Every finding on record at Casa Mora Rehabilitation and Extended Care

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to: failing to provide an anti-parasitic medication to one (#2) of three residents being treated for scabies, failed to ensure staff were accurately educated on the implementation of transmission-based precautions, and ensure personal protective equipment (PPE) was readily available for one (#380) of three sampled rooms posted with transmission-based precautions.Findings included: On 2/7/26 at 1:06 p.m. an observation revealed Resident #2s room was posted with a sign for Enhanced Barrier Precautions directing staff and providers to wear gloves and gowns for high-contact resident care activities. Review of Resident #2's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified psoriasis, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, type 2 diabetes mellitus with foot ulcer, and muscle wasting and atrophy not elsewhere classified multiple sites. Review of Resident #2's paper chart revealed handwritten instructions, dated 2/4/26, from a dermatologist which included but not limited to: Treat for scabies - See handout, this will be repeated in one week (wk), treat all linens, laundry appropriately. Permethrin prescription (rx) today - begin treatment tonight, Isolation from other nursing home residents until second treatment is completed. The prescription for Permethrin, written on 2/4/26, instructed: Permethrin 5% topical cream. Apply neck down to feet overnight x 8 hours. Wash off in a.m. Repeat in 1 week. Review of Resident #2's physician orders revealed an order dated 2/4/26 at 9:54 p.m. for Ivermectin oral tablet 3 milligram (mg) - Give 3 tablets by mouth one time a day, everyday for 5 days for dermatitis- crusted, for 5 administrations. The order was to start on 2/5/26 (day after dermatology appointment) and to continue for 5 administrations. Review of Resident #2's Medication Administration Record (MAR) showed the resident's first dose of Ivermectin scheduled at 9:00 a.m. on 2/5/26, with sequential doses to be given on 2/10, 2/15, 2/20, and 2/25/26. The March MAR did not reveal any scheduled doses. The February MAR showed staff had documented 9 regarding the administration of the first dose of anti-parasitic, Ivermectin on 2/5/26. The documentation legend revealed, 9 see other/nurse's notes. An interview was conducted on 2/7/26 at 3:01 p.m. with Staff B, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff B, LPN/UM reported being told the facility did have Ivermectin in the emergency drug kit (edk). Staff B reviewed the documentation 9 for Resident #2's Ivermectin dose and the related medication administration progress note stating the note was awaiting RX for delivery, notified MD, no adverse reactions noted. Staff B stated if a medication was not available staff were to notify the MD, to see if there were new orders, or to get out of edk. Staff B, LPN/UM said the expectation was the missed dose would be added to the end of the schedule so the resident would receive the ordered 5 treatments. The staff member recognized the resident would have received 4 of the 5 ordered doses of ivermectin.Review of the pharmacy delivery times memo revealed: new order cut-off times and delivery windows included cut-off times of 9:00 p.m., with a delivery window of 12:00 a.m. - 3 a.m. and 12:00 a.m. cut-off time, with a 4:30 a.m. - 7:30 a.m. delivery time. Resident #2's ivermectin was ordered at 9:54 p.m. on Wednesday 2/4/26 allowing for a 4:30 a.m. - 7:30 a.m. delivery window. An interview was conducted on 2/7/26 at 12:11 p.m. with Staff A, LPN. Staff A, LPN stated the resident had a (dermatology) appointment, because she had a rash and the roommate was also being treated for rashes. Review of the facility policy titled Scabies Management, effective August 2025, revealed: The Facility will strive to identify the early stages of potential resident infestation with scabies during daily personal care in weekly skin assessments. It is important to remember that the first time a person gets scabies they usually have no symptoms. Symptoms typically take 4-8 weeks to develop after they are infested; However, they can still spread scabies during this time. The procedure showed:3. Implement contact precautions (due to communicability of scabies) until a diagnosis is confirmed by physician or nurse practitioner.A private room is indicated but if this is not possible, obtain a physician's order to treat the roommate.Utilize a private room for the residents who cannot use good hygiene.May cohort residents during an outbreak. 4. Wear long-sleeved gowns during close contact with the residents, their clothing or bed linens. Cover wrist area with the gown and pull the gloves over the cuff. 5. Obtain an order for the treatment of scabies and apply as directed. 10. Place resident in contact precautions and encourage resident to remain in room for 24 hours post treatment, if possible. 11. Discontinue steps 3-4 24 hours after treatment. 12. Retreat with ordered medication one (1) week later. a. Itching may last for one (1) week or more after treatment has killed the mites. b. The risk of transmission between treatments is possible. On 2/7/26 at 10:03 a.m. an observation was made of signs posted outside of Resident #6 and Resident #7's room. The signs posted showed both Contact precautions and Enhanced Barrier precautions for the residents. The area outside of the resident's room did not reveal any Personal Protective Equipment was stored at the entrance. The sign for contact precautions revealed Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves Before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. An interview was conducted on 2/7/26 at 10:03 a.m. with Staff D, LPN. Staff D, LPN stated the precautions were per protocol as Resident #6 had a wound on back. Staff D reviewed the signs posted outside of the room and stated the resident was on enhanced barrier and would have to look for the contact precautions, as she was a floater and this wasn't her cart. The staff member was unable to locate orders for Contact precautions. An interview was conducted on 2/7/26 at 10:12 a.m. with Staff E, Certified Nursing Assistant (CNA). Staff E, CAN stated being the CNA for Resident #6 and Resident #7 and did not know why the residents were on contact precautions. An observation was made on 2/7/26 at 10:56 a.m. of the Activity Director (AD) in Resident #4's room with no PPE on and in direct contact with Resident #4. A sign for contact precautions was posted on the wall outside of Resident #4's room door. No PPE was available outside of the room. The AD exited the room and reported just having a conversation with the resident and wasn't providing care so PPE did not have to be worn, just hand hygiene. The AD referred to the posted sign for Contact precautions and reported only having to do the top part of related to hand hygiene as she was just having a conversation. The AD read the sign again and stated the sign did not say PPE was to be worn if only doing care and should confirmed she should have been wearing PPE, gown and gloves, before entering the room. An interview was conducted on 2/7/26 at 10:57 a.m. with Staff B, LPN/UM and Staff C, Registered Nurse (RN). The staff members stated staff should be wearing PPE when entering Resident #4 and #5's room. Staff B, LPN/UM agreed with the door open the sign for contact precautions was hard to see. Staff C moved the PPE which was hanging inside the room to outside of the room. Staff C stated staff should know why the residents were on precautions. During an interview on 2/7/26 at 1:27 p.m. Staff G, CNA said staff should gown up before entering an Enhanced Barrier Precautions (EBP) room and the same for Contact precautions. The difference between them is goggles, and gloves is needed for contact precautions. An interview was conducted on 2/7/26 at 3:39 p.m. with the Director of Nursing (DON). The DON said believes the pharmacy delivers once in the afternoon and once late (evening), two deliveries every day and if the medication was ordered at 9:00 p.m. it would come the next day. The expectation if a medication was not at the facility, reach out to the physician and get an order to start when available from pharmacy. Staff should reach out to pharmacy and ask where the medication is and reach out to the physician to ask what they wanted to do. The DON stated the policy for scabies was for 24-hour contact precautions from treatment. The DON described the use of PPE for contact precautions as dress in gown and gloves if staff go into the room, usually they stand at doorway and gather PPE, get dressed in the hallway for contact precautions and PPE should be outside the room. The facility places PPE on the door, so it doesn't look like something crazy is going on. For EBP, PPE is kept behind the door and should be available in all EBP rooms. The DON stated nurses should know what precautions the resident was on, look it up if they have any questions. The DON stated PPE should be worn inside the contact precaution rooms and if the room is posted for contact precautions staff should honor the sign. Review of the facility's policy and procedure for Isolation Precautions - Categories of Transmission-based infections, effective October 2021, revealed: Standard precautions shall be used when caring for residents regardless of their suspected or confirmed infection status. Transmission- based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. The policy instructed for Contact Precautions: In addition to standard precautions, implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with Information Services our resident-care items in the residence environment. The policy included examples of infections requiring Contact Precautions, (9) Scabies. Further review instructed the use of gloves and handwashing after having contact with infective material and gown for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment removing the gown and performing hand hygiene before leaving the resident's environment. The policy instructed (1) For individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, maintain precautions to minimize the risk of transmission to other residents in contamination of environmental services or equipment.

Based on record review, interviews and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse, neglect and misappropriation of property for one resident (#1) of two residents reviewed.Findings included: On 2/7/2026 at 12.03 p.m., an interview was conducted with Resident #1. Resident #1 stated sometime last year, Staff H, Certified Nursing Assistant (CNA) befriended her and started taking money from her. The resident stated she was giving Staff H money to buy visa gift cards. Resident #1 stated Staff H was using the cards to buy adult gummies for both of them. The resident stated the adult gummies contained THC (Tetrahydrocannabinol, the main psychoactive compound in cannabis). Resident #1 stated she gave Staff H, CNA approximately $5,000 or more. She stated she did not remember the exact amount. Resident #1 said the staff member still owes her $1000 for prepaid money card Staff H, CNA never bought. Resident #1stated she reported this information to the previous Nursing Home Administrator (NHA) and the previous Social Services Director (SSD). Resident #1 stated she reported to the police the missing money, and her Power of Attorney (POA) was handling the investigation. Resident #1 stated she did not tell the police about the drug use, because I was afraid I would get in trouble. I told the NHA and SSD though. The resident stated she was getting the THC gummies to ease her pain. She stated every morning, Staff H would come to her room, and they would split a gummy. She stated the staff member would advise her on the potency and would recommend if she would take a half or a full one. Resident #1 stated Staff H had her bank card pin number and would go to the bank and withdraw the money. The resident said, She did not have to steal from me. She stated the staff member was no longer working at this facility. A review of the admission record revealed: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, chronic pain syndrome and opioid abuse with intoxication. Review of a quarterly minimum data set (MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. On 2/7/2026 at 1:01 p.m., an interview was conducted with the NHA and the Risk Manager (RM). The NHA stated he was new to this facility and had not participated in the investigation. The RM stated on 10/05/2025 the resident had reported she gave Staff H, CNA, her bank card to shop for her. She stated during their investigation, they requested bank statements from Resident #1's POA and confirmed the resident had sent money to Staff H, CNA, through a mobile money app. The RM stated the Staff H agreed she had received money from the resident to buy [prepaid money card]. The RM stated when speaking with Resident #1's POA, the POA said [Resident #1] probably did not want me to see the purchases, and that was why Resident #1 did not use the debit card. The RM said they obtained a statement from Staff H, CNA which the RM read, I purchased [prepaid money card] for [Resident #1] totaling $4570. The RM stated the Staff H denied knowing why the resident needed the prepaid money cards. During this interview, the NHA and the RM stated they could not speculate why the resident needed the prepaid money cards. The RM said, I never asked her [Resident #1], but it would make sense now with the allegation of drug use. The NHA stated the previous NHA did not document any notifications to outside agencies. On 2/7/2026 at 4:03 p.m. an interview was conducted with Staff H, CNA. She said, I was buying her stuff and the [prepaid money cards], I don't know why she needed the cards. They were worth hundreds of dollars. She was telling me she would want to buy gifts, I would get her the cards because I have a kind heart, she taught me a lesson. Staff H denied having bought THC gummies. She stated she spent way over $2000 on Resident #1 because she did not mind helping her. Staff H restated the resident never said what she needed the cards for. Staff H said, There was money exchanged between us. She [Resident #1] tried to pay me back. [Resident #1] wrote me a check for $500, more than one time. She [Resident #1] did not give me the money for drugs; it was for the gift cards [prepaid money cards]. Staff H stated as a staff member, she should not have taken money from the resident. She stated, it was not right, I was wrong, I got messed up in the end. I know I am not supposed to do it. Staff H stated the investigation was ongoing. On 2/7/2026 at 2:35 p.m. an interview with the facility's medical director revealed, staff should not provide a resident with THC, it can impact their health due to other medications. He stated if a patient wanted the drug to relieve pain, they should be evaluated and monitored by a provider. In an interview with the NHA on 2/7/2026 at 2:48 p.m., the NHA confirmed the resident gave the staff member money knowingly. He stated the staff member should not have been taking the resident's money for whatever reason. He said, It is against our policy. We did not know she was supplying the resident with THC, until today. We will investigate. The NHA stated the allegation of THC was not documented in their previous investigation. Review of a facility policy titled, Abuse Prevention Program, reviewed September 2025, revealed the following:Exploitation/Misappropriation of Resident Property: Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belongings or money without the resident's consent. Taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion.Investigation: An Event Report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe.Investigation may include, but may not be limited to: Resident statements/interviews; Employee statements/interviews; Visitor statements/interviews; Observation of resident(s), staff, environment; Document review i.e., chart reviews, policy review, education programs, appropriate resource review (such as medical literature); and Re-enactment of event.

Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2, #12, and #13 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed: Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. Upon arrival facility staff were in the hallways and reported that the patient (pt) is not doing well and appeared visibly shaken. Staff were unable to provide a time of onset. Upon entering the room, the patient (pt) was found in a semi-Fowler's position in bed. He was responsive to pain the patient was on blow by humified oxygen. There were thick secretions coming from the pt's tracheostomy tube. Breathing was labored. Lung sounds revealed bilateral rhonchi. Rapid pulse was thready and regular. Skin was normal color, hot and dry. 50 milliliters (ml) of emesis was suctioned from the pt's tracheostomy. Vitals revealed hypoxia. A blood pressure was unable to be palpated or auscultated. The pt was moved on to the stretcher. Prior to moving the pt to the unit [ambulance] his breathing changed from labored to agonal and pulses were no longer present. Cardiopulmonary resuscitation (CPR) was initiated with pulseless electrical activity (PEA) noted as [unreadable]. The pt was moved to the unit. In the unit the pt had an additional 100 ml of emesis suctioned from his tracheostomy. The [NAME] device was used for continuous compressions. The tracheostomy tube (uncuffed) was removed and replaced with a 6.0 ET (endotracheal) tube. He was placed on the ventilator. At the next rhythm check the pt's rhythm was slow PEA that quickly became asystole. CPR was resumed. An Intraosseous Intravenous access (IO) was established and the pt was given 1 milligram (mg) of Epinephrine. Enroute to the hospital CPR was continued with no changes in rhythm. A blood glucose level of 138 milligrams (mg)/deciliter (dL) was obtained. The pt was given 1 mg of epinephrine prior to transferring the pt inside the ED. At the hospital pt care was transferred to the nurse where CPR continued. Review of admission Records showed Resident #2 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, seizures, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, and cardiac arrest due to underlying conditions Review of Resident #2's physician orders showed:-Do Not Resuscitate (DNR) Start: [DATE]. -Full Resuscitation Discontinued: [DATE] Start: [DATE]Review of Resident #2 Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form (AHCA 5000-3008) from hospital discharge, dated [DATE], showed the resident had a Do Not Resuscitate order. Section H, Advanced Care Planning, listed the following: -Advanced Directives- indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)- indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it. -DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospice- indicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896. Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed: Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient. (https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html#:~:text=(3)(a)%20Resuscitation%20may,by%20rule%20of%20the%20department. Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM). Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he did not remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there were not two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the doctor said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and facesheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 from signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct To my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 form for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 form signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission. Review of a facility policy titled Advanced Medical Directives, effective [DATE], showed the following: PolicyAt the time of admission, Admissions shall furnish residents, family members, and/or the resident representative(s) with information regarding Advanced Medical Directives.The resident and/or resident representative shall be asked to provide Social Services with a copy of the resident's current Advanced Medical Directives. Social Services will place the Advanced Medical Directives in the resident's medical record and ensure that the presence, or absence, of Advanced Medical Directives is documented in the resident record.Completion of an Advanced Medical Directive 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 guidance and/or information on Health Care Advanced Directives as required or requested.Procedure1. Verify that information about Advanced Medical Directives was provided to the resident and/or family / resident representative at the time of admission.2. Evaluate factors that may affect the resident capacity to communicate a decision.Notify Physician of any concerns. Consider vision/hearing/cognitive deficits Obtain language preference and utilize translation/interpreter as needed3. Provide culturally appropriate discussion/education for the resident and/or responsible party.4. Obtain any current Advanced Directives from the resident and/or family/resident representative. Read the content to understand the resident's wishes and place the document in the medical record.5. Document the Advanced Medical Directives that are current and in place on the medical record.6. Enter the information on the Advanced Directives/DNR Log upon admission, quarterly, with change in condition, and / or change in Advanced Medical Directive status.7. Update medical record with new or revised Advanced Medical Directives as indicated.8. When a resident rescinds or changes his/her Advanced Medical Directives, have the resident draw a line through the old document, note rescinded/changed, then sign and note date rescinded/changed. Remove the old document from the record and return it to medical records for filing in closed chart. Place updated document in the record and document in the medical record.DNRHow Implemented: An order by the physician that, should the resident's heart stop and/or should respirations cease, CPR is not to initiated. Specific to CPR initiation; does not address other life support measures. Considerations Signed by resident or authorized healthcare decision-maker if resident lacks capacity Means only that CPR will not be initiated; treatable conditions will still be treated Without a DNR order, CPR will be initiated State specific documentation may also be required e.g. yellow form (FL) for EMS The facility's immediate actions to remove the Immediate Jeopardy included: A whole house audit was completed on [DATE] regarding advance directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE]. The Regional Nurse Consultant educated the clinical management team at 100% [DATE] to the Code Status Response Policy. Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy at 97% by [DATE]. The morning clinical worksheet was updated on [DATE]. ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director. Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked across all shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E.

Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were honored and properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. Resident #2 received cardiopulmonary resuscitation (CPR), despite his preference to be a Do Not Resuscitate (DNR) code status, after he was found unresponsive by staff on [DATE]. Staff failed to inform the Emergency Response Team (EMT) of the DNR code status and CPR was begun at the facility and conducted during transport and care in the emergency room (ER). This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed:Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. Upon arrival facility staff were in the hallways and reported that the patient (pt) is not doing well and appeared visibly shaken. Staff were unable to provide a time of onset.Upon entering the room, the patient (pt) was found in a semi-Fowler's position in bed. He was responsive to pain the patient was on blow by humified oxygen. There were thick secretions coming from the pt's tracheostomy tube. Breathing was labored. Lung sounds revealed bilateral rhonchi. Rapid pulse was thready and regular. Skin was normal color, hot and dry. 50 milliliters (ml) of emesis was suctioned from the pt's tracheostomy. Vitals revealed hypoxia. A blood pressure was unable to be palpated or auscultated. The pt was moved on to the stretcher. Prior to moving the pt to the unit [ambulance] his breathing changed from labored to agonal and pulses were no longer present. Cardiopulmonary resuscitation (CPR) was initiated with pulseless electrical activity (PEA) noted as [unreadable]. The pt was moved to the unit.In the unit the pt had an additional 100 ml of emesis suctioned from his tracheostomy. The [NAME] device was used for continuous compressions. The tracheostomy tube (uncuffed) was removed and replaced with a 6.0 ET (endotracheal) tube. He was placed on the ventilator. At the next rhythm check the pt's rhythm was slow PEA that quickly became asystole. CPR was resumed. An Intraosseous Intravenous access (IO) was established and the pt was given 1 milligram (mg) of Epinephrine.Enroute to the hospital CPR was continued with no changes in rhythm. A blood glucose level of 138 milligrams (mg)/deciliter (dL) was obtained. The pt was given 1 mg of epinephrine prior to transferring the pt inside the ED.At the hospital pt care was transferred to the nurse where CPR continued. Review of Resident #2's hospital record, dated [DATE], showed: History of Present Illness (HPI)[Age and gender] with history of anoxic brain injury from prior stroke, tracheal tube, PEG (percutaneous endoscopic gastrostomy) tube, BIBEMS (brought in by emergency medical service) after being found pulseless at this facility. Upon EMS arrival they found him/her in PEA with pink frothy sputum coming out of his/her tracheal tube, they switched out for endotracheal tube. Patient has some point was found to be asystole. Compression were continued until he arrived to the emergency department. He received several rounds of epinephrine and was coded for 30 minutes prior to arrival and transfer to emergency department care. Patient presented from local nursing facility as a pre-hospital cardiac arrest. Report from medics was that they were called because the patient was hypoxic and having significant drainage from his trach. When they arrived, the patient was saturating [oxygen saturation] in the 70s, They said that they suctioned the trach and were getting significant output. They report that it was pink and thick in color. Because of the amount of suctioning they were having to do they were concerned that the trach may have been clogged. Shortly after their arrival the patient went to a cardiac arrest, PEA was the initial rhythm. ACLS (Advanced Cardiac Life Support) protocol was followed. They opted to remove the trach, place a 6-0 endotracheal Lube within the Tracheostomy and then bag the patient. They were able to get improvement in his oxygenation to the 90s with bagging the patient but patient remained between PEA and asystole on pulse checks during transport. ACLS have been ongoing for least 30 minutes on patient arrival. Paramedics report that the patient's blood sugar was in the 130s. He had received 2 rounds of epinephrine prior to arrival. Patient arrived here with a [NAME] device providing chest compressions. Endotracheal tube was within the tracheostomy, and the patient had equal bilateral breath sounds. Additional intraosseous access was obtained and ACLS was continued. He received additional doses of epinephrine including a dirty epi drip and Levophed infusion. He also received bicarb, calcium and magnesium. We did obtain ROSC (return of spontaneous circulation) twice however each was brief. Labs were pulled from the I0 and did not result until after the patient had expired. During the code possible causes of asystole were reviewed, including hypoxia (100% oxygen via endotracheal tube through trach w equal bilateral breath sounds), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on physical exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology. Despite our efforts patient unfortunately expired, Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupils were fixed and dilated at 8 mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at 11:26 AM.Prior to the patient's arrival to the emergency department, we were given a heads-up radio call by EMS. I met with my nursing staff and discussed the radio call information with them. I assigned positions and rolls for the cardiac arrest. I instructed them that we will be using closed loop communication.Upon patient arrival via EMS, the patient was moved to trauma bay for initial examination and resuscitation as per ACLS guidelines. Patient was transferred to ER stretcher where patient was immediately placed on cardiac monitor/defibrillator, 02 sat, ET C02 (end tidal carbon dioxide) waveform (the breath-to-breath concentration of carbon dioxide in exhaled air) capnography , and assessed by nursing staff while simultaneously attempting to place two large bore IV lines. Patient arrived on an auto pulse device, and with an endotracheal tube inStat respiratory therapist was paged prior to patient arrival.Patient is in active cardiac arrest and patient's endotracheal tube was suctioned, easily bagged, with bilateral breath sounds. patient has symmetrical chest expansion, no chest crepitus, bilateral breath sounds, and color capnography changes indicating intubation.Continues waveform capnography is continued. Glucose within normal limits. At 1st pulse check at 10:47 a.m. patient was found to be asystole, chest compressions were resumed, and IO was inserted into the left tibia due to difficulty establishing further IV access. Epi was given every 4 minutes with pull check every 2 minutes. Patient was given calcium bicarbonate and magnesium. On all subsequent pulse checks patient was found to be in pulseless electrical activity. At 11:00 a.m. ROSC was achieved, patient started on no epi drip. At 11:07 a.m. patient was found to be in asystole again; epinephrine was given and ACLS was resumed. After multiple rounds of pulseless electrical activity ROSC was achieved at 11:13 a.m. Patient again went into pulseless electrical activity at 11:22 a.m., The ETC02 has remained at < 10 mmHg, patient expired at 11:26 p.m.Review of admission Records showed Resident #2 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, seizures, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, and cardiac arrest due to underlying conditionsReview of Resident #2's physician orders showed:-Do Not Resuscitate (DNR) Start: [DATE].-Full Resuscitation Discontinued: [DATE] Start: [DATE]Review of Resident #2 Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form (AHCA 5000-3008) from hospital discharge, dated [DATE], showed the resident had a Do Not Resuscitate order. Section H, Advanced Care Planning, listed the following:-Advanced Directives- indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)- indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it.-DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospice- indicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896.Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed:Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient.https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html#:~:text=(3)(a)%20Resuscitation%20may,by%20rule%20of%20the%20department. Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM) Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he didn't remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there weren't two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the Dr said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and face sheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 form signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct to my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him/her the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 from signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The Risk Manager said when she watched the facility video of EMS leaving with Resident #2 she did not feel like the paramedics were doing compressions. She said the paramedic's hand was on the resident's chest, but she did not feel like what the paramedic was doing was compressions. The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission.Review of a facility policy titled CPR Code Status Orders & Response, updated February 2023, revealed the following:Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative. Advanced Directives will be honored.Do Not Resuscitate (DNR) ORDER: Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations.In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status, unless the resident and/or resident representative verbalizes wishes on admission assessment to change to withhold CPR.Code status orders and wishes will be reviewed on admission, quarterly, PRN and with significant change of condition by the Interdisciplinary team.Code status orders will be renewed by physician's review and signature on monthly orders. Code status physician's order (DNR or Full Code), state specific forms and/or resident preference documentation will be filed as the first item within the medical record.Social Services will be notified if resident has any general questions and concerns about advance directives.The facility does not provide Advanced Life Support.ON ADMISSIONStaff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/representative wishes to change their decision.1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible.2. Discuss code status preference with the resident/resident representative.3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders, or if the orders do not address the code status, and the resident does not want to receive CPR, staff will document resident's wishes in the record and contact the physician to obtain the order.4. Notify physician if the resident/resident representative preference is changed, obtain order. In the event that the physician is not available the medical director may be contacted for the order.5. While awaiting the physician's order to withhold CPR, facility staff should document discussions with the resident or resident representative, including the resident's wishes to refuse CPR. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request, the conversation of the request will be printed and placed as the first document of the medical record.a. While the physician's order is pending, staff will honor the documented verbal wishes of the resident or the resident's representative, regarding CPR.Changing code status/while awaiting physician's order:The resident and/or resident representative may change the code status at any time. The staff must notify the MD, describe the requested change and request an order for the DNR or Full Code status to execute the change.The resident wishes will be communicated verbally shift to shift, both witnesses must document conversation in the in the medical record, print and placed as the first document of the medical record.The facility's immediate actions to remove the Immediate Jeopardy included: -On [DATE] a house wide audit was completed verifying advanced directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE].-Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives on [DATE].-Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97% by [DATE].-The Regional [NAME] President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator on [DATE].-The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing on [DATE].-Code Blue drills started on [DATE] and completed on [DATE] each shift.-ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked various shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E.

Based on observations, interviews, and record review, the facility failed to provide supervision to prevent elopement for one resident (#1) out of four residents reviewed for elopement risk. On 7/26/25 Resident #1 exited the facility at 6:30 p.m., unnoticed by staff. Resident #1 was mildly impaired, confused, and had an electronic monitoring device in place. Resident #1 followed another resident out the door which was remotely opened by staff. The door alarm was disabled by a resident who was aware of the code after Resident #1 triggered the alarm upon exit. Resident #1 walked approximately 0.2 miles to a hospital near the facility and was returned with assistance of law enforcement to the facility at 9:00 p.m. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 9/10/2025. The findings of Immediate Jeopardy were determined to be removed on 9/11/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #1's admission record revealed an admission date of 1/19/24 with diagnoses to include encephalopathy, unspecified, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, syncope and collapse, and alcohol use, unspecified. A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], under section C-Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG - Functional Abilities, revealed the resident used a walker for mobility and ambulated independently. Section P, Restraints and Alarms, revealed a wander/elopement alarm was used daily. A review of Resident #1's quarterly MDS, dated [DATE], revealed the same information was marked in sections C, GG, and P as in the assessment date of 7/26/25. A review of Resident #1's order summary report, to include completed and discontinued orders, revealed the following:- LOA [leave of absence] with escort for impaired cognition/elopement risk, with an order date of 1/29/24.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L [left] ankle due to elopement risk, with a start date of 1/22/24 and discontinued 6/6/25.- Electronic Wander Bracelet: Check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly. every night shift for poor safety awareness, with a start date of 1/22/24 and discontinued 9/3/25.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L ankle due to elopement risk exp [expiration] 3/22/27 every day shift until 03/19/2027 23:59 change the wanderguard, with an order date of 6/6/25 and discontinued 9/3/25. - CBC [complete blood count] with diff [differential], CMP [comprehensive metabolic panel] and UA&PCR [urinalysis and polymerase chain reaction test] one time only for Behaviors for 1 Day. with a start date of 7/7/25 and end date of 7/8/25. A review of Resident #1's care plan revealed the following:- COGNITION: [resident name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Impaired decision making Date Initiated: 08/01/2025 Revision on: 08/01/2025, with interventions to include, Report to Nurse any changes in cognitive function, specifically changes in: . memory . confusion . Date Initiated: 08/01/2025.- FALL: [resident name] is at Risk for falls or fall related injury because of: Deconditioning, hx [history] of falls Date Initiated: 01/21/2024 Revision on: 01/29/2024 . - ELOPEMENT RISK: [NAME] is at risk for elopement The resident has cognitive impairment and is independently mobile Date Initiated: 01/23/2024 Revision on: 01/29/2024., with a goal to include the following, [resident name] will not exit the facility without staff knowledge, or appropriate supervision Date Initiated: 01/23/2024 Revision on: 07/29/2025., and with interventions to include the following, . Apply electronic wander bracelet due to elopement risk Date Initiated: 02/09/2024 . Obtain an order for LOA with escort Date Initiated: 02/09/2024 . A review of Resident #1's progress notes revealed the following: - 2/8/24 social services note, SW [Social Worker] was made aware that [resident name] continues to ambulate throughout the facility and has been noted to go to the door and look out the glass. He continues to have a wander guard to ankle. He told SW that he wanted to be discharged to [address] where he was going to reside with his [family member]. SW contacted [family member] at [phone number] . SW was told that [address] was an address where [resident] resided at in [state] and that resident's [family member] had passed away in [year]. She further explained that resident did not have a home in [state] and has been staying at a homeless shelter prior to being admitted to the hospital and subsequently [facility name]. She further stated that when talking to her [family member] he has told her that he has been staying at a motel and that he was wanting to leave to go to the bar and was planning on returning to the motel. SW met with resident following this conversation and conducted a BIMS [Brief Interview for Mental Status] assessment which indicated that [resident name] score was at this time an 11. During conversation it was also determined that he thought that he was in [state] at this time and had forgotten he was now in [state]. He asked why he could not just walk out the facility and stated that he would make his way there. It was discussed that in order to discharge from the facility it would have to be a safe and appropriate discharge and walking out of facility with no predetermined location would not be safe.- 7/7/25 general progress note, Resident observed with behaviors of going to other residents rooms and followed staff easy to redirect by staff.PA [Physician Assistant] made aware. New order received for labs. POA [power of attorney] notified.- 7/9/25 general progress note CBC,CMP results reviewed by PA with no new order at this time.UA result reviewed resident start Bactrim. POA notified.- 7/26/25 change in condition (CIC) evaluation completed at 22:01, . The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. [example] agitation, psychosis) . Mental Status Evaluation: Increased confusion(e.g. disorientation) Other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) . Behavioral Status Evaluation: Other behavioral symptoms . Nursing observations, evaluation, and recommendations are: . wander guard in place and intact and functioning properly. B. New Testing Orders: - Blood Tests Urinalysis or culture . - 7/26/25 post event note, . The following event has occurred: Patient left facility without the proper sign out process . The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. - 7/27/25 general progress note, 1:1 [one to one] care s/p [status post] elopement continues, patient is cooperative with no signs or symptoms of distress.- 7/28/25 general progress note, Clarification: Unauthorized leave/behavior. - 7/28/25 psychotropic medication note, . Medication Type: . Antianxiety Targeted Behaviors: What behaviors is the resident demonstrating that warrants the use of the psychotropic medication(s)? . Wandering . Care Plan Update (Elopement Risk): FOCUS: Elopement Risk - Resident is at risk for elopement GOAL: The resident will not exit the facility without staff knowledge, or appropriate supervision INTERVENTION: Apply electronic wander bracelet due to elopement risk INTERVENTION: Verify the location of the electronic wander bracelet during routine care . - 8/8/25 psychiatry progress note, Date of Service: 2025-07-26 . The patient is seen today at the request of staff after he went outside, he stated that he took a walk and went to the hospital that is across the street from the facility. He was returned unharmed to the facility by law enforcement . he stated that he was just going out for a walk because he was going to a reunion with some friends. The patient has a BIMS of 12 and is doing well and shows no signs or symptoms of any abuse, neglect and no psychosocial distress or injuries noted. History of Present Illness: This patient was admitted to the facility on [DATE] due to encephalopathy with no known allergies. Patient has a medical history of anxiety, alcohol use . Medical necessity/Reason for encounter for today? S visit: . Reportable Incident .- 9/3/25 social services note, Spoke with [resident name] on this date about moving back to the memory care unit per care plan team, due to his prior attempt to leave building. I also spoke with his [family member], on this date to inform her of the move and she agreed but is worried that he won't have as much area to walk around. I let her know that we would monitor how he does in MC [memory care] and let her know if we notice any changes. A review of Resident #1's physician's notes revealed the following: - 5/29/25, . Chief Complaints: 1. Monthly medical visit-s mild dementia . Interim History: [age of resident] male, with medical history including ETOH [alcohol] abuse, previous episodes of syncope . General Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. NEUROLOGIC: cognitive deficits noted at admission - likely chronic encephalopathy secondary to EtOH . Plan: . 4. Generalized anxiety disorder . Clinical Notes: May 29th- patient is seen ambulating throughout the facility. He was friendly, outgoing and show no signs of anxiety. He is followed monthly by Psychiatry. April 21st- . He was last seen by psych on March 31st, with their documentation indicating that he reported to them that he does not like being here but is coping well on his own without medications. -7/9/25, . Chief Complaints: 1. Altered mental status - confusion . HPI: . seen today for follow-up after nursing had reported a significant change in mental status and requested UA to rule out organic cause for his confusion. Urinalysis consistent with UTI [urinary tract infection]. Examination: . MENTAL STATUS: alert and oriented 2-3- some confusion and disorientation. Plan: . 1. Urinary tract infection, site not specified . Clinical Notes: July 9th - urinalysis consistent with urinary tract infection. Patient seen today and does appear mildly more confused. Nursing reports patient had been wandering into other patient's rooms and had been very confused when attempts were made to redirect . 2. Muscle wasting and atrophy, not elsewhere classified, multiple sites . July 9th - . does appear to be more confused and uncertain as to where his room in his - patient does not have any confusion at baseline .- 7/29/25, .HPI: . seen today for follow-up on labs that were ordered due to concern for AMS [altered mental status] after recent elopement. Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. Plan: Treatment: 1. Altered mental status, unspecified Clinical Notes: July 29th- labs reviewed. No leukocytosis, electrolyte imbalance, anemia, acute kidney injury or urinary tract infection . His previous urinary tract infection showed strong case for a urinary tract infection, but PCR was negative. Patient did receive full 7 days of Bactrim at that time. July 28th- patient appears to be very close to baseline level of cognition. Recent elopement - He does present with mild increase in anxiety and possibly increased confusion . A review of Resident #1's psychiatry notes revealed the following:- 3/31/25, HPI [history of present illness] General: . Past psych [psychiatric] history includes alcohol use, tobacco use, GAD [generalized anxiety disorder], cognitive impairment. The patient reports that he does not like being at the facility. He reports he does have some anxiety and depression feelings due to being at the facility, but he is coping well on his own. A review of Resident #1's evaluations revealed the following:- 2/9/24 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 5. Wandering . - 7/26/25 BIMS evaluation, . Score: 10 . Category: Moderate Impairment . - 7/26/25 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 3. Desires to leave facility; verbalizes desires to leave facility such as I don't want to stay here, how do I get out of here, I'm looking for my [family member] etc. 5. Wandering . 10. Attempting to tailgate behind staff, visitors, and/or other residents . A review of the abuse/neglect log revealed Resident #1's elopement was not documented in July 2025. A review of the incident and accident report from 7/8/25 to 9/8/25 revealed Resident #1's elopement was not documented. On 9/8/25 at 9:17 a.m., an observation of Resident #1 revealed he was laying down in bed. Resident #1 did not have a wander monitoring device on. He said he has never tried to leave the facility and could not recall a time when he successfully did. Resident #1 stated, Staff don't let me leave. He stated if he tried to leave, Everyone in the world comes to get me. He said he recalled being in another room before. Resident #1 said he was not sure why there was a room change. He stated he walked around a lot. On 9/8/25 at 11:25 a.m., an interview was conducted with Staff F, Registered Nurse (RN) Supervisor. He confirmed he was the supervisor on duty when Resident #1 left the faciity on 7/26/25. He said a Certified Nursing Assistant (CNA), Staff G, opened the door for Resident #10 who had signed out on LOA. Staff F, RN Supervisor said Staff G, CNA did not see Resident #1 follow Resident #10 out the door. He said Resident #10 called him and said Resident #1 followed him outside. Staff F, RN Supervisor said Resident #10 called the facility approximately five minutes after leaving the facility. He said a code silver was called and a head count was completed in which they discovered Resident #1 was missing. He stated, Staff looked everywhere. Staff F, RN Supervisor said Resident #1 was found by the hospital and police brought him back to the facility. He said he thought the resident was out of the facility for approximately 30 minutes. Staff F, RN Supervisor said the wander exit alarm was functioning and he did not know who shut it off. He stated, It alarmed when the resident came back into the facility. He said Resident #1 told him he went to see if he could get a drink at the bar. Staff F, RN Supervisor said Resident #1 was put on 1 to 1 supervision after the event. He said Resident #1 is now in the memory care unit because they do not want to repeat what happened. He stated, We don't have the manpower to keep him on 1 to 1. Staff F, RN Supervisor said Resident #1 being in the memory care unit is safer and more appropriate. On 9/8/25 at 11:51 a.m., an interview was conducted with Resident #10. He said on 7/26/25 he was trying to leave the facility to take the bus and Resident #1 was by the front door. Resident #10 said he was signing out at the front desk when Resident #1 approached him about the door code. He said he told Resident #1 he did not know the code. He said he went to Staff G, CNA to ask him to open the door and also attempted to warn him about Resident #1 trying to exit. Resident #10 said Staff G, CNA opened the front door remotely from the unit, he heard the wander guard alarm go off and then went left towards the bus stop. He said he recalled three or four staff members who came out while he was waiting at the bus stop and then saw them return inside the facility. He said he never called the facility or saw where Resident #1 went. He stated, When I leave, I don't worry about what happens. Resident #10 stated when he returned from LOA, I got cornered by staff. He stated they asked him, Why did you let him [Resident #1] through. He said the police brought Resident #1 back to the facility. He said facility staff never asked him for a statement. Resident #10 stated, I never signed anything. On 9/8/25 at 12:38 p.m., a phone interview was conducted with Staff F, Advanced Practice Registered Nurse (APRN). She said she saw Resident #1 due to the incident. She stated, He stepped outside for a second and his BIMS was repeated after the incident. Staff F, APRN said Resident #1 told her he took a walk to the hospital which was across the street. She stated, He had mild forgetfulness. Staff F, APRN said she thought he might have had a lapse that day. She said she was not sure how long Resident #1 was away from the facility. Staff F, APRN said when she asked the resident what he was trying to do, his response was he hoped to meet some friends that worked at the hospital. She stated law enforcement had found him and brought the resident back to the facility. On 9/8/25 at 3:03 p.m., a phone interview was conducted with Resident #1's family member. She said Resident #1 has a history of dementia and alcohol abuse. She said his dementia is of unknown origin but potentially related to the resident's issue with alcoholism. The family member said the facility called her around 10:20 p.m. the day the resident exited the facility unwitnessed. She stated she was told he, Snuck out with another resident and found him 20 minutes later. The family member said she suspected Resident #1 was looking for alcohol, and the facility confirmed he told them he was looking for beer. She stated, Sometimes he has better days than others. The family member said Resident #1 referenced family members who have passed, but thinks they are alive, or say he's going to walk down the street of a state he used to reside in. She said the resident's sister and father had dementia. The family member said she did not think the resident had a wander guard on before the incident. She said the staff told her, the day she was notified he had left, about putting a wander guard on him in case he tried to leave again. The family member said the social service staff member called her last week and told her Resident #1 is now in the memory care unit. She said they told her that it is closed off and easier to watch him. The family member said staff have expressed to her Resident #1 wanted to go to an assisted living facility (ALF), but he had never expressed that to her. She stated, It's a horrible idea. He asks about people who've been dead 20 to 30 years. He's been an alcoholic since he was [AGE] years old. He's a danger to himself and others, he cannot be out alone. On 9/8/25 at 3:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The DON said Resident #1 exited the facility on 7/26/25 at 5:00 p.m. The DON said code silver was completed, and it was determined he was out of facility for two and a half to three hours. She said he was evaluated when he returned to the facility, and he was alert and oriented to person, place, time, and event (x4). The DON said she interviewed the resident when he returned, and he knew what he was doing as he told them he planned to go across the street to get a drink. The DON confirmed he had an electronic monitoring bracelet on when he left, and it was functioning. The DON said Resident #1 has had an electronic monitoring bracelet for as long as she's been at the facility. The NHA said the alarm did go off at that time he left, and confirmed staff did not respond to the alarm. She said the alarm was shut off and it was unclear who did it at that time. She said they were not sure if a staff member turned off the alarm. The NHA said they heard a resident had shut it off, not knowing how they would know the code. She stated there were no staff present by the front door where Resident #1 exited. The NHA said Staff G, CNA confirmed he opened the door for Resident #10 but said he did not hear the alarm. She said there are cameras on the unit and Staff G, CNA must have opened the door remotely and did not see Resident #1 leave. The DON said Resident #1's assigned nurse told the supervisor she had just seen him eating dinner, then he was not there. The DON said Resident #1 had no exit seeking behaviors. The NHA said the capability of remotely opening the front door was removed after Resident #1 exited the facility. She said currently staff have to walk to the front door to let residents out. The NHA stated they did not report this because, It was an unauthorized exit. He didn't ask to go out. She said Resident #1 did not follow the LOA process. The DON stated, He was alert and oriented, had a plan, able to navigate himself here. She said Resident #1 was already on his way to the facility and he brought himself back. The NHA and DON said they did not feel he was in harm's way. The NHA said the criteria did not make Resident #1 an elopement risk. On 9/8/25 at 4:23 p.m., a review of Resident #1's change in condition evaluation, dated 7/26/25, was completed with the DON. She confirmed she completed the change in condition evaluation after the resident returned. She said she was assessing him for the behaviors marked on the evaluation, not that he had them. The DON stated it, Shouldn't have been marked like that. On 9/9/25 at 11:39 a.m., an interview was conducted with the Risk Manager (RM). She confirmed the facility was able to identify who turned the wander guard alarm off. She stated, [Resident #11] positioned himself in the lobby and turned it off. The RM said when Resident #11 was interviewed, he said he picked up on the codes to disable the exit alarm. She confirmed Staff G, CNA remotely opened the door, the alarm went off, and Resident #11 shut off the alarm. She said the NHA and DON interviewed Resident #1 and #11. She confirmed no other residents were interviewed. She said she was present, as a witness, during the interview with Staff G, CNA. She said he confirmed he didn't hear the alarm and acknowledged he unlocked the door remotely as he was in the back unit. The RM said Resident #10 was interviewed, but it was not documented. She stated, All he said was somebody let me out, he went out the door and didn't see anyone leave. On 9/9/25 at 1:31 p.m., a phone interview was conducted with Staff J, Physician Assistant (PA). He said Resident #1 had eloped. He said another resident let him out of the building, he was found by police and brought back to the facility. Staff J, PA confirmed he was initially called about the incident before Resident #1 returned. He stated, I can't say how long he was out for. He never eloped prior to that. He would walk around the building and do laps nonstop but never tried to leave before. Staff J, PA said Resident #1 is mildly cognitively impaired and has a BIMS of 12-13. He said the resident has a history of alcoholism and had a cognitive deficit from that. Staff J, PA stated there are, Somethings he [Resident #1] doesn't quite remember. When asked why Resident #1 is currently in the secured/memory care unit, he stated, Guessing it is because he eloped and impaired enough. He confirmed Resident #1 was previously mildly impaired. He stated, They got lucky, what if he tries to leave a second time. Staff J, PA confirmed when Resident #1 eloped, he was not safe because of his cognition. He stated, Unless they have a perfect BIMS score, they probably should not go out alone. He confirmed Resident #1 can go on LOA with assistance for cognition. Staff J, PA confirmed there was a risk for him being out on his own, due to his history of alcohol abuse and cognitive impairment. On 9/9/25 at 3:14 p.m., an interview was conducted with Resident #11. He confirmed he knew the code for the exit door and turned off the alarm the day Resident #1 left the facility. He said it is usually a false alarm when the alarm goes off, so he assumed a resident set it off when they passed by that area. Resident #11 said it's very loud. He said the next day, on 7/27/25, he found out a resident left the facility. Resident #11 stated, I know I shouldn't have done that, but it was going off and no staff were present. He stated he previously knew the code because, Staff don't hide it. He said they do not cover the code when they are putting it in the keypad. Resident #11 said staff members have yelled it out to each other as well. He said he thinks the alarm going off happened around 4:00 - 4:30. Resident #11 said the alarm woke him up and it was on long enough that he was able to get up and turn off the alarm. Resident #11 said there's been times when staff who do not normally work in the reception area do not know the code. He said he has told them he knows the code, gives it to them, and those staff have been thankful when he has done that. A review of Resident #11's annual MDS, dated [DATE], section C - Cognitive Patterns, revealed a BIMS score of 15 indicating intact cognition. On 9/9/25 at 5:28 p.m., a review of video footage from 7/26/25 revealed the following: - At 6:27:10 p.m., Resident #1 was observed walking towards the front door and stopped at the end of the reception desk. No staff were observed in the reception area.- At 6:27:21 p.m., Resident #1 was observed walking away from the front/reception area. - At 6:27:31 p.m., Resident #10 was observed ambulating to the reception area and wrote in the resident sign out log. Resident #1 was observed walking up behind him and stood to the right of Resident #10, next to the reception desk. - At 6:28:26 p.m., Resident #1 left the front area while Resident #10 continued writing in the sign out log. - At 6:28:32 p.m., Resident #1 came back to the front area. Throughout the observation, Resident #1 was standing slightly to the right side of the garbage can located in the front area. It was unclear if the wander guard alarm was going off at that time as there was no audio in the footage observed. - At 6:30:34 p.m., Resident #10 returned to the front reception area and positioned himself right in front of the door. Resident #1 was also in the same area, but in front of the garbage can. - At 6:30:55 p.m., the front doors opened, Resident #10 exited the facility going to the left, and Resident #1 exited right behind him walking towards the left. - At 6:31:24 p.m., Resident #11 was observed ambulating to the front of the facility, went to the keypad, and left the front reception area. - At 6:31:34 p.m., the front doors opened again and closed approximately ten seconds after. Throughout the footage observed, no staff were present, (Video Evidence Obtained). On 9/10/25 at 3:17 p.m., an observation of an electronic wander device was conducted with the RM, and when the device was in proximity to the door the alarm was activated. The RM was holding the device and walked to the point where the fire alarm and garbage can are located by the front door. The exit alarm went off when she passed the fire alarm and garbage can, (Photographic Evidence Obtained). An observation of the 200 unit, where Staff G, CNA was working on 7/26/25, revealed the exit alarm could be heard but it was not loud. Around room [ROOM NUMBER], the exit alarm could not be heard. From rooms 201 to 217, the exit alarm could be heard. During previous interviews with the RM, DON and NHA, they confirmed Staff G, CNA told them he did not hear the exit alarm. On 9/11/25 at 12:15 p.m., an interview was conducted with Staff I, CNA. She said Resident #1 was in the front/reception earlier in the day on 7/26/25. Staff I, CNA said he tried to leave through the front door earlier that day. She stated, We sent him back to nursing staff. She said she called the nurse to let them know he was exit-seeking. She said around the time residents are finished with dinner, the lobby is cleared, and no residents are present. She stated, I warned the nursing staff about him before I left. Staff I, CNA said she noticed his patterns had changed. She said he was usually with another resident walking around the facility, but around that time of the incident, he was wandering by himself. Staff I, CNA said she asked Resident #1 why he tried to leave and where he was going. She stated, He said he wanted to go get a few drinks across the street. Staff I, CNA said he seemed confused as he mentioned he wanted to go see his family member. She stated, I don't know if his [family member] was still alive and I asked social services about that. A review of the facility's policy titled, Abuse Prevention Program, dated November 2024, revealed the following: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect . Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Alleged Violation . A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated, and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. A review of the facility's policy titled, Elopement - Overview, dated October 2021, revealed the following, OVERVIEW The facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility's immediate actions to remove the Immediate Jeopardy included: F689 Removal Plan- Resident #1 was put on enhanced supervision on 7/26/25 and then moved to the secure unit on 9/3/25.- On 7/26/25 and 7/27/25 an audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.- Through the course of the initial audit, identified variances were corrected regarding LOA status.- Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols at 100% completion by 7/30/25. - Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes at 100% completion by 7/30/25.- The remote door releases were deactivated on 7/27/25.- Code Silver drills were completed from 7/26/25 to 8/5/25 every shift.- Random audits were completed at 100% from 7/29/25 to 8/30/25 regarding unauthorized exit, resident LOA status, and resident elopement risk.- Ad hoc QA meeting was conducted on 7/27/25 to review the removal plan, which included the medical director. Verification

Based on observations, interviews, and record review the facility failed to follow the established facility grievance policies and procedures related to investigation and follow-up for resident grievances for five residents (#16, #17, #18, #19, and #20) out of six residents sampled. Findings included:An interview was conducted on 09/09/2025 at 11:15 a.m. with Resident #18. The resident stated he had several grievances filed with the facility and the facility had not followed up with him on most of them. He stated a grievance where he had been awoken by a Certified Nursing Assistant (CNA) making noises in the hall was never addressed by the facility, as well as a grievance about some missing items. An interview was conducted 09/09/2025 at 2:30 p.m. with Residents #16 and #17. They stated there was a joint grievance regarding staff not passing out waters, and regarding the staff being on their personal phones during resident care. Both Resident #16 and #17 voiced no one has discussed their grievances with them and both of their complaints were still ongoing issues and had not been resolved. An interview was conducted on 09/10/2025 11:00 a.m. with Resident #20. The resident stated no one had ever resolved her grievances from July 2025 and no one had followed up on the grievances. The resident stated no staff had come to talk to her about the grievance or informed her of any plans to resolve it. An interview was conducted 09/10/2025 11:07 a.m. with Resident #19. The resident did not want to discuss the specifics of his grievance, however, he did voiced his issues had not been resolved and verified no one had followed up with him regarding his grievance. An interview was conducted with Staff L, Social Services, on 09/10/2025 at 11:34 a.m. Staff L explained the grievance process for the facility. Staff L stated it would depend on the specific situation as to who would follow up with residents and confirmed that no one specific person followed up with the residents to make sure they understood their grievances were either being worked on or completed and signed off. A review of the facility policy titled Grievance/Concern Management, dated May 2025, revealed the following: POLICY :Residents and their representative 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.Residents and their representative have the right to recommend changes in policies and services, and to join with other residents or individuals within or outside the facility to work for improvements in resident care, free from restraint, interference, coercion, discrimination, or reprisal.These rights include access to the State of Florida Long-[NAME] Care Ombudsman and advocates and the right to be a member of, to be active in, and to associate with, advocacy or special interest groups.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. PROCEDURE:1. At, during, or after admission, staff will provide:a. An explanation of the facility concern processb. A copy of the concern / grievance formc. An explanation of where concern forms are located, and that staff will provide a form should it be requestedd. Guidance on assistance available to residents or their representatives who are unable to complete the form unassistede. The names, job titles, and telephone numbers of employees responsible for implementing the facility's concern procedure. This information is found in the admission Booklet and includes the address and toll-free telephone numbers and email addresses for the Ombudsman and the Agency and other survey agencies.f. Outside resources available to the resident: -Ombudsman-Department of Health-Facility specific options such as a toll-free number for reporting concerns2. The facility will prominently display a poster that includes the following:a. The contact information of the Grievance Official to include his / her name, business address (mailing and email address), and business phone number,b. A reasonable expected time for completing a review of the concern,c. The right to obtain a written decision regarding the concern,d. Reference to independent entities with whom concerns may be filed.3. Residents and their representatives who are unable to complete a written concern will be assisted by staff to prepare and submit the form.4. The NH.A is responsible for oversight of the concern process.5. The Social Services representatives/ Grievance Official in collaboration with the NH.A will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident / representative satisfaction upon completion of the investigation and the summary of findings / conclusion.6. Social Service Director in collaboration with the NH.A will be the Grievance Official at the facility7. The facility leadership team will review and discuss concerns and the progress of an investigation(s) and resolution(s). 8. The department involved will document the concern and record the resident/ resident representative's satisfaction with the resolution to the concern.9. The Resident Council will be reminded of the name and location of the grievance officer; how to file a concern; that they may file verbally or in writing and may file anonymously. This reminder will include where they can find the poster with the number where they can make an anonymous report of a concern. The concern process will be reviewed at a minimum annually with the Resident Council.10. Concern forms are confidential, protected Quality Assessment, Assurance and Compliance documents and are not copied.11. Concerns are tracked, trended, and reported in the monthly Quality Assessment, Assurance and Compliance Committee Meeting.12. Retain grievance concern report and logs for three (3) years. Others will be shredded.13. Complete a concern report investigation with summary and conclusion.14. Social Services staff will provide information regarding compliance line information for unresolved concerns.

Based on observations, interviews, and record reviews, the facility failed 1) to properly store and secure medications for two residents (#8 and #9) out of twenty resident sampled, and 2) to properly secure medications out of reach of residents in one nursing station (200) out of four nursing stations. Findings included: An observation and interview was conducted on 9/8/25 at 07:30 a.m. with Resident #8. There was a tube of zinc oxide paste skin cream on the bedside table. Resident #8 stated, “This was brought with me from the hospital and has been in my room since arrival, however it has since been discontinued.” (Photographic evidence obtained) An observation and interview was conducted on 9/8/25 at 07:40 a.m. with Resident #9. There was a tube of Betamethasone Valerate cream on the windowsill. Resident #9 was asked if the medication belong to the resident and the resident replied, “I think so.” (Photographic evidence obtained) During an interview on 9/8/25 at 1:53 p.m. with the Director of Nursing (DON), the DON stated, “All employees are given training regarding misplaced medications in the resident's room. As it pertains to self-administered medication (SAM) residents, we do have a policy, however as of this date, we do not have any SAM residents in the facility and if we find medications in the resident's room, we send them back to the pharmacy. The facility also discourages residents and visitors from bringing in any medications to the facility. During an interview on 9/8/25 at 12:35 p.m. with Staff A, Registered Nurse (RN), Staff A stated, “I adhere to the six patient rights when administering medications, so I would never administer a medication that does not belong to the resident. After I administer a medication, I document the administration in the electronic health record. If there is a medication that is left in the room after administration, I would follow policy and report it to the DON and secure the medication. We do not currently have any SAM residents in this facility. During an interview on 9/8/25 at 10:55 a.m. with Staff B, RN, Staff B stated, “If a resident has a discontinued medication that is left in the resident's room, we return the medication to the pharmacy and we do not have any SAM residents in the facility. During an interview on 9/8/25 at 11:05 a.m. with Staff C, RN, Staff C stated, “Before administration of medications, I confirm the order in the electronic health record and ensure the six resident rights for medication administration, then if after administration, if the medication is not fully used, it is either wasted or returned to the pharmacy depending on the medication. The facility does not currently have any SAM residents. During an interview on 9/8/25 at 11:10 a.m. with Staff D, Licensed Practical Nurse (LPN), Staff D stated, “If I have a discontinued medication, I will return it to the pharmacy and if I find a medication left in the resident's room, I will take it out and return it to the pharmacy. The facility does not currently have any SAM residents. During an interview on 9/8/25 at 11:15 a.m. with Staff E, CNA, Staff E stated, “If I find a medication in the resident's room, I will report it to the on-duty nurse. I am not aware of any SAM residents in the facility. A review of discontinued medications in the electronic health record revealed Resident #8 was prescribed Zinc Oxide and the medication had been discontinued. A review of current and active medications in the electronic health record revealed Resident #9 was prescribed Betamethasone Valerate cream, which was active on 7/22/23 to be used for dermatitis. An observation was conducted on 9/8/25 at 6:27 a.m. of a prescription medication sitting at the 200 hall nurses' station and there was an unlocked treatment cart containing prescription medication sitting outside the nurses' station. There were no staff in sight of the treatment cart of nurses' station. An observation was conducted on 9/8/25 at 3:14 p.m. of two full medication bubble packs, two bottles of liquid medication, and one bag of nebulizer treatments were sitting at the 200 hall nurses' station with no staff in sight and residents sitting nearby. Review of the facility policy titled Self-Administration by resident, dated 11/17, revealed the following: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Review of the facility policy titled Storage of medication, dated 9/18, revealed the following: Policy: Medications and biologicals are stored properly, following manufacturers 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. 1. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. 2. 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 to procedures for medication disposal (Refer to Section 5-Disposal of Medications, Syringes and Needles), and reordered from the pharmacy (Refer to Section 3.2-Ordering and Receiving Non-Controlled Medications), if a current order exists. Review of the facility policy titled Medication administration general guidelines, dated 9/18, revealed the following: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. 1. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observations, record review, and interviews, the facility failed to report an incident of elopement related to lack of supervision for one Resident (#1) out of four residents reviewed for elopement. Findings included: A review of Resident #1's admission record revealed an admission date of 1/19/24 with diagnoses to include encephalopathy, unspecified, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, syncope and collapse, and alcohol use, unspecified. A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], under section C-Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG - Functional Abilities, revealed the resident used a walker for mobility and ambulated independently. Section P, Restraints and Alarms, revealed a wander/elopement alarm was used daily. A review of Resident #1's quarterly MDS, dated [DATE], revealed the same information was marked in sections C, GG, and P as in the assessment date of 7/26/25. A review of Resident #1's order summary report, to include completed and discontinued orders, revealed the following:- LOA [leave of absence] with escort for impaired cognition/elopement risk, with an order date of 1/29/24.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L [left] ankle due to elopement risk, with a start date of 1/22/24 and discontinued 6/6/25.- Electronic Wander Bracelet: Check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly. every night shift for poor safety awareness, with a start date of 1/22/24 and discontinued 9/3/25.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L ankle due to elopement risk exp [expiration] 3/22/27 every day shift until 03/19/2027 23:59 change the wanderguard, with an order date of 6/6/25 and discontinued 9/3/25. - CBC [complete blood count] with diff [differential], CMP [comprehensive metabolic panel] and UA&PCR [urinalysis and polymerase chain reaction test] one time only for Behaviors for 1 Day. with a start date of 7/7/25 and end date of 7/8/25. A review of Resident #1's care plan revealed the following:- COGNITION: [resident name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Impaired decision making Date Initiated: 08/01/2025 Revision on: 08/01/2025, with interventions to include, Report to Nurse any changes in cognitive function, specifically changes in: . memory . confusion . Date Initiated: 08/01/2025.- FALL: [resident name] is at Risk for falls or fall related injury because of: Deconditioning, hx [history] of falls Date Initiated: 01/21/2024 Revision on: 01/29/2024 . - ELOPEMENT RISK: [resident name] is at risk for elopement The resident has cognitive impairment and is independently mobile Date Initiated: 01/23/2024 Revision on: 01/29/2024., with a goal to include the following, [resident name] will not exit the facility without staff knowledge, or appropriate supervision Date Initiated: 01/23/2024 Revision on: 07/29/2025., and with interventions to include the following, . Apply electronic wander bracelet due to elopement risk Date Initiated: 02/09/2024 . Obtain an order for LOA with escort Date Initiated: 02/09/2024 . A review of Resident #1's progress notes revealed the following: - 2/8/24 social services note, SW [Social Worker] was made aware that [resident name] continues to ambulate throughout the facility and has been noted to go to the door and look out the glass. He continues to have a wander guard to ankle. He told SW that he wanted to be discharged to [address] where he was going to reside with his [family member]. SW contacted [family member] at [phone number] . SW was told that [address] was an address where [resident] resided at in [state] and that resident's [family member] had passed away in [year]. She further explained that resident did not have a home in [state] and has been staying at a homeless shelter prior to being admitted to the hospital and subsequently [facility name]. She further stated that when talking to her [family member] he has told her that he has been staying at a motel and that he was wanting to leave to go to the bar and was planning on returning to the motel. SW met with resident following this conversation and conducted a BIMS [Brief Interview for Mental Status] assessment which indicated that [resident name] score was at this time an 11. During conversation it was also determined that he thought that he was in [state] at this time and had forgotten he was now in [state]. He asked why he could not just walk out the facility and stated that he would make his way there. It was discussed that in order to discharge from the facility it would have to be a safe and appropriate discharge and walking out of facility with no predetermined location would not be safe.- 7/7/25 general progress note, Resident observed with behaviors of going to other residents rooms and followed staff easy to redirect by staff.PA [Physician Assistant] made aware. New order received for labs. POA [power of attorney] notified.- 7/9/25 general progress note CBC,CMP results reviewed by PA with no new order at this time.UA result reviewed resident start Bactrim. POA notified.- 7/26/25 change in condition (CIC) evaluation completed at 22:01, . The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. [example] agitation, psychosis) . Mental Status Evaluation: Increased confusion (e.g. disorientation) Other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) . Behavioral Status Evaluation: Other behavioral symptoms . Nursing observations, evaluation, and recommendations are: . wander guard in place and intact and functioning properly. B. New Testing Orders: - Blood Tests Urinalysis or culture . - 7/26/25 post event note, . The following event has occurred: Patient left facility without the proper sign out process . The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. - 7/27/25 general progress note, 1:1 [one to one] care s/p [status post] elopement continues, patient is cooperative with no signs or symptoms of distress.- 7/28/25 general progress note, Clarification: Unauthorized leave/behavior. - 7/28/25 psychotropic medication note, . Medication Type: . Antianxiety Targeted Behaviors: What behaviors is the resident demonstrating that warrants the use of the psychotropic medication(s)? . Wandering . Care Plan Update (Elopement Risk): FOCUS: Elopement Risk - Resident is at risk for elopement GOAL: The resident will not exit the facility without staff knowledge, or appropriate supervision INTERVENTION: Apply electronic wander bracelet due to elopement risk INTERVENTION: Verify the location of the electronic wander bracelet during routine care . - 8/8/25 psychiatry progress note, Date of Service: 2025-07-26 . The patient is seen today at the request of staff after he went outside, he stated that he took a walk and went to the hospital that is across the street from the facility. He was returned unharmed to the facility by law enforcement . he stated that he was just going out for a walk because he was going to a reunion with some friends. The patient has a BIMS of 12 and is doing well and shows no signs or symptoms of any abuse, neglect and no psychosocial distress or injuries noted. History of Present Illness: This patient was admitted to the facility on [DATE] due to encephalopathy with no known allergies. Patient has a medical history of anxiety, alcohol use . Medical necessity/Reason for encounter for today? S visit: . Reportable Incident . A review of Resident #1's evaluations revealed the following:- 2/9/24 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 5. Wandering . - 7/26/25 BIMS evaluation, . Score: 10 . Category: Moderate Impairment . - 7/26/25 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 3. Desires to leave facility; verbalizes desires to leave facility such as I don't want to stay here, how do I get out of here, I'm looking for my [family member] etc. 5. Wandering . 10. Attempting to tailgate behind staff, visitors, and/or other residents . A review of the abuse/neglect log revealed Resident #1's elopement was not documented in July 2025. A review of the incident and accident report from 7/8/25 to 9/8/25 revealed Resident #1's elopement was not documented. On 9/8/25 at 9:17 a.m., an observation of Resident #1 revealed he was laying down in bed. Resident #1 did not have a wander monitoring device on. He said he has never tried to leave the facility and could not recall a time when he successfully did. Resident #1 stated, Staff don't let me leave. He stated if he tried to leave, Everyone in the world comes to get me. He said he recalled being in another room before. Resident #1 said he was not sure why there was a room change. He stated he walked around a lot. On 9/8/25 at 11:25 a.m., an interview was conducted with Staff F, Registered Nurse (RN) Supervisor. He confirmed he was the supervisor on duty when Resident #1 left the faciity on 7/26/25. He said a Certified Nursing Assistant (CNA), Staff G, opened the door for Resident #10 who had signed out on LOA. Staff F, RN Supervisor said Staff G, CNA did not see Resident #1 follow Resident #10 out the door. He said Resident #10 called him and said Resident #1 followed him outside. Staff F, RN Supervisor said Resident #10 called the facility approximately five minutes after leaving the facility. He said a code silver was called and a head count was completed in which they discovered Resident #1 was missing. He stated, Staff looked everywhere. Staff F, RN Supervisor said Resident #1 was found by the hospital and police brought him back to the facility. He said he thought the resident was out of the facility for approximately 30 minutes. Staff F, RN Supervisor said the wander exit alarm was functioning and he did not know who shut it off. He stated, It alarmed when the resident came back into the facility. He said Resident #1 told him he went to see if he could get a drink at the bar. Staff F, RN Supervisor said Resident #1 was put on 1 to 1 supervision after the event. He said Resident #1 is now in the memory care unit because they do not want to repeat what happened. He stated, We don't have the manpower to keep him on 1 to 1. Staff F, RN Supervisor said Resident #1 being in the memory care unit is safer and more appropriate. On 9/8/25 at 11:51 a.m., an interview was conducted with Resident #10. He said on 7/26/25 he was trying to leave the facility to take the bus and Resident #1 was by the front door. Resident #10 said he was signing out at the front desk when Resident #1 approached him about the door code. He said he told Resident #1 he did not know the code. He said he went to Staff G, CNA to ask him to open the door and also attempted to warn him about Resident #1 trying to exit. Resident #10 said Staff G, CNA opened the front door remotely from the unit, he heard the wander guard alarm go off and then went left towards the bus stop. He said he recalled three or four staff members who came out while he was waiting at the bus stop and then saw them return inside the facility. He said he never called the facility or saw where Resident #1 went. He stated, When I leave, I don't worry about what happens. Resident #10 stated when he returned from LOA, I got cornered by staff. He stated they asked him, Why did you let him [Resident #1] through. He said the police brought Resident #1 back to the facility. He said facility staff never asked him for a statement. Resident #10 stated, I never signed anything. On 9/8/25 at 3:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The DON said Resident #1 exited the facility on 7/26/25 at 5:00 p.m. The DON said code silver was completed, and it was determined he was out of facility for two and a half to three hours. She said he was evaluated when he returned to the facility, and he was alert and oriented to person, place, time, and event (x4). The DON said she interviewed the resident when he returned, and he knew what he was doing as he told them he planned to go across the street to get a drink. The DON confirmed he had an electronic monitoring bracelet on when he left, and it was functioning. The DON said Resident #1 has had an electronic monitoring bracelet for as long as she's been at the facility. The NHA said the alarm did go off at that time he left, and confirmed staff did not respond to the alarm. She said the alarm was shut off and it was unclear who did it at that time. She said they were not sure if a staff member turned off the alarm. The NHA said they heard a resident had shut it off, not knowing how they would know the code. She stated there were no staff present by the front door where Resident #1 exited. The NHA said Staff G, CNA confirmed he opened the door for Resident #10 but said he did not hear the alarm. She said there are cameras on the unit and Staff G, CNA must have opened the door remotely and did not see Resident #1 leave. The DON said Resident #1's assigned nurse told the supervisor she had just seen him eating dinner, then he wasn't there. The DON said Resident #1 had no exit seeking behaviors. The NHA said the capability of remotely opening the front door was removed after Resident #1 exited the facility. She said currently staff have to walk to the front door to let residents out. The NHA stated they did not report this because, It was an unauthorized exit. He didn't ask to go out. She said Resident #1 did not follow the LOA process. The DON stated, He was alert and oriented, had a plan, able to navigate himself here. She said Resident #1 was already on his way to the facility and he brought himself back. The NHA and DON said they did not feel he was in harm's way. The NHA said the criteria did not make Resident #1 an elopement risk. On 9/9/25 at 1:31 p.m., a phone interview was conducted with Staff J, Physician Assistant (PA). He said Resident #1 had eloped. He said another resident let him out of the building, he was found by police and brought back to the facility. On 9/11/25 at 12:15 p.m., an interview was conducted with Staff I, CNA. She said Resident #1 was in the front/reception earlier in the day on 7/26/25. Staff I, CNA said he tried to leave through the front door earlier that day. She stated, We sent him back to nursing staff. She said she called the nurse to let them know he was exit-seeking. She said around the time residents are finished with dinner, the lobby is cleared, and no residents are present. She stated, I warned the nursing staff about him before I left. Staff I, CNA said she noticed his patterns had changed. She said he was usually with another resident walking around the facility, but around that time of the incident, he was wandering by himself. Staff I, CNA said she asked Resident #1 why he tried to leave and where he was going. She stated, He said he wanted to go get a few drinks across the street. Staff I, CNA said he seemed confused as he mentioned he wanted to go see his family member. She stated, I don't know if his [family member] was still alive and I asked social services about that. A review of the facility's policy titled, Abuse Prevention Program, dated November 2024, revealed the following: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect . Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Alleged Violation . A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated, and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation.

Based on record review, observation, and interviews, the facility failed to ensure consistent podiatry services were provided to one (#3) of ten sampled residents. Findings included: A review of Resident #3's clinical chart, the face sheet reflected an admission of 01/2024. Medical diagnoses included Alzheimer's disease and need for assistance with personal care. A review of Resident #3's Care Plan reflected a focus area: ADL (Activity of Daily Living): (Resident #3) has an ADL Self Care Performance Deficit r/t Dementia, low back pain. Interventions included: -Dressing: Mod (moderate) Assist of 1 -Bathing: The resident requires set up with supervision of 1 -Report changes in ADL performance to Nursing. A review of Resident #3's progress notes reflected the most recent note prior to the date of survey on 09/18/2024 was 09/05/2024, a Nutrition note. A review of Weekly skin checks reflected assessments had been completed on 09/17/2024 at 21:58 and 09/10/2024 at 16:40, which documented Resident #3 had no new skin conditions. A review of shower documentation reflected Resident #3 had received showers on the following recent dates: -09/16 -09/13 -09/11 -09/09 On 09/18/2024 at 10: 10 a.m., in the secure unit area, Resident #3 was observed sitting in the main dining room, in a regular chair, his back against the wall, he was observed to have his left leg bent and his foot upon his knee. He was observed from across the dining room to be vigorously scratching his foot. A Certified Nursing Assistant, (CNA), Staff A, was observed approaching him and offering to put socks on him. Resident #3 was observed to have a dime sized dark reddish-brown thick scab with the skin reddened around the scab on the middle of the top of his foot. Additional scratch marks were visible on the foot. On the right leg, mid-calf, down towards the ankle, little red marks were scattered. Staff A, CNA, was interviewed at this time, she stated she did not know why the resident was scratching. At 10:12 a.m., on 09/18/2024 Staff B, Licensed Practical Nurse (LPN) was interviewed. She was asked about Resident #3's scratching. She stated, he does not have any treatment at this time. She was observed to walk over to Resident #3 and ask him if she could take him to his room to review. They were observed to leave the common area and proceed to the resident's room. Staff B, LPN was observed to review Resident #3's feet and ankle area. She said, it looks a little red. I am going to get the physician assistant (PA) to look at it. At 10:18 a.m., on 09/18/2024 Staff C, Registered Nurse (RN) was observed to come into Resident #3's bedroom. She was observed to review Resident #3's feet, ankles, and lift his pant legs to review his lower legs. She stated she was just filling in, one of the unit managers was out. Resident #3 was interviewed at this time. He stated the itching had been going on for a while, but he was unable to specify the length of time. He stated it hurts. Yes, I told someone before. He was unable to say who he had told. Resident #3's bare feet were observed. His toenails were long, approximately ¼ inch beyond the nail bed, dark on the underneath in appearance. An interview was conducted on 09/18/2024 at 10:35 a.m. with the Director of Nursing (DON). When asked how the CNAs report skin conditions that they may see when giving a resident a shower. She stated, if CNA's notice, they report to the nurse. The nurses do a weekly skin check, that is in the chart. For the fingernails, we can cut. For the toenails, podiatry services are used. Social Services put the residents on the schedule. An interview was conducted on 09/18/2024 at 11:10 a.m. with the Social Service Director (SSD) She provided the list of residents that had been seen by the podiatrist for the following dates: -08/14/2024 -09/04/2024 -09/11/2024 Review of the podiatry lists provided reflected Resident #3's name was not present on the list. When asked how the residents names get to be on the podiatry list, she stated, the staff will come and tell her. I have a clip board in my office they can put the resident's name on. When asked how she informs the staff of what the process was for staff to know to come to her for putting a resident on podiatrist services list. She stated she talks to them a lot. But offered no specific rhetoric in regard to ensuring staff were aware of the process. She stated, I see what you mean. On 09/18/2024 at approximately 4:30 p.m., the SSD was re-interviewed. She stated the last time Resident #3 was seen by the podiatrist service was on May 3rd, 2024.

Based on record review, resident and staff interview, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that recognize quality deficiencies in the areas of neglect and effective coordination of care related to the use of anticoagulant (blood thinner). Resident #98's medication regimen included long term use of Eliquis (anticoagulant). On 8/28/23 the facility arranged for multiple dental extractions for Resident #98 without documentation of coordination with the dentist or the attending physician related to the use of anticoagulant before and after the extractions. Resident #98 experienced uncontrollable bleeding from the extractions resulting in a transfer to an acute care hospital. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The facility failure to recognize, systematically analyze quality deficiencies and implement corrective actions resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. There were 38 residents receiving anticoagulant medications. The findings included: Cross reference F600, F684 and F835. The facility's Policy and Procedure related to the Quality Assurance Performance Improvement (QAPI) Plan with an effective date of October 2017 noted, The facility will develop a QAPI plan to . identify and prioritize deviations for performance and other problems and issues; systematically investigate and analyze to determine underlying causes of systemic problems and adverse events; develop and implement corrective actions or performance improvement activities; monitor/evaluate the effects of corrective actions/performance activities . The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted the Administrator, DON or designee are responsible for the investigation and reporting of suspected neglect. The Administrator, DON and/or designated individual are responsible for the following: Implementation, ongoing monitoring, investigation, reporting, and tracking and trending. The investigation for Neglect includes initiating an Event Report. The Administrator or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. The facility will follow Federal regulations and State specific reporting requirements. The resident's physician is notified. The Nursing Home Administrator's job description signed and dated 8/11/23 noted the Administrator is responsible and accountable for the Facility Quality Assurance Performance Improvement for all aspects of the facility including but not limited to establishing and implementing policies and procedures, quality of care and regulatory compliance. Review of the clinical record for Resident #98 revealed a reentry date of 9/8/22. Resident #98's medication regimen included long term use of Eliquis (anticoagulant) 5 milligrams twice a day for Atrial Fibrillation (Type of irregular heartbeat). On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [emergency room ] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p (status post) multiple dental extractions . Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. Review of the Medication Administration (MAR) for August 2023, showed Resident #98 received the Apixaban (Eliquis) 5 mg twice a day, every day in August 2023, including before, and after the dental appointment for the multiple extractions on 8/28/23. The manufacturer's insert for Eliquis noted, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . The clinical record lacked documentation of coordination with the dentist or the physician for instructions related to the anticoagulant before and after the scheduled multiple dental extractions. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director who is Resident #98's attending physician said he was not aware the resident was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/24, the Director of Nursing (DON) provided a document which she said was the investigation related to Resident #98's uncontrollable bleeding after the nine dental extractions and transfer to the hospital. The document consisted of a nursing incident description dated 8/28/23 at 5:26 p.m., which noted Resident #98 had, Uncontrollable bleeding of the gums s/p (status post) tooth extraction. No injuries observed at time of incident. Immediate action taken. Description: PA (Physician Assistant) notified, and order received to send resident to the ER (emergency room ) for eval (evaluation). A handwritten statement from Unit Manager, Registered Nurse (RN) Staff D noted, The nurse came and asked me to do an evaluation on the resident (Resident #98) because he was complaining of lightheaded, and he also had gum bleeding. I notified the PA and he gave an order [sic] send resident to the ER. Resident refused to chew on the gauze that he was provided with by the dentist, stating it was not helping. The facility investigation did not include a thorough review of the clinical record to include a timeline, review of the MAR which showed Eliquis was administered to the resident on 8/28/23 at 5:00 p.m., statements of all staff involved in the resident's care, a root-cause analysis, or recommendation for improvement. The investigation did not consider the lack of coordination between staff, the dentist, and the physician. On 2/1/24 at 9:00 a.m., a joint interview was conducted with the Administrator and the Director of Nursing (DON). The DON said the incident involving Resident #98 was reviewed by the Interdisciplinary team (IDT) the next morning, and an event report filed. The DON said the event was locked on 8/30/23 which meant the event had been reviewed and concluded. Both the Administrator and the DON said the consensus of the IDT team was the investigation did not yield any reason to investigate further or implement any interventions. The Administrator said the incident was not discussed in QAPI since it did not meet criteria for adverse incidents. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said she did not know Resident #98 was scheduled for dental extractions on 8/28/23 and administered the Eliquis as ordered. She said if she had known the resident was getting his teeth pulled she would not have given him the blood thinner as it would cause Resident #98 to bleed more. She could not recall when Resident #98 returned to the facility and verified the lack of documentation she evaluated Resident #98 upon his return. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. On 2/2/24 at 1:00 p.m., in a telephone interview, RN Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. She said she called Unit Manager Staff D and informed him the resident refused to get changed. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. RN Staff J said the anticoagulant should have been held the week prior to the extractions and it wasn't. She verified she did not document her evaluation. RN Staff J said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) but could not remember what they were or where she documented them. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. Review of the Emergency Medical Service (EMS) report showed the facility called EMS on 8/28/23 at 5:30 p.m., two and a half hours after the resident was observed to be bleeding. EMS noted they responded to the facility, Pt (patient) has bleeding from the mouth. Staff states pt had multiple teeth pulled today and has been bleeding since. Pt takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of 38 residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of 38 residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the 38 current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Regional Risk Consultant completed education to the Administrator and Director of Nursing on implementing an effective Quality Assurance and QAPI program as verified on 2/2/24 by the survey team through review of signed completed education and interviews with the Administrator and DON. The Regional Nursing Consultant completed education to the facility Interdisciplinary Team on ensuring follow-up documentation is received and addressed following external appointments and coordination of care. On 2/2/24 the survey team verified through review of signed completed education and verbal acknowledgement by the DON and Administrator who are members of IDT team.

Based on record review, resident and staff interview the facility administration failed to use its resources effectively to protect residents' rights to be free from neglect, in that they failed to show effective coordination of care to ensure 1 (Resident #98) of 4 sampled residents received care and services in accordance with professional standards of care. Resident #98 had a diagnosis of Atrial Fibrillation (abnormal heart rhythm) with long term use of anticoagulant (blood thinner) medication. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. There was no documentation of coordination with the dentist and the physician related to the use of the blood thinner before and after the dental extractions. On 8/28/23 at approximately 5:25 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The failure of the facility's administration to prevent neglect and ensure timely assessment of the resident and coordination of care with the physicians resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. The Administrator was notified of the Immediate Jeopardy on 2/2/24 at 5:00 p.m. and provided the IJ templates. The findings included: Cross reference F600, F684, and F867. Review of the Nursing Home Administrator's job description signed and dated 8/11/23 showed the essential duties and responsibilities included, Enacts, implements, and enforces the facility policies regarding the management and operation of the facility. Analyzes . quality of care, compliance, regulatory and other management reports to determine the appropriate management interventions needed then implements the interventions resulting in improved outcomes . Identifies facility needs or issues and obtains consulting assistance, as needed, in the root-cause analysis, recommendation for improvement, education assistance or monitoring . Review of the Director of Nursing's job description signed and dated 10/9/20 noted, The Director of Nursing is responsible for developing, organizing, evaluating, and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for overall delivery of nursing services and ensures the implementation of all clinical policies and procedures . Accountable for adherence by staff to policies, procedures, and standards; delivery and proper documentation of patient care . Supervises nursing staff whether directly or indirectly in accordance with company policies and procedures . The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted neglect is, Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility's policy and procedure for referral services with an effective date of February 2021 noted, . The Director of Social Services or designee works with the interdisciplinary team to identify needs, evaluate resources, and coordinate community resources to meet the needs of the resident . Referral services may include, but are not limited to Dental Services . Follow up on the referrals to community services as appropriate and document the outcome of referrals in the resident/patient chart . Resident #98 was a long term vulnerable resident of the facility with a reentry date of 9/8/22. Resident #98's diagnoses included Atrial Fibrillation (type of irregular heartbeat). Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develop minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. The care plan did not include coordination with the physician or outside providers to address the use of the blood thinner (anticoagulant) before any invasive procedure. Review of the facility's appointment log showed Resident #98 had scheduled appointments with a local dentist on 8/7/23 and 8/28/23. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . The clinical record lacked documentation of follow up on the 8/7/23 visit to the dentist, follow up care needed, and the scheduled 8/28/23 appointment for multiple dental extractions. The clinical record lacked documentation of coordination with the dentist, or the attending physician related to the use of the blood thinner before and after the scheduled dental extractions. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [emergency room ] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p multiple dental extractions. He has consistent oral bleeding since surgery. Currently feels lightheaded and weak. He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers used to replace water and electrolyte loss in patients with low blood volume or low blood pressue) 1L(liter) prior to his CBC (Complete Blood Count). Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters). Oral cavity hemorrhage s/p (status post) multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said Social Service Director Staff H was now trying to see why they did not give the order to hold the Eliquis. He said they normally get a clearance from the physician for anyone going to have a procedure. The dentist is supposed to send the paperwork. The physician signs the clearance, and they fax it over to the dentist. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he has been caring for Resident #98 for approximately two years. He was not aware the resident was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/14 at 8:55 a.m., in an interview the Director of Nursing (DON) said Resident #98 specifically told the Social Service Director he was going to have teeth removed. The Administrator present during the interview said the Social Service Director arranged the dental services. The DON verified the lack of documentation of coordination with the dentist and the attending physician prior to the dental extractions. On 2/1/24 at 9:06 p.m., in an interview Social Service Director Staff H said at the end of July, Resident #98 came to her and said he wanted some teeth extracted. He said he had broken teeth and wanted to be seen by a dentist. She said she made the initial appointment on 8/7/23. She spoke with the resident and asked him how the appointment went. Resident #98 said the appointment went ok. The resident did not tell her he had a follow up appointment, he set up the follow up appointment himself. She said the facility did not receive any paperwork from the dentist. She verified the lack of documentation of the content of the dental appointment on 8/7/23 or coordination with the dentist for the upcoming 8/28/23 appointment for the multiple dental extractions. On 2/1/24 at 9:23 a.m., the DON said the facility investigation from 8/28/23 through 8/30/23 showed Resident #98 knew he was getting the extraction and communicated that to Licensed Practical Nurse (LPN) Staff I. She said Resident #98 was not really able to take care of himself. She said when residents go out for appointments, the physician may not be aware of procedures done such as a wound debridement (Removal of dead tissue) prior to the appointment. She said on 8/28/23 the resident told his nurse he was having the extractions. The DON verified the facility had no documentation related to the resident's dental appointments. She said the facility had no policy addressing third party providers however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. The facility provided a document with a nursing incident description dated 8/28/23 at 5:26 p.m., which noted Resident #98 had, Uncontrollable bleeding of the gums s/p (status post) tooth extraction. The Physician Assistant was notified and issued an order to send the resident to the emergency room for evaluation. The facility lacked documentation of an investigation of the incident, including statements of all staff involved in the resident's care, a root-cause analysis, or recommendation for improvement. On 1/31/24 at 1:26 p.m., in an interview the Administrator said he started employment at the facility in August 2023, and was the risk manager for the facility. He said they do discuss any return to hospital. He said he did not remember the incident involving Resident #98 as a reportable event, or an adverse incident. On 2/01/24 at 8:55 a.m., a meeting was held with the Administrator, the DON and the Social Service Director. The DON said when someone is sent out each morning they go over the events of the prior day, The interdisciplinary team talks about it in Quality Assurance. The NHA said the Social Service Director arranged the dental services. He said the incident involving Resident #98 was not reported in Quality Assurance because it did not meet criteria for an adverse incident. On 2/1/24 at 9:35 a.m., the DON said Resident #98 was sent out within two hours of coming back from the dental appointment. The DON said the facility did not think the incident represented a safety risk and did not put anything in place other than what they currently do for outside providers' appointments. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of 38 residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of 38 residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the 38 current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Risk Management consultant completed education to the Administrator. Director of Nursing and Interdisciplinary team on the following topics: a. The facility's Abuse, Neglect and Exploitation Prevention Program with a focus on the prevention of neglect. Completed 2/1/24. b. Timely evaluation of patients. Completed 2/1/24. c. Appropriate Interventions. Completed 2/2/24. d. Notification of physician to meet each resident's needs. Completed 2/2/24. On 2/2/24 the survey team verified through review of the education, interview with the Administrator and the Director of Nursing. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalized the Abuse, Neglect and Exploitation Prevention Program with a focus on prevention of neglect. All six Licensed Nurses were able to verbalize process for timely evaluation of residents, appropriate interventions, and notification of physician to meet each resident's needs.

Based on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to ensure effective coordination between staff, physicians, and outside medical providers in accordance to professional standards of care to meet the needs of 4 (Residents #98, #9, #99, and #110) of 4 residents reviewed. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. The facility arranged an appointment for multiple dental extractions for Resident #98. The facility did not ensure coordination between facility staff, the dentist, or the attending physician related to the use of anticoagulant (Eliquis) before and after the dental extractions. On 8/28/23 Resident #98 underwent nine extractions and returned to the facility around 3:00 p.m. There was no documentation Resident #98 was evaluated upon return to the facility. On 8/28/23 at approximately 5:25 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post (s/p) dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The facility failure to develop and implement resident care policies to ensure ongoing collaboration and communication processes resulted in noncompliance at the Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. There were 38 residents receiving anticoagulant medications. The findings included: Cross reference F600, F835, and F867. 1. The facility's policy and procedure for referral services with an effective date of February 2021 noted, . The Director of Social Services or designee works with the interdisciplinary team to identify needs, evaluate resources, and coordinate community resources to meet the needs of the resident . Referral services may include, but are not limited to Dental Services . Follow up on the referrals to community services as appropriate and document the outcome of referrals in the resident/patient chart . Resident #98 had a reentry date of 9/8/22. Diagnoses included Atrial Fibrillation, anxiety disorder, and depression. Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . counseling information . To tell their physicians and dentists they are taking Eliquis, and/or any other product known to affect bleeding . before any surgery or medical or dental procedure is scheduled . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develop minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. The care plan did not include coordination with the physician or dentist to address the use of the blood thinner (anticoagulant) before any surgery, medical or dental procedure is scheduled. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . The clinical record lacked documentation of the outcome of dentist's visit for 8/7/23. The facility's appointment log showed Resident #98 had a second dental appointment scheduled for 8/28/23. The clinical record lacked documentation of the reason for the dental appointment, or coordination with the dentist and the physician to address the use of the blood thinner in the event Resident #98 required a dental procedure such as an extraction. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [emergency room ] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p multiple dental extractions . He has consistent oral bleeding since surgery . Currently feels lightheaded and weak . He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers) 1L(liter) prior to his CBC (Complete Blood Count) . Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters) . Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission . On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation in the clinical record of coordination with the dentist and medical practitioners (Physician, Physician Assistant, Advanced Practice Registered Nurse) related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said they normally get a clearance from the physician for anyone going to have a procedure. The physician signs the clearance, and they fax it over to the dentist. The Unit Manager verified the lack of documentation Resident #98's physician was notified of the multiple dental extractions and cleared the resident for the dental procedure. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. In collaboration with the dentist, they determine whether to hold the blood thinner. He said if the cardiologist saw him, the cardiologist would have done the clearance, especially for advanced procedures. Review of the progress notes showed on 8/24/23 the Advanced Practice Registered Nurse (APRN) documented in a follow up cardiology note, Patient is somewhat a limited historian, therefore most information regarding past cardiac medical history has been gained from available records at facility . Patient was previously maintained on coumadin (blood thinner) prior to a hospital admission in 2022, when he developed a severe upper GIB (Gastrointestinal bleed). He was transitioned off coumadin (anticoagulant) to Eliquis . There was no documentation the facility informed the APRN of the upcoming appointment for the multiple extractions scheduled for 8/28/23. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 2:07 p.m., Resident #98 said the morning of the extractions the nurse gave him all his pills, including the blood thinner. He mentioned getting the teeth pulled and thought he should not take the blood thinner. The nurse just told him to take his pills and that is what he did. He said he was at the dentist for a while, they drilled and pulled and drilled and pulled. He said they pulled all of his teeth, and he needed stitches after the extractions. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he was not aware Resident #98 was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/14 at 8:55 a.m., during a joint interview with the Director of Nursing (DON), and the Administrator, the DON said Resident #98 specifically told the Social Service Director he was going to have teeth removed. The Administrator said the Social Service Director arranged the dental services. The DON verified the lack of documentation of coordination with the dentist and the attending physician prior to the dental extractions. On 2/1/24 at 9:06 a.m., in an interview Social Service Director Staff H said at the end of July, Resident #98 came to her and said he wanted some teeth extracted. He said he had broken teeth and wanted to be seen by a dentist. She said she made the initial appointment on 8/7/23. She said the facility did not receive any paperwork from the dentist. She verified the lack of documentation the facility followed up on the dental appointment on 8/7/23 or coordination with the dentist for the upcoming 8/28/23 appointment for the multiple dental extractions. On 2/1/24 at 9:23 a.m., the DON said Resident #98 was not really able to take care of himself. She said on 8/28/23 Resident #98 told Licensed Practical Nurse (LPN) Staff I he was having the dental extractions. She said when residents go out for appointments, the physician may not be aware of procedures done such as a wound debridement (Removal of dead tissue) prior to the appointment. She said the facility had no policy addressing outside medical providers however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. On 2/1/24 at 9:35 a.m., the DON said Resident #98 was sent out within two hours of coming back from the dental appointment. The DON said the facility did not think the incident represented a safety risk and did not put anything in place other than what they currently do for outside medical providers' appointments. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said she did not know Resident #98 was scheduled for dental extractions, and on 8/28/23 at 9:00 a.m., she administered the Eliquis as ordered. She could not recall when Resident #98 returned to the facility and verified the lack of documentation she evaluated Resident #98 upon his return. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. Review of the Medication Administration Record (MAR) showed on 8/28/23 at 5:00 p.m., Registered Nurse (RN) Staff J documented she administered the scheduled dose of Apixaban (Eliquis) 5 milligrams to Resident #98. On 2/2/24 at 1:00 p.m., in a telephone interview, RN Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse (LPN Staff I) gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. She said she called Unit Manager RN Staff D and informed him the resident refused to get changed. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. RN Staff J said the anticoagulant should have been held the week prior to the extractions and it wasn't. She verified she did not document her evaluation. RN Staff J said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) but could not remember what they were or where she documented them. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. The clinical record lacked documentation the physician was immediately notified of the significant oral bleeding upon the resident's return to the facility. Review of the Emergency Medical Services (EMS) report showed on 8/28/23 at 5:30 p.m., they received a call and responded to the facility for a hemorrhage. The report noted staff stated the resident had multiple teeth pulled today and has bleeding since. The primary impression was hemorrhage and the chief complaint Hemorrhage from dental work. Pt (patient) takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . 25618 2. On 2/1/24 review of Resident #9's medical record revealed a re-admitted [DATE] with diagnoses of secondary Parkinsonism, unspecified dementia, dysphagia, cognitive communication deficit, psoriasis, chronic kidney disease and adult failure to thrive. On 12/14/23 a consent for hospice services was signed by the primary caregiver and hospice staff representative. Review of Resident #9's medical record revealed a Physician's Order, dated 12/18/23, for Terminal Diagnosis: The resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis of Parkinson's disease. Review of Resident #9's plan of care for nutrition, Parkinson's disease, discharge planning, cognition, advance directives, activity of daily living, and wound risk revealed the care plans were updated and revised on 12/15/23. The care plans stated the facility would collaborate care with Hospice. On 12/18/23 an invitation to the Care Plan meeting was extended to the Hospice representative. The attendees sign-in sheet for the care plan meeting noted that Hospice had been invited to the meeting, but the Hospice representative did not attend the Care Plan meeting. Review of Resident #9's medical record revealed it did not contain a record of the Hospice plan of care for Resident #9 and/or documentation related to the collaboration of care between Hospice services and the facility in the development of Resident #9's plan of care. 3. On 2/1/24 review of Resident #99's medical record revealed a re-admitted [DATE] with a primary diagnosis of cerebral infarction to thrombosis of right cerebral artery, hemiplegia affecting left side, contracture of right and left knees, dysphagia, and adult failure to thrive. Review of Resident #99's Physician's Order, revealed an order dated 12/11/23 for Terminal Diagnosis: The resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the Terminal diagnosis of: CVA (cardiovascular accident). Review of Resident #99's plan of care for nutrition, dental, discharge planning, cognition, advance directives, activity of daily living, and pain care plans were updated and revised on 12/15/23. The care plans stated the facility would collaborate care with Hospice. On 12/26/23, an invitation to the Care Plan meeting was extended to the Hospice representative. The attendees sign-in sheet for the Care Plan meeting noted it stated that Hospice was invited to the meeting, but the Hospice representative did not attend the care plan meeting. Review of Resident #99's medical record revealed it did not contain a record of the Hospice plan of care for Resident #99 and/or documentation related to the collaboration of care between Hospice services and the facility in the development of Resident #99's plan of care. On 2/1/24 at 5:09 p.m., during an interview with the Clinical Reimbursement Director (CRD), she said she was responsible for the development and creation of each resident's plan of care while at the facility. She said Resident #9 had a Physician's Order for Hospice services dated 12/18/23 and Resident #99 had a Physician's Order for Hospice services on 12/11/23. She confirmed both Residents #9 and #99 plan of care stated the facility and Hospice would collaborate in the development of each resident's plan of care. She further stated neither medical record had a copy of each resident's plan of care developed by Hospice services. She said the Hospice representatives were invited to Resident #9 and #99's plan of care meetings but did not attend their Care Plan meetings. She further said the facility did not have documentation the facility and Hospice had collaborated in the development and implementation of Resident #9 and #99's Care Plans to ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 22651 4. Review of the clinical record revealed Resident's #110 was admitted to the facility on [DATE]. Diagnoses included Congestive Heart Failure, muscle wasting and atrophy. The physician's order as of 1/9/24 included to monitor the blood sugar four times a day via fingerstick, before meals and at bedtime. The physician's order did not include parameters for physician notification for the blood sugar. The Admission Minimum Data Set (MDS) assessment with a target date of 1/11/24 did not list a diagnosis for the blood sugar monitoring. The hospital discharge summary dated 1/7/24 did not list a diabetic medication. Resident #110's diet was for a regular mechanical soft diet. On 2/2/23 at 10:38 a.m., in an interview the MDS Coordinator said, I don't see a diagnosis of Diabetes. The resident is not on steroids, which can elevate blood sugar levels. She is not on insulin or on a hypoglycemic agent. On 2/2/24 at 11:05 a.m., in an interview the Physician Assistant (PA) he said he would have to look into it. On 2/2/24 at 11:41 a.m., in an interview, the PA said, we will stop the Accu Checks (finger sticks) for now. He said he would order blood test used to diagnose Diabetes and decide when he gets the results. On 2/2/24 at 1:10 p.m., in an interview Resident #110 said she did not know why they started doing the finger sticks to monitor her blood sugar. She said they just told her they had to do it. She said the doctor came in earlier, stopped the finger sticks and said he would order some lab work. On 2/2/24 at 4:50 p.m., in an interview Resident #110's spouse said he did not know why they were doing the finger sticks. He said his spouse has never had an issue with her blood sugar. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: The nurse involved in the IJ was immediately suspended pending the outcome of the investigation and the Federal Immediate Report for the allegation of neglect was submitted. The survey team verified through record review and interview with the Administrator. Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Risk Management consultant completed education to the Director of Nursing, Staff Development Coordinator, and Assistant Director of Nursing on the following topics: a. Anticoagulant therapy including monitoring for side effects. Completed 2/1/24. b. Ensure communication with medical provider prior to procedures if resident is taking anticoagulents. Completed 2/1/24. c. Ensuring follow-up documentation is received and addressed following external appointments and coordination of care to meet the resident's physical, mental, and psychosocial needs. Completed 2/1/24. The survey team verified through record review of the education, and interview with the Director of Nursing, and Assistant Director of Nursing. The facility DON, Staff Development Coordinator, and Assistant Director of Nursing (ADON) educated all licensed nurses on the following topics: a. Anticoagulant therapy, including monitoring for signs and symptoms of side effects. Completed 2/1/24. b. Ensure communication with medical provider prior to procedures if resident is taking anticoagulents. Completed 2/1/24. c. Ensure follow-up documentation is received and addressed following external appointments and coordination of care to meet the resident's physical, mental, and psychosocial needs. Completed 2/1/24. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalize anticoagulent therapy monitoring for signs and symptoms of side effects. All six Licensed Nurses were able to verbalize the process for timely evaluation of residents, appropriate interventions, and notification of physician to meet each resident's needs. The Risk Management consultant educated the facility Social Services Director on the coordination of care, following up with internal and external referrals to ensure documentation is reviewed and assessed to meet the resident's physical, mental, and psychosocial needs. Completed 2/2/24. On 2/2/24 the survey team verified through review of the education, interview with the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and the Social Services Director.

Based on record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to protect the residents' rights to be free from neglect. The facility failed to ensure timely evaluation of resident's condition, and immediate physician notification in the presence of an acute change in condition to avoid physical harm for 1 (Resident #98) of 4 residents reviewed for coordination of care. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. The facility had no documentation of coordination with the dentist and medical practitioners related to the use of the blood thinner before and after the dental extractions, and no documentation of timely evaluation and physician notification when Resident #98 experienced significant bleeding from the extraction sites upon return to the facility. On 8/28/23 at approximately 5:30 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The failure of the facility's staff to prevent neglect resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The findings included: Cross reference F684, F835, and F867. The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted neglect is, Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The policy noted the Administrator, DON or designee are responsible for the investigation and reporting of suspected neglect. The Administrator, DON and/or designated individual are responsible for the following: Implementation, ongoing monitoring, investigation, reporting, and tracking and trending. The investigation for Neglect includes initiating an Event Report. The Administrator or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. The facility will follow Federal regulations and State specific reporting requirements. The resident's physician is notified. Resident #98 was a long term resident of the facility with a reentry date of 9/8/22. Resident #98's diagnoses included Atrial Fibrillation (type of irregular heartbeat). Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develops minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . Review of the facility's appointment log showed Resident #98 had scheduled appointments with a local dentist on 8/7/23 and 8/28/23. The clinical record lacked documentation the facility followed up with the dentist after the appointment of 8/7/23. There was no documentation that the facility notified the physician of the upcoming 8/28/23 dental appointment for the multiple extractions. Review of the Medication Administration Record revealed the nurse administered the scheduled dose of apixaban on 8/28/23 at 9:00 a.m., to Resident #98 prior to the dentist appointment for the multiple extractions. The clinical record lacked documentation the physician was notified and approved the administration of the blood thinner on the day of the extractions. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist after the multiple extractions. Review of the Medication Administration Record (MAR) showed documentation the nurse administered the scheduled dose of Apixaban 5 mg to the resident on 8/28/23 at 5:00 p.m. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [emergency room ] for eval [evaluation]. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said Social Service Director Staff H was now trying to see why they did not give the order to hold the Eliquis. He said they normally get a clearance from the physician for anyone going to have a procedure. The dentist is supposed to send the paperwork. The physician signs the clearance, and they fax it over to the dentist. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. On 1/31/24 at 2:07 p.m., in an interview Resident #98 said the morning of the extractions the nurse gave him the blood thinner. He mentioned getting his teeth pulled and thought he should not take the blood thinner. The nurse just told him to take his pills and that is what he did. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he was not aware Resident #98 was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. On 2/1/24 at 9:23 a.m., the DON said Resident #98 told Licensed Practical Nurse (LPN) Staff I he was having the dental extractions. She said the facility had no policy addressing outside medical practitioners however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. The DON verified the lack of documentation Resident #98 was evaluated upon return to the facility after the extractions to promptly address any complication, including bleeding from the extraction sites. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said on 8/28/23 she worked the morning shift, did not know Resident #98 was scheduled for dental extractions and administered the Eliquis (Apixaban) at 9:00 a.m., as ordered. She could not recall when Resident #98 returned to the facility. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. She said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) upon his return to the facility but could not remember what they were or where they documented the vital signs. She verified the lack of documentation she evaluated Resident #98 upon his return. On 2/2/24 at 1:00 p.m., in a telephone interview, Registered Nurse (RN) Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse (LPN Staff I) gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. RN Staff J said she took the resident's vital signs but could not remember what they were or where she documented them. RN Staff J said she did not immediately call the physician but called the Unit Manager. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. The clinical record lacked documentation RN Staff J immediately notified the physician of the significant oral bleeding upon the resident's return to the facility. Review of the Emergency Medical Services (EMS) report showed on 8/28/23 at 5:30 p.m., (approximately two and a half hour after Resident #98 returned to the facility), they received a call and responded to the facility for a hemorrhage. The report noted staff stated the resident had multiple teeth pulled today and has bleeding since. The primary impression was hemorrhage and the chief complaint Hemorrhage from dental work. Pt (patient) takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p [status post] multiple dental extractions. He has consistent oral bleeding since surgery. Currently feels lightheaded and weak. He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers used to replace water and electrolyte loss in patients with low blood volume or low blood pressure) 1L(liter) prior to his CBC (Complete Blood Count). Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters). Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission . After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The Immediate actions implemented by the facility and verified by the survey team included: 1. Nurse identified in the IJ was immediately suspended pending the outcome of the investigation and the Federal Immediate Report for the allegation of neglect was submitted. Completed 2/2/24. On 2/2/24, the survey team verified through record review and interview with the Administrator. 2. The Risk Management Consultant completed a 30 day look back of residents with external appointments as well as internal podiatry & dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry & dental service appointments and their providers were notified of the residents' anticoagulant status. Completed 2/2/24. On 2/2/24 the survey team verified through record review and interview with the Administrator and Director of Nursing. 3. Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through record review. 4. The Risk Management consultant completed education to the Administrator, Director of Nursing and Interdisciplinary Team on the following topics: a. The facility's Abuse, Neglect and Exploitation Prevention Program with a focus on the prevention of neglect. Completed 2/1/24. b. Event Management process to ensure root cause is established for events and interventions implemented are based on the root cause. Completed 2/1/24. On 2/2/24, the survey team verified through review of the completed education, and interview with the Administrator, and the Director of Nursing. They both were able to verbalize understanding of the content of the education provided. 5. The facility Director of Nursing, Staff Development Coordinator and Assistant Director of Nursing conducted education on the facility's Abuse, Neglect and Exploitation Prevention Program. Facility staff education currently at 96% to total and all remaining staff will be removed from the schedule until education occurs. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalize the facility's abuse, neglect, and exploitation prevention program.

Based on observations and staff interviews, the facility failed to ensure a functioning call light system on 2 (room [ROOM NUMBER] and #277) of 32 rooms observed. The findings included: On 1/29/24 at 12:19 p.m., Resident #78 said she turned on her call light for assistance, but no one had answered it. The call light did not turn on when activated. Licensed Practical Nurse (LPN) Staff O present during the observation verified the call light was not functioning. LPN Staff O said, it must have a short in it. On 1/31/24 at 10:36 a.m. Resident #78 said staff did not answer her call light since it did not alarm at the nurse's station. On 1/31/24 at 11:00 a.m., the call light of room [ROOM NUMBER] was turned on. It did not ring at the call light box located the nurse's station to alert the staff of the resident's call for assistance. Six of the rooms on the call light box were missing the top cap that identified the room number. On 2/2/24 at 2:00 p.m., the Maintenance Director said the facility utilizes an electronic system to report maintenance issues. He said he was not aware of the non-functioning call light system on the South Unit. On 2/2/24 at 2:08 p.m., the Maintenance Director was observed turning on the call light in room [ROOM NUMBER]. The call light did not light up or alarmed at the nurse's station. On 2/2/24 at 2:15 p.m., Certified Nursing Assistant, Staff M said approximately a month ago, a company came out a month ago to work on the call light system. It has not been working correctly since then.

Based on observation, record review, review of policies and procedures, and staff interviews, the facility failed to implement an activity program to meet the needs of 3 (Resident #112, #114, and #136) of 3 sampled residents dependent on staff for physical, mental, and psychosocial well-being. The findings included: The Policy Activities Overview effective October of 2021 reads, Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The Activity Programs will reflect individual needs and provide/promote the following: Stimulation or solace Physical, cognitive, and/or emotional health Enhancement, to the extent practicable, of each resident is physical and mental status. Resident Self-respect by providing activities that support self-expression, social and personal responsibility, and choice . Programs will be designed to meet the residents at their level of functioning. Support activities-for residents who may be severely impaired or unable to tolerate the stimulation of the group. Maintenance Activities-schedule events that promote the highest level of physical, emotional, cognitive, psychosocial, and spiritual well-being. 1. Review of the clinical record revealed Resident #112 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease, Dementia, and Depression. The Admission Minimum Data Set (MDS) assessment with a target date of 1/8/24 showed it was very important to the resident to be able to read, listen to music, be around pets, go outside for fresh air, and attend religious activities. Resident #112's cognitive abilities for daily decision making were severely impaired with a Brief Interview for Mental Status (BIMS) score of 07. Resident #112's activities care plan noted she required staff assistance with involvement in activities related to cognitive deficits, including staff assistance to and from activities. The resident activity goal was to participate in activity of her choice. The interventions included: Encourage to participate with activities of choice. Prefers/would benefit from: In Room. Prefers/would benefit from: Passive Active Room Activity. Prefers/would benefit from: Small Group. The resident needs assistance/escort to/and from activity functions. Thank the resident for attendance at activity function. On 1/30/24 at 9:55 a.m., and 1:40 p.m., Resident #112 was observed sitting her wheelchair in the main living area of the memory care unit in front of the television. On 2/2/24 at 9:49 a.m., Resident #112 was observed sitting in front of the television on the memory care unit. On 2/2/24 at 10:30 a.m., Resident #112 remained in her wheelchair in front of the television with 17 other memory care residents. The movie observed playing on the television was Ground Hog's Day. There were no activity staff observed in the memory care unit. On 2/2/24 at 3:30 p.m., Resident #112 was observed in the dining room area of the memory care unit. Thirteen other residents were observed in the living area in front of the television. There were no activity staff noted in the memory care unit. Review of the electronic documentation of activity participation showed Resident #112 attended three group activities since 1/4/24. One group activity was marked N/A (not applicable.) 2. Review of the clinical record revealed Resident #114 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease with early onset, Dementia with psychotic disturbance. Resident #114 had a history of Cerebral Infarction, Dysphagia, Alzheimer's Disease with early onset, Dementia with Psychotic Disturbance, Hemiplegia and Hemiparesis, Bi-Polar Disorder, and Obsessive-Compulsive Disorder. The Annual MDS with a target date of 11/18/23 showed Resident #114's cognitive abilities for decision making were severely impaired with a BIMS score of 05. The Annual MDS with a target of 11/18/23 noted the following activities were very important to Resident #114: Reading, listening to music, being around pets, keeping up with the news, having group activities, attending religious services, and doing her favorite activity. Resident #114's care plan showed she required staff to assist her with involvement in activities related to cognitive deficits. The activity's goal for Resident #114 was to participate in activities of choice and answer simple questions. The interventions for Resident #114 were the same as Resident #112, and included: Encourage to participate with activities of choice. Prefers/would benefit from: In Room. Prefers/would benefit from: Passive Active Room Activity. Prefers/would benefit from: Small Group. The resident needs assistance/escort to/and from activity functions. Thank the resident for attendance at activity function. Review of the activity participation showed Resident #114 attended five group activities in the last 30 days. Three other group activities were marked not applicable. On 1/29/24 at 11:01 a.m., Resident #114 was observed sleeping in her bed. Multiple random residents on the memory care unit were observed in front of the television. No activity staff was noted in the memory care unit at the time of the observation. On 2/2/24 at 9:49 a.m. Resident #114 was observed sitting in front of the television on the memory care unit. The activity listed on the calendar for 2/2/24 at 10:00 a.m., was Grove to the music. On 2/2/24 observation from 10:00 a.m., to 10:30 a.m., showed Resident #114 remained sitting in front of the television with 17 other memory care residents. The movie observed playing on the television was Ground Hog's Day. There were no activity staff observed in the memory care area. The activity listed on calendar for 2/2/24 at 3:30 p.m., listed Vantage Time. On 2/2/24 at 3:30 p.m., Resident #114 was observed in her bedroom on the memory care unit without any activity. Thirteen other residents were observed in the living area in front of the television. There were no activity staff noted in the memory unit at that time. 3. Review of the clinical record for Resident #136 showed an admitted [DATE]. Diagnoses included Anoxic (lack of oxygen) Brain Damage, Bi-Polar (Episodes disorder and Post Traumatic Stress Disorder. The Annual MDS with a target date of 9/5/23 showed Resident #136 was able to answer questions regarding activity preferences. The Annual MDS assessment showed reading, music, being around pets, and doing her favorite activity were very important to the resident. The Quarterly MDS with a target date of 12/6/23 showed Resident #136's cognitive abilities for decision making were moderately impaired with a BIMS score of 08. The activity care plan listed the same interventions as Resident #112 and #114 which included: Encourage to participate with activities of choice. Prefers/would benefit from: In Room. Prefers/would benefit from: Passive Active Room Activity. Prefers/would benefit from: Small Group. The resident needs assistance/escort to/and from activity functions. Thank the resident for attendance at activity function. Review of the electronic activity participation over the last 30 days showed Resident #136 attended three group activities. Six activities were marked not applicable. On 1/29/24 at 11:10 a.m., Resident #136 was observed in bed in her room on the memory care unit. On 2/2/24 at 9:49 a.m., Resident #136 was observed wandering from the living area to her bedroom on the memory care unit. Staff were observed redirecting the resident to her bedroom at times. On 2/2/24 at 10:30 a.m., Resident #136 was observed wandering from her bedroom to the living room area of the memory care unit. A movie (Ground Hog's Day) was observed playing on the television. No activity staff was observed in the memory care area. On 2/2/24 at 3:30 p.m., Resident #136 was observed sitting in front of the television in the living room area of the memory care unit. Thirteen other residents were observed in the living area in front of the television. There were no activity staff noted in the memory unit. Ground Hogs Day was playing on the television. Review of the facility assessment dated [DATE] showed the facility has a capacity of 240 residents. The facility assessment showed one Activities person and one activities assistant were adequate to provide individualized activities for residents. On 1/27/24 the census was 197 residents. On 2/2/24 at 11:30 a.m., the Activity Director (AD) said they did not have enough staff to do one-to-one activities with the residents. The AD said the activity department consisted of two activity staff for all the residents. When asked about Residents #112, #114, and #136's lack of group activities the AD said she did not have time to document the activities being completed. She said the activity staff did not transport residents to group activities. On 2/2/24 at 3:39 p.m. Registered Nurse, Staff L was asked about activities on the memory care unit. She stated she worked on Fridays and Saturdays and her shift started at 3:00 p.m. She stated when she arrived on the memory care unit there were no activities being provided. She stated by 3:00 p.m. all activities at the memory care unit were completed on Fridays and Saturdays. Review of the memory care unit activity calendar for February of 2024 showed three to four activities listed daily. One to two of the daily activities listed were for residents to watch television, and included: Game Show, Vintage movie, Let's Make A Deal, Church on TV, I love [NAME], and Superbowl.

Based on observation, clinical record review and staff and resident interview, the facility failed to provide the appropriate monitoring and application of splints for 1(Resident #24) of 1 resident reviewed with a limitation in range of motion (ROM). This had the potential to cause pain and worsening of the contracture. The findings included: Review of the clinical record revealed Resident #24 was [AGE] years old with an admitted [DATE]. The residents' diagnoses included hemiparesis and hemiplegia affecting the left side, dementia, schizoaffective disorder, muscle wasting, contracture of left elbow, left wrist, and left hand. Review of the activities of daily living care plan, initiated 4/19/22, specified palm guard to left hand on in am for 8 hours - may remove for skin checks and care - refuses to wear most days. Review of the physician order dated 10/13/20 documented Patient to wear Palm Guard for up to 8 hours per day to reduce risk of skin breakdown and contracture of left hand, every day and evening shift. Check skin integrity pre and post application. On 1/29/24 at 11:14 a.m., resident #24 was observed seated in her wheelchair, her left hand was noted to be in a tight fist, and she said she was not able to straighten her fingers. There was a splint on the dresser, and she said sometimes the staff put it on for her. On 1/30/24 at 9:53 a.m., Resident #24 had been out of bed for 2 hours and no splint was observed in the left hand. The splint was observed on the table next to the television. On 1/31/24 at 5:02 p.m., Resident #24's left hand splint was observed on the table near the television., Photographic evidence obtained. On 2/1/24 at 1:20 p.m., in an interview the Director of Nursing (DON) said the nursing staff were to apply the splints. She said she was not aware Resident #24 did not have the splint on and said, I will see if she has an order for it. On 2/1/24 at 1:22 p.m., in an interview Certified Nursing Assistant (CNA) Staff C said the resident has the contracture and when she is assigned to the resident she will try and put the splint on for her but she refuses a lot of the time. The CNA said if the resident refused to wear the splint then she would tell the nurse so it could be documented. On 2/1/24 at 4:34 p.m., in an interview with Occupational Therapist (OT) Staff K said the resident had recently come off services for the hand splint. At the time of her discharge, she was wearing the splint 4-5 hours. The resident can remove the splint. The OT said the resident does have a history of refusing care, but she never refused for me. She would say I don't want to wear it today and I was able to talk with her and she eventually agrees. On 2/1/24 at 4:50 p.m., in an interview the Rehab Director said we do splint audits every 6 months to ensure the splints are still appropriate, do they need a different device, is the splint still fitting the resident. The audits are to be done every 6 months but right now we are a year behind. When we discharge a resident from any therapy with a device, we provide an in-service to the CNA and the nurse. We demonstrate how to apply the device and they demonstrate back to us that they can apply the device. We teach them to check the resident's skin before and after applying the splint. Review of the therapy notes received from the Rehab Director revealed on 11/28/23 OT Staff K provided an in-service to 2 registered nurses and, 1 licensed practical nurse and 1 CNA regarding the application of the splint. Review of the OT progress and discharge summary note revealed the start date of care for Resident #24 was 8/8/23 and end of date of her therapy was 1/6/24. The summary documented the diagnosis for the therapy was hemiplegia following a cerebral vascular accident affecting the left side. The goal for the resident specified that the patient will wear functional position splint for 4-6 hours according to wear schedule with 90% accuracy as applied by trained caregivers. On 2/1/24 at 6:00 p.m., in an interview the DON, said the resident was able to remove the splint, I just spoke with her, and she did not want to put it on. The DON said she updated the plan of care to document the resident's refusal of the splint. The DON said, the expectation is the CNA puts it on and if the resident refuses it should be documented. The DON said the application of the splint was documented by the nurse on the medication administration record (MAR). Review of the MAR documented a physician order dated 10/13/20 specified Patient to wear Palm Guard for up to 8 hours per day to reduce risk of skin breakdown and contracture of left hand. The MAR showed from 1/25/24 to 1/31/24 the splint was documented as off. There was no documentation as to why the splint was off when it should have been on. On 2/2/24 at 3:10 p.m., in an interview the DON said the facility had no policy for the application of splints. She said staff are educated on the device by therapy. The DON said we document it on the MAR if it is on or off and said the resident refuses to wear it at times and it is care planned. The DON confirmed there was no documentation the staff attempted to apply the splint and no documentation the resident refused it or removed it. Without documentation there was no way to know how long the splint was on for, or if the resident refused to wear it.

Based on observation, review of facility policy and procedure, and staff interview, the facility failed to store respiratory equipment in a sanitary manner for 1(Resident #489) of 2 residents reviewed for respiratory care. This had the potential to cause respiratory infections in compromised residents. The findings included: The facility policy Medication Administration via Nebulizer 1/2020, documented Store the dry nebulizer (administers medication directly into the lungs) in a storage bag labeled with resident name and date. Review of Resident #489's clinical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), and a history of lung cancer. The physician's order dated 1/25/24 included to administer Pulmicort Inhalation Suspension 0.25 milligram/2 milliliters (Budesonide (Inhalation)) 1 vial inhale orally via nebulizer two times a day for COPD. On 1/30/24 at 9:55 a.m., and 5:50 p.m., Resident #489 was observed to have a nebulizer on the nightstand. The handheld pipe mouthpiece was stored uncovered and touching other items on the cluttered nightstand. During random observations on 1/31/24 at 10:07 a.m., and on 2/2/24 at 9:00 a.m., Resident #489 's nebulizer machine with the pipe mouthpiece was stored uncovered on top of the portable cooling unit in the room. A second nebulizer machine was observed on the bedside nightstand. The handheld pipe mouthpiece was stored uncovered on the nightstand. The resident did not answer questions appropriately. Photographic evidence obtained. On 2/2/24 8:16 at a.m., in an interview Licensed Practical Nurse (LPN) Staff B said the nebulizer is to be stored in a plastic bag when not in use to keep it clean. The mouthpiece is to be washed and dried after use. On 2/2/24 at 9:26 a.m., in an interview Registered Nurse (RN) Supervisor Staff D said the nebulizer machines should be covered when not in use and placed on the nightstand. Staff D observed, and confirmed both nebulizer machines and pipe mouthpiece were not covered.

Based on observation, clinical record review, and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #31 and #184) of 5 dependent residents reviewed for Activities of Daily Living (ADLs). The findings included: 1. Review of the clinical record revealed Resident #31 had a readmitted [DATE]. Diagnoses included fracture of the left femur, dementia, muscle wasting, and history of falling. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 12/13/23 documented Resident #31 required assistance of one for transfer to and from bed and was dependent on staff for personal hygiene and bathing. The MDS noted Resident #31's cognitive skills for daily decision making were moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. On 1/29/24 at 11:00 a.m., Resident #31 was observed in bed. His fingernails extended approximately half an inch from the nail beds with an accumulation of brown substance under the nails. The resident had approximately four days of facial hair growth. Resident #31 was not able to respond appropriately to any questions regarding his personal hygiene and bathing. On 1/30/24 at 1:32 p.m., Resident #31 was observed in bed wearing a neon green, long-sleeved shirt. The resident remained unshaven and the fingernails remained long with a dark brown substance under the nails. On 1/31/24 at 10:29 a.m., and 12:22 p.m., during random observations Resident #31 was observed in bed wearing the same long sleeved, neon green shirt as the previous day. The front of the shirt now had multiple food stains. Resident #31 had approximately five days of facial hair growth. His fingernails remained long with black/brown substance under the nails. On 1/31/24 at 10:24 a.m., in an interview Certified Nursing Assistant (CNA) Staff C said Resident #31 was dependent for bathing and all ADLs and only able to feed himself after set up. He did not refuse or resist care and was not combative. The CNA said, if a resident refused care, she would notify the nurse. The CNA said the process for the showers was to check the assignment book and it provides the name of the resident to be showered on that day and then the CNA signs it when completed. On 1/31/24 at 2:04 p.m., in a joint observation, Licensed Practical Nurse (LPN) Staff G verified Resident #31's fingernails extended approximately half an inch from the nail bed and had an accumulation of black and brown substance under the nails. Staff G also verified Resident #31 wore the same stained neon green shirt from the previous day and was not shaved. Staff G said, ok and left the room. A review of the facility shower schedule revealed Resident #31 was scheduled for showers on Mondays, Wednesdays, and Fridays on the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA documentation for December 2023, and January 2024 revealed Resident #31 received eight of 27 scheduled showers. Resident #31 received a bed bath on 12/1/23, 12/6/23, 12/8/23, 12/13/23, 12/15/23, 12/18/23, 12/20/23, 12/22/23, 12/27/23, 12/29/23, 1/1/24, 1/3/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, 1/19/24. There was no documentation Resident #31 refused the scheduled showers. 2. Review of the clinical record revealed Resident #184 had an admitted [DATE]. Diagnoses included Parkinson's disease, anxiety, and depression. The admission MDS with an ARD of 1/9/24 documented Resident #184 required extensive to maximum assistance with showers and moderate assistance of one for personal hygiene. The MDS noted the resident's cognitive skills for daily decision making were moderately impaired with a BIMS score of 12. During random observations on 1/29/24 at 10:45 p.m., and 1/30/24 at 9:15 a.m., Resident #184 was observed in his bed, he was unshaven with approximately four days of facial hair growth. The resident's fingernails extended approximately half an inch from the nail bed with an accumulation of brown/black substance under the nails. Resident #184 did not respond appropriately to interview questions. On 1/31/24 at 10:57 a.m., Resident #184 was observed in bed sleeping, dressed in a hospital gown. He appeared unkempt, unshaven, with approximately five days of facial hair growth. On 1/31/24 at 2:06 p.m., in a joint observation, LPN Staff E, confirmed Resident #184 had approximately five days of facial hair growth, and his nails extended approximately half an inch from the nail bed with black and brown substance under the nails. LPN Staff E asked Resident #184 if he'd like to be shaved. He said, That would be nice, I could use a shave. Review of the CNA documentation from admitted [DATE] to 1/30/24 showed documentation Resident #184 received three of the 12 scheduled showers. Resident #184 received a bed bath on 1/4/24, 1/6/24, 1/13/24, 1/16/24 and 1/25/24. Resident #184 received a partial bed bath on 1/9/24, 1/23/24 and 1/30/24. The clinical record had no documentation Resident #184 refused his scheduled showers. On 1/31/24 at 4:39 p.m., in an interview the Director of Nursing (DON), said the expectation for showers and personal hygiene was for the showers to be given as scheduled. If the resident refuses, then a bed bath is given. The CNA should let the nurse know the resident refused the shower. For shaving it is up to the individual, some residents may not want to be shaved every day and some resident's family members may want them shaved daily or not shaved at all, so it is up to the individual and the family. On 1/31/24 at 5:12 p.m., in an interview CNA Staff A, said there are no razors, it is very hard to find any. I told the nurse I needed razors to shave, and she said to wait because she is busy. The razors they have are not good quality and it takes three razors sometimes to shave one resident. I have spoken with the DON about it, but I still can't get a razor when I want to shave someone. CNA Staff A said, The men need to be shaved every day if they want it. On 1/31/24 at 4:25 p.m., in an interview, the DON said the facility had no policy on ADL care for residents.

Based on observations, resident and staff interviews, the facility failed to provide necessary maintenance and repairs to maintain a safe, clean, and homelike environment for residents on 3 (300 wing, South, and North wing) of 4 wings observed. The findings included: On 1/29/24 at 10:26 a.m., Resident #32 was observed in bed. The floor by the air conditioning unit had missing tiles. Resident #32 said the tiles have been missing for at least two weeks. On 1/29/24 at 11:10 a.m., Resident #76's wheelchair was observed. The arm rest had areas that were worn and torn. Resident #76 said she has asked them multiple times to replace the arm rest but as of today they have not replaced them. On 1/31/24 at 11:34 a.m., a pervasive sewage like odor was noted on the 300 hall around rooms 331 to 336. On 1/31/24 at 12:05 p.m., Certified Nursing Assistant (CNA) Staff O said the malodorous smell has been occurring at certain times of the day on the 300 hall for about a year. CNA Staff O said the administrative staff was aware of the unpleasant smell on the unit. The odor appeared even when residents were not being changed or toileted. On 2/2/24 at 2:15 p.m., during an environmental tour with the Maintenance Director, he verified: The sewage-like odor in the hallway around room [ROOM NUMBER]. The missing floor tiles in front of the air conditioning unit in Resident #32's room. The hole in the drywall behind the front door, and the missing floor tiles behind the toilet of room [ROOM NUMBER]. The worn-down arm rests on Resident #76's wheelchair. On 2/2/24 at 2:32 p.m., the Maintenance Director said he started employment at the facility two days ago and was still training. He said the electronic system used by the facility to report maintenance issues had 38 items logged. The oldest item was entered in the log 30 days ago.

Based on observations, interviews and record review, the facility did not ensure the environment was free from odors in two units (Hall 300 and Hall 200) of four units related to sewer gas smells in Hall 300 and cigarette smoke smell in the Hall 200, for four days (3/21/22, 3/22/22, 3/23/22 and 3/24/22) of a four day survey. Findings included: 1. During a facility tour on 03/21/22 at 10:44 AM, a strong odor of sewer gas was noted in Hall 300. An interview was conducted with Resident #119. Resident #119 sated her room has been smelling like sewage. Resident #119 did not know how long the smell had been going on. Resident #119 stated she does not shower in her bathroom because of the gases. Her roommate stated she thought the sewage smell was from gases coming up the shower drain. On 03/21/22 at 11:26 AM, an interview was conducted with Resident #29. Resident #29 stated the only problem he had was that his bathroom smells like sewage. Resident #29 stated he did not think the facility was in a hurry to fix it. An interview was conducted with Resident #18 on 03/21/22 at 12:19 PM. Resident #18 stated his bathroom smells like sewage. Resident #18 reported this has been going on for more than six weeks. Resident #18 said, It's horrible, the gases make you sleepy. On 03/21/22 at 1:15 PM, An interview was conducted with Resident #143. Resident #143 said, My bathroom smells horrible. It makes the whole room smell like sewage. An interview was conducted on 03/21/22 at 1:24 PM with Resident #149 and a visiting family member. Resident #149 reported smelling gases. Resident #149 said, It's probably from the sewage. It is horrible. It makes you sick. An interview was conducted on 03/22/22 at 10:53 AM with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed the sewage smell has been an on-going issue. Staff C stated the head of housekeeping department had been notified. On 03/23/22 at 12:30 PM an interview was conducted the Regional Environmental Services (EVS) Manager and the facility's EVS manager. The Regional EVS said, The sewer problem is obvious in Hall 300. You can't miss it. The facility's EVS Manager stated there has been an on-going sewage maintenance issue. He stated that residents and staff report smelling gas. The facility's EVS Manager stated the administration was aware of the sewer gas issue. The facility's EVS Manager stated housekeeping did not have anything to do with it and that a follow -up should be done with the Nursing Home Administrator (NHA) or maintenance department. An interview was conducted on 03/23/22 at 1:20 PM with the Director of Maintenance. (DOM) The DOM said, There is a problem in Hall 300. The gases go through the drain and come up to the residents' rooms. The DOM said, I am aware of the concerns. It has been an issue for about six months or so. It comes and goes. The DOM stated they had not received any work orders or reports recently. A follow up interview was conducted with the NHA on 03/23/22 at 1:45 PM. The NHA said, We have four gas traps. I am aware that it is leaking gas. I think the problem is a crack in the ground. It has been an issue at least six weeks or so. The NHA stated that he would make a call to schedule a scope procedure for the traps. The NHA said, I know, the residents should be in a comfortable and sanitary environment. 2. During a facility tour of Hallway 200 on 03/21/22 at 9:42 AM, a strong smell of cigarettes was noted inside the building. The smell was in the residents' rooms, hallway, and staff offices in the vicinity. The hallway is adjacent to the courtyard where residents go out to smoke. On 03/22/22 at 1:50 PM, an interview was conducted with Staff D, CNA. Staff D stated the 200 hallway always smells like cigarette smoke. Staff D said, It is not fair for those who do not smoke. Staff D confirmed the residents in this hall complain about it. Staff D stated when the door is opened for smokers, the smoke is trapped inside the building. Staff D stated the problem was lack of ventilation. On 03/23/22 at 12:30 PM, an interview was conducted with the Regional EVS and the facility's EVS manager. They stated the problem with the smoke smell has been ongoing. The facility's EVS manager said, It is pungent. The residents, staff and everyone talks about it. We have had meetings with the NHA trying to address the issue. The facility's EVS Manager stated he has suggested installing smoke eaters. The facility's EVS Manager stated they installed a humidifier in the room before the courtyard, but the problem is still persistent. A follow-up interview was conducted on 03/23/22 at 1:20 PM with the DOM. The DOM stated the administration is aware of the problem of cigarette smells in the rooms near the courtyard entrance. The DOM stated the 200 hallway is affected the most. The DOM stated staff have reported the problem and the administration is addressing it. The DOM did not have a timeline of when they anticipated a resolution. On 03/23/22 at 1:45 PM an interview was conducted with the NHA related to the smoke smell in resident rooms and hallway in hall 200. The NHA said, I know it is a problem and it is not fair for those residents. The NHA stated he has asked social services to speak with all of them [residents in the 200 hall] today and offer them a room switch. The NHA stated they are considering using silicone coding on doors and windows to keep the smoke outside. The NHA stated they will service the air curtains on the courtyard doors. The NHA stated during COVID they switched the entrance to the courtyard and that was where the problem started. The NHA said, We will review all options. Of course, our residents' comfort is our priority. A follow up interview was conducted with the NHA on 03/24/22 2:08 PM. The NHA stated he has plumbers coming to scope, put a camera through the sewer system and down the 300 Hall to rule out cracks in the grease traps. The NHA stated the residents have not complained to him but, a family member said something about it. The NHA confirmed he was aware of the smoke problem in Hall 200. Review of a document titled, Resident Handbook, dated 02/17, Page 5, showed under housekeeping and maintenance services, the housekeeping and maintenance staff keep the facility safe, comfortable, and clean. We consider a pleasant environment important to your well-being. Review of a facility policy titled, Physical Environment, dated January 1, 2020, showed an expectation to ensure a safe, clean, comfortable, and home- life environment is provided for each resident / patient.

Based on interview and record review the facility failed to provide supervision to prevent a fall with head injury for one (Resident #5) of two sampled residents. Resident #5 had a documented history of falls prior to his admission at the facility, documented falls throughout his stay at the facility, and fell three times in the span of his final 11 days as a resident there. Two of the falls within those last 11 days required transfer to the hospital. Findings Included: A review of the facility document titled High Risk Fallers dated 05/29/20 revealed that Resident #5 was listed under the category Multi-Fallers in Last 30 Days. A review of the facility report titled Incidents By Incident Type for the three months preceding his last fall, on 06/12/20, revealed that the resident fell eight times in that period on 3/14/20, 3/30/20, 4/5/20, 4/26/20, 5/5/20, 6/2/20, 6/11/20 and 6/12/20. A review of progress notes for the month of June 2020 revealed: Event/Post Event Note dated 06/02/20 written by Staff A, Licensed Practical Nurse (LPN): resident (#5) was sitting in chair in dining room and fell to the floor on his right side. resident did hit his head. resident right scapula (shoulder blade) swollen and resident c/o (complains of) pain at times .resident had just came back from being weighed and was in the dining room. resident had no socks on at the time .called 911 to transport resident to (hospital name) ER (emergency room ) for eval (evaluation) and tx (treatment) . Activity Progress Note dated 06/07/20: (Resident #5) is alert and oriented to self. He is up out of bed to wheelchair. He will attempt to ambulate and needs reminders to stay in his chair. he needs encouragement to stay in room or to be safety (safe) when he is (in) hallway . Event/Post Event Note dated 06/11/20 written by Staff B, Registered Nurse (RN) Supervisor: Patient observed lying on the floor, assessed and no visible injury noted .assist resident back in bed, notified MD (medical doctor) and family member. Neuro check initiated and within limits, patient also on 15 minutes check. Care Plan/IDT (interdisciplinary team) Note dated 06/12/20: IDT met to review s/p (status [REDACTED]. Neurochecks and q (every) 15 (minutes) started .Care plan reviewed and updated. Event/Post Event Note dated 06/12/20 at 10:30 am written by Staff B, RN Supervisor: Patient observed sitting on the floor mat, upon assessment, a cut noted to right side of head and forehead, vital sign within limit .MD (medical doctor) ordered to send patient to ER (emergency room ) for CT (computed tomography) scan, patient left the building on a stretcher with EMT (emergency medical transport) to (name of hospital). A note written by Staff B, dated 06/13/20 revealed: Called (name of hospital) to check on the resident status, Patient was admitted with Subdural Hematoma (collection of blood under the skull outside of the brain). A review of the medical record for Resident #5 revealed that he was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been deemed not competent to make his own decisions and resided in the locked memory care unit of the facility. A review of the most recent completed Minimum Data Sets ((MDS) dated [DATE] and 06/12/20 revealed the following: severely impaired cognitive skills for daily decision making; BIMS (brief inventory of mental status) score of 4 which meant that the resident was severely cognitively impaired; impaired balance while standing, walking, transferring. The MDS dated [DATE] revealed 1 fall with injury since admission/reentry/prior assessment and the MDS dated [DATE] revealed 1 fall without injury since admission/reentry/prior assessment. The care plan revealed the following focus areas: Cognition: (Resident #5) has severely impaired cognition/thought processes r/t (related to) dementia.; .he has a statement of incapacity.; Fall: (Resident #5) falls frequently and is at risk for fall related injury r/t (related to) dx (diagnoses) of [MEDICAL CONDITION], dementia and Alzheimer, poor balance at times; Elopement Risk: (Resident #5) is an elopement risk: he is significantly cognitively impaired and is independently mobile; he is actively exit-seeking. He wanders through the secured unit .Resident is at increased risk for exit seeking behaviors related to the Covid-19 precautions that have been put in place . Staff A, LPN was interviewed on 07/24/20 at 9:37 a.m. She confirmed that she had known Resident #5 well. She described him as alert with confusion, forgetful, ambulatory with physical decline towards the end, and that he was unable to use a walker because of his cognitive impairments. She said, in the end he had a wheelchair but would constantly get up on his own She stated that Resident #5 was combative at times, had no safety awareness or deficit insight, and had no ability to remember redirection from one moment to the next. She said, he was one that if I didn't know where he was, I better find out. Regarding his falls at the facility, Staff A said, last one I was involved in was in the dining room. She confirmed that was the fall that occurred on 06/02/20 and said, he had just gotten back from being weighed and was sitting in his wheelchair in the dining room and got up and fell in an instant. She said, he needed constant eyes on him. The facility Rehabilitation Director was interviewed on 07/24/20 at 12:51 p.m. She confirmed that Resident #5 had received multiple courses of Physical Therapy (PT) and Occupational Therapy (OT) during his time at the facility. She confirmed that he was receiving therapy from PT and OT prior to his last fall on 06/12/20 and the focus had been on strengthening, balance, gait training, and transfers. She stated that the resident had declined in the months leading to his discharge due to frequent hospitalization s and that he had been having more falls. She stated that the resident would constantly get up on his own even though he needed hand-held assistance to safely walk and required supervision for safety. At 10:24 a.m. on 07/24/20 an interview was conducted with the facility Risk Manager. She confirmed that Resident #5 had several falls during his stay here where he hit his head. She confirmed that the resident had a series of falls leading up to his last fall on 06/12/20: a witnessed fall on 06/02/20 and a fall from bed on 06/11/20. She confirmed that he was on the new admission isolation unit at the time of his falls on 06/11/20 and 06/12/20 due to precautions related to COVID-19 with residents readmitted from the hospital. She confirmed that he was in a private room on that unit and that his room door was required to be closed because of infection control precautions in the facility. She confirmed that the falls on 06/11/20 and 06/12/20 were unwitnessed and stated that the fall on 06/12/20 had occurred in the resident's room, that his Certified Nursing Assistant (CNA) had just been in his room, and that after the fall the resident said, I lost my balance but couldn't provide any more details. The Risk Manager confirmed that Resident #5 was on the facility list of residents at high risk for falling and was on 15-minute checks at the time of his fall on 06/12/20. She stated that Resident #5 had been put on 15-minute checks because he was newly readmitted to an unfamiliar unit, had a history of [REDACTED]. Regarding one to one (1:1) supervision, she stated that was only used in the facility in 911 situations which she explained as short term emergency intervention for safety. Regarding fall prevention measures for Resident #5, the Risk Manager said, there was not a lack of supervision .we followed our process and care plan .had him on 15-minute checks. At 11:40 a.m. on 07/24/20 Staff B, RN Supervisor and Staff C, RN Unit Manager were interviewed. Staff C confirmed that she was the unit manager for the isolation unit. She confirmed that Resident #5 had been in a private room on that unit and that he was pretty confused and disoriented .he liked to sit in the chair in his room. Staff B confirmed that he was working in the facility on 06/12/20 and said, I was called to asses (Resident #5) when he was found on the floor .I observed there was a cut on his head so I decided he needed to be sent to the hospital .he was conscious and alert. At 11:59 a.m. Staff D, Certified Nursing Assistant (CNA) was interviewed. She confirmed that she had been assigned to care for Resident #5 at the time of his fall on 06/12/20. She stated the resident had eaten and she had just been in his room to remove his tray and within 15 minutes later when she entered his room to check on him, he was on the floor. Staff D confirmed that Resident #5 was on 15-minute checks. She stated the resident was very confused and impulsive. She confirmed that his door was required to be closed by facility policy and so at times she had brought him to the nurse's station with a mask on so that he could be supervised. A review of medical records from the hospital where Resident #5 was admitted after falling at the facility on 06/02/20 revealed that he was admitted for brain bleed and surgery eval (evaluation). A CT (computerized tomography) scan of the brain was performed on 06/02/20: There is a small subacute subdural hematoma (collection of blood under the skull outside of the brain) measuring 4mm (millimeters) thick along the right fontal and parietal lobe (areas of the brain). A review of the medical records from the hospital when Resident #5 was admitted after falling on 06/12/20 revealed chief complaint of head injury and headache. A CT scan of the brain was performed on 06/12/20: .subdural hematoma .increased to 1.2 cm (centimeters) versus 6mm (millimeters) on the prior study .most consistent with .microhemorrhage (bleeding at the brain). The records revealed that the resident was discharged with a discharge [DIAGNOSES REDACTED]. The facility policy titled, Fall and Injury Reduction Policy dated February 2020 revealed: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Falls and Injury Reduction Policy. Resident data is collected to identify fall risk factors. The interdisciplinary team works with the resident and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The facility policy titled Frequent Observation dated November 2017 revealed the following: Frequent Observation will be initiated when Resident Behaviors indicate. Frequent observation may include: Continuous, with documentation of observed behaviors every 15 minutes; Observation every 15 minutes with documentation of behaviors observed . The associated procedure revealed: 1. Residents who are placed on continuous one to one are to be in the line of vision of the person assigned to the resident. 2. Residents may be placed on one to one (1:1) by the supervisor in an emergency situation, or by the Risk Manager, Assistant Director of Nursing, the Director of Nursing, or the Administrator after review of the clinical data.

Based on the Florida Nurse Practice Act, resident record review, staff and resident interviews, and facility policy reviews of policy and procedures regarding: Advanced Directives; Code Status Orders and Response, dated [DATE], and the Cardiopulmonary Resuscitation policy (not dated), revealed that the facility staff nurses failed to follow professional standards of practice for one (#2) of three sampled residents, by not honoring the resident's Advanced Directives and her expressed wish for a "Full Code." It was determined that resident #2, and her representative had requested to receive Cardio-Pulmonary Resuscitation (CPR) in the event that she was found unconscious, without a pulse and/or respirations. The facility failed to provide resident #2 with the requested necessary life sustaining CPR/emergency medical care in accordance with her expressed desires to receive such services. She was pronounced expired at the facility after she was discovered unconscious. She did not receive CPR. There was no documentation that resident #2 was pronounced deceased by EMS, a physician or other qualified person. Per the Nurse Practice Act this was beyond the scope and practice of the two LPNS, with expired CPR certifications, that responded to the unconscious resident. There was no detailed documentation regarding the specific condition describing resident #2 on [DATE] at 3:30 a.m., when she was found unconscious, detailing attempts to locate the orders of her CPR status, skin condition, and nurse's attempts at arousal, flaccid or ridged extremities, body temperature, blood pressure respirations, pulse oximetry and other evaluations of life processes. There was no documentation specifying exactly who pronounced the body deceased and when. One nurse, nurse A, stated she called 911 however; there was no documentation of 911 evaluating the resident. There was no record of the call to 911 or response by EMS. The facility, as of [DATE], could not provide documentation if anyone in the facility had current CPR certification, from either the American Heart Association or the American Red Cross. These findings resulted in the identification of immediate jeopardy and were determined to be ongoing as of [DATE], after the conclusion of the survey complaint investigation. One hundred and eleven residents of the current census of 169 had expressed desires for CPR. The facility was unaware of what staff was qualified to provide the life-saving skill. Findings include: The Florida Department of Health, Florida Board of Nursing Nurse Practice Act, Chapter 64B9, F.A.C, 464.003 Definitions state: "(3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychosocial, biological, physical, and social sciences which shall include, but not to be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts." 464.001 (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 464.002 Purpose.--The sole legislative purpose in enacting this part is to ensure that every nurse [MEDICATION NAME] in this state meets minimum requirements for safe practice. It is the legislative intent that nurses who fall below minimum competency or who otherwise present a danger to the public shall be prohibited from [MEDICATION NAME] in this state. Neither the Nurse Practice Act nor the facility job description stated that an LPN could pronounce a death. 1. Record review on [DATE], for resident #2, revealed the following: Review of the facility admission face sheet, dated [DATE], the physician's orders [REDACTED].#2 was a fifty-eight year old female with a [DIAGNOSES REDACTED]. She was a "Full Resuscitate" status. It was further documented that resident #2 was initially admitted to the facility on [DATE], from the hospital. She had readmitted to the facility on [DATE] initially for short term rehabilitation and therapy, but had three additional hospitalization s since that admission, [DATE], [DATE] and [DATE]. After resident #2's last readmission, from the hospital to the facility, on [DATE], she expired at the facility on [DATE]. Review of resident #2's medical chart, an interview with the Administrator and Social Service Director on [DATE], and an interview with the Primary Care Physician on [DATE] at 10:30 a.m., all parties confirmed that resident #2 had not, at any time, received Hospice services from the time of her first admission to the facility on [DATE] through the date of her expiration on [DATE]. Further review of the resident's chart indicated she signed a "Consent to Treatment" form on [DATE]. Review of the chart revealed resident #2 signed a document of "Designation of Health Care Surrogate" dated [DATE]. Resident #2 gave her daughter permission to make health care decisions. 2. An interview with resident #2's daughter, on [DATE] at 9:30 a.m., revealed she was notified that resident #2 was admitted to the hospital on [DATE], due to shortness of breath, clogging/hardening of her arteries, and complications from multiple areas [MEDICAL CONDITION]. The resident subsequently "died " at the hospital but, was revived with Cardiopulmonary Resuscitation (CPR). She revealed her mother was readmitted to the facility [DATE]. Resident #2's daughter revealed that upon this admission to the facility, she was asked about her Advanced Directives, specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2's daughter stated that resident #2 expressed that she wanted her daughter to make that decision for her. Resident #2's daughter indicated she made it clear on [DATE] she wanted resident #2 to be on Full Code status, which was her prior request upon initial facility admission on [DATE], and continued throughout the recent hospitalization s. The daughter stated she completed her visit with her mother and then left the State of Florida to return home on [DATE]. Resident #2's daughter revealed that on [DATE] she was informed by the facility that her mother had expired and nurse A, an LPN, told her that her mother "was a DNR." Resident #2's daughter then revealed that she called later that day and complained to the Administrator that staff did not try to revive her mother. She reported to the NHA that she was told by a staff member that "they believed my mother (resident #2) was a DNR status." 3. Review of the admission Social Service Progress notes, dated [DATE] at 11:00 a.m., revealed resident #2 had [MEDICAL CONDITION] and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) infection that she was alert and oriented times three, and needed minimum assistance with Activities of Daily Living (ADLs). The note continued to indicate, although "named family member," (not daughter) is resident #2's emergency contact on the computer but prefers to go through her daughter. Resident #2's daughter was not the Health Care Surrogate at this time and was designated as such on [DATE]. The Social Service Progress note dated [DATE] further revealed the facility staff discussed Advanced Directives with resident #2, since she had none in the chart, and explained the options. The note revealed the resident indicated she was going to think about it and as of this date she was in favor of DNR, but then stated her daughter could decide. It was explained to her that she would have to sign paperwork for that. The progress note further indicated the writer would follow up with her, since she was uncertain at this time. The medical record for resident #2 was not clear as to when the decision was to remain a Full Code status, but this was the daughter's (Health Care Surrogate's) wishes as of [DATE], when she took over making health care decisions. 4. Review of resident #2's demographic face sheet, dated [DATE], indicated she was "Full Resuscitate" status. Also, review of the resident's medical record, including the Advanced Directives section, did not include a "Yellow" DNR order. Review of the physician's orders [REDACTED]. Review of resident #2's admission assessment dated [DATE], and care plans dated [DATE] after the resident expired, all failed to identify resident's Code Status and Advanced Directives wishes. It was determined through the entire record review for resident #2, there was no indication she wanted DNR status, but rather indicated clearly she was a "Full Resuscitate" status at the time of expiration. 5. Review of resident #2's progress notes, which were multiple discipline electronic notes that included Nursing and Social Service revealed the following entries: - Written by Risk Manager [DATE] at 8:04 p.m. Resident readmitted from the Hospital with daughter. - Written by LPN [DATE] at 11:19 p.m. Resident alert with confusion and able to make wants known. - Written by LPN [DATE] at 3:11 p.m. Poor appetite, difficulty swallowing, speech to evaluate. Has family and is now out of town. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2 ' s condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 6. During the interview with nurse A, on [DATE] she revealed that she had a CPR card, but it had been expired since 2008. A. Interview with employee A, via telephone on [DATE] at 12:34 p.m., a Licensed Practical Nurse who was the first responding nurse to resident #2 revealed on [DATE] at approximately 3:30 a.m. She was asked by employee D to come to resident #2 ' s room, as he and employee C found her to be unresponsive. Employee A indicated she finished with what she was doing and locked her medication cart and was the first nurse to respond to resident #2. She asked employee C and D to leave the room and proceeded to attempt to find a pulse on resident #2. She explained the resident had no pulse and put her fingers to her mouth and knew she had already expired. She further revealed the resident felt really cold and that she had " passed away " . Employee A then stated she called out for another nurse, employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to employee B that resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told employee B that she " believed resident was a " DNR " ; even though there was no " DNR " bracelet and " believed the resident was also on Hospice services " . Employee A did not know if employee B followed up with finding out if resident #2 was indeed a " Full Code " or " DNR " . Employee A was asked, what does a " Yellow " Bracelet/band mean? Employee A further revealed that resident #2 did not have a " yellow " bracelet/band on her arm. Employee A stated that if a resident had a " yellow " bracelet/band on their arm, that it meant the resident was a " DNR " status. Employee A continued to say that resident #2 had just returned to the facility and was readmitted from the hospital. She didn ' t think the resident was provided with a " yellow " bracelet, as she " believed " she should have, and that sometimes the facility staff take several days to put them on " . Employee A further indicated that she and employee B were the only responding nurses and that employee E was the nurse assigned to resident #2, and that she was on lunch break when resident #2 expired. Employee A also stated that she told employee E, the agency Licensed Practical Nurse, assigned to resident #2, that resident #2 had been found unresponsive and had expired. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician ' s answering service, and the daughter (Health Care Surrogate) and then went back to her normal assignment. Employee A was asked if she looked in the chart or electronic record to verify if resident #2 was a " Full Code " or " DNR " and she said that she did not initially but then saw in the chart, while documenting, that the resident was a " Full Code " . Employee A was asked where specifically she found that resident #2 was a " DNR " . She revealed the ,[DATE] physician's order [REDACTED]. However, review of the ,[DATE] physician's order [REDACTED]. It indicated resident #2 was " Full Resuscitate " . Employee A indicated she was called back to the facility from home after her night shift on [DATE] at around 10:00 a.m., and was asked by administration why neither she, nor employee B ever performed CPR on resident #2 on [DATE], when she was found unresponsive. She indicated it was her understanding that resident #2 was a " DNR " status and was on Hospice. Employee A confirmed after she was shown resident #2 was a " Full Code " , she did not honor her wishes by performing CPR. B. On [DATE] at 1:50 p.m. and 3:00 p.m. and again on [DATE] at 1:00 p.m. and again at 3:00 p.m., employee B was called and unable to be contacted. Employee B could not be interviewed. However, during an interview with the Nursing Home Administrator, on [DATE] at approximately 3:15 p.m., she provided a statement written by employee B, dated [DATE]. The statement read, as written, " my name is employee B and I was the nurse working the north wing on [DATE] for the ,[DATE] shift. The phone rang and it was the South wing nurse, employee A, who stated to come to the South wing. When I (employee B) came over, I saw employee A. sitting at the nursing station typing on the computer she stated that one of my patients " just died " . I (employee B) asked her " what did you do " ? She replied resident #2 was a DNR and a Hospice patient. She continued typing and stated I (employee A) am charting about her I already called her Daughter and the Funeral Home, go and see her. I went to the room and with a CNA behind me. I (employee B) asked when did resident #2 pass away and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said " I already cleaned her up " . Another CNA came in the room from the North wing and resident ' s mouth was opened, she positioned her mouth to keep it closed. I (employee B) observed the resident lying in bed with no sign of life " . No further documentation was noted by employee B. It was later determined she was not CPR certified. C. During an interview on [DATE] at 7:15 a.m., with employee C an aide, who had resident #2 on her assignment on [DATE], she revealed that she entered resident #2 ' s room on [DATE], at approximately 3:30 a.m., to assist with her roommate. After she completed the care of her roommate, she noticed resident #2 ' s leg was hanging off the side of the bed in a dangerous manner and asked her to pick up her leg and put it back on the bed. Employee C asked resident #2 to pick up her leg a couple of times, with no response. She then stated she looked at resident #2 ' s face and saw that her eyes had a " funny " look and tapped her shoulder to continue to tell her to pick up her leg. Employee C said there was still no response. The aide then lifted resident #2 ' s wrist to feel for a pulse and did not detect a pulse. She then placed her hand at the resident ' s lips and did not feel any breaths. The aide also indicated the resident ' s lips, face and arm reported they were very cold to the touch. Employee C said at that time, she walked to the room door and called out for help. Employee C indicated employee D, also a CNA, came directly in the room, where he was told by Employee C that resident #2 was not responsive and not breathing. Employee D told employee C to stay in the room and wait with the resident while he went to find a nurse. Employee C stated that the nurse assigned to the resident, employee E was an agency nurse and was on her lunch break at the time. Another nurse was brought in by Employee D. Employee C indicated that employee A, a staff Licensed Practical Nurse (LPN) came into the room and asked what happened. Employee C reported that, she told employee A what she discovered when she came in the room and found the resident unresponsive. At that time, employee C was asked to leave the room and the door was closed. Nurses A and B were in the room. Employee C was asked if she was aware if resident #2 was a " Full Code " status or DNR " . She did not know. Employee C was also asked by the surveyor, if she was current with CPR certifications. She revealed that she does have a valid and current CPR card. It should be noted that the electronic progress note at 3:30 a.m. by nurse A. The writer failed to complete the documentation of the physical condition of the resident including skin color, attempts at apical pulse, state of incontinence, flaccid extremities or other clinical findings at the time of the evaluation. The next note, at 4:08 a.m., the nurse called the physician to release the body. She left a message. The next note at 4:20 a.m. stated the DON was advised. There was no note regarding who pronounced the resident deceased and the time of the death. D. Interview with employee (D) on [DATE] at 7:08 a.m., CNA who did not have resident #2 on assignment, revealed he was called to resident #2 ' s room by employee C on [DATE] at approximately 3:30 a.m. He further revealed he was told by employee C that resident #2 was unresponsive and thinks she might have " passed away " . Employee D at that time told employee C to remain in the room while he went to find a nurse. Employee indicated he did not know who the assigned nurse for resident #2 was, but proceeded to find the closest nurse for assistance. Employee D stated he found employee A, who is a Licensed Practical Nurse. He told the nurse that employee C found resident #2 unresponsive and needed help. Employee D stated that the nurse, employee A, went to the room and asked the two aides (employee C and D) to leave the room and closed the door. Employee D was asked if he knew if resident #2 was a " Full Code " or " DNR " . He indicated he did not know. Employee D was then asked if he was CPR certified and he revealed he is and has a valid and current CPR card. Review of the employee files and interviews with the Nursing Home Administrator and Director of Nursing, failed to verify CPR certifications for employee D neither of the two nurses were certified. Through the above record review and interviews it was determined that two employees, A and B, both Licensed Practical Nurses, responded to resident #2 when she was found unresponsive. Neither nurse clarified resident #2 ' s code status. Nurse A told nurse B that she " believed " resident #2 was a DNR status and was on Hospice. It was also determined that Nurse B did not clarify the resuscitation status in the chart, and believed nurse A. It was determined neither nurses called out on the page system for " Code Blue " , nor brought the crash cart to the resident ' s room per the facility policy. It was further determined that nurse A had no current CPR certification. 7. An interview with the Administrator and Risk Manager, on [DATE] at 11:11 a.m., revealed resident #2 had been hospitalized several times since her admission to the facility on [DATE] and they had only seen the resident in passing and were not aware of her medical status in depth. The Risk Manager revealed the resident was not interviewable upon last admission [DATE], and had been declining. The Administrator and Risk Manager were asked by the surveyor how they were informed that resident #2 was not provided with CPR when she was found unresponsive on [DATE]. They both indicated that during the stand-up (ADHOC) meeting on [DATE], at approximately 8:30 a.m., resident #2 ' s chart was brought to their attention. They both stated that it was then discovered, through review of the notes and advanced directives, that the resident was a " Full Code " status and was not given CPR when found unresponsive on the [DATE] night shift. The Administrator and Risk Manager both immediately called in all parties involved during the 11:00 p.m. - 7:00 a.m. shift [DATE] - [DATE]. This included employees A, B, C, D, E and F. It was indicated from the Risk Manager and Administrator that employees A, B, C, D, E and F, after the interviews, were suspended until the investigation was concluded. The administrator revealed upon completion of their investigation, that the incident was adverse, related to neglect on the facility ' s part. They began retraining staff. Through interview with the Administrator on [DATE], at 3:20 p.m. it was revealed she, the NHA was unaware who had current CPR certifications, and stated they did not require them upon hire. They could not verify if nurse B was currently certified in CPR. It was further determined that neither nurse A or B followed their standards of practice as per the Florida Board of Nursing Practice Act and facility policy and procedure related to " Cardiopulmonary Resuscitation " (not dated), in part b., #5 to ensure that the basic techniques used in CPR meet current practice according to the American Hearth Standards. Also, the administration did not follow this policy per part b., #6 to ensure that all nurses have current CPR registration that is kept in their personnel files, and only those current CPR registrations may perform CPR. Registration is to be completed biannually. Per the facility DON, had only worked at the facility two weeks and was unavailable for the interview on [DATE]. She had no knowledge of the situation. The prior DON was unavailable for interview. 8. Review of the facility ' s " Advanced Directives " policy and procedure, provided to the survey team for review on [DATE] by the Administrator, was dated with an effective date of [DATE], and revised [DATE] and [DATE]. It revealed the following relevant information: Policy statement: Overview -The overview of the policy stated that the facility strived to comply with all valid Advance Medical Directives (per the State regulations) including living wills, durable power of attorney for health care ( " DPOA " ), including the provisions for refusal or withdrawal of nutrition and hydration. These facilities shall accept both resuscitate and DNR orders signed by Physicians. The overview stated that the In-service training was provided to staff on the topics of: resident/patients ' rights including information about Advance Medical Directives, DNR orders, and the resident/patient ' s right to participate in medical decision making. The facility shall provide for both individual and group education for staff and the community on issues concerning Advance Medical Directives. Review of the " Code Status Orders & Response " policy and procedure, provided to the survey team for review on [DATE] by the Administrator, revealed it was dated with an effective date of [DATE] and revised on [DATE] and [DATE]. The policy statement, revealed the following relevant information: The physician's order [REDACTED]. Advanced Directives will be honored during the code process. The policy statement further revealed: The facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. Policy statement further read - DNR ORDER - means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. - Supportive comfort & care for the resident/patient & emotional support for the resident/patient shall continue. - Federal & State-specific regulations will be adhered to. - Each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. The policy continued: " Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines " . This statement conflicted with the statement to provide (BLS), an American Heart Association and Certificate of competency for Health Care Professionals. The facility NHA failed to explain, on [DATE] at around 1:30 p.m., how they could comply with resident expectations of skilled nursing CPR at the BLS level when they did not require CPR certification for their staff, and were unaware of who among the staff were currently certified. A request was made to the administrator on [DATE] at 9:00 a.m. for Cardiopulmonary Resuscitation policies. At approximately 10:00 a.m. the administrator provided the " Cardiopulmonary Resuscitation " policy and procedure (not dated), for review and had the following relevant information: 1. Persons Responsible: The following respiratory therapist/nursing personnel should respond to an emergency page: a. Staff assigned to the area where the arrest occurs, or b. Any person nearby the area should respond to offer assistance as needed. Note: After the initial response, only designated persons should be present. 2. Policy statement indicates; In the event that a resident ' s condition requires cardiopulmonary resuscitation (CPR) to be performed, the respiratory therapist/nurse will assume responsibility for: a. Provide assistance with the following procedures: 1. Establish patent airway 2. Ventilate the resident as necessary 3. Administer oxygen 4. Perform external cardiac compression 5. Aid in suctioning when needed 6. Perform pulse oximetry when needed 7. Contact 911, physician and family 8. Prepare paperwork for discharge to hospital b. Establishment of airway and ventilation: 1. Clear oral airways 2. Connect bag and mask 3. Administer oxygen Additionally the policy statement included: 5. Ensure that the basic techniques used in CPR meet current practice according to the American Heart standards. 6. Ensure that all respiratory therapist/nurses have current CPR registration that is kept in their personnel files. Only those with current CPR registration may perform CPR. Registration is to be completed biannually. 9. An interview with resident #2 ' s Primary Care Physician, on [DATE] at 10:11 a.m., revealed he was aware that resident #2 had multiple hospitalization s since her initial admitted on [DATE], and that the resident had shortness of breath and with [MEDICAL CONDITION] that had metastasized. The Primary Care Physician continued to state he was made aware on [DATE] that resident #2 had expired on [DATE] during the night shift. He was not aware of the details. The Primary Care Physician stated he was not surprised at the death of resident #2, as she was " declining quickly " . He further revealed he was notified later in the day of [DATE] or possibly the next day, that after resident #2 expired her Advanced Directives related to her code status were not followed. He further revealed he was told by the Administrator that when resident #2 was found unresponsive, the responding nurses did not provide CPR, against her wishes to require it. Resident #2 ' s Primary Care Physician did not, at the time of expiration, recall resident #2 ' s code status. He did remember speaking to the resident a couple of times but did not remember the outcome of her wishes. Resident #2 ' s Primary Care Physician did confirm he signed all of resident #2 ' s orders, including the physician's order [REDACTED]. The Primary Care Physician also stated his expectations were that when a resident became unresponsive, staff were to verify the resident ' s Advanced Directives related to code status and honor those wishes/orders. He further indicated that during a " Full Code " , staff are to do whatever they can do to provide CPR and try to revive the resident, until 911 arrives. He also confirmed that if a resident ' s wishes were for DNR states, the facility will honor those wishes when they were found unresponsive, document and notify the Primary Care Physician, whatever the outcome. 10. An interview with the facility ' s Medical Director on [DATE] at 11:51 a.m. revealed he had been the Medical Director since ,[DATE] and had attended Quality Assurance meetings quarterly as required. He had reviewed facility policy and procedures. The Medical Director revealed he first noticed, around ,[DATE], that per the " Code Status Orders & Response " Policy and procedure, the facility did not require CPR certification upon hire. The Medical Director revealed he believes the facility should have a policy that forms a " Rapid Response " team, at all times, that have current CPR certifications and he planned to discuss that with the facility administration at his meeting today, [DATE]. He further confirmed he was made aware of the situation with resident #2, who became unresponsive on [DATE] and was not provided CPR in spite of her expressed to do so, per physicians orders for resuscitation, and the wishes of both the resident and her daughter, the Health Care Surrogate. The Medical Director revealed he was made aware of this information during a telephone Quality Assurance meeting conducted sometime on [DATE]. 11. Review of the following LPN nursing job description revealed: A. Licensed Practical Nurse (not dated), who reports to the Director of Nursing. Summary of Position: The Licensed Practical Nurse is responsible for providing direct nursing care to the residents and assumes responsibility and accountability for assigned residents/patients for a shift of duty to ensure that the highest degree of quality care is maintained at all times. The LPN adheres to the standards of care for the area, manages the environment to maintain resident/patient safety and supervise the resident/patient care activity p

Based on resident record review, facility policy file reviews, facility's policy for: Prevention & Reporting of Suspected Resident/Patient Abuse (dated [DATE]); Advanced Directives, Code Status orders and response (dated [DATE]); Cardiopulmonary Resuscitation (not dated), review of the admission packet including Advanced Directives, and interviews with residents, family and staff members, it was determined that the facility failed to provide medical services necessary to ensure that one of two sampled residents (#2), was provided with professional Cardiopulmonary Resuscitation (CPR) services, as per the resident and her Health Care Surrogate's expressed wishes. The physician's orders [REDACTED]. The facility staff failed to determine the correct code status and failed to obtain the skilled resources needed to ensure resident #2's wishes regarding "Full Code" status were honored. Resident #2 ultimately expired as a result of the failure to provide CPR efforts. Record review of one of three sampled residents (#2 ), who expired at the facility, revealed both had "Full Code" status, and were provided CPR by Licensed Practical Nurses. It was unknown if those nurses had current/updated CPR certifications to provide Life Saving Support/CPR to those residents (#2 and #32). The NHA, as of [DATE] at 5:00 p.m., could not provide documentation that anyone in the facility had current CPR certification, by either the American Heart Association or the American Red Cross, the two main agencies responsible for CPR training. Per the website for United States Department of Human Services, titled "To Code or Not to Code", found on the Internet on [DATE], it stated the following: "Ineffective CPR can be the result of either a deliberate decision to withdraw CPR prematurely, the unintended consequence of delay, or inadequate training of facility personnel, as per standards of care regarding to CPR." The two night nurses that responded to unresponsive resident #2 on [DATE] did not have current CPR certification. One of the two stated her card expired in 2008. Failure of facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy. These findings resulted in the identification of immediate jeopardy and were determined to be ongoing as of [DATE] at 3:20 p.m., after the conclusion of the survey complaint investigation. One hundred eleven of 169 current residents, wished to be resuscitated, remained at risk for neglect and abuse until qualified staff for CPR were identified and staff retraining completed on facility full code and CPR policies. Findings include: 1. An interview with the Nursing Home Administrator and Risk Manager on [DATE], at 11:11 a.m. revealed the facility had an event on [DATE] in which nursing staff did not provide CPR to resident #2, who was found unresponsive and without vital signs. The resident was identified as a full resuscitation status. According to the administrator and Risk Manager, at approximately 3:30 a.m. on [DATE], a CNA found resident #2 in bed and unresponsive. The CNA immediately called another CNA for assistance. It was further stated that the second aide, after confirming resident #2 was unresponsive, went out to the hall to locate a nurse. At that time, employee A, a Licensed Practical Nurse, came to the room and did a vital sign check. She concluded that resident #2 had expired. The Administrator and Risk Manager further stated that nurse, employee A, then asked for assistance from another nurse, employee B, a Licensed Practical Nurse. The Risk Manager and Administrator stated that employee B asked employee A what resident #2's Advanced Directives were and if she was a "Full Code" or "DNR" status. The administrator further revealed employee A told employee B that she "thinks" resident #2 is a DNR and is receiving Hospice services. The Administrator and Risk Manager both indicated that employee B did not verify employee A's answer in the chart and neither employee A or B, both LPNs, verified resident #2's code status. The Administrator further revealed that as a result of no CPR, resident #2 expired. The Administrator and Risk Manager were asked by the surveyor how they became aware that resident #2 was not provided CPR when she was found unresponsive on [DATE]. They both indicated that during the stand-up (ADHOC) meeting on [DATE] at approximately 8:30 a.m., resident #2's chart was brought to their attention. They both indicated it was then discovered, through review of the notes and advanced directives, that the resident was a "Full Code" status and was not given CPR when found unresponsive. The Administrator and Risk Manager both immediately called in all parties involved during the 11:00 p.m.- 7:00 a.m. shift on [DATE] - [DATE], event which included employee A, B, C, D, E and F. It was indicated from the Risk Manager and Administrator that employees A, B, C, D, E and F, after the completion of the interviews, all the involved staff were suspended, until the investigation was concluded. The Administrator revealed as a result of their investigation, on [DATE] involving the expiration of resident #2, employees A, B and F were terminated and employees A and B, both Licensed Practical Nurses, were reported to the Board of Nursing and Department of Health. 2. An interview on [DATE] at 9:30 a.m. was conducted with resident #2's Health Care Surrogate. She revealed she was notified that resident #2 was admitted to the hospital on approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, and complications due to multiple areas [MEDICAL CONDITION]. She subsequently "died " at the hospital, but was revived with Cardiopulmonary Resuscitation (CPR). She revealed she, the daughter, visited her mother (#2) while at the hospital. The Health Care Surrogate stated her mother was ultimately re-admitted to the facility on [DATE]. Resident #2's daughter, (the Health Care Surrogate,) revealed resident #2, upon readmission to the facility, was asked about her advanced directives, specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2's daughter continued to say resident #2 initially asked to not be resuscitated but after a few moments, then expressed that she wanted her daughter, the Health Care Surrogate to make that decision for her. Resident #2's Health Care Surrogate indicated she made it clear she wanted resident #2 to be on Full Code status, which was what she, the resident, had stated upon the initial facility admission on [DATE], and continued throughout the other hospitalization s. Resident #2's Health Care Surrogate completed her visit with her mother and then left the state to return home. Resident #2's daughter revealed on [DATE], that she was informed by a telephone call from the facility that her mother expired. She was told her mother was a DNR by a Nurse A, a Licensed Practical Nurse. Resident #2's Health Care Surrogate then revealed she called and complained to the Administrator that staff did not try to revive her mother and was told by a staff member that "they believed resident #2 was a DNR status." 3. A telephone interview was conducted via telephone with employee A, a Licensed Practical Nurse, on [DATE] at 12:34 p.m. She confirmed she was the first responding nurse to resident #2 on [DATE] at approximately 3:30 a.m. She was asked by employee D to come to resident #2's room, as he and employee C had found her to be unresponsive. Employee A indicated she completed what she was doing, locked her medication cart, and responded to resident #2. No CPR was in process. She asked employees C and D to leave the room and she proceeded to try to find a pulse on resident #2. She explained the resident had no pulse and the nurse then put her fingers to her mouth and "knew she had already expired." She further revealed the resident felt really cold and that she had "passed away." Employee A then stated she called out for another nurse, employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to employee B that resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told employee B that she "believed" that the resident was a "DNR", even though there was no "DNR" bracelet and "believed" the resident was also receiving Hospice services. Employee A did not know if employee B followed up with finding out if resident #2 was indeed a "Full Code" or "DNR." Employee A was asked by the surveyor, "What does a "Yellow" Bracelet/band mean?" Employee A further revealed that resident #2 did not have a "yellow" bracelet/band on her arm. Employee A indicated that if a resident had a "yellow" bracelet/band on their arm, that it meant the resident was "DNR" status. Employee A continued to say that resident #2 had just come back to the facility and had been readmitted from the hospital. She didn't think the resident was outfitted with a "yellow" bracelet as she believed she should have been and that "sometimes the facility staff takes several days to put them on." Employee A further indicated that she and employee B were the only responding nurses and that employee E was the nurse assigned to resident #2. She was on lunch break when resident #2 expired. Employee A also stated that she told employee E, who was an agency Licensed Practical Nurse assigned to resident #2, that she was found unresponsive and had expired. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician answer service and the Daughter (Health Care Surrogate) and then went back to her normal assignment. Employee A was asked if she looked in the chart or electronic record to verify if resident #2 was a "Full Code" or "DNR" status, and she said that she did not initially, but then saw in the chart while documenting, that the resident was a "Full Code." She did not respond. Employee A was then asked where specifically she found that resident #2 was a "DNR" status. She revealed the ,[DATE] physician's orders [REDACTED]." However, review of the ,[DATE] physician's orders [REDACTED]." It indicated resident #2 desired to receive "Full Resuscitate" status. Employee A indicated she was called back to the facility, from home after her shift on [DATE], at around 10:00 a.m. She was asked by administration why neither she nor employee B, did not perform CPR on resident #2 on [DATE], when she was found unresponsive. She indicated it was her understanding that resident #2 was a "DNR" status and was receiving Hospice care. Employee A confirmed after she was shown that resident #2 was a "Full Code" status, on the medical record, by the administrative staff, and that she did not honor the resident's wishes by performing CPR. Neither nurse A nor nurse B had current CPR certification. Nurse A stated on [DATE] that her certification expired in 2008. 4. On [DATE] at 1:50 p.m. and 3:00 p.m. and again on [DATE] at 1:00 p.m. and again at 3:00 p.m., employee B was called and could not be reached. Employee B could not be interviewed. However, during an interview with the Nursing Home Administrator, on [DATE] at approximately 3:15 p.m., The Nursing Home Administrator (NHA) provided a statement written by employee B, dated [DATE]. The statement read as written: "my name is employee B and I was the nurse working the north wing on [DATE] for the ,[DATE] (11:00 p.m. - 7:00 a.m.) shift. The phone rang and it was the South wing nurse, employee A indicating to come to the South wing. When I (employee B) came over, I saw employee A sitting at the nursing station typing on the computer and stated one of my patients just died . I (employee B) told her what did you do? She replied resident #2 is a DNR and Hospice. She continued typing and stated I (employee A) am charting about her I already called her daughter and the Funeral Home, go and see her. I came to the room and with a CNA behind me. I (employee B) asked when did resident #2 pass away and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said I already cleaned her up. Another CNA came in the room from the North wing and resident's mouth was opened, she fixed her mouth to keep it closed. I (employee B) observed the resident lying in bed with no sign of life." No further documentation was noted by employee B. 5. An interview was conducted with employee C, an aide, on [DATE] at 7:15 a.m., who was assigned resident #2 on [DATE]. It was revealed that she went into resident #2's room on [DATE] at approximately 3:30 a.m. to assist with her roommate. After she completed her work with her roommate, she noticed resident #2's leg was hanging off the side of the bed in an awkward and dangerous manner. The aide asked her to pick up her leg and put it back on the bed. Employee C continued to prompt resident #2 to pick up her leg with no response. She then stated she looked at resident #2's face and saw that her eyes had a "funny" look and tapped her on the shoulder and continued to tell her to pick up her leg. Employee C said there was still no response. She then picked up resident #2's wrist to feel for a pulse and did not locate one. She further placed her hand at the resident's lips and did not feel any breaths. She also evaluated the resident's lips, face and arm and found they were very cold to the touch. Employee C said at that time, she walked to the room door and called out for help. Employee C indicated employee D, also a CNA, came directly in the room, where he was told by employee C that resident #2 was not responsive and not breathing. Employee D told employee C to stay in the room and wait with the resident while he left the room to find a nurse. Employee C indicated that the nurse, employee E, an agency nurse, was on her lunch break at the time and another nurse was brought in by Employee D. Employee C indicated that employee A, a Licensed Practical Nurse, came into the room and asked what happened. Employee C continued to say, she told employee A what she found when she came in the room and found resident #2 unresponsive. At that time, employee C was asked to leave the room and the door was closed. Employee C was asked if she was aware if resident #2 was a "Full Code" status or DNR." She stated she did not know. Employee C was also asked by the surveyor if she was current with CPR certifications. She revealed that she did have a valid and current CPR card. 6. An interview with employee D, on [DATE] at 7:08 a.m., a C.N.A., was conducted. He confirmed he did not have resident #2 on his assignment on [DATE]. He revealed he was called to resident #2's room, by employee C, on [DATE] at approximately 3:30 a.m. He further revealed he was told by employee C that resident #2 was unresponsive and thought she might have passed away. Employee D stated that at that time he told employee C to remain in the room while he located a nurse. Employee D indicated he did not know who the assigned nurse for resident #2 was, but proceeded to find the closest nurse for assistance. Employee D stated he found employee A, a Licensed Practical Nurse. He told the nurse that employee C found resident #2 unresponsive and needed help. Employee D stated that the nurse, employee A, went to the room and asked the two aides, employees C and D, to leave the room and close the door. Employee D was asked if he knew if resident #2 was a "Full Code" or "DNR." He indicated he did not know. Employee D was then asked if he is CPR certified and he revealed he is and had a valid and current CPR card. No CPR was provided by any of the staff during his time with the resident. 7. Review of resident #2's medical record on [DATE] revealed the following: As per Resident #2's demographic/face sheet, she was initially admitted to the facility, on [DATE], from the hospital. Resident #2 was admitted to the facility initially for short term rehabilitation and therapy, but had three hospitalization s since admission, [DATE], [DATE] and [DATE]. After resident #2's last readmission, from the hospital to the facility, on [DATE], she ultimately expired at the facility on [DATE], after the staff failed to provide CPR. The resident had ongoing [DIAGNOSES REDACTED]. Review of the resident #2's medical chart, interviews with the Administrator and Social Service Director on [DATE], and an interview with the Primary Care Physician on [DATE] at 10:30 a.m., all confirmed that resident #2 was not, at any time, receiving Hospice services from the time of her first admission to the facility on [DATE] through the date of her expiration on [DATE]. Further review of the resident's chart revealed that she signed a "Consent to Treatment" form on [DATE]. Also, review of the chart indicated resident #2 signed a "Designation of Health Care Surrogate" form dated, [DATE], which gave her daughter permission to make health care decisions. An interview with resident #2's family member, Health Care Surrogate, on [DATE] at 9:30 a.m. revealed she was notified that resident #2 was admitted to the hospital on or about approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, and complications of multiple [MEDICAL CONDITION]. She stated that the resident subsequently "died " at the hospital, but was revived with Cardiopulmonary Resuscitation (CPR). She revealed that she visited with her mother, resident #2, while at the hospital and then the resident was ultimately re-admitted to the facility on [DATE]. Resident #2's daughter, the Health Care Surrogate, revealed resident #2, upon this admission, was asked about advanced directives; specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2's daughter continued to say resident #2 initially asked to not be resuscitated, but after a few moments, she then expressed that she wanted her daughter, the Health Care Surrogate, to make that decision for her. Resident #2's daughter the Health Care Surrogate, indicated she made it clear on [DATE] that she wanted resident #2 to be Full Code status, which was the status she had upon the initial facility admission on [DATE], and throughout her hospitalization s. Resident #2's Health Care Surrogate daughter completed her visit with her mother and then left the state to return home. Resident #2's daughter revealed, on [DATE], that she was informed that her mother had expired, and was told her mother was a DNR by Nurse A, a Licensed Practical Nurse. Resident #2's Health Care Surrogate then revealed she called the facility on [DATE] and complained to the Administrator that staff did not try to revive her mother and she was told by a staff member that "they believed" resident #2 was a DNR status. The Social Service Progress notes revealed the facility staff discussed Advanced Directives with her, resident #2, on [DATE], since she had none in the chart, and explained the options. The progress note further indicated the writer was to follow up with her, since she was uncertain at this time. The medical record for resident #2 was not clear as to when the decision was made to maintain at a Full Code status, but this was the Health Care Surrogate daughter's stated wishes, as of [DATE], when she assumed the role of Health Care Surrogate, making health care decisions. Review of resident #2's demographic face sheet indicated she was a " Full Resuscitate " status. Review of the resident ' s medical record, including the Advanced Directives section, did not include a " Yellow " DNR order. Review of the electronic physician's order [REDACTED]. Review of resident #2 ' s electronic progress notes revealed the following: - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2 ' s condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. The facility failed to take measures to confirm who among the staff had CPR certifications, or assure that those who had CPR certifications were current with American Heart Association standards, at the BLS level as written in their policy. The Nursing Home Administrator confirmed in three interviews that she was unable to state ,on [DATE] at around 1:30 p.m., if at least one person on each shift had current CPR skills and certification. The Administrator did not consider the immediacy of the situation which required action to ensure 111 of 169 residents (as of the [DATE] census), who all had " Full Code " status, would have been provided with appropriate and current CPR skills, should they require emergency interventions for unresponsiveness, or require skilled [MEDICATION NAME] maneuvers. 9. Review of the facility ' s policies included: " Advanced Directives " policy and procedure, which was provided to the survey team for review on [DATE], by the Administrator, dated with an effective date of [DATE], with revisions on [DATE] and [DATE], revealed the following relevant information Policy statement: Overview - A resident/patient has the right to refuse treatment and to participate in planning their health decisions. . The overview continued to indicate the facility strives to comply with all valid Advance Medical Directives, per State regulations including living wills, durable power of attorney for health care ( " DPOA " ) and, including the provisions for refusal or withdrawal of nutrition and hydration. The facility failed to comply with the specified Advance Directives for resident #2. The order for " Full Resuscitation " was verified in the medical record for resident #2. It was dated [DATE]. Review of the " Code Status Orders & Response " policy and procedure, which was provided to the survey team for review on [DATE] by the Administrator and dated, with an effective date of [DATE] and revised on [DATE] and [DATE], revealed the following relevant information Policy statement: Advanced Directives will be honored during the code process. This was not done for resident #2. She died on [DATE] after CPR was not performed. Policy statement further revealed, " The facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. " Policy statement further read: - DNR ORDER - means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. - Supportive comfort & care for the resident/patient & emotional support for the resident/patient shall continue. - Federal & State-specific regulations will be adhered to. - Each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. The policy statement further read: " Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines " . This statement was in direct conflict with the earlier statement that the facility would provide BLS CPR, a certification of skilled for health care workers by the American Heart Association. The policy statement to provide BLS level CPR was not ensured as the facility had no documentation regarding qualified staff at the BLS level. This procedure was not followed for resident #2. No " Code Blue " documentation was found. Review of the " Cardiopulmonary Resuscitation " policy and procedure, was provided to the survey team for review on [DATE] by the Administrator. It was not dated, and revealed the following relevant information 1. Persons Responsible: The following respiratory therapist/nursing personnel should respond to an emergency page: a. Staff assigned to the area where the arrest occurs, or b. Any person nearby the area should respond to offer assistance as needed. Note: After the initial response, only designated persons should be present. 2. Policy statement indicates; In the event that a resident ' s condition requires cardiopulmonary resuscitation (CPR) to be performed, the respiratory therapist/nurse will assume responsibility for: a. Provide assistance with the following procedures: 1. Establish patent airway 2. Ventilate the resident as necessary 3. Administer oxygen 4. Perform external cardiac compression 5. Aid in suctioning when needed 6. Perform pulse oximetry when needed 7. Contact 911, physician and family 8. Prepare paperwork for discharge to hospital None of the steps of item 2 were provided to resident #2. b. Establishment of airway and ventilation: 1. Clear oral airways 2. Connect bag and mask 3. Administer oxygen c. Maintenance of follow up procedures by respiratory therapist/nurse: 1. Keep airway patent 2. Assure necessary ventilation with appropriate Fi02 3. Monitor parameters of ventilation and gas exchange a. Breath sounds b. Chest expansion c. Pulse oximetry d. Vital signs e. Resident color and overall assessment 4. Complete necessary forms and documents 5. Ensure that the basic techniques used in CPR meet current practice according to the American Heart standards. This was not done as evidenced by the fact that neither nurse in this situation had certification for current CPR skills. 6. Ensure that all respiratory therapist/nurses have current CPR registration that is kept in their personnel files. Only those with current CPR registration may perform CPR. Registration is to be completed biannually. This was not done. The Nursing Home Administrator and Director of Nursing stated they were unaware of who on the staff had current CPR certification. The facility failed to follow this policy and neglected to provide lifesaving skills to resident. It was determined that the facility staff, including employee A and B, (Licensed Practical Nurses) on [DATE] did not follow the facility policies by failing to provide Basic Life Support (BLS)/CPR, failed to honor resident and Health Surrogates wishes, and failed to follow physician's order [REDACTED]. The policy for Code Response stated: in the absence of the yellow bracelet the Medical record was to be checked for physician's order [REDACTED]. The facility nurses failed to do this, failed to call " Code Blue " on the over page system to indicate resident room number, and failed to begin CPR. Also, employees A and B, Licensed Practical Nurses, did not adhere to the " Cardio [MEDICAL CONDITION] Resuscitation " policy by not assuming responsibility of performing and establish patent airway, ventilate the resident, administering oxygen, perform external cardiac compressions, aide in suctioning, perform pulse oximetry, and failed to perform any other tasks of the basic techniques used in CPR current practice, according to the American Heart Association standards. The facility administration failed to, as part of their " Cardio [MEDICAL CONDITION] Resuscitation " policy, ensure that nursing staff, have current CPR registration, kept in their personnel files, failed to have knowledge of who in the facility had CPR certifications, to determine who can and cannot perform CPR, and failed to ensure registration for CPR was to be completed biannually. During an interview with the Administrator on [DATE] at approximately 10:30 a.m., when asked what CPR curriculum was provided to staff, she explained that they have none, as the facility does not require CPR certifications when hiring. The Administrator further revealed that Licensed Nurses are qualified with CPR when licensed as a nurse and CNA ' s are qualified in CPR when they are certified as a CNA. The administrator stated she could not provide any documentation of any employees in the building having current CPR certifications/cards, with current American Heart Association guidelines. The administrator confirmed that she does not know if staff that have had CPR training, have ever been updated with current American Heart Association guidelines, which changed in 2010. The Administrator was then asked if anyone in the facility provides training and CPR classes for the staff. She again explained that nobody in the facility provided training, as the facility did not require staff to be CPR certified. The Administrator and Corporate Vice President indicated they have a staff development person who was responsible to ensure staff has CPR updates. However, the Administrator and Corporate Vice President could not provide any documentation or evidence this was done. Also, during the time of the complaint investigation visit, from [DATE] through [DATE], the staff development person was not available at the facility, nor available for phone interview. The Administrator, at this time, could not state or indicate how all current employees were updated to ensure they were certified with current American Heart Association standards. The Administrator continued to say, " we are only required to go over what our policy and procedures are and they, nursing staff, are in compliance with requirements every time they renew their license " . The Administrator was, again, asked on [DATE] at approximately 2:00 p.m. who in the facility is certified in CPR. She replied, " once again, we do not require staff to have CPR certifications/cards and that this is part of our standards of practice and scope of their license. " An interview with the facility ' s Medical Director on [DATE] at 11:51 a.m. revealed that he had been the Medical Director since ,[DATE] and had attended Quality Assurance meetings quarterly. He stated he had reviewed facility policies and procedures. The Medical Director revealed he first noticed around ,[DATE], that per the " Code Status Orders & Response " Policy and procedure, revealed the facility does not require CPR certification upon hire of staff. The Medical Director revealed he believed the facility should have a policy that forms a " Rapid Response " team at all times with current CPR certifications and he will be discussing that with the facility. He planned to discuss a resolution with Administration at his meeting today, [DATE]. He further confirmed he was made aware of a situation with resident #2 who became unresponsive on [DATE] and was not provided CPR, as indicated per physician orders, and specific wishes of the resident and Health Care Surrogate. The Medical Director revealed he was made aware of this information during a telephone Quality Assurance meeting conducted sometime on [DATE]. The facility had not implemented the Medical Director ' s guidance for a specific response team at the time of this

Based on review of resident medical charts, family and resident interviews, staff interviews, facility policies regarding Advanced Directives, Code Status Orders and Response, dated [DATE], and Cardiopulmonary Resuscitation policy (not dated); review of clinical records; and interviews with residents, family and staff members, it was determined that the facility failed to protect the rights of one (#2) of three sampled residents with her end of life status choices, according to an advanced directives audit, on [DATE]. It was determined that when Resident #2 was found unresponsive and with a "Full Code" status, the facility failed to operationalize the system for Cardiopulmonary Resuscitation (CPR), and as a result, she expired. The facility failed to initiate the system for identifying the Advanced Directives expressed by the resident and her Health Care Surrogate. The facility also did not implement and practice their policies and procedures related to advanced directives, by not giving Basic Life Support (BLS)/CPR, as promised to resident #2, with a Full Resuscitation status. Failure of the facility staff to correctly implement advanced directives related to CPR, resulted in the identification of immediate jeopardy and was determined to be on-going as of [DATE], after the completion of the survey complaint investigation. Findings include: Record review revealed the following: 1. Record review on [DATE] at approximately 10:30 a.m., for Resident #2, revealed the following: Review of the admission demographic/face sheet, dated [DATE], the physician's orders [REDACTED].#2 was a fifty-eight year old female who had [DIAGNOSES REDACTED]. It was further indicated that Resident #2 was initially admitted to the facility on [DATE] from the hospital, initially for short term rehabilitation and therapy, but had three additional hospitalization s since admission, [DATE], [DATE] and [DATE]. After Resident #2's last readmission from the hospital to the facility on , [DATE], she ultimately expired at the facility on [DATE] after CPR was not given. Review of Resident #2's medical chart, interviews with the Administrator and Social Service Director on [DATE], and an interview with the Primary Care Physician on [DATE] at 10:30 a.m., all confirmed that Resident #2 had not, at any time, received Hospice services, from the time of her first admission to the facility on [DATE] through her expiration on [DATE]. Further review of the resident's chart indicated she signed a "Consent to Treatment" form on [DATE]. Also, review of the chart indicated Resident #2 signed a "Designation of Health Care Surrogate" form, dated [DATE], and gave her daughter permission to make health care decisions. 2. An interview with Resident #2's daughter on, [DATE] at 9:30 a.m., prior to facility survey entrance date, revealed she was notified Resident #2 was admitted to the hospital on approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, and complications due to multiple areas [MEDICAL CONDITION] and she subsequently "died " at the hospital but, was revived with Cardiopulmonary Resuscitation (CPR). She revealed she visited with her mother while at the hospital and then she was ultimately readmitted to the facility [DATE]. Resident #2's daughter revealed Resident #2, upon readmission, was asked about her advanced directives, specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2's daughter continued to say Resident #2 expressed that she wanted her daughter to make that decision for her. Resident #2's daughter indicated she made it clear on [DATE] that she wanted Resident #2 to be on Full Code status, which was what she, Resident #2, had upon initial facility admission on [DATE] and throughout the recent hospitalization s. The daughter stated she completed her visit with her mother and then left the state to return home on [DATE]. Resident #2's daughter revealed on [DATE] she was informed by a facility nurse that her mother expired and was told her mother "was a DNR" by a Nurse A, a Licensed Practical Nurse. Resident #2's Health Care Surrogate then revealed she called and complained to the Administrator that staff did not try to revive her mother and was told by a staff member that "they believed resident #2 was a DNR status." 3. Review of the admission Social Service Progress notes, dated [DATE] at 11:00 a.m., revealed Resident #2 had [MEDICAL CONDITION], a [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) infection, that she was alert and oriented times three and needed minimum assistance with Activities of Daily Living (ADLs). The note continued to indicate, although "named family member," (not daughter) is resident #2's emergency contact on the computer but prefers to go through her daughter. Resident #2's daughter was not the Health Care Surrogate and was designated as such on [DATE]. The Social Service Progress note dated [DATE] further revealed the facility staff discussed Advanced Directives with Resident #2, since she had none in the chart, and explained the options. The note revealed the resident indicated she was going to think about it and as of this date she was in favor of DNR, but then stated her daughter could decide. It was explained to her that she would have to sign paperwork for that. The progress note further indicated the writer would follow up with her, since she was uncertain at this time. The medical record for Resident #2 was not clear as to when the decision was made to remain a Full Code status, but this was the daughter's (Health Care Surrogate's) wishes as of [DATE], when she took over making health care decisions. 4. Review of Resident #2's demographic face sheet, dated [DATE], indicated she was "Full Resuscitate" status. Also, review of the resident's medical record, including the Advanced Directives section, did not include a "Yellow" DNR order. Review of the physician's orders [REDACTED]. Review of Resident #2's admission assessment dated [DATE] and care plans dated [DATE] (after resident expired), all failed to indicate the resident's Code Status and advanced directives wishes. It was determined through the entire record review for Resident #2, there was no indication she was ever a DNR status, but rather indicated clearly she was at the time of expiration, a "Full Resuscitate" status. 5. Review of Resident #2's progress notes, multiple discipline electronic notes that included Nursing and Social Service revealed the following entries: - Written by Social Service Worker (SSW) [DATE] at 2:27 p.m. Went to resident to see if she made any decisions on Advanced Directives. She told writer to call her daughter. Daughter was called about advanced directives. Daughter stated they were uncertain at that time what they wanted to do and would call the next week once she and her mother had talked more. The note further indicated that if the daughter was to be left in charge of health care decisions, she doesn't want her mom to sign a DNR because she wants to have her mom resuscitated. - Written by SSW [DATE] at 4:34 p.m. Spoke with resident's daughter about Advanced Directives. They decided to go with Health Care Surrogate at this time. Paperwork was filled out and original sent to daughter. - Written by Risk Manager (R.M.) [DATE] at 4:34 p.m. 9:00 a.m. (late entry) resident had walked without oxygen on, to the nurse station and stated, "I wanted to go to the hospital and something is not right; can I have something for anxiety?" Istructed aide to walk with resident back to the room and apply oxygen due to unsteady gait. 9:05 a.m. resident was on the phone with 911. Writer spoke with 911 operator and states, "the resident called and wants to go to the hospital." Unit manager made aware and resident sent to the hospital via stretcher. The note further indicated she spoke with Resident #2's Physician's nurse practitioner. - Written by MDS nurse [DATE] at 4:54 p.m. - (late entry) spoke with Resident #2's daughter to discuss Mother's recent hospitalization related to respiratory distress. Informed Health Care Surrogate that Resident #2 had fallen with no injuries. Discussed resident's present respiratory condition. - [DATE] at 3:17 a.m. Returned from hospital - Written by an LPN [DATE] at 7:30 a.m. Resident yelled out, "I feel like my heart is about to jump out of my chest." Resident refused the nebulizer treatment and requests to be sent to the Hospital. Physician was notified and stated to send the resident to the Hospital right now. EMS called and conference person attempted contacted. Risk Manager was made aware. - Written by an LPN [DATE] at 5:40 p.m. readmitted from the Hospital and under the care of the Primary Care Physician. Resident able to make needs known. - Written by RN [DATE] at 7:31 a.m. Resident awake throughout the night able to make needs known at times. Confused and unable to communicate at other times. - Written by RM [DATE] at 1:45 p.m. Resident requested to be sent to the Hospital to evaluate for weakness and shortness of breath. Resident stated, "I can't swallow the food." MD notified and ordered to the Hospital and stated, "I'm on my way to see the patient." - Written by RM [DATE] at 8:04 p.m. Resident readmitted from the Hospital with daughter. - Written by LPN [DATE] at 11:19 p.m. Resident alert with confusion and able to make wants known. - Written by LPN [DATE] at 3:11 p.m. Poor appetite, difficulty swallowing, speech to evaluate. Has family and is now out of town. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in Resident #2's condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 6. Review of the facility's "Advanced Directives" policy and procedure, provided to the survey team for review on [DATE] by the Administrator was dated with an effective date of [DATE]; revised on [DATE] and [DATE]. It revealed the following relevant information: Policy statement: Overview - A resident/patient has the right to refuse treatment and to participate in planning their health decisions. A court appointed guardian, appointed under the State's guardianship statutes, possesses the legal authority to make health care decisions for the adjudicated incompetent resident/patient. An attorney-in-fact under the durable power of attorney for health care may give medical decision-making directives for the resident/patient. The directives of the attorney in fact must be in compliance with the authority granted to an attorney-in-fact by the durable power of attorney for the health care statute. The overview of the policy continued to indicate the facility strived to comply with all valid Advance Medical Directives (per the State regulations) including living wills, durable power of attorney for health care ("DPOA"), including the provisions for refusal or withdrawal of nutrition and hydration. These facilities shall accept both resuscitate and DNR orders signed by Physicians. The overview continued to indicate the In-service training is provided to staff on resident/patients' rights including information about Advance Medical Directives, DNR orders and the resident/patient's right to participate in medical decision making. The facility shall provide for both individual and group education for staff and the community on issues concerning Advance Medical Directives. The facility failed to comply with the Advance Directive for resident #2. The guidelines of this policy specify: 1. Provide information about the facility's resident/patient's rights policies to all residents/patients and /or the authorized representatives or sponsors (collectively, the "resident/patient") prior to or upon admission. a. Provide these policies to the resident/patient at an additional time during the resident/patient's stay in the facility per request, or upon any changes in the policies. 2. Inform the resident/patient of the law regarding the DPOA and the living will and the facility's policy regarding resuscitation and DNR orders. 3. Provide information in writing with an oral description of the information, including the resident/patient's right to refuse medical treatment. a. The information will be in a language and with content understandable to the resident/patient. b. The facility will assist the resident/patient in obtaining the appropriate forms for execution of a living will or DPOA. 4. Give the resident/patient a full explanation of various treatment options available, including providing CPR treatment, at the time of admission and anytime during their stay. a. An explanation shall be provided of the benefits and potential risks of the treatment options, side effects, and outcomes of each option. This policy further read: Documentation: 1. Inquire as to the existence of an Advance Medical Directive at the time of admission. 2. Document in the resident/patient's medical whether or not an Advance Medical Directive has been executed by the resident/patient. 3. Place a copy of such Advance Medical Directive in the permanent medical record. 4. Place a copy of any guardianship documents in the permanent medical record. 5. Document in writing each offering of information to the resident/patient. 7. Review of the "Code Status Orders & Response" policy and procedure, which was provided to the survey team for review on [DATE] by the Administrator, revealed it was dated with an effective date of [DATE] and revised on [DATE] and [DATE]. The policy statement revealed the following relevant information: The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. Policy statement further revealed: The facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. Policy statement further read: - DNR ORDER - means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. - Supportive comfort & care for the resident/patient & emotional support for the resident/patient shall continue. - Federal & State-specific regulations will be adhered to. - Each resident will have the elected code status documented in their medical record within the physician's orders [REDACTED]. The facility nurses (Employee A & B) failed to operationalize this policy to confirm, Resident #2 status per the physician's orders [REDACTED]. The policy statement further read: "Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines." This statement conflicted with the statement to provide (BLS), an American Heart Association and Certificate of competency for Health Care Professionals. The NHA, on [DATE], failed to state how these two conflicting statements would be resolved to put the system for CPR response in place. The procedures of this policy specified: 1. The Physician &/or Social Services/Clinical team will discuss the resident/patient or authorized responsible party wishes regarding code Status as it related to the current clinical condition. This discussion will include an explanation of DNR "Do Not Resuscitate" &/or "Full Code." a. 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 written order signed by the Physician indicating the chosen Code Status. This may be a T.O. if signed off by two nurses, with MD signature at next visit. a. Code status is either - full code or DNR. 3. Once the resident/responsible party elects the DNR option the following measures will be implemented: a. Nursing will place a YELLOW DNR bracelet on the resident. Resident identification will be verified by two (2) staff members when applying the bracelet - either 2 nurses or nurse and social services. 4. Response: a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, & pulse c. Check for the YELLOW DNR bracelet - if none is found the Medical Record will be checked for physician's orders [REDACTED]. d. If the resident is a full code, the respondent to the call for help will immediately overhead page a "code blue" & indicate the room number, or the location of the resident/patient & deliver the Medical Record & Emergency Cart & AED if applicable to the location of the Code Blue. e. If Code Status is "DNR" - DO NOT initiate CPR (Notify Physician, Supervisor and Family) f. If Code Status includes Full Code, BEGIN Cardio [MEDICAL CONDITION] Resuscitation g. If Code Status is not designated, the resident is a FULL CODE & CPR will be initiated h. A scribe will be designated to record activity related to the Code Blue using the "Code Blue worksheet" provided on the Emergency Cart i. The CPR will continue until: Relieved by EMS, relieved by another staff member who will take over CPR, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. - EMS (911) - Physician - Family/Legal Representative 5. Document actions in the medical record using the "Code Blue" worksheet as a reference. 6. Review Code status and DNR orders quarterly, PRN & with change in condition and renew by Physician's signature on monthly orders. It was determined through review of this policy, that on the morning of [DATE], after resident #2 became unresponsive, neither nurse A or B operationalized #4, parts d, e, f and g to confirm in the record the resuscitation status and begin life saving measures. It was also determined had nurses A or B did not follow protocol in the absence of a "yellow" DNR band mentioned in item 4 c. Review of the undated "Cardiopulmonary Resuscitation" policy and procedure, provided to the survey team for review on [DATE] by the Administrator, revealed the following relevant information: 1. Persons Responsible: The following respiratory therapist/nursing personnel should respond to an emergency page: a. Staff assigned to the area where the arrest occurs, or b. Any person nearby the area should respond to offer assistance as needed. Note: After the initial response, only designated persons should be present. 2. Policy statement indicates; In the event that a resident's condition requires cardiopulmonary resuscitation (CPR) to be performed, the respiratory therapist/nurse will assume responsibility for: a. Provide assistance with the following procedures: 1. Establish patent airway 2. Ventilate the resident as necessary 3. Administer oxygen 4. Perform external cardiac compression 5. Aid in suctioning when needed 6. Perform pulse oximetry when needed 7. Contact 911, physician and family 8. Prepare paperwork for discharge to hospital b. Establishment of airway and ventilation: 1. Clear oral airways 2. Connect bag and mask 3. Administer oxygen c. Maintenance of follow op procedures by respiratory therapist/nurse: 1. Keep airway patent 2. Assure necessary ventilation with appropriate Fi02 3. Monitor parameters of ventilation and gas exchange a. Breath sounds b. Chest expansion c. Pulse oximetry d. Vital signs e. Resident color and overall assessment 4. Complete necessary forms and documents 5. Ensure that the basic techniques used in CPR meet current practice according to the American Heart standards. 6. Ensure that all respiratory therapist/nurses have current CPR registration that is kept in their personnel files. Only those with current CPR registration may perform CPR. Registration is to be completed biannually. 8. Interviews with facility staff revealed the following: A. An interview was conducted with Employee C, an aide, on [DATE] at 7:15 a.m. She confirmed that had Resident #2 on her assignment on the night shift of [DATE]. She revealed she went into Resident #2's room on [DATE] at approximately 3:30 a.m. to assist with her roommate. After she finished with her roommate, she noticed Resident #2's leg was hanging off the side of the bed, in a dangerous manner, and asked her to pick up her leg and put it back on the bed. Employee C asked Resident #2 to pick up her leg a couple of more times, with no response. She then stated she looked at Resident #2's face and saw that her eyes had a "funny" look and tapped her shoulder to continue to tell her to pick up her leg. Employee C said there was still no response. The aide then picked up Resident #2's wrist to feel for a pulse and did not detect a pulse. She further placed her hand at the resident's lips and did not feel any breaths. The aide also indicated the resident's lips, face and arm were very cold to the touch. Employee C said at this time, she walked to the room door and called out for help. Employee C indicated employee D (who is also a CNA), came directly in the room, where he was told by Employee C, that resident #2 was not responsive and not breathing. Employee D told Employee C to stay in the room and wait with the resident while he went to find a nurse. Employee C indicated that the nurse, Employee E, an agency nurse, was on her lunch break at the time and another nurse was brought in by Employee D. Employee C indicated that Employee A, a Licensed Practical Nurse, came into the room and asked what happened. Employee C continued, stating that she described to Employee A how she had found the resident unresponsive. At that time, Employee C was asked to leave the room and the door was closed. Employee C was asked if she was aware if resident #2 was a "Full Code" status or "DNR" status. She confirmed that she did not know. Employee C was also asked if she is current with CPR certifications. She revealed that she does have a valid and current CPR card. B. An interview with Employee D, on [DATE] at 7:08 a.m., he was the second aide to respond to the situation. He was not the CNA had Resident #2 on assignment, but revealed he was called to resident #2's room by Employee C on [DATE] at approximately 3:30 a.m. He further revealed he was told by Employee C that Resident #2 was unresponsive and thinks she might have "passed away." Employee D stated that, at that time, he told Employee C to remain in the room while he went to find a nurse. Employee D indicated he did not know who the assigned nurse for resident #2 was, but proceeded to find the closest nurse for assistance. Employee D stated he found Employee A, a Licensed Practical Nurse. He told the nurse that Employee C found Resident #2 unresponsive and needed help. Employee D stated that the nurse, Employee A, went to the room and asked the two aides (Employee C and Employee D) to leave the room and closed the door. Employee D was asked by the surveyor if he knew if Resident #2 was a "Full Code" or "DNR." He indicated he did not know. Employee D was then asked if he was CPR certified and he revealed he is and that he has a valid and current CPR card. Review of the employee files and multiple interviews with the Nursing Home Administrator and Director of Nursing, failed to verify CPR certifications for employees, C and D. Neither one of the two nurses, who responded to the emergency, were certified in CPR. C. An interview with Employee A was conducted via telephone, on [DATE] at 12:34 p.m. She stated she was a Licensed Practical Nurse and was the first responding nurse to Resident #2 on [DATE] at approximately 3:30 a.m. She stated she was asked by Employee D to come to Resident #2's room, as he and Employee C found her to be unresponsive. Employee A indicated she finished with what she was doing, locked her medication cart, and was the first nurse to respond to Resident #2. She asked Employee C and D to leave the room and proceeded to find a pulse on Resident #2. She explained the resident had no pulse, then put her fingers to the residents' mouth, and "knew" she had already expired. She did not begin CPR. She further revealed the resident felt really cold and that she had "passed away." Employee A then stated she called out for another nurse, Employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to Employee B that Resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told Employee B that she "believed resident is a DNR" ; even though there was no DNR bracelet and "believed" the resident was also receiving Hospice services. Employee A did not know if Employee B followed up with finding out if Resident #2 was indeed a "Full Code" or "DNR." Employee A was asked if she was aware of the meaning of a "Yellow" Bracelet/band. Employee A stated that if a resident had a "yellow" bracelet /band on their arm, that it meant the resident was "DNR" status. Employee A further revealed that Resident #2 did not have a "yellow" bracelet/band on her arm. Employee A continued to say stated that if a resident has a "yellow" bracelet/band on their arm, that it means the resident is "DNR" status. Employee A further stated that Resident #2 had just returned to the facility from the hospital and that she "believed" the resident had not yet been outfitted with a "yellow" bracelet because "sometimes the facility staff takes several days to put them on" the residents with DNR orders. Employee A further indicated that she and Employee B were the only responding nurses and that Employee E was the nurse assigned to Resident #2, and that she was on lunch break when resident #2 expired. Employee A also stated that she told Employee E (the agency Licensed Practical Nurse, assigned to Resident #2) that Resident #2 had been found not responsive and had expired. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician's answering service, and the daughter (Health Care Surrogate) and then went back to her normal assignment. Employee A was asked if she looked in the chart or electronic record to verify if Resident #2 was a "Full Code" or "DNR." She said that she did not initially, but then saw in the chart, while documenting, that the resident was a "Full Code." Employee A was asked where, specifically, she found that Resident #2 was a "DNR." She revealed the ,[DATE] physician's orders [REDACTED]." However, review of the ,[DATE] physician's orders [REDACTED].#2 was "DNR." It indicated Resident #2 was "Full Resuscitate" status. Employee A stated she was called back to the facility, from home, after her night shift on [DATE], at around 10:00 a.m., and was asked by administration why neither she, nor Employee B ever performed CPR on Resident #2 on [DATE], after she was found unresponsive. She indicated it was her understanding that Resident #2 was a "DNR" status and was receiving Hospice services. Employee A confirmed, after she was shown Resident #2 was a "Full Code", that she had not honored the residents Advanced Directives of Full Resuscitation status by not providing CPR to the resident when she was found unresponsive on [DATE]. On [DATE], the surveyor spoke with the dispatcher at the local EMS dispatch station. There was no record of any call placed to the EMS dispatch station on [DATE] from anyone at the facility and it was confirmed that EMS was never dispatched to the scene on that date. D. On [DATE] at 1:50 p.m. and 3:00 p.m. and, again, on [DATE] at 1:00 p.m. and, again, at 3:00 p.m., Employee B, the second staff LPN that worked on [DATE] night shift, was called and unable to be contacted. Employee B could not be interviewed. However, during an interview with the Nursing Home Administrator, on [DATE] at approximately 3:15 p.m., she provided a statement written by Employee B which was dated [DATE]. The statement read, as written, "My name is (Employee B) and I was the nurse working the north wing on [DATE] for the (11:00 p.m. - 7:00 a.m.) shift. The phone rang and it was the South wing nurse (Employee A), who stated to come to the South wing. When I (Employee B) came over, I saw (Employee A) sitting at the nursing station typing on the computer. She stated that one of my patients "just died ." I (Employee B) asked her, "What did you do?" She replied (Resident #2) was a DNR and a Hospice patient. She continued typing and stated 'I (Employee A) am charting about her I already called her Daughter and the Funeral Home, go and see her.' I went to the room with a CNA behind me. I (Employee B) asked 'when did (Resident #2) pass away', and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said "I already cleaned her up." Another CNA came in the room from the North Wing and the resident's mouth was opened. She positioned her mouth to keep it closed. I (Employee B) observed the resident lying in bed with no sign of life." No further documentation was provided regarding Employee B. If the status of resident #2 for full resuscitation had been correctly identified staff LPN's A & B were expected to follow this policy, beginning with item #2. It was determined the facility staff failed to operationalize their above listed policies related to "Advance Medical Directives", "Code Status Orders & Response" and "Cardiopulmonary Resuscitation" as evidenced by Resident #2 not receiving CPR to include Basic Life Saving (BLS), when found unresponsive, and ultimately expired. E. An interview with Resident #2's Primary Care Physician, on [DATE] at 10:11 a.m., revealed he was aware that Resident #2 had multiple hospitalization s since her initial admitted on [DATE] and that the resident had shortness of breath and with spreading [MEDICAL CONDITION] that had metastasized. The Primary Care Physician continued to state he was made aware that on [DATE] Resident #2 had expired on [DATE] but, was not aware of the details. The Primary Care Physician stated he was not surprised of the death of Resident #2, as she was "declining quickly." He further revealed he was notified later in the day of [DATE] or possibly the next day, that Resident #2 expired and that her advanced directives related to her code status were not followed. He further revealed he was told by the administrator that Resident #2 expired and the responding nurses did not provide CPR, as per the residents/Health Care Surrogate's wishes. Resident #2's Primary Care Physician did not, at the time of expiration, know Resident #2's code status. He did remember speaking to the resident a couple of times and did not remember the outcome of her wishes. Resident #2's Primary Care Physician did confirm he signed all of Resident #2's orders

Based on the review of the closed medical record including review of written CPR desires for resident #2, review of clinical records; and interviews with residents, family and staff members, it was determined that the facility failed to follow the documented wishes for one (#2) of three sampled residents, regarding the implementation of end of life status. Resident #2, a [AGE] year old resident, and her representative, had requested to receive Cardio-Pulmonary Resuscitation (CPR) in the event that she was found unresponsive, without a pulse and/or respirations. The facility failed to provide resident #2 with necessary life sustaining CPR/emergency medical care, in accordance with her expressed desires to receive such services. She was pronounced expired at the facility, after not receiving CPR. The facility staff did not properly interpret and implement the documentation of a desire for resident #2 to receive CPR. One hundred and eleven of the one hundred and sixty-nine current residents had documented desires for "Full Resuscitation", i.e. CPR. These findings resulted in the identification of immediate jeopardy and were determined to be on-going as of [DATE] at 3:20 p.m., after the completion of the survey complaint investigation. Findings include: 1. Review of the facility's "Advanced Directives" policy and procedure, provided to the survey team for review on [DATE] by the Administrator, revealed it was dated with an effective date of [DATE], and revised on [DATE] and [DATE]. It revealed the following relevant information: Policy statement: Overview: The overview of the policy indicated the facility strived to comply with all valid Advance Medical Directives (per the State regulations) including living wills, durable power of attorney for health care ("DPOA"), including the provisions for refusal or withdrawal of nutrition and hydration. These facilities shall accept both resuscitate and DNR orders signed by Physicians. The overview continued to indicate the In-service training was provided to staff on resident/patients' rights including information about Advance Medical Directives, DNR orders and the resident/patient's right to participate in medical decision making. The facility shall provide for both individual and group education for staff and the community on issues concerning Advance Medical Directives. The guidelines of this policy specify: 2. Inform the resident/patient of the law regarding the DPOA and the living will and the facility's policy regarding resuscitation and DNR orders. 4. Give the resident/patient a full explanation of various treatment options available, including providing CPR treatment, at the time of admission and anytime during their stay. a. An explanation shall be provided of the benefits and potential risks of the treatment options, side effects, and outcomes of each option. This policy further read: Documentation: 2. Document in the resident/patient's medical whether or not an Advance Medical Directive has been executed by the resident/patient. 3. Place a copy of such Advance Medical Directive in the permanent medical record. Per the facility policy and procedure for Code Status Orders and Response, the facility stated: The facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. The policy statement further stated: "Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines." This statement conflicted with the statement to provide BLS level CPR, an American Heart Association Certificate of competency for Health Care Professionals providing CPR. The facility policy continued: 3. Once the resident/responsible party elects the DNR option the following measures will be implemented: a. Nursing will place a YELLOW DNR bracelet on the resident. Resident identification will be verified by two (2) staff members when applying the bracelet - either 2 nurses or nurse and social services. applicable, to the location of the Code Blue. f. If Code Status includes Full Code, BEGIN Cardio [MEDICAL CONDITION] Resuscitation g. If Code Status is not designated, the resident is a FULL CODE & CPR will be initiated h. A scribe will be designated to record activity related to the Code Blue using the "Code Blue worksheet" provided on the Emergency Cart i. The CPR will continue until: Relieved by EMS, relieved by another staff member who will take over CPR, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. 6. Review Code status and DNR orders quarterly, prn & with change in condition and renew by Physician's signature on monthly orders. 2. A record review on [DATE] for resident #2, revealed the following: Resident #2 was initially admitted to the facility on [DATE] from the hospital. She was [AGE] years old. Resident #2 was admitted to the facility for short term rehabilitation and therapy, but had three additional hospitalization s since the initial admission, [DATE], [DATE] and [DATE]. After resident #2's last readmission, from the hospital, [DATE], she expired at the facility on [DATE], after CPR was not provided after she was found unresponsive. Review of the physician's orders [REDACTED]. A review of the Hospital History and Physical sheet, dated [DATE], confirmed the current diagnoses. Review of resident #2's facility medical chart, interviews with the Administrator and Social Service Director on [DATE], and an interview with the Primary Care Physician on [DATE] at 10:30 a.m., all confirmed that resident #2 had not, at any time, received Hospice services, since her initial admission on [DATE] through her expiration on [DATE]. Also, review of the chart indicated resident #2 signed a "Designation of Health Care Surrogate" form, dated [DATE], designating her daughter permission to make health care decisions. An interview was conducted ,by the surveyor, with Resident #2's daughter, the Health Care Surrogate, on [DATE] at 9:30 a.m., prior to the onsite investigation. She stated she was notified that resident #2 was admitted to the hospital on approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, complications due to multiple areas [MEDICAL CONDITION]. She stated that the resident subsequently "died " at the hospital but, was revived with Cardiopulmonary Resuscitation (CPR). She revealed she visited with her mother while at the Hospital and then her mother was ultimately readmitted to the facility's care on [DATE]. Resident #2's daughter, the Health Care Surrogate, revealed that resident #2, upon admission to the facility, was asked about her Advanced Directives and, specifically, whether she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2's daughter continued to say that resident #2 expressed that she wanted her daughter, Health Care Surrogate, to make that decision for her. Resident #2's daughter indicated she made it clear on [DATE], that she wanted resident #2 to be on Full Code status, which was her desire upon the initial facility admission on [DATE] (and continued throughout the recent hospitalization s). The daughter stated she completed her visit with her mother and then left the state to return home on [DATE]. Resident #2's daughter revealed that, on [DATE], she was informed, by the facility nurse, that her mother expired. She was told by Nurse A, a Licensed Practical Nurse, that her mother "was a DNR." Resident #2's daughter then revealed she called the facility later in the day and complained to the Administrator that staff did not try to revive her mother. She was told by a staff member that "they believed her mother was a DNR status." Review of the admission Social Service Progress notes, dated [DATE] at 11:00 a.m., revealed resident #2 had [MEDICAL CONDITION] and a [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) infection, that she was alert and oriented times three, and needed minimum assistance with Activities of Daily Living (ADLs). Resident #2's Daughter was not the Health Care Surrogate at that time but, was designated as such on [DATE]. The Social Service Progress note dated, [DATE], further revealed the facility staff discussed Advanced Directives with resident #2, since she had none in the chart, and explained the options. The note revealed the resident indicated she was going to think about it, and as of this date, she was in favor of DNR, but then stated her daughter could make the final decision. It was explained to her that she would have to sign paperwork for that. The progress note further indicated the writer would follow up with her, since she was uncertain at this time. The medical record for resident #2 was not clear as to when the decision was made to remain a Full Code status, but this was the daughter's (Health Care Surrogate's) wishes, as of [DATE], when she took over responsibilities for making health care decisions for the resident. Review of resident #2's demographic face sheet, dated [DATE], indicated she was "Full Resuscitate" status at the time she was discovered unconscious. Also, review of the resident's medical record, including the Advanced Directives section, did not include a "Yellow" DNR order. Review of the physician's orders [REDACTED]. Review of resident #2's admission assessment dated [DATE], and care plans dated [DATE], after resident #2 expired, all failed to indicate the resident's Code Status and advanced directives wishes. Review of resident #2's progress notes, from the multiple discipline electronic notes, that included Nursing and Social Service, revealed the following documentation: - Written by Social Service Worker (SSW) [DATE] at 2:27 p.m. Went to resident to see if she made any decisions on Advanced Directives. She told writer to call her daughter. Daughter was called about advanced directives. Daughter stated they were uncertain at this time what they want to do and will call next week once she and her mother have talked more. The note further indicated that if the daughter was to be left in charge of health care decisions, she doesn't want her mom to sign a DNR because she wants to have her mom resuscitated. - Written by SSW [DATE] at 4:34 p.m. Spoke with resident's daughter about Advanced Directives. They decided to go with Health Care Surrogate at this time. Paperwork was filled out and original sent to daughter. - Written by RM [DATE] at 8:04 p.m. Resident readmitted from the Hospital with daughter. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2's condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 3. A An interview with employee A was conducted, via telephone on [DATE] at 12:34 p.m. She stated she was a Licensed Practical Nurse and was the first responding nurse to resident #2 on [DATE] at approximately 3:30 a.m. She stated she was asked by employee D to come to resident #2's room, as he and employee C found her to be unresponsive. Employee A indicated she finished with what she was doing, locked her medication cart, and was the first nurse to respond to resident #2. She asked employees C and D to leave the room and proceeded to attempt to find a pulse on resident #2. She explained the resident had no pulse, then put her fingers to the resident's mouth, and "knew" she had already expired. She did not begin CPR. She further revealed the resident felt really cold and that she had "passed away." Employee A then stated she called out for another nurse, employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to employee B that resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told employee B that she "believed resident is a "DNR"; even though there was no "DNR" bracelet and "believed" the resident was also on Hospice services." Employee A did not know if employee B followed up with finding out if resident #2 was indeed a "Full Code" or "DNR." Employee A was asked by the surveyor, what a "Yellow" Bracelet/band meant? Employee A stated that if a resident had a "yellow" bracelet/band on their arm, that it meant the resident was "DNR" status. Employee A further revealed that resident #2 did not have a "yellow" bracelet/band on her arm. Employee A continued to say that resident #2 had just returned to the facility from the Hospital. She didn't think the resident was outfitted with a "yellow" bracelet, as she "believed she should have and that sometimes the facility staff take several days to put them on." Employee A further indicated that she and employee B were the only responding nurses and that employee E was the nurse assigned to resident #2, and she was on lunch break when resident #2 expired. Employee A also stated that she told employee E (the agency Licensed Practical Nurse, assigned to resident #2) that resident #2 had been found unresponsive and had expired. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician's answering service, and the daughter (Health Care Surrogate) and then went back to her normal assignment. Employee A was asked by the surveyor if she looked in the chart or electronic record to verify if resident #2 was a "Full Code" or "DNR." She said that she did not initially, but then saw in the chart, while documenting, that the resident was a "Full Code." Employee A was asked where specifically, she found that resident #2 was a "DNR." She revealed the ,[DATE] physician's orders [REDACTED]." Employee A stated she was called back to the facility, from home, after her night shift on [DATE], at around 10:00 a.m., and was asked by administration why neither she, nor Employee B, ever performed CPR on resident #2 on [DATE], after she was found unresponsive. She indicated it was her understanding that resident #2 was a "DNR" status and was on Hospice. Employee A confirmed after she was shown resident #2 was a "Full Code", that she did not honor her wishes by performing CPR. Review of the ,[DATE] physician's orders [REDACTED]. B. On [DATE] at 1:50 p.m. and 3:00 p.m. and, again, on [DATE] at 1:00 p.m. and, again, at 3:00 p.m., Employee B, the second staff LPN that worked on [DATE] night shift, was called and unable to be contacted. Employee B could not be interviewed. However, during an interview with the Nursing Home Administrator, on [DATE] at approximately 3:15 p.m., she provided a statement written by Employee B which was dated [DATE]. The statement read, as written, "my name is employee B and I was the nurse working the north wing on [DATE] on the (11:00 p.m. - 7:00 a.m.) shift. The phone rang and it was the South wing nurse, employee A, who stated to come to the South wing. When I (employee B) came over, I saw employee A sitting at the nursing station typing on the computer. She stated that one of my patients "just died ." I (employee B) asked her "what did you do?" She replied resident #2 was a DNR and a Hospice patient. She continued typing and stated 'I (employee A) am charting about her I already called her Daughter and the Funeral Home, go and see her.' I went to the room and with a CNA behind me. I (employee B) asked 'when did resident #2 pass away,' and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said "I already cleaned her up." Another CNA came in the room from the North wing and the resident's mouth was opened, she positioned her mouth to keep it closed. I (employee B) observed the resident lying in bed with no sign of life." No further documentation was given regarding employee B. 4. An interview with the Administrator and Risk Manager, on [DATE] at 11:11 a.m., revealed resident #2 had been hospitalized several times since admission on [DATE], and they stated they had only seen the resident in passing and were not aware of her medical status in depth. The Risk Manager revealed the resident was not interviewable after the last admission [DATE], and had been declining. The Administrator and Risk Manager were asked by the surveyor how they discovered that resident #2 was not provided with CPR when she was found unresponsive on [DATE]. They both stated that during the stand-up (ADHOC) meeting on [DATE], at approximately 8:30 a.m., resident #2's chart was brought to their attention. They both stated that it was then they discovered, through review of the notes and advanced directives, that the resident was a "Full Code" status and was not given CPR when found unresponsive. The Administrator and Risk Manager both immediately called in all parties involved from the night on [DATE] - [DATE], specifically employees A, B, C, D, E and F. It was indicated from the Risk Manager and Administrator that employees A, B, C, D, E and F, after the interviews of the involved employees, all were suspended until the investigation was concluded. The administrator revealed she and her team immediately started their investigation. The Administrator revealed, upon completion of their investigation, that the incident was determined to be adverse, related to neglect on the facility's part. 5. An interview with resident #2's Primary Care Physician, on [DATE] at 10:11 a.m., revealed he was aware that resident #2 had multiple hospitalization s since her initial admitted on [DATE] and that the resident had shortness of breath, with [MEDICAL CONDITION] that had metastasized. The Primary Care Physician continued to state he was made aware that resident #2 had expired on [DATE] on that date but, was not aware of the details. The Primary Care Physician stated he was not surprised of the death of resident #2, as she was "declining quickly." He further revealed he was notified later in the day of [DATE] or possibly the next day, that resident #2 expired and that her advanced directives related to her code status were not followed. He was told by the administrator that resident #2 expired and the responding nurses did not provide CPR, as per the resident's/Health Care Surrogate's wishes. Resident #2's Primary Care Physician did not at the time of expiration; know resident #2's code status. He did remember speaking to the resident a couple of times and did not remember the outcome of her wishes. Resident #2's Primary Care Physician did confirm he signed all of resident #2's orders, including the physician's orders [REDACTED]. He further indicated that during a "Full Code", staff were to do whatever they could do to provide CPR, and try to revive the resident until 911 arrived. He also confirmed that if a resident's wishes were for DNR states, the facility would honor those wishes, when they were found unresponsive, document the event and notify the Primary Care Physician, whatever the outcome. 6. An interview with the facility's Medical Director on [DATE] at 11:51 a.m. revealed he had been the Medical Director since ,[DATE], had attended Quality Assurance meetings quarterly, and had reviewed facility policy and procedures. The Medical Director revealed he first noticed, around ,[DATE], that per the "Code Status Orders & Response" Policy and procedure, it revealed the facility did not require CPR certification upon hire. The Medical Director revealed he believed the facility should have a policy that formed a "Rapid Response" team at all times that have current CPR certifications, and he would be discussing that with the facility administration at his meeting today, [DATE]. He further confirmed he was made aware of the situation with resident #2, who became unresponsive on [DATE] and was not provided CPR against her expressed wishes to receive it. He confirmed that it stated to resuscitate her on the attending physician's orders [REDACTED]. The Medical Director revealed he was made aware of this information during a telephone Quality Assurance meeting conducted sometime on [DATE]. 7. It was determined through record review, policy review, and staff interviews that employee A failed to clarify resident #2's Code status when she was found unresponsive. Employee A assumed resident #2 had a DNR in place and thought that since resident #2 was newly readmitted from the hospital, she had not received the "yellow" bracelet band that indicated a resident had a DNR order. It was further determined that the second responding nurse, employee B, failed to follow through and re-check resident #2's code status when it was confirmed she was unresponsive. It was determined this nurse also just took the inaccurate information from employee A that resident #2 was a DNR. It was determined that both nurses (employee A and B) blatantly disregarded checking resident #2's medical record for clarification of advanced directives related to code status orders and wishes. 8. At the conclusion of the investigation on [DATE] at 5:05 p.m. the Nursing Home Administrator failed to provide the survey team a list of current CPR/BLS certified staff, and failed to assure that all staff were trained on where to find code status orders for the residents. At the time of the exit there were 111 of 169 current residents requesting CPR. The survey team was unable to determine if qualified staff was assigned to each shift were available to perform this skill. Immediate Jeopardy was determined to be ongoing at the time of the exit, [DATE] at 5:05 p.m.

Based on facility management interviews, an interview with the Medical Director, review of the Medical Director Agreement, and review of the facility policies and procedures for Advanced Medical Directives (Effective date of [DATE]), Code Status Order & Response (Effective date of [DATE], and Revised [DATE] and revised again [DATE]), Cardiopulmonary Resuscitation (no date), and Risk Management/Quality Assurance Committee (Effective date [DATE]), the Medical Director failed to collaborate with the facility leadership to implement and evaluate resident care policies and procedures that reflect current standards of practice to ensure resident safety. The Medical Director further confirmed that he had not discussed the facility ' s policy of not requiring staff to have skilled CPR certifications in the Quality Assurance meetings. Since acquiring this knowledge in November, he had only made the suggestion of a " Rapid Response Team " being initiated on [DATE], during an interview with the survey team. He failed to discuss his concerns with the facility and intervene, after he discovered that the policies that facilitated life sustaining efforts of medical care were inconsistent with applicable current standards of practice for health care workers, and again after the administrative review of the death of resident #2. The Administration of the facility, along with the Medical Director, were not aware, and could not provide documentation of personnel in the facility qualified to provide skilled CPR to the one hundred-eleven of the one hundred sixty-nine residents currently in the facility , with the code status of Full Resuscitation. One of three sampled residents (#2) had requested Cardiopulmonary Resuscitation (CPR) services through her Advanced Directives and physician's order [REDACTED]. The resident died in the facility, after the Medical Director identified his concerns. Any guidance by the Medical Director for resolution of this situation of qualified staff was unknown at the time of the survey exit. Findings Include: 1. An interview with the Medical Director, on [DATE] at 11:51 a.m., he revealed he had been the Medical Director since February 2012 and had attended Quality Assurance meetings quarterly. He confirmed that he had reviewed facility policy and procedures. The Medical Director revealed he first noticed , around ,[DATE], that per the " Code Status Orders & Response " Policy and procedure, and that it revealed the facility does not require CPR certification upon hire. He confirmed that he did not discuss or collaborate with the facility leadership, staff or other practitioners/ consultants during the Quality Assurance meetings, or anytime thereafter, to develop this policy to reflect current standards of practice. During the interview the Medical Director stated that he believed the facility should initiate a " Rapid Response " team, available at all times, with all members of that team having current skilled CPR certifications. He further stated his concerns regarding the current policy that does not mandate staff to have CPR certification and the idea regarding a Rapid Response Team would be discussed with the facility administration at a meeting scheduled for that day ([DATE]). 2. During an interview with the NHA, on [DATE] at 3:10 p.m., she was asked who in the facility was required to have Cardiopulmonary Resuscitation (CPR) certification. She stated, " Nobody is required per the job description to be CPR certified; not LPN ' s, RN ' s, or CNA ' s. " She confirmed at that time that the facility had not done an audit of CPR certifications and did not know at that time who in the building or how many staff members had CPR certifications. During an additional interview with the NHA, on [DATE] at 3:58 p.m., she revealed that the next Quality Assurance (QA) meeting was to be held on [DATE] and that the staff had been conducting QA meetings weekly since [DATE]. She stated that the MD has been involved in all QA meetings, attending some by phone. She further stated, " The Medical Director had nothing to add and to just follow the policy. " On [DATE] at 10:30 a.m. an additional interview with the NHA was conducted and she again confirmed that no one in the facility has a CPR certification on file " because we don ' t require it. " She stated that administration had asked the staff a list of questions on [DATE] (and provided a list of questions to survey team) to see if staff knew how to perform current CPR. She stated that no information handouts were given to the staff. When asked why the facility did not require CPR certification, the NHA stated, " That is how this organization is and they don ' t have it in the job description and they don ' t require it. " She further confirmed that the Medical Director was aware of the policies and procedures.At the time of the surveyor exit on [DATE] at 5:05 p.m., the Nursing Home Administrator (NHA) confirmed she was not aware of the staff level of expertise and CPR certifications. One hundred and eleven of the one hundred and sixty-nine current residents had a code status of Full Resuscitation. The NHA was unable to determine who on staff was qualified to provide skilled CPR to those residents. She stated she did not recall any directions provided by the Medical Director regarding the policy. 3. Review of the Medical Director Agreement, signed and dated [DATE], revealed the following in Section III. Responsibilities and Functions of the Medical Director: ? Subsection 1: " Be responsible for the medical direction and overall coordination of medical care in the facility. " ? Subsection 3: " Be responsible for evaluating and taking steps to correct situations of possible inadequate medical care that the Medical Director identifies or receives a report of. " ? Subsection 12: " Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care ... " ? Subsection 14: " Advise the Facilities Administrator as to the adequacy of the facilities resident care services ... and participate in any review care by the Facility. " These responsibilities assigned to the Medical Director were not carried out. 4. Review of the facility ' s " Advanced Medical Directives " policy and procedure, provided to the survey team for review on [DATE] by the NHA, (dated with an effective date of [DATE]) revealed the following relevant information: ? " The overview of the policy continued to indicate the facility strived to comply with all valid Advance Medical Directives (per the State regulations) including living wills, durable power of attorney for health care ( " DPOA " ), including the provisions for refusal or withdrawal of nutrition and hydration. These facilities shall accept both resuscitate and DNR orders signed by Physicians. " ? " The overview continued to indicate the In-service training is provided to staff on resident/patients ' rights including information about Advance Medical Directives, DNR orders and the resident/patient ' s right to participate in medical decision making. The facility shall provide for both individual and group education for staff and the community on issues concerning Advance Medical Directives. " Review of the " Code Status Orders & Response " policy and procedure, which was provided to the survey team for review on [DATE] by the NHA, revealed it was dated with an effective date of [DATE] and revised on [DATE] and [DATE] policy statement, it revealed the following relevant information: ? " Advanced Directives will be honored during the code process. " ? " The facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. " ? " DNR ORDER - means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. " ? " Supportive comfort & care for the resident/patient & emotional support for the resident/patient shall continue. " ? " Federal & State-specific regulations will be adhered to. " ? " Each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. " ? " Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines " . This statement conflicted with the statement to provide (BLS), an American Heart Association and Certificate of competency for Health Care Professionals. The Medical Director did not consult with the facility administration for clarification 5. Record review on [DATE] at approximately 10:30 a.m., related to resident #2 revealed the following: Resident #2 was initially admitted to the facility on [DATE], from an acute care hospital, for short term rehabilitation and therapy, but had three additional hospitalization s since admission, [DATE], [DATE] and [DATE]. After resident #2 ' s last readmission from the hospital to the facility, on [DATE], she ultimately expired at the facility on [DATE]. Per the physician's order [REDACTED]. Review of the Hospital History and Physical sheet, dated [DATE], the [DIAGNOSES REDACTED].#2 was not, at any time, receiving Hospice services since the time of her first admission to the facility on [DATE] through the date of her expiration on [DATE]. 6. An interview with resident #2 ' s family member, who was the Health Care Surrogate, on [DATE] at 9:30 a.m. revealed she was notified that resident #2 was admitted to the hospital on approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, complications due to multiple areas [MEDICAL CONDITION] and subsequently " died " at the hospital but, was revived with Cardiopulmonary Resuscitation (CPR). She revealed she visited with her mother while at the hospital and then her mother was ultimately readmitted to the facility ' s care on [DATE]. Resident #2 ' s daughter, the Health Care Surrogate, revealed resident #2, upon admission on [DATE], was asked about her Advanced Directives, specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2 ' s daughter continued to say resident #2 expressed that she wanted her daughter, the Health Care Surrogate, to make that decision for her. Resident #2 ' s Health Care Surrogate indicated she made it clear she wanted resident #2 to be on Full Code status, which was the status that the resident had upon initial facility admission on [DATE] and throughout the recent hospitalization s. The daughter stated she completed her visit with her mother and then left the state to return home on [DATE]. Resident #2 ' s daughter revealed, on [DATE], that she was informed by the facility that her mother expired and was told her mother " was a DNR " by Nurse A, a Licensed Practical Nurse. Resident #2 ' s Health Care Surrogate then revealed she called and complained to the Administrator that staff did not try to revive her mother and was told by a staff member that they " believed resident #2 was a DNR status " . 7. Review of resident #2 ' s demographic face sheet, dated [DATE], indicated her code status to be " Full Resuscitate " . Also, review of the resident ' s medical record, including the Advanced Directives section, did not include a " Yellow " DNR order. Review of the physician's order [REDACTED]. Review of resident #2 ' s admission assessment dated [DATE] and care plans dated [DATE] (after resident expired), all failed to indicate the resident ' s Code Status and advanced directives wishes. Review of resident #2 ' s progress notes, which are multiple discipline electronic notes, that include Nursing and Social Service entries revealed the following: - Written by LPN [DATE] at 3:11 p.m. Poor appetite, difficulty swallowing, speech to evaluate. Has family and is now out of town. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2 ' s condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 8. Interviews with staff who responded to resident #2, on [DATE] at 3:30 a.m. are as follows: 1. An interview with Employee A was conducted via telephone, on [DATE] at 12:34 p.m. She stated she was a Licensed Practical Nurse and was the first responding nurse to resident #2 on [DATE] at approximately 3:30 a.m. She stated she was asked by Employee D to come to resident #2 ' s room, as he and Employee C found her to be unresponsive. Employee A indicated she finished what she was doing, locked her medication cart, and was the first nurse to respond to resident #2. She asked Employee C and D to leave the room and proceeded to attempt to find a pulse on resident #2. She explained the resident had no pulse, then put her fingers to the residents ' mouth, and " knew " she had already expired. She did not Begin CPR. She further revealed the resident felt really cold and that she had " passed away. Employee A then stated she called out for another nurse, Employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to Employee B that resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told Employee B that she " believed resident is a DNR " ; even though there was no DNR bracelet and " believed " the resident was also receiving Hospice services. Employee A did not know if Employee B followed up with finding out if resident #2 was indeed a " Full Code " or " DNR " . Employee A was asked if she was aware of the meaning of a " Yellow " Bracelet/band. Employee A stated that if a resident had a " yellow " bracelet /band on their arm, that it meant the resident was " DNR " status. Employee A further revealed that resident #2 did not have a " yellow " bracelet/band on her arm. Employee A stated that if a resident has a " yellow " bracelet/band on their arm, that it means the resident is " DNR " status. Employee A further stated that Resident #2 had just returned to the facility from the hospital and that she " believed " the resident had not yet been outfitted with a " yellow " bracelet because " sometimes the facility staff takes several days to put them on " the residents with DNR orders. Employee A further indicated that she and Employee B were the only responding nurses and that Employee E was the nurse assigned to resident #2, and that she was on lunch break when resident #2 expired. Employee A also stated that she told Employee E (the agency Licensed Practical Nurse, assigned to resident #2) that resident #2 had been found not responsive and had expired. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician ' s answering service, and the daughter (Health Care Surrogate) and then went back to her normal assignment. Employee A was asked if she looked in the chart or electronic record to verify if resident #2 was a " Full Code " or " DNR " . She said that she did not initially, but then saw in the chart, while documenting, that the resident was a " Full Code " . Employee A was asked where, specifically, she found that resident #2 was a " DNR " . She revealed the ,[DATE] physician's order [REDACTED]. However, review of the ,[DATE] physician's order [REDACTED].#2 was " DNR " . It indicated Resident #2 was " Full Resuscitate " status. Employee A stated she was called back to the facility, from home, after her night shift on [DATE], at around 10:00 a.m., and was asked by administration why neither she, nor Employee B ever performed CPR on Resident #2 on [DATE], after she was found unresponsive. She indicated it was her understanding that resident #2 was a " DNR " status and was receiving Hospice services. Employee A confirmed, after she was shown Resident #2 was a " Full Code " , that she had not honored the residents Advanced Directives of Full Resuscitation status by not providing CPR to the resident when she was found unresponsive on [DATE]. 2. On [DATE] at 1:50 p.m. and 3:00 p.m. and, again, on [DATE] at 1:00 p.m. and, again, at 3:00 p.m., Employee B, the second staff LPN that worked on [DATE] night shift, was called and unable to be contacted. Employee B could not be interviewed. However, during an interview with the Nursing Home Administrator, on [DATE] at approximately 3:15 p.m., she provided a statement written by Employee B which was dated [DATE]. The statement read, as written, " My name is (Employee B) and I was the nurse working the north wing on [DATE] for the (11:00 p.m. - 7:00 a.m.) shift. The phone rang and it was the South wing nurse (Employee A), who stated to come to the South wing. When I (Employee B) came over, I saw (Employee A) sitting at the nursing station typing on the computer. She stated that one of my patients " just died " . I (Employee B) asked her, " What did you do " ? She replied (resident #2) was a DNR and a Hospice patient. She continued typing and stated ' I (employee A) am charting about her I already called her Daughter and the Funeral Home, go and see her ' . I went to the room with a CNA behind me. I (Employee B) asked ' when did resident #2 pass away ' , and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said " I already cleaned her up " . Another CNA came in the room from the North Wing and the resident ' s mouth was opened. She positioned her mouth to keep it closed. I (Employee B) observed the resident lying in bed with no sign of life " . Review of the employee files and multiple interviews with the Nursing Home Administrator and Director of Nursing, failed to verify CPR certifications for employees, Neither of the two nurses who responded to the emergency were certified in CPR. 9. An interview with the Administrator and Risk Manager, on [DATE] at 11:11 a.m., revealed resident #2 had been in and out of the Hospital since admission on [DATE] and they had only seen the resident in passing and were not aware of her medical status in depth. The Risk Manager revealed the resident was not interviewable upon last admission on [DATE] and had been declining. The administrator and Risk Manager were asked how they became aware that resident #2 was not provided with CPR when she was found unresponsive on [DATE]. They both indicated during stand-up (ADHOC) meeting on [DATE] at approximately 8:30 a.m., resident #2 ' s chart was brought to their attention. They both stated that it was then discovered, through review of the notes and advanced directives, that the resident was a " Full Code " status and was not given CPR when found unresponsive. The Administrator and Risk Manager both immediately called in all parties involved during the ,[DATE] shift [DATE] - [DATE], which included employee A, B, C, D, E and F. It was indicated from the Risk Manager and Administrator that employees A, B, C, D, E and F, after the interviews, were all suspended until the investigation was concluded. The administrator revealed she and her team immediately started their investigation and called resident #2 ' s Primary Physician, the Medical Director, Law Enforcement, Department of Children and Families and Agency for Health Care Administration reporting hotline. 10. An interview with resident #2 ' s Primary Care Physician, on [DATE] at 10:11 a.m., revealed he was aware that Resident #2 had multiple hospitalization s since her initial admitted on [DATE] and that the resident had shortness of breath and with spreading [MEDICAL CONDITION] that had metastasized. The Primary Care Physician continued to state he was made aware that resident #2 had expired on [DATE] on that dated but, was not aware of the details. The Primary Care Physician stated he was not surprised of the death of resident #2, as she was " declining quickly " . He further revealed he was notified later in the day of [DATE] or possibly the next day, that resident #2 expired and that her advanced directives related to her code status were not followed. He further revealed he was told by the administrator that resident #2 expired and the responding nurses did not provide CPR, as per the resident ' s/Health Care Surrogate ' s wishes. Resident #2 ' s Primary Care Physician did not, at the time of expiration, know resident #2 ' s code status. He did remember speaking to the resident a couple of times and did not remember the outcome of her wishes. Resident #2 ' s Primary Care Physician did confirm he signed all of resident #2 ' s orders, including the physician's order [REDACTED]. He further indicated that during a " Full Code " , all staff employees are to do whatever they can do to provide CPR and try to revive the resident until 911 arrives. He also confirmed that if a resident ' s wishes were for DNR states, the facility will honor those wishes when they were found unresponsive, document and notify the Primary Care Physician, whatever the outcome. It was determined through record review, policy review, and staff interviews that employee A failed to clarify Resident #2 ' s code status when she was found unresponsive. Employee A assumed Resident #2 had a DNR in place and thought that since resident #2 was newly readmitted from the hospital, she had not received the " yellow " bracelet band that indicated a resident had a DNR order. It was further determined that the second responding nurse, Employee B, failed to follow through and re-check Resident #2 ' s code status when it was confirmed she was unresponsive. It was determined this nurse also just took the inaccurate information from Employee A that Resident #2 was a DNR. It was determined that both nurses (Employee A and B) disregarded checking Resident #2 ' s medical record for clarification of Advanced Directives related to code status orders and wishes. 10. After the death of Resident #2 on [DATE], the Medical Director had direct knowledge of the facility policy which did not require facility staff to be certified in Cardiopulmonary Resuscitation (CPR). He confirmed on [DATE] at 11:21 a.m. that he was aware of this policy prior to the death of resident #2 on [DATE]. He stated to the surveyor that he intended to provide suggestions for resolution to the facility administration today, [DATE]. 11. It was determined that the Medical Director failed to discuss with the facility his concerns with how the processes in the Policies and Procedures, regarding Advanced Directives and Cardiopulmonary Resuscitation would be followed by facility personnel lacking skilled CPR certification training. He further failed to guide the facility in identifying, evaluating, and addressing/resolving medical and clinical concerns and issues that affected medical care related to provisions of services of CPR by licensed health care practitioners in the facility, after reviewing the details of the death of resident #2, on [DATE]. 12. At the conclusion of the investigation on [DATE] at 5:05 p.m., the NHA failed to provide the survey team a list of current CPR/BLS certified staff. At the time of the exit there were one hundred and eleven of one hundred and sixty-nine residents with Full Resuscitation status. The survey team was unable to determine if qualified staff was assigned to each shift. The NHA was informed of Immediate Jeopardy on [DATE] at 3:20 p.m. The Immediate Jeopardy was determined to be ongoing at the time of the survey team's exit.

Based on resident record review, staff interviews, family interview, and review of policies and procedures related to Code Status Orders and Response Policy, dated [DATE], and to Cardiopulmonary Resuscitation (CPR) policy (not dated), it was revealed that the facility failed to follow the documented wishes for one (#2) of three sampled residents, with Full Resuscitation requests. It was determined that two nurses failed to verify resident #2 ' s physician's orders [REDACTED]. She expired as a result. It was also determined that the facility was not aware of which nursing staff were CPR qualified and able to provide appropriate Basic Life Safety support as per the American Heart Association and/or American Red Cross guidelines, to one hundred and eleven of one hundred and sixty-nine total residents, who were all determined to be " Full Code " status on the physician ' s Plan of Care. The facility, as of [DATE], could not provide documentation that anyone in the facility had current CPR certification, as per the American Heart Association or the American Red Cross, to provide the documented physician ' s care plan task of providing emergency measures to the remaining 111 of 169 residents care planned for CPR. These findings resulted in the identification of immediate jeopardy which was determined to be on-going as of [DATE]. Findings include: 1. Record review of resident #2, on [DATE], revealed the following: Resident #2 was initially admitted to the facility on [DATE] from the hospital, for short term rehabilitation and therapy. She had three additional hospitalization s since the admission, [DATE], [DATE] and [DATE]. Resident #2 ' s last readmission, from the hospital to the facility was [DATE]. She expired at the facility on [DATE] after not receiving CPR. Review of the physician's order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" Full Resuscitate " status. Review of resident #2 ' s demographic face sheet, considered a part of the plan of care, dated [DATE], indicated she was " Full Resuscitate " status. Also, review of the resident ' s medical record, including the Advanced Directives section, did not include a " Yellow " DNR order. 2. Further review of the resident ' s chart indicated she signed a " Consent to Treatment " form on [DATE]. She also signed a " Designation of Health Care Surrogate " form, dated on [DATE], that gave her daughter permission to make health care decisions. An interview with resident #2 ' s daughter, the Health Care Surrogate, on [DATE] at 9:30 a.m., revealed she made it clear to the facility that she wanted resident #2 to be on Full Code status. This was the choice she made upon initial facility admission and throughout the recent hospitalization s. The daughter stated she completed her visit with her mother and then left the state of Florida to return home on [DATE]. Resident #2 ' s daughter revealed that on [DATE] she was informed by the facility that her mother expired. She was told her mother " was a DNR " , by Nurse A, a Licensed Practical Nurse. Resident #2 ' s Health Care Surrogate then revealed she called and complained to the Administrator that staff did not try to revive her mother and was told by a staff member that " they believed resident #2 was a DNR status " . 3. Review of the admission Social Service Progress notes, dated [DATE] at 11:00 a.m., revealed resident #2 had [MEDICAL CONDITION] and [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) infection and that she was alert and oriented times three and needed minimum assistance with Activities of Daily Living (ADLs). The note continued to indicate, although " named family member " , (not Daughter) is resident #2 ' s emergency contact on the computer; she wanted her daughter to be her Health Care Surrogate. The Social Service Progress note dated [DATE] further revealed the facility staff discussed Advanced Directives with resident #2, since she had none in the chart, and explained the options. The note revealed the resident indicated she was going to think about it and as of this date she was in favor of DNR, but then stated her daughter could decide. It was explained to her that she would have to sign paperwork for that. The progress note further indicated the writer would follow up with her, since she was uncertain at this time. Resident #2 ' s Daughter was designated as Health Care Surrogate on [DATE]. The medical record for resident #2 was not clear as to when the decision was made to remain a Full Code status, but this was the daughter ' s (Health Care Surrogate ' s) documented wishes as of [DATE], when she took over making health care decisions. 4. Review of resident #2 ' s progress notes, which are multiple discipline electronic notes that include Nursing and Social Service revealed the following entries: - Written by RM [DATE] at 8:04 p.m. Resident readmitted from the Hospital with daughter. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2 ' s condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 5. During an interview with the Administrator on [DATE] at approximately 10:30 a.m., when asked what CPR curriculum was provided to qualify staff to perform CPR, she explained that they have none, as the facility does not require CPR certifications when hiring. The administrator further revealed that Licensed Nurses are qualified with CPR when licensed as a nurse, and CNA ' s are qualified in CPR when they are certified as a CNA. The administrator stated she could not provide any documentation of any employees in the building with qualified skills resulting in CPR certifications/cards, by current American Heart Association guidelines. The administrator confirmed that she does not know if staff that had CPR training, or had ever been updated with the current American Heart Association guidelines, which changed in 2010. The administrator was then asked if anyone in the facility provided training and CPR classes to assure the staff were qualified to perform this skill. She again explained that nobody in the facility provided training, as the facility did not require staff to be CPR certified. The administrator and Corporate Vice President indicated they have a staff development person, who was not available, that was responsible to ensure staff had CPR updates. The Administrator, Corporate Nursing Home Administrator, and Corporate Vice President could not provide any documentation or evidence this was done prior to the death of resident #2. The Administrator, at this time, could not state or indicate how all current employees could ensure that they were current with American Heart Association standards, updated 2010. The Administrator continued to say, " We are only required to go over what our policy and procedures are and they, nursing staff are in compliance with requirements every time they renew their license " . The administrator was again asked on [DATE] at approximately 2:00 p.m. who, in the facility, was qualified to perform the skill of CPR as residents needed and expected per their care plan. She replied, " once again, we do not require staff to have CPR certifications/cards and that this is part of our standards of practice and scope of their license " . Review of the Board of Nursing guidelines on [DATE] revealed that C.P.R. was not listed as a mandatory course needed to renew a nursing license. 6. Interview with employee A (a Licensed Practical Nurse), via telephone on [DATE] at 12:34 p.m., revealed she was the first responding nurse to resident #2 ' s unconscious state. She stated that on [DATE] at approximately 3:30 a.m. she was asked by employee D to come to resident #2 ' s room, as he and employee C found her to be unresponsive. Employee A indicated she finished what she was doing, locked her medication cart, and was the first nurse to respond to resident #2. She asked employees C and D to leave the room and proceeded to attempt to find a pulse on resident #2. She explained to the surveyor that the resident had no pulse and she then put her fingers to her mouth and " knew she had already expired " . She further revealed the resident felt really cold and that she had " passed away " . Employee A then stated she called out for another nurse, employee B, also a Licensed Practical Nurse, for assistance. Employee A explained to employee B that resident #2 was found unresponsive and when she checked for the pulse, she found none. Employee A said she told employee B that she " believed resident #2 was a " DNR " ; even though there was no " DNR " bracelet and " believed the resident was also on Hospice services " . Employee A did not know if employee B followed up with finding out if resident #2 was indeed a " Full Code " or " DNR " . Employee A was asked, by the surveyor, what does a " Yellow " Bracelet/band mean? Employee A further revealed that resident #2 did not have a " yellow " bracelet/band on her arm. Employee A stated that if a resident has a " yellow " bracelet/band on their arm, that it meant the resident was a " DNR " status. Employee A continued to say that resident #2 had just returned to the facility from the hospital. She didn ' t think the resident was outfitted with a " yellow " bracelet as she " believed " she should have, and that sometimes the facility staff take several days to put them on " . Employee A further indicated that she and employee B were the only responding nurses and that employee E was the nurse assigned to resident #2. She, employee E, was on lunch break when resident #2 expired. Employee A also stated that she told employee E, an agency Licensed Practical Nurse. Employee A then stated that she documented the incident in the computer notes, called 911, the Risk Manager, Director of Nursing, Physician ' s answering service, and the daughter (Health Care Surrogate), and then went back to her normal assignment. Employee A was asked if she looked in the chart or electronic record to verify if resident #2 planned for and expected either " Full Code " or " DNR " status and she said that she did not initially, but then saw in the chart, while documenting, that the resident was a " Full Code " . Employee A was asked where specifically she found that resident #2 was a " DNR " . She revealed the ,[DATE] physician's order [REDACTED]. A record review of the ,[DATE] physician's order [REDACTED]. It indicated resident #2 was " Full Resuscitate " . Employee A further indicated she was called back to the facility, from home after her night shift on [DATE], at around 10:00 a.m., and was asked by administration why neither she, nor employee B ever performed CPR on resident #2 on [DATE], when she was found unresponsive. She indicated it was her understanding that resident #2 was a " DNR " status and was on Hospice. Employee A confirmed, after she was shown resident #2 was a " Full Code " , she did not honor her wishes, that she did not follow the care plan, and did not perform CPR. 7. On [DATE] at 1:50 p.m. and 3:00 p.m. and again on [DATE] at 1:00 p.m. and again at 3:00 p.m., employee B was called and unable to be contacted and therefore could not be interviewed. However, during an interview with the Nursing Home Administrator (NHA) , on [DATE] at approximately 3:15 p.m., she provided a statement written by employee B which was dated [DATE]. The statement read, as written, " my name is (employee B) and I was the nurse working the north wing on [DATE] for the ,[DATE] shift. The phone rang and it was the South wing nurse, (employee A), who stated to come to the South wing. When I (employee B) came over, I saw (employee A) sitting at the nursing station typing on the computer she stated that one of my patients " just died " . I (employee B) asked her " what did you do " ? She replied resident #2 was a DNR and a Hospice patient. She continued typing and stated I (employee A) am charting about her I already called her Daughter and the Funeral Home, go and see her. I went to the room and with a CNA behind me. I (employee B) asked when did (resident #2) pass away and she did not answer me. She was touching her feet and said she was already cold. Her CNA for the night was in the hallway in front of her room and said " I already cleaned her up " . Another CNA came in the room from the North wing and resident ' s mouth was opened, she positioned her mouth to keep it closed. I (employee B) observed the resident lying in bed with no sign of life " . No further documentation was noted by employee B. 8. Review of the " Code Status Orders & Response " policy and procedure, which was provided to the survey team for review on [DATE] by the Administrator, revealed it was dated with an effective date of [DATE] and revised on [DATE] and [DATE] policy statement. It revealed the following relevant information: Policy statement revealed the facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. - The procedure for this policy, read as follows: 4. Response: a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, & pulse c. Check for the YELLOW DNR bracelet - if none is found the Medical Record will be checked for physician's order [REDACTED]. d. If the resident is a full code the respondent to the call for help will immediately overhead page a " code blue " & indicate the room number, or the location of the resident/patient & deliver the Medical Record & Emergency Cart & AED if applicable to the location of the Code Blue. e. If Code Status is " DNR " - DO NOT initiate CPR (Notify Physician, Supervisor and Family) f. If Code Status includes Full Code, BEGIN Cardio [MEDICAL CONDITION] Resuscitation g. If Code Status is not designated, the resident is a FULL CODE & CPR will be initiated h. A scribe will be designated to record activity related to the Code Blue using the " Code Blue worksheet " provided on the Emergency Cart i. The CPR will continue until: Relieved by EMS, relieved by another staff member who will take over CPR, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. - EMS (911) - Physician - Family/Legal Representative 9. On [DATE] at 3:20 p.m. it was determined that the facility administration failed to monitor that nurses were providing care and services in accordance with the residents ' plan of care related to advance directives and administration of CPR. The Nursing Home Administrator was informed of findings of ongoing Immediate Jeopardy at this time. At 5:05 p.m. the survey team exited the building and the status of Immediate Jeopardy remained ongoing.

Based on resident record review, review of the Administrator ' s Position Description, Policy/Procedure review related to Advanced Directives, Code Status Orders and Response (both dated [DATE]) and Cardiopulmonary Resuscitation (not dated), and interview with residents, family and staff members, it was determined that the administration failed to provide resource management to meet the needs for one (#2) of three residents with Advanced Directives related to " Full Code " , according to her Advanced Directives. Administration did not ensure the direct functions and operations of the facility were in accordance with current facility policies for Advanced Directives, failed to ensure systems were in place for implementation regarding residents who with Full Code status, and failed to ensure that residents with Full Code status, per their Advanced Directives, received skilled Cardiopulmonary Resuscitation (CPR). Resident #2 and her representative had requested to receive Cardio-Pulmonary Resuscitation (CPR) services in the event that she was found absent of pulse and respirations. The facility failed to provide Resident #2 with necessary life sustaining treatments of CPR/emergency medical care in accordance with her expressed desires to receive such services. Facility staff did not properly interpret and implement the systems to confirm required documentation of a valid Resuscitation Order, in accordance with their procedures. These findings resulted in the identification of immediate jeopardy and were determined to be on-going as of [DATE] at 3:20 p.m., after the completion of the survey complaint investigation. Findings include: Record review on [DATE] at approximately 10:30 a.m., related to resident #2 revealed the following: 1. Per the medical record , resident #2 was initially admitted to the facility on [DATE] from an acute care hospital for short term rehabilitation and therapy, but had three additional hospitalization s since admission, [DATE], [DATE] and [DATE]. After resident #2 ' s last readmission from the hospital to the facility, on [DATE], she expired at the facility on [DATE]. Per the physician's order [REDACTED]. Review of the hospital History and Physical sheet, dated [DATE], the [DIAGNOSES REDACTED].#2 was not, at any time, receiving Hospice services since the time of her first admission to the facility on [DATE] through the date of her expiration on [DATE]. Further review of the resident ' s chart indicated she signed a " Consent to Treatment " form on [DATE]. Also, review of the chart indicated resident #2 signed a " Designation of Health Care Surrogate " form dated on [DATE] and gave her daughter permission to make health care decisions. 2. An interview with resident #2 ' s family member, the Health Care Surrogate, on [DATE] at 9:30 a.m., revealed she was notified that resident #2 was admitted to the hospital on approximately [DATE], due to shortness of breath, clogging/hardening of her arteries, complications due to multiple areas [MEDICAL CONDITION] and subsequently " died " at the hospital but, was revived with Cardiopulmonary Resuscitation (CPR). She revealed she visited with her mother while at the hospital and then her mother was ultimately readmitted to the facilities care on [DATE]. Resident #2 ' s daughter, the Health Care Surrogate, revealed resident #2, upon admission on [DATE], was asked about her Advanced Directives, specifically if she wanted to have a Do Not Resuscitate (DNR) or Full Code status. Resident #2 ' s daughter continued to say resident #2 expressed that she wanted her daughter, the Health Care Surrogate, to make that decision for her. Resident #2 ' s Health Care Surrogate indicated she made it clear she wanted resident #2 to be on Full Code status, which was the status that the resident had upon initial facility admission on [DATE] and throughout the recent hospitalization s. The daughter stated she completed her visit with her mother and then left the state to return home on [DATE]. Resident #2 ' s daughter revealed, on [DATE], that she was informed by the facility that her mother expired and was told her mother " was a DNR " by Nurse A, a Licensed Practical Nurse. Resident #2 ' s Health Care Surrogate then revealed she called and complained to the Administrator that staff did not try to revive her mother and was told by a staff member that they " believed (resident #2) was a DNR status " . 3. After review of the medical record for resident #2, it could not be determined as to when the decision was made for the resident to remain Full Code status. This was the daughter ' s (Health Care Surrogate ' s) wishes as of [DATE], when she took over making health care decisions. Review of resident #2 ' s demographic face sheet, dated [DATE], indicated her code status to be " Full Resuscitate " . Also, review of the resident ' s medical record, including the Advanced Directives section, did not include a " Yellow " DNR order. Review of the physician's order [REDACTED]. Review of resident #2 ' s progress notes, the multiple discipline electronic notes, that included Nursing and Social Service, revealed the following entries: - Written by LPN [DATE] at 3:11 p.m. Poor appetite, difficulty swallowing, speech to evaluate. Has family and is now out of town. - Written by LPN [DATE] at 11:47 p.m. Resident is alert and oriented with much confusion able to make wants known. - Written by LPN A [DATE] at 3:30 a.m. During Certified Nursing Assistant (CNA) rounds, employee C observed the resident not breathing. The writer observed the resident with no vitals, not breathing and she has expired at this time. - Written by LPN A [DATE] at 4:08 a.m. Placed call out to Physician to get an order to release body. Answer service to call back soon. - Written by LPN A [DATE] at 4:20 a.m. Placed call to Risk Manager and to Director of Nursing to notify of the change of condition of the resident. Placed call to the Health Care Surrogate, daughter and notified her of the change in resident #2 ' s condition and wanted funeral home to pick her up. - Written by LPN A [DATE] 4:34 a.m. Received a call back from Primary Care Physician and notified him of change of condition and he gave order to release body. 4. An interview with the Administrator and Risk Manager, on [DATE] at 11:11 a.m., revealed the facility had an incident on [DATE] in which nursing staff did not provide Cardiopulmonary Resuscitation (CPR) to resident #2, who was found unresponsive and without vital signs. Per [DATE] Physicians Orders, resident #2 ' s Advanced Directives, she was to be full code status. According to the Administrator and Risk Manager, at approximately 3:30 a.m. on [DATE], the residents assigned Certified Nursing Assistant (CNA) (Employee C) found resident #2 in bed, unresponsive. She immediately called another CNA (Empolyee D) for assistance. It was further stated that after Employee D confirmed Resident #2 was unresponsive, she went out into the hall to locate a nurse. At that time, Employee A, a Licensed Practical Nurse (LPN), came to the room to check the resident for a pulse or respirations. She concluded that Resident #2 had expired. The Administrator and Risk Manager further stated that Employee A then asked for assistance from another nurse, Employee B, a Licensed Practical Nurse. The Risk Manager and Administrator stated that Employee B asked Employee A of Resident #2 ' s code status per her advanced directives. The Administrator revealed Employee A told Employee B that she " thinks " that Resident #2 is a " DNR " and is receiving Hospice services. The Administrator and Risk Manager both indicated that Employee B did not verify Employee A ' s response to the residents code status in the residents chart. She further stated that neither Employee A nor Employee B followed the facilities policy of verified Residents #2 ' s code status in the medical chart. The Administrator further revealed that as a result, Resident #2 expired. The Administrator and Risk Manager were asked when were they made aware of the fact that Resident #2 was not provided CPR. They both indicated that during the stand-up (ADHOC) meeting on [DATE], at approximately 8:30 a.m., Resident #2 ' s chart was brought in for review. They both indicated it was then discovered, through review of the notes and Advanced Directives, that the resident was a " Full Code " status and was not given CPR when found unresponsive. The administrator and Risk Manager confirmed that all employees involved were called in immediately. It was confirmed from the Risk Manager and the administrator, after the completion of the interviews, all the involved staff were suspended until the investigation was concluded. The Administrator revealed that as a result of their investigation on [DATE] involving the expiration of Resident #2, Employees A and B, both LPN ' s, were terminated and were reported to the Board of Nursing and Department of Health. 5. During an interview with the Nursing Home Administrator, on [DATE] at 10:30 a.m., she was asked what CPR curriculum was provided to staff. She stated, " We do not require CPR certifications at this facility " . She further stated, " When staff are licensed and certified as CNA ' s, they are current with those qualifications " . The Nursing Home Administrator was then asked who provides CPR training and CPR classes for staff. She stated, " Nobody in house. This is done outside of the facility " . The Administrator and Corporate Vice President both revealed the staff development person, who was not available for interview at the facility during all three days of survey, would be responsible for ensuring that staff is trained to the American Heart Association standards. The Nursing Home Administrator continued to say, " We rely on DOH (Department of Health) and American Heart Association to do the training when these people get their license and certifications " . The Nursing Home Administrator could not provide any documentation or give indication of how staff is updated to ensure they are knowledgeable to the current American Heart Association standards. The administrator further stated, " We do not train with CPR, as we do not require our employees to be CPR certified upon hire " , and " This is part of their standards of practice and scope of their license " . The Nursing Home Administrator confirmed, at this time, neither she nor any of her staff are aware of who has CPR cards and are current with American Heart Association standards. The Nursing Home Administrator further confirmed that neither she nor staff development offer any training related to CPR. 6. During an interview with the nursing home administrator, on [DATE] at 3:45 p.m., she was asked by the surveyor if she could provide evidence to ensure staff knew how to give CPR, as per current guidelines. She revealed they conducted interviews with staff on [DATE] and [DATE], but refused to share that information with the survey team as it was protected by their Quality Assurance. She then provided a question sheet that was answered by staff on [DATE] during the 7: 00a.m. - 3:00p.m. shift and the 3:00p.m. -11:00 p.m. shift. The questionnaire titled, " Conversation with the nursing staff concerning state surveyors " . This questionnaire was asked by staff members to staff member and included the following questions: - How many breaths to compressions are performed during the CPR process? - Which is initiated first? The Nursing Home Administrator was then asked for a list of CPR certified staff with current BLS/CPR cards as per the American Heart Association or American Red Cross, the names of the staff employees who provided the questionnaires to the facility direct care staff, and if the staff employees who conducted the questionnaires had current CPR instructor cards, as per the American Heart Association or American Red Cross. The Nursing Home Administrator revealed she did not have knowledge of any staff in the facility that had current CPR certifications or CPR training cards and could not produce any documentation to support that the questions answered by staff were correct and per the American Heart Association and American Red Cross guidelines. 7. Review of the facility ' s Nursing Home Administrator ' s job description (not dated) revealed, she/he will report to the Regional Vice President. The Summary of Position indicated that 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 include, but not limited to: - 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 and guidelines are available and followed. - Ensure 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. Supervisory Responsibilities include, but not limited to: - Supervises staff whether directly or indirectly in accordance with company policies and procedures. Responsible for the training of employees. Abilities to include, but not limited to: - 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. Of the same policy reference #6, the Nursing Home Administrator also did not have knowledge and failed to ensure her nursing staff had adequate and current skills to provide CPR and failed to have knowledge of who of the facility staff had current CPR certifications as per the American Heart BLS Standards. The administrator adamantly stated, " We do not require our employees to have CPR certification, upon hire " . This statement conflicted with the facility ' s stated policy of providing BLS level CPR. 8. Review of the facilities policies provided to the survey team by the Nursing Home Administrator on [DATE] revealed the following: A. Review of the facility ' s " Advanced Directives " policy and procedure, dated with an effective date of [DATE]; revised on [DATE] and [DATE], revealed the following relevant information: Policy statement Overview : The overview of the policy indicated the facility strived to comply with all valid Advance Medical Directives (per the State regulations) including living wills, durable power of attorney for health care ( " DPOA " ), including the provisions for refusal or withdrawal of nutrition and hydration. These facilities shall accept both resuscitate and DNR orders signed by Physicians. The overview continued to indicate the In-service training is provided to staff on resident/patients ' rights including information about Advance Medical Directives, DNR orders and the resident/patient ' s right to participate in medical decision making. The facility shall provide for both individual and group education for staff and the community on issues concerning Advance Medical Directives. The guidelines of this policy specify: 4. Give the resident/patient a full explanation of various treatment options available, including providing CPR treatment, at the time of admission and anytime during their stay. a. An explanation shall be provided of the benefits and potential risks of the treatment options, side effects, and outcomes of each option. This policy further read: Documentation: - Inquire as to the existence of an Advance Medical Directive at the time of admission. - Document in the resident/patient ' s medical whether or not an Advance Medical Directive has been executed by the resident/patient. - Place a copy of such Advance Medical Directive in the permanent medical record. - Place a copy of any guardianship documents in the permanent medical record. - Document in writing each offering of information to the resident/patient. B. Review of the " Code Status Orders & Response " policy and procedure, which was provided to the survey team for review on [DATE] by the Administrator revealed it was dated with an effective date of [DATE] and revised on [DATE] and [DATE] policy statement, it revealed the following relevant information: The physician's order [REDACTED]. Advanced Directives will be honored during the code process. Policy statement further revealed, the facility provides Basic Life Support (BLS)/CPR only. No Advanced Life Support services (ALS) are offered in the facility or by facility staff. Automatic External Defibrillators (AED) Units are part of the BLS program. AEDs are used in accordance with state requirements. Policy statement further read: - DNR ORDER - means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. - Supportive comfort & care for the resident/patient & emotional support for the resident/patient shall continue. - Federal & State-specific regulations will be adhered to. - Each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. The policy statement further read: " Employee CPR certification is not required by the facility; however the facility will be compliant with any state regulations/guidelines " . This statement conflicted with the statement to provide (BLS), an American Heart Association and Certificate of competency for Health Care Professionals. 9. It was determined the Nursing Home Administrator did not have knowledge and failed to thoroughly review of the scope of the job description, failed to follow policies related to " Cardiopulmonary Resuscitation " (not dated) with reference to #5, and failed to be keep records of who in her facility were CPR qualified per the American Heart Standards, maintaining current with CPR cards on file. The procedures of this policy specified: 1. The Physician &/or Social Services/Clinical team will discuss the resident/patient or authorized responsible party wishes regarding code Status as it related to the current clinical condition. This discussion will include an explanation of DNR " Do Not Resuscitate " &/or " Full Code " . 2. Obtain a written order signed by the Physician indicating the chosen Code Status. This may be a T.O. if signed off by two nurses, with MD signature at next visit. a. Code status is either - full code or DNR. 4. Response: a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, & pulse c. Check for the YELLOW DNR bracelet - if none is found the Medical Record will be checked for physician's order [REDACTED]. d. If the resident is a full code The respondent to the call for help will immediately overhead page a " code blue " & indicate the room number, or the location of the resident/patient & deliver the Medical Record & Emergency Cart & AED if applicable to the location of the Code Blue. e. If Code Status is " DNR " - DO NOT initiate CPR (Notify Physician, Supervisor and Family) f. If Code Status includes Full Code, BEGIN Cardio [MEDICAL CONDITION] Resuscitation g. If Code Status is not designated, the resident is a FULL CODE & CPR will be initiated h. A scribe will be designated to record activity related to the Code Blue using the " Code Blue worksheet " provided on the Emergency Cart i. The CPR will continue until: Relieved by EMS, relieved by another staff member who will take over CPR, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. - EMS (911) - Physician - Family/Legal Representative 5. Document actions in the medical record using the " Code Blue " worksheet as a reference. 6. Review Code status and DNR orders quarterly, PRN & with change in condition and renew by Physician ' s signature on monthly orders. C. Review of the " Cardiopulmonary Resuscitation " policy and procedure, which was provided to the survey team for review on [DATE] by the Administrator and not dated, revealed the following relevant information: 1. Persons Responsible: The following respiratory therapist/nursing personnel should respond to an emergency page: a. Staff assigned to the area where the arrest occurs, or b. Any person nearby the area should respond to offer assistance as needed. Note: After the initial response, only designated persons should be present. 2. Policy statement indicates; In the event that a resident ' s condition requires cardiopulmonary resuscitation (CPR) to be performed, the respiratory therapist/nurse will assume responsibility for: a. Provide assistance with the following procedures: 1. Establish patent airway 2. Ventilate the resident as necessary 3. Administer oxygen 4. Perform external cardiac compression 5. Aid in suctioning when needed 6. Perform pulse oximetry when needed 7. Contact 911, physician and family 8. Prepare paperwork for discharge to hospital b. Establishment of airway and ventilation: 1. Clear oral airways 2. Connect bag and mask 3. Administer oxygen c. Maintenance of follow op procedures by respiratory therapist/nurse: 1. Keep airway patent 2. Assure necessary ventilation with appropriate Fi02 3. Monitor parameters of ventilation and gas exchange a. Breath sounds b. Chest expansion c. Pulse oximetry d. Vital signs e. Resident color and overall assessment 4. Complete necessary forms and documents. 5. Ensure that the basic techniques used in CPR meet current practice according to the American Heart standards. 6. Ensure that all respiratory therapist/nurses have current CPR registration that is kept in their personnel files. Only those with current CPR registration may perform CPR. Registration is to be completed biennially. 10. Although the steps for performance of the life-saving measures were identified in the facility policy and procedure manuels, the NHA failed to assure that staff were trained appropriately and able to carry out these measures. 11. At the time of the survey exit, [DATE] at 5:05 p.m., the Nursing Home Administrator could not produce names of any current staff members certified as able to meet the facility ' s commitment to provide Basic Life Support (BLS)/CPR to one hundred and eleven residents, whose advanced directives and wishes are " Full Resuscitate " status. The NHA was aware that the status of Immediate Jeopardy remained ongoing at the time of the survey team's exit on [DATE] at 5:05 p.m.