Employee F agreed by signing the "Consent Received Form," it appeared she had received them, reviewed them, and that they were valid. Employee F could not recall if she had actually received Resident #4's Advanced Directives or if she just initialed that she had received them. 5. A telephone interview was conducted on [DATE] at 5:31 p.m. with the previous Director of Nurses (DON) for the facility who confirmed she was working at the facility on the day this event occurred. The DON confirmed that CPR was initiated on Resident #4 without confirming the code status on the medical record. The DON also confirmed that the Resident's medical record could not be located and that the facility's policy and procedure stated to view the DNR golden rod form before initiating CPR. The DON confirmed that the staff did not look into the facility's electronic medical record system to verify the Resident's code status stating, "There is just too much room for an error." The DON said she had spoken with the resident's POA on [DATE] and informed her of his death. The DON stated, "I did not tell the resident's POA that we had performed CPR." The DON confirmed that the Social Services Director had not followed the facility's policy and procedure to ensure the resident's advanced directives were complete and valid upon his admission. We started staff education regarding our CPR policy and procedure after this event. There were no changes made to the policy and procedure, we just reinforced what our procedure was. The DON stated, "This was a very serious mistake. I guess in hindsight, we did not follow our facility policy and procedure on admission to verify the advance directives. We accepted the Resident code status as a DNR." 6. An interview on [DATE] at 1:48 p.m. with Employee A revealed she was the assigned Certified Nursing Assistant for Resident #4 on [DATE]. She recalled feeding the resident breakfast that morning and he began coughing. Employee A went and got Employee B, Resident #4's assigned nurse, who checked his throat and elevated the head of the resident's bed. Employee A stated she then left Resident #4 in the care of his nurse and began caring for other residents. The next thing, Employee A recalled was coming back in to check on Resident #4 who was found to be alone, with the head of the bed still elevated, but he was slumped over and looked yellow and was cold to the touch. She could not recall how much time had elapsed between the time in which she had left the resident with the nurse and returned to find him in this state. Employee A stated she then went and got Employee B again. When Employee B observed the Resident, she (Employee B) called a Code Blue and instructed Employee A to go get the Resident's chart. Employee A did not make an attempt to retrieve the chart as she thought someone else had. The last thing Employee A recalled was someone coming down the hall with the crash cart. Employee A stated she heard the Director of Nursing (DON) arrive at the room and state, "You have started CPR, keep going." Employee A did not have any further involvement in the event. 7. A telephone interview was conducted on [DATE] at 2:30 p.m., with Employee B who confirmed she was the nurse for Resident #4 on [DATE]. "I made my rounds on the 200 hall around 8:45 a.m., the resident had a choking spell, and I raised the head of his bed up." She could not recall who called the code that day but stated she never left the resident's side. Employee B stated she thought the resident was a full code, but I could not confirm the resident's code status since no one could find the medical record. Employee B confirmed that the DNR order would have also been in their electronic medical record system, "but I want to see the actual copy for myself. I do not trust the computer." When the paramedics arrived the medical record was brought in and the paramedics looked at the goldenrod DNR form on the medical record and instructed us to stop CPR. Employee B confirmed that later she checked the resident's code status in their electronic medical record system and that there was an order for [REDACTED]. "I am just confused by all of this. I still do not understand was the resident a DNR or not? Since the goldenrod DNR status was in the clinical record at the time of the event, I thought he was a DNR." Employee B stated that Resident #4 was confused and would not have been able to make his wishes known. 8. An interview was conducted on [DATE] at 1:30 p.m. with the Risk Manager, R.N., who confirmed that she heard the overhead page on [DATE] for the code blue and she responded. "When I got to the resident's room, I saw the resident in bed and assessed the resident. There was no pulse. I initiated CPR because Employee B, who was the resident's nurse that day, confirmed to me three (3) times that she was sure that the resident was a full code. I started CPR. We did not look in the chart because the chart could not be located by anyone. In fact, the record was not found and brought into the resident's room until the paramedics arrived. They took one look at the DNR and had me stop CPR." A follow-up interview with the Risk Manager on [DATE] at 2:10 p.m. revealed, "I should not have accepted the word of Employee B telling me the resident was a full code. I should have waited on the medical record." If I had seen the medical record when the code was called and was presented with the goldenrod DNR I would not have started CPR. I should have looked for the code status in the computer, "it would have been quicker." The Risk Manager stated this incident was "majorly investigated" by our corporate nurse. The Risk Manager stated this was "definitely, a system breakdown." The Risk Manager was unsure if the Power of Attorney was notified of the CPR which was provided to Resident #4. 9. An interview was conducted on [DATE] at 1:52 p.m., with Employee C, R.N., who confirmed that a code blue was called for Resident #4 and she observed the crash cart being wheeled down to the resident's room. Employee C, R.N., then stated, "When I arrived to the resident's room, the Risk Manager, R.N., was on the floor and had already initiated CPR. I assumed the resident was a full code since I saw the Risk Manager on the floor doing compressions. I am not sure why my floor nurse, Employee B, thought that Resident #4 was a full code. They know they had to check the medical record first." The Risk Manager was not able to get air movement so I assisted with the respirations while she did compressions. I am not sure how much time had elapsed when the medical record was finally located and brought into the resident's room. I verified the resident had a DNR on the record. We continued CPR since we had already started and continued until the paramedics arrived. We stopped only long enough to check for a pulse, switch off and we continued. When the paramedics arrived, they saw the DNR order on the resident's record and called their boss. The paramedics instructed us to stop and the resident was pronounced dead. If I had seen the DNR on the goldenrod paper in the resident's medical record at the time of the event I would have believed it was valid. "If it was not a valid DNR then why would it be in the medical record at the time of the event? I would have believed it was valid. "If it was not a valid DNR then why would it be in the medical record?" 10. A review of the medical record for Resident #4 revealed an Admission Record sheet with a date of birth of [DATE], ([AGE] years old) and an original date of admission to the facility of [DATE]. The Admission Record notated that the resident had never been married and listed himself as his own responsible party and listed the contact person as his POA and close friend. The Admission Record also notated an Advanced Directive of DNR. A review of the physician orders [REDACTED]. The Advanced Directive Status was marked, "current and verified." A review of the medical record revealed the resident had the following [DIAGNOSES REDACTED]. A review of the advanced directives section of the clinical record revealed the following relevant documents: a) Durable Power of Attorney document signed by the Resident and the POA and close friend dated [DATE]. b) A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the resident's POA/close friend and hospital physician on [DATE]. c) An "ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES" form signed by the facility's Administrative Assistant and POA and close friend dated [DATE]. d) A review of the Advance Directives Policy and Record, dated and initialed by the Administrative Assistant on [DATE], revealed: It is the facility's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. 1. Decisions Concerning Medical Care and Valid Advance Directives. Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. b. Valid Advance Directives made in accordance with state law. The making of Advance Directives by the resident is not a precondition to; nor does the facility otherwise discriminate against a resident based on whether or not Advance Directives have been made. 2. Invalid Advance Directives or No Advance Directive. If the resident has an invalid Advance Directive or no Advance Directive and the resident or the representative wishes to refuse, withhold, or withdraw life sustaining medical treatment, such decision, such decision shall be made consistent with state law and in conjunction with the facility staff, management staff and the attending physician. Full consideration shall be given to the applicable law as interpreted by the Legal Department. An Authorization to Use and/or Disclose Health information signed and dated by the POA and close friend on [DATE]. e) A Review of the facility "Consent to Treatment" form dated [DATE], signed by the POA and close friend revealed, "The resident and/or legal representative hereby authorizes the appropriate staff of this facility to perform such functions as are necessary to maintain the well-being of the resident, including, but not limited to bathing and hygiene, dressing, toiletry-daily activities-assistance with general nursing care, the administration of medications and treatments, the performance of therapies, as prescribed by the resident's physician and the resident's plan of care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the resident by federal or state law. The undersigned legal representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the resident, that documents supporting such authority have been delivered to this facility, and that such representative hereby consents on behalf of the resident to the treatment described above." The name of the authority listed at the bottom of the Consent to Treatment form is checked off as the Durable Power of Attorney for Health Care. A review of the physician's assessment note, dated [DATE], revealed a history of present illness of a [AGE] year old with metastatic lung cancer, methicillin resistant staph aureus (MRSA) of a urinary tract infection (UTI), cervical cord compressions, a fracture of the neck after a fall and stroke before Christmas. The resident had surgery for [REDACTED]. "Cardiac problems unclear of type with recent hospitalization ." There is a "large left lung mass with biopsy and then transferred from the hospital to hospice for end of life care. He then transferred to the facility with a reason for admission listed as End of Life Care. History a little unclear came from his POA and friend, major weight loss, mental decline, no improvement." The assessment noted the resident was a DNR. The review of systems noted mental impairment, wasting, clubbing and muscle wasting of the joints and extremities, heart rate very irregular, no longer able to recognize the POA and friend of 5 years, left hemiparesis, and questionable eroded metastatic deposit of the right scapular area. The physician's [DIAGNOSES REDACTED]. "Plan: palliative comfort care. Diagnosis: [REDACTED]. Plan: palliative comfort care; only comfort meds. Diagnosis: [REDACTED]." A review of the admission Minimum Data Set assessment (MDS) with an assessment reference date of [DATE] revealed a Brief Interview of Mental Status (BIMS) was conducted with a score of 3, which indicated severe impairment. According to the CMS Resident Assessment Instrument (RAI) MDS 3.0 Manual: "The BIMS (total score is highly correlated with Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment, where residents can hear all questions and the resident is not delirious, suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment." Review of Resident #4's care plan, initiated [DATE], revealed: Resident Advance Directives is as follows: Resident/authorized responsible party request DNR wish to be honored. Durable Power of Attorney for health care decisions, Durable Power of Attorney for financial decisions. Goal: Residents Advance Directives will be honored. Interventions: Inform residents that Advance Directive can be revoked or changed if resident and/or appointed health care representative changes their mind about the medical care they want delivered. Verify presence of physicians order for DNR. Review DNR status and orders quarterly and PRN. Review of the care plan initiated [DATE] revealed: The resident had impaired cognitive function/dementia or impaired thought processes related to severely impaired: BIMS score ,[DATE], short term memory loss, long term memory loss. A review of the Nurse's Progress Notes revealed the following relevant entries: On [DATE] at 5:38 p.m., the Director of Nurses (DON) documented the patient was found unresponsive in his bed. No pulse and no respirations. A Code was called, and 911 were also notified. CPR was initiated. When the Paramedics arrived, they phoned their Medical Director, who pronounced the Resident. On [DATE], at 5:46 p.m., the DON documented that the POA, physician, and the National Cremation were notified. The note documents that the POA came in to sit with the resident. National Cremation arrived at 2:00 p.m. The POA was notified that they had arrived to transport the Resident. A review of the complete medical record for Resident #4 revealed no Social Service or Nursing documentation was present to indicate that Advance Directive decisions had been discussed and reviewed with the resident or the POA and close friend. In fact, no Social Service notes were present in the record. 11. A telephone interview was conducted on [DATE] at 4:13 p.m. with the Resident's Power of Attorney (POA) and close friend. The POA and close friend stated, "He told me right out of his mouth (Resident #4,) that he did not want to be resuscitated. This was back when he was able to talk before he had a stroke and then was diagnosed with [REDACTED].? He told me that if anything happened to him, for me to call his daughter and that, when I go I just want to go." The POA and close friend stated the resident told her, "I can't walk, I can't talk right and I can't hear." The POA and close friend confirmed that the resident had never been married and had a daughter who had not been in contact with him in years. The POA confirmed they were longtime friends and there was no family involvement, so, "I carried out his wishes." I called his daughter when that man was sick on his bed and his daughter sent me a text back stating, "that man does not exist." I made sure I let his daughter know everything, but she did not want to have anything to do with him. "I knew he wanted to be cremated and so that is what I did." The POA and close friend confirmed that the facility had called her on [DATE] at around 10:00 a.m. "They told me he had died . They did not tell me anything else. I went to the facility and sat with his body for two hours." 12. An interview was conducted on [DATE], at 10:54 a.m., with the resident's primary physician at the facility who confirmed he was notified immediately on [DATE] when the resident expired. "I did not know about the facility initiating CPR until yesterday ([DATE]) when the NHA gave me a call." The resident's primary physician stated, "As I recall, this resident had been in and out of the hospital a couple of times, then went to hospice where he lived longer than expected so hospice transferred him to the facility for end of life care with advanced directives already in place. I would have honored the DNR as I would have not had a reason to think it was erroneous." The physician confirmed that the resident was a DNR stating, " Oh, my gosh, yes, he was a DNR. The resident initially had a stroke and has been going downhill for the past 5 months. The resident had lost weight, had no appetite and was recently diagnosed with [REDACTED]. "The POA clearly was invested in doing the right thing for her friend. When I assessed him he was totally death and his cognition was clearly not there. He just stared off into space." The physician confirmed that he got more of a history from the POA than the information he had received from hospice." I admitted this resident for end of life care. The resident had lung cancer and now it had metastasized through to his right shoulder. The resident also had rapid fire atrial fibrillation, and was cachectic (wasting away). I saw him a total of three times while he was in the facility. The resident had been sick for several months and the POA confirmed that. I discussed with the POA what the resident's wishes were and I wrote them down. The resident could not hear, his cognition was minimal, his wishes had been expressed." I gave an order for [REDACTED]. "It was a very sad case. But, to me his end of li

Based on clinical record review, policy and procedure review for Code Status and Process and Abuse Prevention Policy and Procedure, Nursing Home Administrator (NHA) job description review, and interviews with the facilities nursing and administrative staff, Power of Attorney and close friend, the attending physician, and Medical Director, it was determined that administration failed to provide resource management to ensure the right to refuse treatment and exercise advanced directives for end of life decisions were protected for one (#4) of 28 residents identified as having a DO NOT RESUSCITATE order (DNR). 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 was unable to locate the medical record for Resident #4 during an event. The facility failed to ensure that Resident #4's Advance Directives of DNR were properly carried out as facility personnel administered Cardio- [MEDICAL CONDITION] 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 advanced directives and the right to refuse treatment were honored and protected led to the findings of immediate jeopardy which was removed on [DATE] at 12:45 p.m., to a scope and severity of D. Findings Include: 1. Review of the job description for the Nursing Home Administrator signed by the NHA on [DATE], revealed the following relevant information: Summary of Position: The Nursing Home Administrator is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents. Essential Duties and Responsibilities (To be completed without harming or injuring the resident/patient, co-worker, self or others): Plans, develops, organizes, implements, and directs the facility's programs and activities; Ensures that each resident's right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced; Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations are available and followed; Conducts Residents Council Meetings regularly; Ensures that an adequate number of personnel are employed to meet the needs of the residents and State requirements; Maintains his license on a current status as required by law and maintains a copy of such license on the premise; Ensures that all facility personnel, residents, visitors, etc., follow established safety regulations to include fire protection/prevention, smoking regulations, accident prevention, sanitation/infection control, etc.; Monitors and ensures compliance with all state and federal regulations including wage and hour laws, affirmative action, Americans with Disabilities Act, OSHA and other related programs. Attends and participates in training classes, performance improvement committees, and other meetings as needed; Responsible for the financial, administrative and personnel management of the facility; Responsible for Survey Management, Responsible for Census Development; Responsible for Account Receivables Outcomes. Supervisory Responsibilities: Supervises staff whether directly or indirectly in accordance with company policies and procedures; Responsible for the hiring, selection, training and coaching of employees. Minimum Qualifications: Ability to perform all assigned tasks in accordance with the Facility's established policies and Procedures; Has the ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. 2. A review of the medical record for Resident #4 revealed an admission record sheet with a date of birth of [DATE] ([AGE] years old) and an original date of admission to the facility of [DATE]. The admission record notated that the resident had never been married and listed himself as his own responsible party and listed the contact person as his POA and close friend. The Admission Record also notated an Advanced Directive of DNR. A review of the physician orders [REDACTED]. The Advanced Directive Status was marked, "current and verified." A review of the medical record revealed the resident had the following [DIAGNOSES REDACTED]. A review of the advanced directives section of the clinical record revealed the following relevant documents: a) Durable Power of Attorney document signed by the resident and the POA and close friend dated [DATE]. b) A State of Florida DO NOT RESUSCITATE ORDER form printed on yellow goldenrod paper and signed by the Resident's POA/close friend and hospital physician on [DATE]. c) An "ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES" form signed by the facility's Administrative Assistant and POA and close friend dated [DATE]. d) An Authorization to Use and/or Disclose Health information signed and dated by the POA and close friend on [DATE]. e) A facility "Consent to Treatment" form dated [DATE] signed by the POA and close friend. Review of the Consent to Treatment document revealed, "The resident and/or legal representative hereby authorizes the appropriate staff of this facility to perform such functions as are necessary to maintain the well-being of the resident, including, but not limited to bathing and hygiene, dressing, toiletry-daily activities-assistance with general nursing care, the administration of medications and treatments, the performance of therapies, as prescribed by the resident's physician and the resident's plan of care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the resident by federal or state law. The undersigned legal representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the resident, that documents supporting such authority have been delivered to this facility, and that such representative hereby consents on behalf of the resident to the treatment described above." The name of the authority listed at the bottom of the Consent to Treatment form is checked off as the Durable Power of Attorney for Health Care. A review of the physician's assessment note dated [DATE] revealed a history of present illness of a [AGE] year old with metastatic [MEDICAL CONDITIONS] Resistant Staph Aureus. (MRSA) of a urinary tract infection [MEDICAL CONDITION], cervical cord compressions, a [MEDICAL CONDITION] after a fall and stroke before Christmas. surgery for [REDACTED]. Continued to have falls. Cardiac problems unclear of type with recent hospitalization . There is a "large left lung mass with biopsy and then transferred from the hospital to hospice for end of life care. He then transferred to the facility with a reason for admission listed as End of Life Care. History a little unclear came from his POA and friend. Major weight loss, mental decline, no improvement." The assessment noted the resident was a DNR. The review of systems noted mental impairment, wasting, clubbing and muscle wasting of the joints and extremities, heart rate very irregular, no longer able to recognize the POA and friend of 5 years, left [MEDICAL CONDITION], and questionable eroded metastatic deposit of the right scapular area. The physician's [DIAGNOSES REDACTED]. "Plan: palliative comfort care. Diagnosis: [REDACTED]. Plan: palliative comfort care; only comfort meds. Diagnosis: [REDACTED]." A review of the admission minimum data set assessment (MDS) with an assessment reference date of [DATE] revealed a Brief Interview of Mental Status (BIMS) was conducted with a score of 3, which indicated severe impairment. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment." A review of the Nurse's Progress Notes revealed the following relevant entries: On [DATE] at 5:38 p.m., the Director of Nurses (DON) documented the patient was found unresponsive in his bed. No pulse and no respirations. A Code was called, and 911 were also notified. CPR was initiated. When the Paramedics arrived, they phoned their Medical Director, who pronounced the resident. On [DATE], at 5:46 p.m., the DON documented that the POA, physician, and the National Cremation were notified. The note documented that the POA came in to sit with the resident. National Cremation arrived at 2:00 p.m. The POA was notified that they had arrived to transport the resident. A review of the complete medical record for Resident #4 revealed no Social Service or Nursing documentation was present to indicate that Advance Directive decisions had been discussed and reviewed with the resident or the close friend. In fact, no Social Service notes were present in the record. 3. Review of the care plan initiated [DATE] revealed: Resident Advance Directives is as follows: Resident/authorized responsible party request DNR wish to be honored. Durable Power of Attorney for health care decisions, Durable Power of Attorney for financial decisions. Goal: Residents Advance Directives will be honored. Interventions: Inform residents that Advance Directive can be revoked or changed if resident and/or appointed health care representative changes their mind about the medical care they want delivered. Verify presence of physicians order for DNR. Review DNR status and orders quarterly and PRN. Review of the care plan initiated [DATE] revealed: The resident had impaired cognitive function/dementia or impaired thought processes related to severely impaired: BIMS score ,[DATE], short term memory loss, long term memory loss. 4. An interview was conducted on [DATE] at 9:45 a.m. with the Nursing Home Administrator (NHA) and the facility's Social Services Director. Both confirmed that an event occurred on [DATE] around 8:45 a.m., during which a code blue was called involving Resident #4. The NHA stated, "I remember it well, I was running late that morning and we were to have our stand up meeting at 9:00 a.m. As soon as I got to the facility, I hear a code blue being called overhead." The Social Services Director and NHA- stated that upon admission, "we look at the advanced directives, go through and contact family at admission time to bring them in if necessary and we review the advanced directives for accuracy. With the DNR's we look at it to make sure the appropriate people have signed them. If a family comes in with a resident that does not have a DNR with health care proxies, we review these at care planning meetings. A DNR signed by the MD is considered an order. We do not trust the accuracy of the information scanned into our electronic medical record system. We feel it is quicker to grab the chart and actually see the DNR order. If the chart cannot be found, we continue to look for the chart." The NHA stated, "we have always had the practice and even with this recent code, the chart has to go to the room." If a staff member cannot locate a resident's medical record, we would then verify a resident's code status by using the electronic medical record to verify the code status. The Social Services Director stated, "With the recent code, Employee D, our medical records person was in the computer at the desk at the nurse's station when the code was called. They have been trained to find the medical record and bring it to the room for the nurses. I don't think she thought to look up the code status in our electronic medical record system." In a follow-up interview with the Social Services Director on [DATE] at 1:15 p.m., she confirmed that there was a breakdown in the process and she had missed reviewing this resident's Advanced Directive documentation upon admission. 5. An interview was conducted on [DATE] at 3:00 p.m. with Employee F, Administrative Assistant, who confirmed that she assists admissions by going over the admission paperwork with new admits. I just help out the admission director with admission packs and what to go over with the new admissions. Employee F confirmed that she had not received any training on the admission packs or what to look at when getting advanced directives from residents or their family member. "I often initial the receipt of advanced directives without seeing them based on the Social Services Director telling me she has them." Employee F agreed by signing the Consent Received Form, it appeared she had received them, reviewed them, and that they were valid. Employee F could not recall if she had actually received Resident #4's Advanced Directives or if she just initialed that she had received them. 6. An interview was conducted on [DATE] at 1:30 p.m. with the Risk Manager, R.N., who confirmed that she heard the overhead page on [DATE] for the code blue and she responded. "When I got to the resident's room, I saw the resident in bed and assessed the resident. There was no pulse. I initiated CPR because Employee B, who was the resident's nurse that day, confirmed to me three (3) times that she was sure that the resident was a full code. I started CPR. We did not look in the chart because the chart could not be located by anyone. In fact, the record was not found and brought into the resident's room until the paramedics arrived. They took one look at the DNR and had me stop CPR." A follow-up interview with the Risk Manager on [DATE] at 2:10 p.m. revealed, "I should not have accepted the word of Employee B telling me the resident was a full code. I should have waited on the medical record." If I had seen the medical record when the code was called and was presented with the goldenrod DNR I would not have started CPR. I should have looked for the code status in the computer, "it would have been quicker." The Risk Manager stated this incident was "majorly investigated" by our corporate nurse. The Risk Manager stated this was "definitely, a system breakdown." The Risk Manager was unsure if the Power of Attorney was notified of the CPR which was provided to Resident #4. 7. An interview was conducted on [DATE] at 1:24 p.m., with Employee D, medical records clerk, who confirmed that she remembered the event and hearing the code blue being called on [DATE]. Employee D confirmed that she had been at the nurses' station in the computer system at the time of the event, but did not look up the resident's code status because their process was to get the medical record and take it down to the room so the nurse can visualize the DNR. "I never walked down to the resident's room during the code because I was looking for the resident's medical record. The record was finally found locked in the Minimum Data Set (MDS) Coordinator's office. Our Business Office Manager had a master key and went in the MDS office and found the record." 8. An interview on [DATE] at 1:48 p.m. with Employee A revealed she was the assigned Certified Nursing Assistant for Resident #4 on [DATE]. She recalled feeding the resident breakfast that morning and he began coughing. Employee A went and got Employee B, Resident #4's assigned nurse, who checked his throat and elevated the head of the resident's bed. Employee A stated she then left Resident #4 in the care of his nurse and began caring for other residents. The next thing, Employee A recalled was coming back in to check on Resident #4 who was found to be alone, with the head of the bed still elevated, but he was slumped over and looked yellow and was cold to the touch. She could not recall how much time had elapsed between the time in which she had left the resident with the nurse and returned to find him in this state. Employee A stated she then went and got Employee B again. When Employee B observed the resident, she (Employee B) called a Code Blue and instructed Employee A to go get the resident's chart. Employee A did not make an attempt to retrieve the chart as she thought someone else had. The last thing Employee A recalled was someone coming down the hall with the crash cart. Employee A stated she heard the Director of Nursing (DON) arrive at the room and state, "You have started CPR, keep going." Employee A did not have any further involvement in the event. 9 . A telephone interview was conducted on [DATE] at 2:30 p.m., with Employee B who confirmed she was the nurse for Resident #4 on [DATE]. "I made my rounds on the 200 hall around 8:45 a.m., the resident had a choking spell, and I raised the head of his bed up." She could not recall who called the code that day but stated she never left the resident's side. Employee B stated she thought the resident was a full code, but I could not confirm the resident's code status since no one could find the medical record. Employee B confirmed that the DNR order would have also been in their electronic medical record system, "but I want to see the actual copy for myself. I do not trust the computer." When the paramedics arrived the medical record was brought in and the paramedics looked at the goldenrod DNR form on the medical record and instructed us to stop CPR. Employee B confirmed that later she checked the resident's code status in their electronic medical record system and that there was an order for [REDACTED]. I still do not understand was the resident a DNR or not? Since the goldenrod DNR status was in the clinical record at the time of the event, I thought he was a DNR." Employee B stated that Resident #4 was confused and would not have been able to make his wishes known. 10. An interview was conducted on [DATE] at 1:52 p.m., with Employee C, R.N., who confirmed that a code blue was called for Resident #4 and she observed the crash cart being wheeled down to the resident's room. Employee C, R.N., then stated, "When I arrived to the resident's room, the Risk Manager, R.N., was on the floor and had already initiated CPR. I assumed the resident was a full code since I saw the Risk Manager on the floor doing compressions. I am not sure why my floor nurse, Employee B, thought that Resident #4 was a full code. They know they had to check the medical record first." The Risk Manager was not able to get air movement so I assisted with the respirations while she did compressions. I am not sure how much time had elapsed when the medical record was finally located and brought into the resident's room. I verified the resident had a DNR on the record. We continued CPR since we had already started and continued until the paramedics arrived. We stopped only long enough to check for a pulse, switch off and we continued. When the paramedics arrived, they saw the DNR order on the resident's record and called their boss. The paramedics instructed us to stop and the resident was pronounced dead. If I had seen the DNR on the goldenrod paper in the resident's medical record at the time of the event I would have believed it was valid. "If it was not a valid DNR then why would it be in the medical record?" 11. A telephone interview was conducted on [DATE] at 4:13 p.m. with the resident's Power of Attorney (POA) and close friend. The POA and close friend stated, "he told me right out of his mouth (Resident #4,) that he did not want to be resuscitated. This was back when he was able to talk before he had a stroke and then was diagnosed with [REDACTED].? He told me that if anything happened to him, for me to call his daughter and that, when I go I just want to go." The POA and close friend stated the resident told her, "I can't walk, I can't talk right and I can't hear." The POA and close friend confirmed that the resident had never been married and had a daughter who had not been in contact with him in years. The POA confirmed they were longtime friends and there was no family involvement so "I carried out his wishes." I called his daughter when that man was sick on his bed and his daughter sent me a text back stating "that man does not exist." I made sure I let his daughter know everything, but she did not want to have anything to do with him. "I knew he wanted to be cremated and so that is what I did." The POA and close friend confirmed that the facility had called her on [DATE] at around 10:00 a.m. "They told me he had died . They did not tell me anything else. I went to the facility and sat with his body for two hours." 12. An interview was conducted on [DATE], at 10:54 a.m., with the resident's primary physician at the facility who confirmed he was notified immediately on [DATE] when the resident expired. "I did not know about the facility initiating CPR until yesterday ([DATE]) when the NHA gave me a call." The resident's primary physician stated, "As I recall, this resident had been in and out of the hospital a couple of times, then went to hospice where he lived longer than expected so hospice transferred him to the facility for end of life care with advanced directives already in place. I would have honored the DNR as I would have not had a reason to think it was erroneous." The physician confirmed that the resident was a DNR stating, "Oh, my gosh, yes he was a DNR. The resident initially had a stroke and has been going downhill for the past 5 months. The resident had lost weight, had no appetite and was recently diagnosed with [REDACTED]. "The POA clearly was invested in doing the right thing for her friend. When I assessed him he was totally death and his cognition was clearly not there. He just stared off into space." The physician confirmed that he got more of a history from the POA than the information he had received from hospice. "I admitted this resident for end of life care. The resident had [MEDICAL CONDITION] and now it had metastasized through to his right shoulder. The resident also had rapid fire [MEDICAL CONDITION], and was cachectic (wasting away). I saw him a total of three times while he was in the facility. The resident had been sick for several months and the POA confirmed that. I discussed with the POA what the resident's wishes were and I wrote them down. The resident could not hear, his cognition was minimal, his wishes had been expressed." I gave an order for [REDACTED]. But, to me his end of life wishes had been expressed and his wishes were not to be resuscitated. The facility's little glitch caused a non-productive outcome and a non-productive outcome for the resident. It would have all fallen on the POA anyway since there was no one else. There is a real difficulty here, we as physicians get DNR's all of the time, in every health care setting and we do everything we can to ensure they are correct. This DNR was initiated in the hospital, accepted in hospice and accepted by this facility when the resident was admitted . The resident was admitted by me for end of life care and there should have been no question about his code status." 13. An interview was conducted on [DATE] at 3:56 p.m. with Employee G, LPN who confirmed that on [DATE], a code blue was called during the standup meeting and she responded to the code. "Once I was in the room everyone was yelling, what's the code status? I am not sure who said it was a DNR. We looked everywhere for the medical record. I was upset when I realized the record I had been working on in my office was for" Resident #4. The resident's assessment was due that day. Employee G confirmed that the Business Office Manager had a master key, unlocked her office, got the chart and brought it down to the resident's room. Employee G confirmed that on [DATE] in the afternoon a meeting was called by the NHA and he gave the managers an in-service to make sure the charts are signed out when they leave the nurse's station. "He gave us this new process and showed us the chart sign-in and sign out form." The in-service was not on CPR, but it was on advanced directives. Employee G confirmed that the resident status code was in their electronic medical record system but that the facility's process was to check the medical record and bring it to the resident's room. The administrator was trying to educate us on the process. 14. A telephone interview was conducted on [DATE] at 5:31 p.m. with the previous Director of Nurses (DON) for the facility who confirmed she was working at the facility on the day this event occurred. The DON confirmed that CPR was initiated on Resident #4 without confirming the code status on the medical record. The DON also confirmed that the resident's medical record could not be located and that the facility's policy and procedure stated to view the DNR golden rod form before initiating CPR. The DON confirmed that the staff did not look into the facility's electronic medical record system to verify the resident's code status stating, "There is just too much room for an error." The DON said she had spoken with the resident's POA on [DATE] and informed her of his death. The DON stated, "I did not tell the resident's POA that we had performed CPR." The DON confirmed that the Social Services Director had not followed the facility's policy and procedure to ensure the resident's advanced directives were complete and valid upon his admission. We started staff education regarding our CPR policy and procedure after this event. There were no changes made to the policy and procedure, we just re-enforced what our procedure was. The DON stated, "This was a very serious mistake. I guess in hindsight, we did not follow our facility policy and procedure on admission to verify the advance directives. We accepted the resident code status as a DNR." 15. A review of the facility's "Code Status Orders and Response" - Policy and Procedure which was in effect at the time of the [DATE] event revealed the following information: Policy: "The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support (BLS) CPR only. No Advanced Life Support services are offered in the facility by facility staff. DNR ORDER- The resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN, and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 (DNR) document should not be placed in the Resident's chart as the DNR order is not valid. The patient or authorized designee may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. Procedure for Admission: 1. Review Advance Directive acknowledgement with the Resident and the family. 2. Obtain all Advance Directive decision making documents at the time of admission when available. If not available, request the family to bring copies to the facility as soon as possible. Educate the Resident and the family of the requirement for the forms to be available and complete in order for staff to execute and Advance Directives. 3. Social Services or Nursing should discuss Advance Directive decisions with the patient and or family. Ascertain that the patient/responsible party understands the decision. 4. Notify the attending physician of the patients request for DNR status. 5. If a DNR order did not accompany the Resident upon transfer, request from the attending physician, a completed DNR order (State of Florida). Assure the form is completed by the patient or patient representative and signed by the physician. The form must be completed with both signatures and copied on yellow paper to be valid. 6. Obtain a written physician order [REDACTED]. 7. Scan the DNR form into the electronic medical record system (where scanning is available). 8. Update the care plan and kardex system. 9. Notify all staff members of the code status. Procedure for Changing Code Status: 1. The physician and/or social services/clinical team will review the resident/patient or authorized responsible party wishes regarding code status as it relates to the current clinical condition. This discussion will include an explanation of DNR " Do Not Resuscitate " and/or " Full Code " . If the resident/patient is a minor that has not been emancipated, the physician shall also give such explanation to the resident/patient's parents or legal guardian. 2. Obtain a completed 1896 form (State of Florida DO NOT RESUSCITATE ORDER) completed by the patient or health care representative and signed by the physician. The form must be copied on yellow paper and signed by the physician and resident/health care representative to be valid. 3. Obtain a written MD order for the patient's medical record. This can be written on a telephone order if the order is obtained in the presence of two nurses. Transcribe the order into the facility's electronic medical record system. Code status is either-full code or DNR. 4. Update the resident care plan and nursing kardex system. 5. Scan the form 1896 into electronic medical record system (where scanning is available). 6. Place the code order and the 1896 form in the front of the medical record. 7. Review in the next clinical meeting, any changes to code status or advance directives. 8. The patient retains the right to withdraw or change any type of advance directive including code status at any time. Procedure for Initiating CPR: Once CPR is started, CPR will continue until: 1. Relieved by emergency medical services, 2. Relieved by another staff member who will take over CPR, 3. Physician orders [REDACTED]. 4. Resident pulse and respirations are palpable/observable. First nurse on the scene 1. Confirms cardiac or respiratory arrest. (Point of Emphasis: CODE status must be confirmed by checking the medical record.) 2. Calls for HELP. 3. Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR if appropriate based on previously expressed advanced directives. 6. Continues CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. The role of the second responder is to assist the fir