Every finding on record at Charlotte Bay Rehab and Care Center

Based on observation, record review, review of facility's policy and procedure and staff interviews, the facility failed to ensure the safe storage of medications to prevent unauthorized use for 1 (Resident #875) of 3 residents' rooms observed. The findings included:Review of the facility policy and procedure Clinical Medication Administration (revised 12/10/25) revealed, .Residents who are deemed appropriate to self-administer and wish to keep their medication at bedside, will be provided with a locked container or drawer to house the medication when not in use.On 3/16/2026 at 9:53 a.m., observation of Resident #875's room revealed a Dulera inhaler (medication used to reduce airway inflammation) and four vials of Ipratropium-Albuterol solution (bronchodilator) nebulizer solution stored unsecured and unattended on the resident's bedside table. Resident #875 was not in the room at the time of the observation. Photographic evidence obtained.Review of Resident #875's Medication Administration Record (MAR) for March 2026 revealed she received the Dulera inhaler twice a day and the Ipratropium-Albuterol solution via nebulizer on 3/14/26. On 3/16/26 at 9:58 a.m., Licensed Practical Nurse (LPN) Staff C verified that the Dulera inhaler and the four vials of Ipratropium-Albuterol solution were not locked and were left unattended and unsecured at Resident #875's bedside. LPN Staff C said that Resident #875 always self-administered her inhaler and knew how to do it.

Based on record review, review of facility's policies and procedures, and staff interviews the facility failed to ensure Licensed Nurses had the skills set to safely care for residents with indwelling urinary catheters, including inserting the catheters, monitor residents, recognize significant changes in condition and complications from urinary catheters requiring immediate physician notification and interventions to prevent further deterioration. On 1/28/25 at approximately 5:30 a.m., Licensed Practical Nurse (LPN) Staff B changed Resident #1's urinary catheter and did not ensure free flow of urine to verify the tip of the catheter was in the appropriate location in the bladder. On 1/28/25, Unit Manager LPN Staff D did not monitor Resident #1 from 7:00 a.m., to 2:00 p.m. to ensure the urinary catheter was functioning and draining urine. On 1/28/25 at approximately 5:00 p.m., LPN Staff A received a practitioner's order to monitor Resident #1 and send him to the hospital when the urinary catheter was removed and the resident had significant bleeding and was passing blood clots from his penis. She did not monitor Resident #1 and did not transcribe the order until 1/28/25 at 10:00 p.m., five hours after receiving the order. On 1/28/25 at 10:00 p.m., Resident #1 was unresponsive and bleeding through his penis and was emergently transferred to an acute care hospital via Emergency Medical Services (EMS). Resident #1 was intubated in the emergency room and admitted to the Intensive Care Unit. The facility failure to ensure Licensed Nurses had the skill sets and were competent to provide safe care to residents with indwelling urinary catheters placed Resident #1 and other residents with urinary catheters at a likelihood of significant harm, injury or death from catheter associated complications such as trauma from improper catheter insertion, urinary tract infections, and blood infection. This failure resulted in the determination of Immediate Jeopardy. On 3/20/25 at 4:45 p.m., the Administrator was notified in the determination of Immediate Jeopardy. The findings included: Cross reference to F600, F690 and F835 Review of the Facility Assessment Tool revealed the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually per requirement. The Facility Assessment Tool noted the facility accepts residents with genitourinary system diagnoses such as neurogenic bladder (lack of bladder control due to a brain or spinal cord condition), benign prostatic hyperplasia (enlarged prostate), obstructive uropathy (blockage of urinary tract), urinary incontinence. The assessment noted services and care offered based on resident needs included intermittent or indwelling or other urinary catheter. 1. Review of the facility's incident investigations revealed on 2/4/25 at approximately 11:50 a.m., Resident #1's spouse reported to the facility that her husband was on life support at the hospital as a result of a urinary tract infection and pneumonia that he acquired during his stay at the facility due to improper care. The Administrator noted the facility recognized this statement as an allegation of neglect and started an investigation. The investigation noted that on the morning of 1/28/25 Resident #1's catheter was changed per the physician order. The resident was later noted to have no urine output, and his catheter was irrigated with blood clots observed. New orders were obtained from the Advanced Practice Registered Nurse to remove the catheter at which time further blood clots were noted by nursing staff. Additional orders were then obtained to hold aspiring and Plavix and to transfer resident out if no urine output was observed and clots continued. Nursing continued to evaluate resident with no urine output identified with continued blood clots and resident was subsequently transferred to the hospital. The facility's investigation noted, Conclusions: After a complete and thorough investigation, this allegation of neglect cannot be verified. The facility provided care to (Resident #1) in adherence with physician orders. Due to (Resident #1) health status he was subsequently sent to the hospital at which time he was admitted . Summary of all corrective actions taken: Nursing staff education has been initiated r/t (related to) neglect with an emphasis on foley catheter care upon receiving this allegation . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Diagnoses included prostatic hyperplasia (enlarged prostate) with urinary symptoms. Resident #1 was admitted with an indwelling urinary catheter (catheter inserted in the bladder to drain urine). Review of the Treatment Administration Record (TAR) for January 2025 revealed on 1/28/25 Licensed Practical Nurse (LPN) staff B changed Resident #1's urinary catheter. The clinical record lacked documentation LPN Staff B verified the catheter was properly inserted and draining urine. On 3/18/25 at 10:00 a.m., in a telephone interview LPN Staff B said she followed the physician's order to change Resident #1's catheter. On 1/28/25 at approximately 5:30 a.m., when she changed the catheter, there was no urine in the drainage bag. She said she got a small amount of urine return when she inserted the catheter and had no blood. She verified she left work on 1/28/25 at 7:00 a.m., Resident #1 had no urine in the drainage bag. She did not write a progress note for the catheter change, including the small amount of urine return. On 1/28/25 at 11:36 p.m., LPN Staff B documented in a progress note for an effective date of 1/28/25 at 10:00 p.m., she received [shift] report from the dayshift nurse to send Resident #1 to the hospital per the APRN order if Resident #1 was not able to void and clots continues. Staff B documented, clots continued, no voiding pt (patient) sent to hospital at 2200 (10:00 p.m.) for further evaluation. Family notified. On 3/19/25 at 8:30 a.m., in an interview LPN Staff B verified on 1/28/25 at 5:30 a.m., there was no urine in Resident #1's urinary catheter bag before she changed the catheter and when she left work on 1/28/25 at 7:00 a.m. When she returned to work on 1/28/25 at 7:00 p.m., LPN Staff A told her Resident #1 had no urine output since the previous evening. He only passed blood and clots when they tried to irrigate the catheter. She said Resident #1 was alert but lethargic when EMS (Emergency Medical Services) arrived. She could not remember when Resident #1 became lethargic. She verified there was no documentation she monitored Resident #1's for changes in condition, including continuous or increase bleeding, vital signs, and physician's notification Resident #1 had no urine output for more than eight hours. Review of the facility's employee list revealed LPN Staff B's date of hire was 4/9/24. The orientation for LPN Staff B did not include care of residents with indwelling urinary catheters, including verification LPN Staff B was able to safely and correctly insert an indwelling catheter in a male or female resident. On 1/28/25 at 10:59 p.m., LPN Staff A documented in a progress note dated 1/28/25 at 5:00 p.m., Resident #1's indwelling catheter was removed per the Advanced Practice Registered Nurse (APRN) order due to blood and clots, no urine output. The nurse documented, order given to monitor urine output for a couple of hours if no void and clots continue send resident to ER (emergency room ) for further evaluation. The clinical record lacked documentation Resident #1's condition was monitored, including an evaluation of the resident, amount of bleeding, vital signs or urine output. LPN Staff A did not transcribe the APRN's order until 1/28/25 at 10:02 p.m., five hours after receiving the order. The order read, Send out to ER (emergency room ) if resident does not void within a couple hours. The transcribed order did not include to monitor for bleeding and clots. On 3/18/25 at 3:00 p.m., in an interview LPN Staff A verified on 1/28/25 Resident #1's spouse told her there was no urine in the drainage bag. When she checked on the resident on 1/28/25 at approximately 4:00 p.m., the drainage bag was empty. She said no one told her the resident had no urine output all day. Review of the facility's staff roster revealed LPN Staff A's date of hire was 4/19/24. The orientation, competency and skills checklist completed on 4/30/24 did not include indwelling urinary catheters. On 3/18/25 at 1:00 p.m., in a telephone interview the APRN said on 1/28/25 at 4:15 p.m., LPN Staff C sent her a text message to let her know Resident #1 had no urine output. She told the nurse to irrigate the catheter and call her back. They told her Resident #1 passed blood clots when they tried to irrigate the catheter. She gave an order to remove and reinsert the catheter. When they removed the catheter, copious amounts of blood came out. She told them to hold the anticoagulants. She gave the order to wait an hour, call her or send the resident to the ER if the resident did not urinate or continued to pass clots. She said she never told the nurse to wait for two hours. Staff never told her Resident #1 had no urine output for more than eight hours. She would have sent the resident to the hospital immediately. On 3/18/25 at 1:30 p.m., in a telephone interview LPN Staff C said on 1/28/25 at approximately 3:30 p.m., he observed Staff A attempting to irrigate Resident #1's urinary catheter. The APRN was giving orders. He said there was no urine in the urinary drainage bag. He removed Resident #1's catheter, and a copious amount of blood and clots came out. The APRN gave an order to LPN Staff A to stop all anticoagulants (medications to prevent formation of blood clots) and send the resident to the emergency room if he kept bleeding or had no urinary output. LPN Staff C said he did not know Resident #1 had no urine output since the previous night. There was no documentation LPN Staff C, obtained vital signs, monitored Resident #1 for continuous or increased bleeding. Review of the facility's employee roster revealed LPN Staff C's date of hire was 4/3/24. LPN Staff C's orientation and competency evaluation did not include management of residents with urinary catheters, complications, and significant change in condition from a urinary catheter warranting immediate physician notification. On 3/18/25 at 2:00 p.m. in an interview LPN Staff D (Unit Manager) said she was assigned to Resident #1 on 1/28/25 from 7:00 a.m., until 2:00 p.m. She said LPN Staff B never told her Resident #1 had no urine output. She said she could not remember if she checked the resident's catheter bag for urine output that day. She left work on 1/28/25 at 2:00 p.m., and the CNA who worked with Resident #1 was supposed to empty the drainage bag around 3:00 p.m. She verified the lack of documentation verifying she monitored Resident #1 for adequate urine output, complications and significant change in condition. Review of the facility's employee roster revealed LPN Staff D's date of hire was 5/15/23. LPN Staff D's competency validation dated 5/21/24 did not include management of residents with urinary catheters, complications, and significant change in condition from a urinary catheter warranting immediate physician notification. On 3/19/25 at 5:05 p.m., in an interview RN Staff F said she had been the Staff Educator at the facility for [AGE] years and was responsible to ensure the competency of the nursing staff. She said LPN Staff B has been employed at the facility since 4/9/24 and did not have a skills competency completed to ensure she had the skills to properly insert urinary catheters and monitor the residents for complications. RN Staff F provided a list titled, Tasks that must be observed/deemed competent in performing and a list titled Daily tasks (This is not a complete list). She said the items on the list are covered on day 2 of orientation for nurses. The list did not include insertion of urinary catheters, monitoring and prompt identification of and change of condition from complications of urinary catheters. She said the facility has not been doing urinary catheter care competencies, and did not ensure the nurses were knowledgeable to insert catheters and monitor residents with urinary catheters. She said, We will now. She provided a skills checklist which she said the facility started to use on 3/18/25 to verify the nurse's competency on urinary catheters. She said the facility uses a mannequin for the competency demonstration. Review of the competency evaluation for LPN Staff B dated 3/18/25 included indwelling catheter insertion for male and female and Straight catheter (In and Out). The Staff Educator checked P for previous experience, D for Demonstrated and/or instructed by the Department head, Supervisor or Mentor/Preceptor, and RD for Return demonstration by the orientee and/or meets Performance Objective. The Staff Educator said she checked the boxes D and RD on the checklist without observing LPN Staff B inserting the urinary catheter to ensure competency. On 3/19/25 at 5:35 p.m., in an interview the Director of Nursing said Resident #1's spouse voiced multiple complaints related to his care, including the urinary catheter. She said she investigated her complaints, but she did not focus on urinary catheter output, the lack of assessment and vital signs when Resident #1 experienced acute bleeding. She said she discussed the concerns this week in an Ad Hoc (Unplanned) Quality Assurance and Performance Improvement Plan on 3/18/25. 41905 On 3/22/25 after verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 3/22/25. The Immediate actions implemented by the facility and verified by the survey team included: On 3/18/25 the facility educated their licensed nurses on completing a Change in Condition Assessment on residents. The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or psychosocial status; life threatening conditions or clinical complications including changes in urinary output including color, consistency and output; circumstances that require an alteration in treatment including acute and chronic conditions. A complete nursing evaluation must be conducted and documented in the medical record of systems. The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs. The provider shall be notified of pertinent evaluation findings. Nurses must visualize catheters for urine amount of output, color and clarity during each shift. 48 out of 50 licensed nurses were educated by 3/21/25. All remaining licensed nurses will be educated prior to working their next scheduled shift. On 3/21/25 the facility began CNA and licensed nurse competencies on obtaining vital signs. Vital signs obtained for a change in condition are to be documented in the electronic record under the weights and vitals tab, so they populate in the change in condition assessment. As of 3/21/25 40 out of 82 CNAs and 22 out of 50 nurses were educated. On 3/20/25 the facility completed audits including weekends and off hours to ensure the proper documentation of vital signs for all residents. On 3/20/25 the facility initiated the completion of audits 7 days a week and off hours to include urinary output for all residents with urinary catheters. On 3/22/25 the surveyor randomly selected 6 residents in the facility to ensure the facility was obtaining and documenting vital signs and urinary output. On 3/19/25 the daily clinical meeting form was edited to include review of the 24-hour report for change in condition; vital signs and timely transfer to a higher level if necessary; indwelling catheters for new and existing residents to ensure orders to monitor output were in place; review of the nurses' Change in condition Assessment to include current vital signs during the change, and review of the vital signs for all residents per the physician's orders. On 3/19/25 the RN assessed all residents currently at the facility for vital signs and urinary output if indicated. Any changes were communicated to the provider and family. On 3/19/25 the facility began competencies on the proper insertion of indwelling urinary catheters. 42/50 licensed nurses had completed by 3/21/25. The remaining licensed nurses would complete the competency prior to working their next scheduled shift. On 3/20/25 the facility added to the orientation agenda for newly hired licensed nurses. They will complete competency on the proper insertion of indwelling catheters with return demonstration prior to resident care. On 3/20/25 the facility began education with licensed nurses on the requirement of detailed communication during shift-to-shift report to include any changes in condition, new orders, and review any existing devices including foley catheters. 39/50 licensed nurses were educated as of 3/21/25. All remaining nurses to be re-educated prior to their next shift. The education was also added to the orientation for all newly hired nurses. On 3/20/25 the facility began educating nurses on 3/20/25 on ensuring new orders for indwelling catheters will include placement, patency/draining, irrigation, catheter securement, catheter care every shift and recording of output on the MAR. Verified 37 nurses out of 50 were educated by 3/21/25. Verified through observation and interview, nurses were educated prior to working their next shift. On 3/22/25 the surveyor verified through interview with the DON and review of audits completed, interviews with 3 CNAs, 3 nurses and review of 6 random residents records to ensure proper nursing care and services for residents with urinary catheters and those experiencing changes in condition. On 3/20/25 an ad hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy Director, Minimum Data Set nurse, Nurse, CNA.

Based on record review and staff interviews, the facility's Administration failed to utilize resources effectively to ensure nursing staff were trained, knowledgeable and competent to prevent the neglect of residents with urinary diagnoses, including insertion of urinary catheters and monitoring for complications from the urinary catheters. Resident #1 was an [AGE] year-old-male admitted to the facility with a diagnosis of prostatic hyperplasia (enlarged prostate). Resident #1 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). On 1/28/25 at 5:30 a.m., nursing staff changed Resident #1's urinary catheter and failed to ensure the catheter was properly inserted and draining. Nursing staff neglected to notify the physician until 1/28/25 at approximately 4:30 p.m. that Resident #1 had no urinary output since the catheter was inserted. On 1/28/25 at approximately 4:30 p.m., Resident #1 experienced a copious amount of bleeding and blood clots when the catheter was removed. Nursing staff neglected to take vital signs (Temperature, pulse, respiration and blood pressure) and monitor the resident with acute and significant bleeding. On 1/28/25 at 10:00 p.m., Resident #1 was emergently transferred to the hospital via Emergency Medical Services. The resident was unresponsive, and bleeding from his penis. Resident #1 had no documented urine output since 1/27/25 at 10:00 p.m. The failure of the facility Administration to ensure nursing staff had the appropriate knowledge and competencies to safely care for residents with urinary catheters created a likelihood of serious harm, rehospitalization and death of Resident #1 and other residents with urinary catheters from catheter associated urinary tract infection, blood infection, bleeding from trauma from improper catheter insertion and resulted in the determination of Immediate Jeopardy. On 3/20/25 at 4:45 p.m., the Administrator was notified of the determination of Immediate Jeopardy. The findings included: Cross Reference to F600, F690, and F726. Review of the Administrator's job description signed on 1/30/24 revealed, The primary purpose of this position is to direct the day-t0-day functions of the facility in accordance with current federal state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. The duties and responsibilities of the Administrator included, Ensure that an adequate number of appropriately trained, competent, licensed professionals and non-licensed personnel are on duty at all times to meet the needs of the residents. The Director of Nursing job description signed on 5/8/23 noted, the primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator, or the Medical Director to ensure that the highest degree of quality care is maintained at all times. The Director of Nursing duties and responsibilities included, Develop, implement, and maintain an ongoing quality assurance program for the nursing service department . Assist the Quality Assessment & Assurance committee in developing and implementing appropriate plans of action to correct identified deficiencies . Assist in developing plans of action to correct potential or identified problem areas . Nursing Care Functions . Ensure that direct nursing care be provided by LPN (Licensed Practical Nurses), CNA's (Certified Nursing Assistants), and/or a nurse aide trainee qualified to perform the procedure . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided in accordance with the resident's wishes . Develop and participate in the planning, conducting and scheduling of timely in-service training classes that provide instructions on how to do the job and ensure a well-educated nursing service department . develop, implement and maintain an effective orientation program that orients the new employee to the department, its policies and procedures, and to his/her job position and duties. Review of the Facility Assessment Tool revealed the facility accepts residents with genitourinary system diagnoses such as neurogenic bladder (lack of bladder control due to a brain or spinal cord condition), benign prostatic hyperplasia (enlarged prostate), obstructive uropathy (blockage of urinary tract), urinary incontinence. The assessment noted services and care offered based on residents needs included intermittent or indwelling or other urinary catheter. 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included benign prostatic hyperplasia. Resident #1 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). The physician's orders as of 1/22/25 included to measure and record [Foley] urine output every shift. The CNA's urine output documentation for Resident #1 differed from the urine output documented by the Licensed Nurses on the Treatment Administration Record (TAR), making it difficult to determine Resident #1's urinary output for the following days: On 1/22/25 at 10:56 p.m., the CNA documented the output was 1400 cc. The Licensed Nurse documented on the TAR the output was 250 cc. On 1/23/25 at 8:57 p.m., the CNA documented the output was 700 cc. The Licensed Nurse documented the output was 450 cc. On 1/24/25 the CNA documented at 2:59 p.m., Response not required. The Licensed Nurses documented a total of 750 cc. On 1/25/25 the CNA documentation showed a total of 1000 cc. The Licensed Nurses documented a total of 650 cc. On 1/26/25 the CNA documentation showed a total of 700 cc. The Licensed Nurses documented a total of 550 cc. On 1/27/25 there was no CNA documentation of urine output. The Licensed Nurses documented a total of 1000 cc. There was no urine output documented for the night shift of 1/27/25, the day shift of 1/28/25, or the evening shift of 1/28/25. On 3/18/25 at 9:20 a.m., in an interview Registered Nurse Staff E said the facility policy was to document intake and output on the Treatment Administration Record (TAR). He said the nurses get the output from the CNAs each shift and document the total output on the TAR. On 3/19/25 at 4:10 p.m., a joint interview was conducted with the Administrator, the Director of Nursing and the Regional Nurse Consultant to discuss Resident #1's care and emergent transfer to the hospital on 1/28/25. The Regional Nurse Consultant verified the documentation of urine output for Resident #1 was not accurate. The Director of Nursing said the best practice would be for the nurses to monitor the urinary catheter and the output and document on the TAR. She verified she did not review Resident #1's clinical record for accuracy of the documentation when he was transferred to the hospital until the concerns voiced this week related to the accuracy and lack of CNA documentation of urine output. Review of the Treatment Administration Record (TAR) for January 2025 revealed on 1/28/25 Licensed Practical Nurse (LPN) Staff B changed Resident #1's urinary catheter. The clinical record lacked documentation LPN Staff B verified the catheter was properly inserted and draining urine. There was no urine output documented for the day shift of 1/28/25, or the evening shift of 1/28/25. On 1/28/25 at 10:59 p.m., LPN Staff A documented in a progress note for an effective date of 1/28/25 at 5:00 p.m., Resident #1's indwelling catheter was removed per the Advanced Practice Registered Nurse (APRN) order due to blood and clots, no urine output. The nurse documented, order given to monitor urine output for a couple of hours if no void and clots continue send resident to ER (emergency room ) for further evaluation. LPN Staff A did not transcribe the APRN's order until 1/28/25 at 10:02 p.m., five hours after receiving the order, and after Resident #1 was transferred to the hospital. The order read, Send out to ER (emergency room ) if resident does not void within a couple hours. The order did not include to monitor for bleeding and clots. Review of the nursing progress notes revealed on 1/28/25 a 11:36 p.m., LPN Staff B documented in a progress note for an effective date of 1/28/25 at 10:00 p.m., she received report from the day shift nurse to send Resident #1 to the hospital per the Advanced Practice Registered Nurse (APRN) order if Resident #1 was not able to void and clots continued. LPN Staff B documented, Clots continued, no voiding pt (patient) sent to hospital at 2200 (10:00 p.m.) for further evaluation. Family notified. The clinical record lacked documentation Resident #1 was monitored, vital signs obtained, and amount of bleeding assessed and documented to promptly identify significant changes requiring physician notification. Review of the Emergency Medical Services (EMS) Prehospital Care Report revealed the unit was notified by dispatch on 1/28/25 at 9:51 p.m. The narrative noted Resident #1 was found lying supine (face up) in bed with a facility nurse at his side. Resident #1 was unresponsive but breathing. The facility nurse stated that earlier today Resident #1 had a Foley catheter (urinary catheter) removed and since has been having penile bleeding with blood clots and was recommended by the facility provider to call EMS if the bleeding does not improve. The nurse also stated that she's been unable to wake patient up, patient is normally awake and verbal. Last seen normal three hours ago. EMS documented that the resident was unresponsive, breathing fast with a radial pulse, skin hot and clammy, bruising noted on abdomen. The report noted under patient condition the primary complaint type was unresponsive, and other. Bleeding from penis with large blood clots. The date and time of symptom onset was 1/28/25 at 6:07 p.m. Review of the local hospital record revealed Resident #1 was initially seen in theER on [DATE] at 10:22 p.m. The ER progress note documented Resident #1 arrived at the Emergency Department from the facility for complaint of blood clots after foley removal. Upon EMS arrival, Resident #1 was unresponsive to painful stimuli, and had a temperature of 100.2. Review of the facility's incident investigations revealed on 2/4/25 at approximately 11:50 a.m., Resident #1's spouse reported to the facility that her husband was on life support at the hospital as a result of a urinary tract infection and pneumonia that he acquired during his stay at the facility due to improper care. The Administrator noted the facility recognized this statement as an allegation of neglect and started an investigation. The investigation noted that on the morning of 1/28/25 Resident #1's catheter was changed per the physician order. Resident #1 was later noted to have no urine output and his catheter was irrigated (flushed) with blood clots observed. New orders were obtained from the Advanced Practice Registered Nurse to remove the catheter at which time further blood clots were noted by nursing staff. Additional orders were then obtained to hold aspiring and Plavix and to transfer resident out if no urine output was observed and clots continued. Nursing continued to evaluate Resident #1 with no urine output identified with continued blood clots and resident was subsequently transferred to the hospital. As part of their investigation, the facility obtained statements from LPN Staff A, LPN Staff B and LPN Staff C. The facility's investigation did not include statements from the Certified Nursing Assistants who took care of Resident #1 on 1/27/25 and 1/28/25 and did not document urinary output. The facility's investigation noted, Conclusions: After a complete and thorough investigation, this allegation of neglect cannot be verified. The facility provided care to (Resident #1) in adherence with physician orders. Due to (Resident #1) health status he was subsequently sent to the hospital at which time he was admitted . Summary of all corrective actions taken: Nursing staff education has been initiated r/t (related to) neglect with an emphasis on foley catheter care upon receiving this allegation . The facility's investigation did not include the lack of monitoring of Resident #1's urinary output, LPN Staff B's lack of documentation of urine return verifying correct placement of the catheter, the resident's condition including vital signs (Temperature, pulse, respiration and blood pressure) with the acute onset of copious bleeding, the passing of blood clots, and amount of bleeding, and the change in mental status not addressed by the nursing staff. On 3/19/25 at 8:30 a.m., in an interview LPN Staff B said on 1/28/25 at 5:30 a.m., there was no urine in Resident #1's urinary catheter bag before she changed the catheter. She said when she left work on 1/28/25 at 7:00 a.m., there was no urine in the drainage bag. When she returned to work on 128/25 at 7:00 p.m., LPN Staff A told her Resident #1 had no urine output since the previous evening. He only passed blood and clots when they tried to irrigate the catheter. LPN Staff B verified the Advanced Practice Registered Nurse gave orders to monitor the resident and send him out if he did not stop bleeding on 1/28/25 at approximately 5:00 p.m., but she did not transcribe the orders until 1/28/25 at 10:00 p.m. She said she took Resident #1's vital signs twice during her shift but did not document them. She said Resident #1 was alert but lethargic when Emergency Medical Services (EMS) arrived. She could not remember when Resident #1 became lethargic. On 3/19/25 at 5:05 p.m., in an interview RN Staff F said she had been the Staff Educator at the facility for [AGE] years and was responsible to ensure the competency of the nursing staff. She said LPN Staff B had been employed at the facility since 4/9/24 and did not have a competency to ensure she had the skills to properly insert urinary catheters and monitor the residents for complications. She said the facility had not been doing urinary catheter care competencies, and did not ensure the nurse's were knowledgeable to insert catheters and monitor residents with urinary catheters. She said, We will now. She provided a skills checklist which she said the facility started to use on 3/18/25 to verify the nurses competency on urinary catheters. She said the facility uses a mannequin for the competency demonstration. Review of the competency evaluation for LPN Staff B dated 3/18/25 included indwelling catheter insertion for male and female and Straight catheter (In and Out). The Staff Educator checked P for previous experience, D for Demonstrated and/or instructed by the Department head, Supervisor or Mentor/Preceptor, and RD for Return demonstration by the orientee and/or meets Performance Objective. The Staff Educator said she checked the boxes D and RD on the checklist without observing LPN Staff B inserting the urinary catheter to ensure competency. On 3/19/25 at 5:35 p.m., in an interview the Director of Nursing said Resident #1's spouse voiced multiple complaints. In the investigation she did not focus on urinary catheter output, the lack of assessment and vital signs when Resident #1 experienced acute bleeding. She verified she discussed the concerns identified this week in an Ad Hoc (Unplanned) Quality Assurance and Performance Improvement Plan on 3/18/25. 41905 On 3/22/25 after verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 3/22/25. The Immediate actions implemented by the facility and verified by the survey team included: On 3/21/25 the [NAME] President of Operations reviewed their job descriptions with the Nursing Home Administrator (NHA) and Director of Nursing (DON). During this review it was discussed in detail that the administrator must ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. On 3/21/25 the [NAME] President of Operations and NHA re-reviewed the job description of the DON with the DON. It was discussed in detail that the purpose of her position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with regulations and standards, guidelines, and to ensure the highest degree of care is maintained at all times. As of 3/21/25, the DON will be lead investigator on all clinical investigations to ensure resident care met all accepted standards. This investigation will include a 72-hour look back in time to include additional information on the events leading to the event. As of 3/21/25 the investigations on Abuse, Neglect, Exploitation, Misappropriation, and Injury will be reviewed in detail with the medical director to ensure all areas of the investigation were completed and that the facility has identified the root cause analysis of the incident. As of 3/21/25 the NHA and DON will complete a comprehensive investigation to include a 72-hour look back on events to ensure no deprivation of care or services occurred. On 3/20/25 the NHA and DON were educated by the regional nurse consulted on utilizing an investigation checklist to ensure all elements and facts are thoroughly reviewed and completed. On 3/18/25 the facility conducted an unplanned (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy Director, Minimum Data Set nurse, Nurse, CNA. The meeting addressed the adequate monitoring of urine output for residents with foley catheters and the adequate monitoring of vital signs for residents with changes in condition. The DON rereviewed the facility assessment and identified the facility's clinical capabilities included caring for residents with catheters without nurse competency for indwelling catheters completed. On 3/19/25 the facility initiated training to the nurses for foley catheter insertion and return demonstration for 42 of 50 nurses with all nurses to be retrained prior to working their next shift. Verified the retraining and return demonstration for Staff A, LPN, Staff C, LPN, Staff B, LPN, and Staff D. On 3/20/25 the facility added to the orientation plan of all newly hired nurses to include complete competencies on the proper insertion of indwelling catheters with return demonstration prior to providing resident care. On 3/18/25 CNA education was initiated to ensure the following: any notable changes in urine output for residents with foley catheters and those residents experiencing a change in condition must be reported immediately to the nurse. 77/82 CNAs were educated by 3/21/25. All remaining CNAs are to be educated prior to working their next shift. On 3/18/25 the facility educated their licensed nurses on completing a Change in Condition Assessment on residents. The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or psychosocial status; life threatening conditions or clinical complications including changes in urinary output including color, consistency and output; circumstances that require an alteration in treatment including acute and chronic conditions. A complete nursing evaluation must be conducted and documented in the medical record of systems. The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs. The provider shall be notified of pertinent evaluation findings. Nurses must visualize catheters for urine amount of output, color and clarity during each shift. On 3/21/25 48/50 nurses were re-educated. The remaining nurses will be educated prior to working their next shift. On 3/20/25 the facility initiated audits of residents in the facility to ensure the nursing staff was recording vital signs and proper documentation of those vital signs. On 3/20/25 the facility initiated audits of residents with urinary catheters 7 days a week to ensure the measuring and documenting of the urine output each shift. On 3/19/25 the facility edited the daily clinical meeting to include the review of all residents with changes in condition to ensure vital signs and a timely transfer was completed; review of all new and existing residents with urinary catheters had monitoring and documenting of urine output amount in place; review of vital signs for all residents per physician order. On 3/19/25 the Nursing Home Administrator (NHA) and Director of Nursing (DON) were re-educated on the policy and procedure for Abuse, Neglect, and Exploitation by the Regional Clinical Nurse. The education included screening, training staff to prevent abuse, neglect and exploitation. All allegations of neglect are to be reported to the NHA or the person in charge immediately. Investigation, protection, and reporting to follow. On 3/19/25 the facility began staff in-service training and education on Abuse and Neglect with the emphasis on failure to protect resident rights to be free of neglect by failing to monitor urinary output and to monitor the resident when the catheter was discontinued. The resident experienced copious amounts of bleeding and blood clots through his penis. The facility failed to monitor vital signs with a significant change in condition. 141 of 171 staff members received this education by 3/21/25. All remaining staff would be educated prior to working their next shift. On 3/21/25 the DON and nurse management team was re-educated by the regional clinical director on the components of the management of foley catheters with an emphasis on Abuse, Neglect, Exploitation, Misappropriation, and Injury. On 3/20/25 the facility initiated education with licensed nurses to ensure new orders for indwelling catheters included placement, patency/draining, irrigation, catheter securement, catheter care each shift and recording of output on the MAR. 37 nurses out of 50 were educated by 3/21/25. On 3/22/25 the surveyor verified through interviews that the nurses were educated prior to working their next shift. On 3/20/25 for educating nurses on the requirement of detailed communication during shift-to-shift report will include any changes in condition, any new orders, and review any new or existing devices including urinary catheters. Verified the training of 39/50 nurses by 3/21/25. All remaining licensed nurses will be educated prior to working their next shift. This education has also been added to the orientation agenda for all newly hired licensed nurses to be provided prior to resident care. On 3/20/25 an (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy Director, Minimum Data Set nurse, Nurse, CNA. On 3/22/25 the surveyor verified through interviews with the DON and facility staff, review of the audits, and review of 6 random resident records to ensure accurate assessment of resident vital signs, obtaining and documenting catheter urine output and proper documentation for residents experiencing a change in condition.

Based on family and staff interviews and record review, the facility failed to protect residents' rights to be free from neglect. The facility failed to appropriately monitor the urinary output after insertion of an indwelling urinary catheter and failed to monitor the resident's change of condition for 1 (Resident #1) of 5 residents with urinary catheter reviewed. Resident #1 was admitted to the facility on [DATE] with diagnoses including prostatic hyperplasia (enlarged prostate). Resident #1 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). On 1/28/25 at approximately 5:30 a.m., Resident #1's urinary catheter was changed. There was no documentation Resident #1 was monitored to ensure the catheter was properly inserted and draining urine. On 1/28/25 at approximately 4:30 p.m., Resident #1 had no urinary output. The urinary catheter was removed. Resident #1 experienced copious amount of bleeding and clots. There was no documentation the facility monitored Resident #1's status, including obtaining vital signs (temperature, pulse, respiration and blood pressure) with the acute change in condition. On 1/28/25 at approximately 10:00 p.m., Resident #1 was emergently transferred to an acute care hospital. The resident was unresponsive, had no urinary output and was bleeding. The facility's failure to provide the necessary care and services to prevent neglect created a likelihood of serious harm, injury, or death of Resident #1 and other residents with an indwelling urinary catheter from catheter associated complications, including trauma from catheter insertion, urinary tract infections, and blood infections. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on 1/28/25. On 3/20/25 at 4:45 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The findings included: Review of the facility's policy and procedures titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of unknown source and Investigations with an effective date of 04/01/2022 revealed, Neglect is the 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 . The facility shall conduct their own internal investigation including but not limited to staff . resident, and family/resident representative interview, medical record reviews, 24 hours reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident . The facility shall take all necessary corrective action(s) depending on the results of their investigation and must notify the proper agencies as well as licensing authorities of any incidents that would indicate an employee is unfit for service. The facility shall analyze the occurrences to determine what changes are needed, if any, to the residents' care plan or policies and procedures to prevent further occurrences. Review of the facility's policy and procedures titled, Nursing-Catheter Care-Urinary with an effective date of 04/01/22 and a revision date of 02/21/23 revealed, Observe the resident for complications associated with urinary catheters . Check the urine for unusual appearance (i.e., color, blood, etc.) . Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed . Observe for signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Diagnoses included prostatic hyperplasia (enlarged prostate) with urinary symptoms. Resident #1 was admitted with an indwelling urinary catheter (catheter inserted in the bladder to drain urine). Review of the Treatment Administration Record (TAR) for January 2025 revealed on 1/28/25 Licensed Practical Nurse (LPN) staff B changed Resident #1's urinary catheter. The clinical record lacked documentation LPN Staff B verified the catheter was properly inserted and draining urine. On 1/28/25 at 10:59 p.m., LPN Staff A documented in a progress note for an effective date of 1/28/25 at 5:00 p.m., Resident #1's indwelling catheter was removed per the Advanced Practice Registered Nurse (APRN) order due to blood and clots, no urine output. The nurse documented, order given to monitor urine output for a couple of hours if no void and clots continue send resident to ER (emergency room ) for further evaluation. The clinical record lacked documentation Resident #1's condition was monitored, including an evaluation of the resident, amount of bleeding, vital signs or urine output. LPN Staff A did not transcribe the APRN's order until 1/28/25 at 10:02 p.m., five hours after receiving the order. The order read, Send out to ER (emergency room ) if resident does not void within a couple hours. The transcribed order did not include to monitor for bleeding and clots. On 1/28/25 at 11:36 p.m., LPN Staff B documented in a progress note with an effective date of 1/28/25 at 10:00 p.m., she received shift report from the dayshift nurse to send Resident #1 to the hospital per the APRN order if Resident #1 was not able to void and clots continue. Staff B documented clots continued, no voiding pt (patient) sent to hospital at 2200 (10:00 p.m.) for further evaluation. Family notified. Review of the documentation in the clinical record, including licensed nurses and Certified Nursing Assistant (CNA) notes and entries revealed the last urinary output was documented on 1/27/25 at 10:00 p.m. There was no documentation of urine output for the night shift (of 1/27/25, the day shift of 1/28/25 and the evening shift of 1/28/25. Review of the Emergency Medical Services (EMS) Prehospital Care Report revealed the unit was notified by dispatch on 1/28/25 at 9:51 p.m. The narrative noted Resident #1 was found lying supine (face up) in bed with a facility nurse at his side. Resident #1 was unresponsive but breathing. The facility nurse stated that earlier today Resident #1 had a Foley catheter (urinary catheter) removed and since has been having penile bleeding with blood clots and was recommended by the facility provider to call EMS if the bleeding does not improve. The nurse also stated that she's been unable to wake the patient up, patient is normally awake and verbal. He was last seen normal three hours ago. EMS documented that the resident was unresponsive, breathing fast with a radial pulse, skin hot and clammy, bruising noted on abdomen. The report noted under patient condition the primary complaint type was unresponsive, and other, bleeding from penis with large blood clots. The date and time of symptom onset was 1/28/25 at 6:07 p.m. Review of the local hospital record revealed Resident #1 was initially seen in theER on [DATE] at 10:22 p.m. The ER progress note documented Resident #1 arrived at the Emergency Department from the facility for complaint of blood clots after foley removal. Upon EMS arrival, Resident #1 was unresponsive to painful stimuli, and had a temperature of 100.2. The hospital History and Physical noted, The nursing staff at the facility stated that due to decreased urinary output they switched the catheter out and received large amounts of blood and clots shortly after that the patient became unresponsive . The patient was found immediately hypotensive and hypoxic requiring airway oxygen support with intubation . Resident #1 was admitted to the Intensive Care Unit with respiratory support on ventilator. The assessment and plan was: Septic shock (life threatening infection), Metabolic encephalopathy (impaired brain function due to imbalance in metabolism), Hematuria (blood in urine), Urinary retention. Review of the facility's incident investigations revealed on 2/4/25 at approximately 11:50 a.m., Resident #1's spouse reported to the facility that her husband was on life support at the hospital as a result of a urinary tract infection and pneumonia that he acquired during his stay at the facility due to improper care. The Administrator noted the facility recognized this statement as an allegation of neglect and started an investigation. The investigation noted that on the morning of 1/28/25 Resident #1's catheter was changed per the physician order. The resident was later noted to have no urine output, and his catheter was irrigated with blood clots observed. New orders were obtained from the APRN to remove the catheter at which time further blood clots were noted by nursing staff. Additional orders were then obtained to hold aspirin and Plavix (prevents clots from forming) and to transfer resident out if no urine output was observed and clots continued. Nursing continued to evaluate the resident with no urine output identified with continued blood clots and Resident #1 was subsequently transferred to the hospital. Review of the nursing staff statements obtained as part of the investigation revealed: LPN Staff B documented in an undated statement she worked on 1/27/25 from 7:00 p.m. to 7:00 a.m. She used sterile technique to replace Resident #1's urinary catheter. LPN Staff B wrote at 5:50 a.m., she informed Resident #1 she was going to change the catheter. She documented, Sterile technique used to remove Foley (urinary) catheter. No retention or bleeding. Resident #1 denied pain or discomfort. Pericare was provided and sterile technique used to insert catheter, no resistance noted. No complaints of discomfort from resident . LPN Staff B wrote, I will come back to check on you, resident was alert and thankful. Writer followed up with the resident at approximately 0630 (6:30 a.m.), no urine output. Writer palpated abdomen, no distention, resident denied discomfort or pain. 0700 (7:00 a.m.) report given to day shift. LPN Staff B told the on coming nurse at the time of insertion, no resistance was noted, and the resident was denying discomfort, no urine output noted yet. LPN Staff A's statement dated 2/5/25 noted on 1/28/25 at approximately 3:00 p.m., Resident #1's spouse called her to the room and voiced concerns about no urine in the catheter drainage bag. LPN Staff A said Resident #1 was alert, oriented, very pleasant and cooperative. His abdomen was not distended, was not tender to touch. Resident #1 had no complaints or discomfort. LPN Staff A flushed the catheter with saline with return of small clots passing in drainage tubing. Staff A said she called the APRN while at the bedside. The APRN gave an order to hold the aspirin and Plavix for three days and keep the catheter out. The APRN said not to send the resident to the hospital, to just monitor him for urine output without the catheter. If Resident #1 did not void and continued to clot send him out for further evaluation. On 2/7/25 at 2:18 p.m., in an email addressed to the Director of Nursing, LPN Staff C documented on 1/28/25 at 3:26 p.m., he took over Resident #1's care and received report from LPN Staff A. LPN Staff A was irrigating Resident #1's catheter. The resident's spouse told him he still has no pee. LPN Staff C documented he contacted the APRN about the resident not passing urine and passing one blood clot from irrigating the catheter. The APRN gave an order to remove and reinsert the catheter. LPN Staff C said he removed the catheter, and copious amount of blood came from penis. He immediately applied pressure to the penis region. LPN Staff C documented, Writer asked spouse to put on gloves, apply pressure to the area, and asked the patient does he have any pain? Patient denied pain or discomfort to lower abdominal region still nondistended. Staff C documented he had to call the doctor. While spouse was applying pressure to penis region writer rushed to nurse's station to get LPN Staff A for assistance. The writer sanitized his hands and applied gloves. Resident #1's Spouse removed her hands and writer continued to apply pressure. Writer waited approximately 5 minutes and stopped applying pressure . Patient released a quarter size blood clot after writer stopped applying pressure. He applied pressure to the penis region and ask LPN Staff A to call the APRN. The APRN gave a verbal order to not reinsert the catheter, hold blood thinners, monitor urine output. If the resident has not voided, and clots continue to pass then send the resident to the ER. LPN Staff C documented he stopped applying pressure, the bleeding and clot passing stopped. LPN Staff B documented in the witness statement on 1/28/25 at 7:00 p.m., she received a report from the previous nurse that Resident #1 had no urine output during the day. The catheter was irrigated, and the resident had passed a blood clot during removal of the catheter. Staff B documented she checked on the resident at the beginning of the shift and asked the Certified Nursing Assistant (CNA) to keep an eye on resident's output. At 8:50 p.m., she documented the resident's vital signs and blood sugar were within normal limits. The resident had no blood or urine in his brief. At approximately 9:45 p.m., she checked on Resident #1. She called the resident by name. Resident #1 was alert. Resident #1 appeared lethargic. LPN Staff B documented again she took the resident's vital signs, and they were within normal limits. LPN Staff B and the CNA checked the resident's brief and observed a medium size blood clot. The CNA remained in the room with another CNA to change the resident's brief while LPN Staff B called 911. The facility's investigation noted, Conclusions: After a complete and thorough investigation, this allegation of neglect cannot be verified. The facility provided care to (Resident #1) in adherence with physician orders. Due to (Resident #1) health status he was subsequently sent to the hospital at which time he was admitted . Summary of all corrective actions taken: Nursing staff education has been initiated r/t (related to) neglect with an emphasis on foley catheter care upon receiving this allegation . On 3/18/25 the Administrator provided In-service Attendance Record Signature sheets dated 2/4/25, 2/7/25, and 2/9/25, for inservice education for neglect provided to the nursing staff. The content of the education was, Neglect is the failure to provide goods and services to maintain the residents' physical mental and psychological wellbeing. This includes but is not limited to providing showers, turning and positioning, ADL (Activities of Daily Living) care and peri care. Catheter care is also on this list. Catheter care is to be provided a minimum of once a shift by the CNA. For residents' incontinence of stool after the stool is cleaned then catheter care needs to be provided again. Also making sure the tubing and bag are positioned properly and not touching the floor. The education did not include failing to appropriately monitor the resident's urinary output and failure to monitor the resident's condition, amount of bleeding, obtaining vital signs with the acute onset of bleeding constituted neglect. 14 of 33 nurses employed by the facility signed that they attended the in-service. On 3/18/25 at 8:30 a.m., in a telephone interview Resident #1's daughter said on 1/28/25 her mother was at the facility. She complained to facility staff several times that he was not passing urine after the catheter was changed that morning. On 1/28/25 at 10:00 p.m., a nurse called and told her mother that he was unresponsive and had been transferred to the hospital. Her father (Resident #1) was placed on a ventilator and admitted . Her mother complained to the Administrator about the care he received. On 3/18/25 at 10:00 a.m., in a telephone interview LPN Staff B said she had a physician's order to change the catheter. On 1/28/25 at approximately 5:30 a.m., there was no urine in the catheter drainage bag when she changed the catheter. She said she got a small amount of urine return when she changed the catheter and there was no blood. On 3/18/25 at 12:21 p.m., in a telephone interview, the Consulting Physician said he was not aware of the incident involving Resident #1. He said Staff should have obtained Resident #1's vital signs at least every shift and with any change in condition. He said Resident #1 should have been sent to the hospital within eight hours of no urine output. He said staff should have notified the physician if Resident #1 was not having a minimum of 30 milliliters of urine output hourly. On 3/18/25 at 1:00 p.m., in a telephone interview the APRN said staff never told her Resident #1 had no urine output for more than eight hours. She would have sent the resident to the hospital immediately. She said on 1/28/25 at 4:15 p.m., LPN Staff C sent her a text message to let her know Resident #1 had no urine output. She told the nurse to irrigate the catheter and call her back. They told her Resident #1 passed blood clots when they tried to irrigate the catheter. She gave an order to remove and reinsert the catheter. When they removed the catheter, copious amounts of blood came out. She told them to hold the anticoagulants (medication to prevent blood clots). She gave the order to wait an hour, call her or send the resident to the emergency room if he did not urinate or continued to pass clots. The APRN said she never told the nurse to wait two hours. On 3/18/25 at 1:30 p.m., in a telephone interview LPN Staff C said on 1/28/25 at approximately 3:30 p.m., he observed Staff A attempting to irrigate Resident #1's urinary catheter. The APRN was giving orders. He said there was no urine in the urinary drainage bag. He removed Resident #1's catheter, and a copious amount of blood and clots came out. The APRN gave an order to LPN Staff A to stop all anticoagulants and send the resident to the ER if he kept bleeding or had no urinary output. LPN Staff C said he did not know Resident #1 had no urine output since the previous night. On 3/18/25 at 2:00 p.m., in an interview Unit Manager LPN Staff D said on 1/28/25 she was assigned to Resident #1 from 7:00 a.m., to 2:00 p.m. She said LPN Staff B who worked the night shift did not tell her the resident had no urine output. She said the CNAs empty the urinary drainage bag at the end of each shift. The CNA who worked the day shift on 1/28/25 did not tell her Resident #1 had no urine output. Staff D said she could not remember if she checked the resident's catheter or drainage bag. On 3/18/25 at 3:00 p.m., in an interview LPN Staff A verified on 1/28/25 Resident #1's spouse told her there was no urine in the drainage bag. When she checked on the resident on 1/28/25 at approximately 4:00 p.m., the drainage bag was empty. She said no one told her the resident had no urine output all day. On 3/19/25 at 8:30 a.m., in an interview LPN Staff B said there was no urine in Resident #1's urinary catheter bag before she changed the catheter on 1/28/25 at 5:30 a.m. She said when she left work on 1/28/25 at 7:00 a.m., there was no urine in the drainage bag. When she returned to work on 1/28/25 at 7:00 p.m., LPN Staff A told her Resident #1 had no urine output since the previous evening. He only passed blood and clots when they tried to irrigate the catheter. LPN Staff B verified the APRN's orders to monitor the resident and send him out if he did not stop bleeding were not transcribed until 1/28/25 at 10:00 p.m. She said she took Resident #1's vital signs twice during her shift but did not document them. She said Resident #1 was alert but lethargic when EMS arrived. She could not remember when Resident #1 became lethargic. On 3/19/25 at 3:05 p.m., in a telephone interview Resident #1's spouse said on 1/28/25 she spent the whole day at her husband's bedside. At 9:00 a.m., she noticed there was no urine in the urinary drainage bag. At approximately 11:00 a.m., 12:00 p.m., she told LPN Staff D the catheter was not draining urine. LPN Staff D told her she was busy and would come later. She never came to the room and left at 2:00 p.m. On 1/28/25 at approximately 4:00 p.m., LPN Staff A tried to flush the catheter and said, it was traumatized. LPN Staff C came in the room and removed the catheter. A large blood clot came out. On 3/19/25 at 4:10 p.m., a joint interview was conducted with the Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant to discuss the facility's neglect investigation related to Resident #1's care and emergency transfer to the hospital. The Regional Nurse Consultant said she could not argue with the fact that there were no vital signs taken and no assessment documented for Resident #1. The DON said she interviewed the nurses as part of the investigation but did not interview the CNAs. She verified that no corrective actions were implemented related to the lack of assessment, and timely transfer of Resident #1 when he had not passed urine for more than eight hours. On 3/19/25 at 5:05 p.m., in an interview Registered Nurse Staff F said she has been the Staff Educator at the facility for [AGE] years and was responsible for competencies of the nursing staff. She said the facility had not been doing urinary catheter care competencies, including ensuring the nurses were knowledgeable to insert catheters and monitor residents with urinary catheters. She said, We will now. 41905 On 3/22/25 after verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 3/22/25. The Immediate actions implemented by the facility and verified by the survey team included: On 3/22/25 at 2:04 p.m. during an interview with the Director of Nursing (DON) she said she has completed education for almost all of the nursing staff. The remaining staff will be educated before the start of their next scheduled shift. She said there have been several in-person live events and there have been over the phone education for (2 nurses) and they will complete their competencies before their next working shift. She said there were no new hires for nursing staff. They are re-educating the Certified Nursing Assistants (CNAs), Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). On 3/19/25 the facility Administrator and Director of Nursing were re-educated by the Regional Nurse Consultant on: The components of the regulation F600 Free from Abuse and Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin with indicators of Neglect including screening, training, prevention, identification, investigation, protection, and reporting. On 3/19/25 the facility began staff education on Abuse and Neglect with the emphasis on failure to protect resident rights to be free of neglect by failing to monitor urinary output and to monitor the resident when the catheter was discontinued. 141/171 staff members have received this education by 3/21/25. All remaining staff will receive this education prior to returning to work. The facility neglected to monitor the residents' status, including vital signs with a significant change in condition. On 3/18/25 the facility completed a facility wide audit of 155 residents to ensure that all residents have physician's orders to take vital signs was in place and transcribed to the medication administration record (MAR). Long term care resident vital signs are obtained on a weekly basis and short-term rehab residents vital signs are obtained daily. On 3/18/25 the facility reviewed all foley catheter orders. Urinary output was added to the medication administration record (MAR) on 3/19/25 to ensure nursing documentation. On 3/18/25 CNA education was initiated to ensure any changes in urinary output for residents with foley catheters, and any residents experiencing a change in condition must be reported immediately to the nurse. 77 of 82 CNAs were educated by 3/21/25. All remaining CNAs will be educated prior to working their next scheduled shift. On 3/21/25 the facility initiated vital sign assessment competencies including temperature, pulse, respirations, and blood pressure on staff members. On 3/22/25 the surveyor verified through a record review of 3 randomly selected residents that the facility was monitoring the vital signs for the selected short and long term residents. On 3/22/25 interviews with 3 Certified Nursing Assistants (CNA), and 3 nurses verified they had been re-educated on catheter care including measuring, reporting, and documenting the amount on the MAR. On 3/22/25 the surveyor verified through record review of 3 randomly selected residents with urinary catheters the facility was monitoring and documenting vital signs every shift. The nursing staff was measuring and recording the amount of urine for residents with urinary catheters. On 3/22/25 the surveyor confirmed through interview with 3 random CNAs they were educated to report to the nurse any changes in urinary output for residents with catheters, and to report changes in resident condition immediately to the nurse. On 3/22/25 the surveyor verified through record reviews of 3 random residents that the facility was documenting the vital signs on the MAR twice a day. On 3/18/25 the facility educated their licensed nurses on completing a Change in Condition Assessment on residents. The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or psychosocial status; life threatening conditions or clinical complications including changes in urinary output including color, consistency and output; circumstances that require an alteration in treatment including acute and chronic conditions. A complete nursing evaluation must be conducted and documented in the medical record of systems. The nurses were educated to obtain a new set of vital signs and document them in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs. The provider shall be notified of pertinent evaluation findings. Nurses must visualize catheters for urine amount of output, color and clarity during each shift. On 3/19/25 the facility daily clinical meeting agenda was edited to include the review of all residents with changes in condition to ensure vital signs and a timely transfer was completed; review of all new and existing residents with urinary catheters had monitoring and documentation of urine output amount in place. On 3/19/25 the facility conducted RN assessments of every current resident including vital signs and foley catheter observations for output and patency. Any changes were reported to the family and the provider. On 3/20/25 the facility initiated audits of residents in the facility to ensure the nursing staff completed proper documentation of those vital signs. On 3/20/25 the facility completed a 7-day audit for residents with urinary catheters to ensure measuring and documenting of the urine output was completed on each shift. On 3/20/25 an ad hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI meeting included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy Director, Minimum Data Set nurse, Nurse, CNA. On 3/21/25 48 of 50 nurses were re-educated. The remaining nurses will be educated prior to working their next shift. On 3/22/25 a review of three random resident records was completed to ensure accurate assessment and interventions were in place to prevent neglect related to the care of residents with foley catheters and for those who experience a change in condition.

Based on record review and interview, the facility failed to implement procedures to identify risk for elopement and adequately monitor 1 (Resident #1) of 1 cognitively impaired resident reviewed who left the facility without staff knowledge. The findings included: Review of the facility's policy titled, Nursing - missing resident/elopement with a revision date of 2/20/23 indicated: 1. Residents of the facility shall be maintained in a safe and secure environment. Residents may be considered missing and or to have eloped if they: d. leave the facility without authorization. 3. Locating the resident. D. Documentation regarding the elopement should be done in the interdisciplinary progress notes. E. An accident/incident form should be completed by a nurse including statements from all involved staff. F. At the next scheduled morning report, safety committee meeting, and QAPI (Quality Assurance and Performance Improvement) meeting the incident should be discussed and root cause analysis of elopement should be identified. 4. An event report should be completed and available for review by the facility Risk Manager. 5. The facility Risk Manager should determine if the event qualifies (according to state guidelines) as an adverse incident then appropriate reporting should be carried out. On 2/25/25 at 9:12 a.m., an entrance conference was held with the Administrator and Director of Nursing (DON). The Administrator said there had been no elopements as far as they knew. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood. The Admission Minimum Data Set (MDS) assessment with a target date of 10/31/24 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status Score of 07. Resident #1 used a manual wheelchair and was dependent on staff to wheel 50 feet. Review of the elopement risk evaluation dated 10/28/24 revealed Resident #1 had no cognitive impairment and was not at risk for elopement. The care plan initiated on 10/28/24 and revised on 1/21/25 specified Resident #1 could go on leave of absence with responsible party. Review of the Rehab Speech Screen dated 10/29/24 revealed documentation Resident #1 presented with, baseline speech, language and cognitive deficits. Poor participation during eval . Pt (patient) also stated, I want out of here. On 11/3/24 the Social Worker initiated a care plan indicating Resident #1 had impaired cognitive function/dementia or impaired thought processes related to short term memory loss. Interventions included to cue, reorient and supervise the resident as needed. The elopement evaluation dated 1/24/25 noted Resident #1 was cognitively impaired and had poor decision-making skills. Resident #1 did not have the ability to leave the facility. The evaluation noted the resident had no exit seeking behaviors and was not at risk of elopement. Review of the progress notes revealed an entry dated 2/19/25 that read, Elopement Risk- Wander guard in place. (Alerts staff when a resident leaves a designated safe area). The progress note did not explain the reason for the wander alert bracelet. On 2/19/25 Resident #1's care plan was updated and noted the resident was an elopement risk/wanderer related to impaired safety awareness. The goal was to maintain the resident's safety. The interventions included checking the placement and function of the wander alert bracelet. On 2/25/25 at 9:53 a.m., in an interview the Maintenance Director said on 2/19/25 Assistant Director of Nursing (ADON) Staff B found Resident #1 outside, on the sidewalk near C wing. ADON Staff B notified the Director of Nursing (DON) and followed the resident in her car. He drove the DON in his car and dropped her off a few streets away from where Resident #1 was. The Maintenance Director said the front door opens at 8:00 a.m., and Resident #1 probably went out that door and then around the building. On 2/25/25 at 9:55 a.m., in an interview ADON Staff B said on 2/19/25 she arrived in the parking lot of the facility at approximately 8:30 a.m. She saw Resident #1 coming out the door located on the side of building by the C wing. The door was open, but she did not hear an alarm going off. When she pulled into the parking space, she realized Resident #1 was leaving the parking lot in his electric scooter. He did not stop and began crossing the road. ADON Staff B said physically she was not able to get to the resident on foot. She got back in her car, called the DON and followed Resident #1 in her car. Resident #1 had crossed the road and was on the sidewalk. He went down the street to the curve by a restaurant, turned right on a street, then left on another street. She said she followed Resident #1 to keep him safe while talking on the phone to the DON. ADON Staff B said she finally got him to stop. She asked him where he was going, and if he had signed out. Resident #1 responded he just wanted to get out for a little while. The DON arrived by car with the Maintenance Director. The DON walked with Resident #1 back to the facility. ADON Staff B said she has had training in elopement. To her understanding, an elopement was when a resident is outside the building without staff knowledge. ADON Staff B said Resident #1 exited the facility through a door equipped with a wander alert alarm. Resident #1 did not have a wander alarm bracelet; therefore, the door would not have alarmed. On 2/25/25 at 10:53 a.m., in an interview the Maintenance Director said he didn't know if Resident #1 exited the building through the side door. He said the side door has an alarm which he checks the function every day. He said once the alarm is activated, a pass key is needed to turn off the alarm. He said no one told him there was a problem with the alarm of the side door. On 2/25/25 at 10:11 a.m., the C wing door was observed with the Administrator. The Administrator explained the first door can be opened by pushing a green button. The second door can only be opened by punching a code or pressing on the egress bar for 15 seconds. However, when the egress bar releases, it will activate an alarm. On 2/25/25 at 10:40 a.m., in an interview the DON said on 2/19/25 at around 8:20 a.m., ADON Staff B called her and said she was watching Resident #1 going down the road. The ADON told her where Resident #1 was. She stayed on the phone with the ADON until she got to where the resident was. The ADON got the resident to stop. She walked him back to the facility. The DON said she was not familiar with Resident #1. He said he was getting air. The DON said she verified Resident #1 did not sign out before leaving the facility. She said Resident #1's scored a 07 on the Brief Interview for Mental Status (a score of 07 or below indicated severe cognitive impairment). She said Resident #1 had no prior attempt to leave the facility. After the incident, they updated the resident's care plan and initiated a wander alarm. She said they really did not know through which door the resident exited the building. She spoke to a few staff members at the time of the incident but did not do a formal investigation. She reported the incident to the Regional Nurse since the Administrator was on vacation. She said she did not consider the incident an elopement since ADON Staff B followed the resident in her car the entire time. On 2/25/25 at approximately 10:45 a.m., the side door by the C wing was observed with the DON. The DON pushed the green button and opened the first door. She pushed the egress bar on the second door for approximately 15 seconds. The door opened and the alarm went off. The Minimum Data Set (MDS) nurse responded to the alarm and said the door will continue to alarm until it is turned off with a key. On 2/25/25 at 10:58 a.m., in an interview the Regional Nurse verified the DON notified her when Resident #1 left the faciity on [DATE]. She said no investigation had been done. She did not consider the incident to be an elopement. She said ADON Staff B followed Resident #1 in the car and would have been able to stop him from getting hit by a car or involved in any type of accident. On 2/25/25 at 12:00 p.m., observation of the route taken by Resident #1 on 2/19/25 showed the resident crossed two streets and traveled approximately 0.3 miles from the facility when ADON Staff B was able to get him to stop. On 2/25/25 at 2:25 p.m., in an interview the Speech Therapist said during the first assessment on 10/29/25 Resident #1 scored 07 on the BIMS. She said it indicated severe cognitive deficit, but the resident was not participatory, and it was not a true picture of his cognition. She said he got the electric scooter on 2/5/25. Occupational Therapy evaluated him and determined he was safe to use the scooter. Review of the Occupational Therapist progress note dated 2/12/25 revealed documentation the resident needed distant supervision with use of personal power wheelchair in facility and outside of facility on sidewalk and sitting areas. The resident has been instructed each session on safety rules and facility protocols with resident knowing he is not allowed in parking lot or off facility grounds. Overall it is recommended resident be distant supervision with use of personal power chair in order to provide the resident with as much independence during the day as possible. On 2/25/25 at 3:50 p.m., in a telephone interview the Psychiatric Advanced Practice Registered Nurse (APRN) said she had seen and assessed Resident #1. She said Resident #1's cognition was not that great, and he was child-like. He was not able to be on his own and leave the facility on his own. On 2/25/25 at 4:40 p.m., a meeting was held with the Administrator, the DON and the Regional Nurse. The DON verified Resident #1's cognition was severely impaired and verified an elopement evaluation was not done when the resident started using the electric scooter. The Administrator said Resident #1 could have left through the front door and proceeded around the building, but they did not know and did not investigate. He said they would look into the incident and develop a plan to prevent further occurrences.

Based on observation, interview and record review, the facility failed to ensure a resident admitted with a urinary catheter was assessed for removal of the catheter as soon as possible, received services to prevent urinary tract infections, and had the proper securing device to prevent friction and movement at the insertion site for 1 (Resident #305) of 2 residents reviewed for urinary catheters. The findings included: Review of the facility Policy for Urinary Catheter Care revised 2/21/23 included instructions for infection control: Be sure the catheter tubing and drainage bag are kept off the floor. Catheter changing instructions included: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Review of the clinical record for Resident #305 revealed an admitted [DATE] for rehabilitation after pacemaker surgery. Diagnoses included vascular implant infection, diabetes, and chronic kidney disease. Resident #305 was admitted with a urinary catheter. The hospital record dated 1/7/25 noted the resident had a recent surgery for infected pacemaker. During the hospital course, a urinary catheter had been removed shortly before discharge. The bladder scan showed full bladder; therefore, Foley catheter will be placed. The hospital records did not include a diagnosis of obstructive uropathy. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) showed Resident #305 was incontinent, with a urinary catheter placed on 1/12/25. The reason for the urinary catheter was urinary retention. The physician's order dated 1/14/25 included to secure the catheter once every seven days and as needed. The physician's order dated 1/15/25 gave instructions to administer Myrbetriq 50 milligrams once a day for overactive bladder. The facility's comprehensive assessment dated [DATE] listed an active diagnosis of obstructive uropathy. On 1/27/25 at 3:48 p.m., Resident #305 was observed sitting in the wheelchair in her room. The urinary catheter drainage bag tubing was on the floor. The catheter was not secured to the resident's thigh resident to prevent irritation or friction. In an interview during the observation, Resident #305 said the tubing was uncomfortable, pulls in her crotch and digs in her skin. The resident said she really just wants the catheter out. On 1/29/25 at 12:36 p.m., Resident #305's catheter was observed. It was not secured to the resident's thigh to prevent movement or friction. On 1/29/25 at 4:19 p.m., in an interview Resident #305 said she never had a urinary catheter before. She said it was uncomfortable, and she wanted it out. The catheter tubing was not secured to the resident's thigh. The drainage bag was under the wheelchair and resting on the floor. On 1/29/25 at 4:26 p.m., in an interview Registered Nurse (RN) Staff G said she was taking care of Resident #305. She said she did not know why the resident had the urinary catheter. The resident's catheter was observed with the RN Staff G. RN Staff G verified the catheter was not secured to the resident's thigh to prevent pulling and friction and verified the urinary catheter drainage bag was stored on the floor. Staff G said the bag and tubing should not be on the floor and the catheter should be secured to the resident's thigh for comfort. On 1/29/25 at 4:40 p.m., in an interview Unit Manager Staff A said the resident has not had a voiding trial or urology follow-up since being admitted to the facility. She said upon the resident's admission, she consulted with the Advanced Practice Registered Nurse who gave the obstructive uropathy diagnosis. On 1/30/25 at 9:06 a.m., in an interview Certified Nursing Assistant Staff K said the floor was covered with germs, the urinary catheter bag and tubing should be off the floor at all times. She said the catheter should be secured with a leg strap. On 1/30/25 at 9:43 a.m., in an interview Resident #305 said she retained urine and took medication for it. The resident said she never needed a urinary catheter before and wanted this one out. The resident said at the hospital they told her she needed it. Resident #305 said she was able to void. On 1/30/25 at 9:52 a.m., in an interview RN Staff H said when a resident is admitted with a urinary catheter, the nurse should obtain a thorough medical history to determine whether the resident really needs the catheter. Too many times, hospitals insert urinary catheters for convenience. On 1/30/25 at 9:57 a.m., Unit Manager Staff A said the Advanced Practice Registered Nurse gave orders to discontinue the Myrbetriq for Resident #305 and for bladder retraining. She said they would be contacting the urologist. On 1/30/25 at 10:09 a.m., in an interview, Minimum Data Set (MDS) Coordinator RN Staff I said she reviewed the resident's medical record and did not see a diagnosis justifying the use of the urinary catheter. She said she consulted with the Unit Manager and Advanced Practice Registered Nurse who gave the diagnosis of obstructive uropathy.

Based on clinical record review, review of facility's policies and procedures, and staff interviews, the facility failed to ensure staff followed safety precautions in the care plan while providing care to prevent avoidable fall and fall related fracture for 1 (Resident #50) of 3 residents reviewed for accidents. The findings included: Review of the facility's policy for Falls and Fall Risk-Managing with effective date of 4/1/2022 revealed, Based on previous evaluations and current data, the staff should identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Review of the clinical record for Resident #50 revealed an admitted [DATE]. Diagnoses included Chronic Kidney Disease, and anemia. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 12/2/24 noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The assessment noted the resident was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) for toileting, shower, bathing, upper and lower body dressing. The resident required substantial/maximal assistance to roll left and right. Review of the Care Plan for Resident #50 revealed the resident was dependent on staff for activities of daily living care, transfers and mobility, related to physical limitations. The care plan noted Resident #50 was at risk for falls related to general weakness, decreased mobility, anemia, Hypertension, Thyroid disorder, insomnia, and potential side effects of medications. The care plan specified, The resident requires assist (assistance) of 2 staff to turn and reposition in bed. Review of the facility's incident investigations revealed on 1/21/25 at approximately 6:30 p.m., Resident #50 rolled out of her bed during patient care, resulting in a fracture of the right distal femur (thigh bone) proximal to the knee joint. The investigation noted Certified Nursing Assistant (CNA) Staff F was providing a bed bath to the resident independently. After review of the resident's care profile, it was identified that the resident was a two person assist for bed mobility. The investigation noted CNA Staff F failed to follow Resident #50's Kardex (Provides instructions for safe care) by assisting the resident with bed mobility by herself and not with the assistance of another staff member as indicated in Resident #50's medical record. The investigation noted, The facility concludes from this investigation that this injury to (Resident #50) could potentially have been avoided had CNA Staff F followed Resident #50's Kardex as indicated in her medical record. Review of the Certified Nursing Assistant Kardex howed Resident #50 required dependent assistance of two staff to turn and reposition in bed and used bulateral enablers to maximize independence with turning and repositioning in bed. The investigation included an interview with Resident #50 who said CNA Staff F gave her a bed bath. The CNA was drying her off and changing the sheets. CNA Staff F was standing on the left side of the bed. Resident #50 said she used the assist bar to roll to the right side of the bed while the CNA changed her sheets. She did not know what happened. The resident stated one of her legs must have gone too far and her legs slid off the bed, her right knee hit the floor and then she slid off the bed. Resident #50 stated her knee hurt and the nurses were providing her with pain medication. Review of CNA Staff F witness statement revealed Resident #50 asked for a bed bath. When she was finishing up drying the resident's back while making the bed, Resident #50 used her side rail to pull herself on her side by herself. She was facing away from me holding the side rail her legs went off the bed. Her knee hit the floor then I call the nurse ect [sic]. On 1/22/25, Resident #50 was emergently transferred to a local hospital and admitted . On 1/28/25 at 11:40 a.m., in an interview the Administrator said Resident #50 received a bed bath in her room. The resident turned herself using the enabler bars. Her legs shifted and she rolled off the bed. CNA Staff F was changing sheets and drying her off. The Administrator said CNA Staff F did not follow the requirements outlined in the Kardex, she was still suspended pending investigation. On 1/30/25 at 9:30 a.m., a joint interview was conducted with the Regional Director of Nursing, the Administrator, and the Director of Nursing. They all agreed that CNA Staff F failed to provide the required two person care during a bed bath which resulted in Resident #50 falling out of bed and sustaining a major injury. They said CNA Staff F was suspended and remains on suspension.

Based on observation, review of the clinical record, facility policy and procedure and resident and staff interviews, the facility failed to maintain urinary catheters in a sanitary manner for 4 (Residents #61, # 249, #252, and #305) of 4 residents observed with urinary catheters. The facility also failed to ensure intravenous (IV) access devices were dated and secured properly for 2 (Resident #252, and #305) of 3 residents reviewed. The findings included: The facility policy Nursing- Catheter Care- Urinary. The purpose of this procedure is to prevent catheter associated urinary tract infections (UTI's). Infection Control) . Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag . Be sure the catheter tubing and drainage bag are kept off the floor. Review of the clinical record revealed Resident #61 had a readmitted [DATE] with diagnoses including obstructive, reflux uropathy and urinary tract infection. Record Review documented the resident's labs results were positive for a UTI (Urinary Tract Infection) on 11/6/24 and 10/21/24 and required the use of antibiotics. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a target date of 12/15/24 documented Resident #61 was dependent on staff for all ADL's. The MDS noted Resident #61's cognitive skills for daily decision making were intact. The care plan initiated 9/15/24 and revised 11/1/24 identified Resident #61 had an indwelling urinary catheter The goals for Resident #61 specified she would be/remain from catheter related trauma and the residents risk for urinary infections will be minimized. The interventions included to report any signs or symptoms of UTI to the physician, provide catheter care as ordered, and position catheter bag and tubing below the level of the bladder. On 1/27/25 at 1:14 p.m., Resident #61 was observed in bed, and catheter drainage bag was on the floor. Photographic evidence obtained. On 1/28/25 at 9:35 a.m., Resident #61 was sleeping in her bed, and the catheter drainage bag was on the floor. Photographic evidence obtained. On 1/28/25 at 9:37 a.m., the Registered Nurse, Staff Development Coordinator confirmed Resident #61's drainage bag was on the floor. Review of the clinical record revealed Resident #249 had an admitted [DATE] with diagnoses including chronic kidney disease. The care plan initiated on 1/21/25 identified the resident has Indwelling catheter. The goals for Resident #249 specified the resident will show no signs or symptoms of urinary infection. The resident will be/remain free from catheter-related trauma through review date. On 1/27/25 at 11:32 a.m., Resident #249 was observed in bed with the bed in the low position. The catheter tubing and drainage bag were in contact with the floor. Photographic evidence obtained. On 1/27/25 at 00:00 Resident #249 was sent to the local emergency department and did not return to the facility. Review of the clinical record revealed Resident #252 had an initial admitted [DATE] with readmissions on 1/11/25 and 1/23/25 following hospitalization . Admitting diagnoses included ileostomy (surgical opening in the abdominal wall in which part of the small intestine is brought to the surface) and dependence on renal dialysis. The Admission MDS with a target date of 1/11/25 documented Resident #252 required substantial to maximum assistance personal hygiene and was dependent for toileting. The MDS noted Resident #252's cognitive skills for daily decision making were intact. On 1/27/25 at 12:12 p.m., during an observation Resident #252's ileostomy drainage bag was attached to the side of the bed facing the open door. There was no privacy bag, and the catheter system was visible to anyone passing by the resident's room. The drainage bag spout was touching the metal frame of the beds wheels. Photographic evidence obtained. On 1/30/25 at 10:50 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said catheter drainage bags are attached to the bed frame and the tubing and drainage bag should never be on the floor. CNA Staff F said if the bed is in the low position, the drainage bag is placed in a wash basin to keep it off the floor. Review of the clinical record revealed Resident #305 was admitted to the facility on [DATE] with an indwelling urinary catheter. On 1/27/25 at 3:48 p.m., Resident #305 was observed in the bedroom sitting in the wheelchair. The urinary catheter tubing was observed under the seat of the wheelchair, touching the floor. On 1/29/25 at 4:19 p.m., Resident #305 was observed in the bedroom sitting in the wheelchair. The urinary catheter tubing and drainage bag were observed below the seat of the wheelchair and touching the floor. Registered Nurse Staff G confirmed the tubing and bag were on the floor. Staff G said the tubing and drainage bag should not be in contact with the floor. On 1/30/25 at 9:06 a.m., CNA Staff K said the floor was covered with germs, and the urinary catheter drainage bag and tubing should not be in contact with the floor. The facility policy Guidelines for Preventing Intravenous Catheter -Related Infections documented The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters.Catheter Site Dressing Regimens. Change initial dressing after placement within 24 hours. Use sterile transparent dressing.Change the transparent dressing every 5 to 7 days or as needed if . loosened. On 1/27/25 at 12:12 p.m., Resident #252 was observed with an IV access catheter in his left antecubital. In an interview the resident said he thinks he was receiving antibiotics in the hospital prior to his admission at the facility. There was no date on the dressing. The transparent dressing was rolled up on the edges. Photographic evidence obtained. On 1/27/25 at 4:04 p.m., the Infection Preventionist observed Resident #252's intravenous insertion site dressing and said she was not able to tell when the dressing was changed because there was no date on it. The Infection Preventionist said the policy for IV dressings to be changed was weekly and as needed. Review of the clinical record revealed Resident #305 was admitted to the facility on [DATE] for rehabilitation following surgery for an infected pacemaker. The physician ordered an IV antibiotic on 1/14/25 to be given daily every 2 days until 2/20/25. On 1/14/25, the physician ordered a dressing change to the IV catheter insertion cite to be completed on admission or 24 hours after insertion and weekly thereafter and as needed. Review of the medication administration record revealed the nurse signed off the IV cover dressing was changed on 1/21/25. On 1/27/25 at 3:48 p.m., during an observation of Resident #305's IV cover dressing, the date handwritten on the dressing was 1/17/25. Photographic Evidence Obtained On 1/27/25 at 4:05 p.m., in an interview the Infection Preventionist, verified the IV cover dressing was dated 1/17/25 and was outdated. She said the IV dressing should be changed every seven days to prevent infection. On 1/27/25 at 5:10 p.m. during an interview RN Staff J said she administered the IV antibiotic to Resident #305 today with the outdated cover dressing. She said the Medication Administration Record did not trigger her to check the date and she did not notice it was outdated. On 1/30/25 at 11:50 a.m., in an interview the Infection Preventionist said the nurse who signed off the dressing change was completed on 1/21/25 should not have signed off something that was not done. She said the IV dressing was outdated.

Based on observations, review of the facility policy and procedures, resident and staff interviews, and review of the clinical record, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion (ROM) for 1 (Resident #61) of 1 resident reviewed for limitation in ROM. The findings included: The facility policy Nursing-Mobility and Range of Motion with an effective date of 4/1/2022 documented, Residents with limited ROM should receive treatment and services to increase and or prevent a further decrease in ROM. As part of the resident's comprehensive assessment the nurse should identify the resident's.limitations in movement or mobility. The nurse should also identify conditions that place the resident at risk for complications related to ROM. including.contractures. The care plan should include specific interventions, exercises and therapies to maintain, prevent avoidable decline in or improve mobility and ROM. Review of the clinical record revealed Resident #61 had a readmitted [DATE]. Diagnoses included dementia. Resident #61 required assistance with personal care. The Quarterly MDS with a target date of 12/20/24 documented Resident #61 was dependent on staff for all activities of daily living. Resident #61 had limitation in ROM to one side of the upper body and both sides of the lower body. The MDS noted Resident #61's cognitive skills for daily decision making were intact with a Brief Interview for Mental Status score of 14. The care plan initiated 9/23/24 and revised 11/1/24 identified Resident #61 had an ADL (activities of daily living) self-care performance deficit related to weakness, functional decline, and dementia. The care plan interventions specified, Resident to wear a palm guard (protective device) to left hand as tolerated/as ordered, remove for hygiene and skin checks. On 1/27/25 at 12:31 p.m., in an interview Resident #61 said she was not able to open her left hand. The fingers of the left hand were observed curled into a tight fist. Resident #61 was not wearing the palm guard specified in the care plan to the left hand. A hand splint was observed on the residents' nightstand. On 1/28/25 at 10:57 a.m., Resident #61 was observed with Unit Manager LPN Staff A. Resident #61 was in bed and was not wearing the palm guard to the left hand. The left hand fingernails extended approximately 1/2 inch from the fingertips. The resident's left hand was curled in a fist. In an interview during the observation, Resident #61 said she was not able to open her left hand and it was starting to hurt. Resident #61 said she did not know if she had a splint for her hand. Unit Manager Staff A said Resident #61 was supposed to wear a splint to the left hand. On 1/29/25 at 12:35 p.m., in an interview Certified Nursing Assistant (CNA) Staff B said she often took care of Resident #61. Staff B said the resident had a splint for her left hand. She said the therapist shows the staff how to put apply and remove the splint and how to take care of the splint. She said the information was on the Kardex (Provides instructions for safe care). Review of the CNA Kardex revealed, Resident to wear palm guard to left hand as tolerated/as ordered, remove for hygiene and skin checks.

Based on observations, review of the clinical record, resident and staff interviews and review of facility policy and procedures, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents #252 and #61) of 3 residents reviewed for activities of daily living (ADL's). The findings included: Review of the facility's policy, Activities of Daily Living effective 4/1/22 documented Purpose: To ensure all residents needs are met in a manner that promotes their quality of life and preferences . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good . grooming, and personal and oral hygiene . Review of the clinical record revealed Resident #252 had an initial admitted [DATE] with readmissions on 1/11/25 and 1/23/25 following hospitalization . The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a target date of 1/11/25 documented Resident #252 required substantial to maximum assistance with showers and personal hygiene. The MDS noted Resident #252's cognitive skills for daily decision making were intact with a Brief Interview for Mental Status Score of 15. The care plan initiated on 1/15/25 identified Resident #252 had an ADL self-care deficit related to overall functional decline. The interventions for Resident #252 specified the resident requires substantial to maximum assistance by one staff with personal hygiene. The care plan instructed to Check nail length and trim and clean on bath day and as necessary. On 1/27/25 at 3:49 p.m., Resident #252 was observed in bed. He was unshaven with approximately seven days of facial hair growth. In an interview during the observation, Resident #252 said before he went into the hospital, he had a mustache and goatee. He said a Certified Nursing Assistant (CNA) shaved him once in the last four weeks. The resident said, I could use a shave, but I have not told anyone. He said he had not received any showers recently, They washed me up in the bed. Resident #252 said he would enjoy a shower and did not know why he had not received his scheduled showers. On 1/28/25 at 10:35 a.m., Resident #252 was observed in his room in bed. The resident remained unshaved and had approximately one inch of beard growth. His fingernails were observed to extend approximately 1/2 inch from the fingertips. They were jagged and with a brown substance under the nails. The resident said, someone came in and said they would take care of it today. Review of the CNA documentation revealed Resident #252 preferred showers and was scheduled for showers on Tuesdays and Fridays on the 7:00 a.m., to 3:00 p.m., shift. The documentation from 1/4/25 through 1/28/25 revealed the resident received bed baths on 1/4/25, 1/11/25, 1/14/25, 1/15/25, 1/17/25, 1/18/25, 1/19/25, 1/23/25, 1/24/25 and 1/28/25. The only documented shower was on 1/13/25. On 1/29/25 at 11:22 a.m., in an interview CNA Staff C said resident care information including showers, splints and care needs was documented in the CNA Kardex (provides information for safe care) in the electronic record and that is how she gets resident information. The CNA said she checks residents' daily, shaves and provides fingernails care as needed. On 1/29/25 at 12:31 p.m., Resident #252 was observed in his room in a recliner chair. He had a full beard and mustache of approximately one inch growth. He said he was waiting for someone to shave him. On 1/29/25 at 3:48 p.m., Resident #252's facial hair growth (beard and mustache) was observed with Unit Manager Licensed Practical Nurse (LPN) Staff A. LPN Staff A said Resident #252 was readmitted with the beard and mustache on 1/3/25. She verified the resident had requested to be shaved. Staff A said she would have staff shave him. On 1/30/25 at 8:48 a.m., Resident #252 was observed in his bed. He was not shaved. His fingernails remained long and jagged, extending approximately half an inch. In an interview during the observation, Resident #252 said, Last night someone came in the room and said they were going to shave me, and they would get what they needed and left. They never came back so I don't know what is going on. Review of the clinical record revealed Resident #61 had a readmitted [DATE]. Diagnoses included dementia. Resident #61 required assistance with personal care. The Quarterly MDS with a target date of 12/15/24 documented Resident #61 was dependent on staff for all ADL's. The MDS noted Resident #61's cognitive skills for daily decision making were intact with a Brief Interview for Mental Status score of 14. The care plan initiated 9/23/24 and revised 11/1/24 identified Resident #61 had an ADL self-care performance deficit related to weakness, functional decline, and dementia. The care plan specified resident was totally dependent on 2 staff for showering/bathing per schedule and as needed. On 1/27/25 at 12:34 p.m., Resident #61 was observed sleeping in bed. Her fingernails extended approximately 1/2 inch. An accumulation of brown/black substance was observed under the nails. Facial hair was observed under her chin and the neck area. On 1/28/25 at 10:57 a.m., Resident #61 was observed with Unit Manager LPN Staff A. Resident #61 was in bed. The left and right hand fingernails extended approximately 1/2 inch from the fingertips and remained with a black/brown substance under the nails. The resident's left hand was curled in a fist. In an interview during the observation, she said she was not able to open her left hand and it was starting to hurt. The resident's lips were dry. The lower lip was peeling. Resident #61 said no one had cleaned her teeth for her. She said she did not get out of bed and did not know why. LPN Staff A observed the resident's left hand and verified the fingernails extended approximately 1/2 inch from the fingertips and were curled into a fist. Staff A said Resident #61 was supposed to wear a splint to the left hand. On 1/29/25 at 11:21 a.m., CNA Staff B was observed providing care to Resident #61 in her room. In an interview CNA Staff B said she cleans the resident in bed, provides range of motion to her legs and fixes the resident's her hair. CNA Staff B said, I do mouth care for her and I speak with her. CNA Staff B said with two person assist, they use a shower bed to take Resident #61 to the shower room. Staff B said some days the resident refuses her shower and she cleans her in bed and fixes her hair. Review of the CNA documentation revealed Resident #61 was scheduled for showers on Wednesdays and Saturdays during the 3:00 p.m., to 11:00 p.m., shift. The documentation showed on 1/8/25, 1/11/25, 1/18/25 and 1/22/25 Resident #61 did not receive her scheduled showers.

Based on observation, record review, resident, resident representative and staff interviews, the facility failed to ensure 3 (Residents #899, #799 and #75) of 4 sampled residents at risk for compromised nutrition received dietary supplements as ordered to maintain acceptable parameters of nutrition. The findings included: 1. On 2/6/24 at 9:00 a.m., in an interview Resident #900 said the facility runs out of food often and they have no salt packets right now. They are out of health shakes. The resident said her roommate (Resident #899) is supposed to get a health shake (dietary supplement) and had not received the shake with her meals for a few weeks now. Review of the clinical record for Resident #900 revealed an Admission Minimum Data Set (MDS) assessment with a target date of 12/5/23. The Assessment noted Resident #900's cognitive abilities for daily decision making were intact with a Brief Interview for Mental Status score of 15. 2. Review of the clinical record for Resident #899 revealed a physician's order dated 12/5/23 for health shakes with meals. Review of Resident #899's weight record revealed on 10/23/23 the recorded weight was 113.2 pounds (lbs.). On 12/5/23 the recorded weight was 109.8 lbs., a weight loss of 3.4 lbs. in two months. On 2/6/24 at 9:05 a.m., Resident #899's breakfast tray was observed, and did not include a health shake, or substitution. The meal ticket listed a health shake. On 2/6/24 at 9:05 a.m., Resident #899's family member who was present during the observation said, I'm here every day and I can tell you there has not been a health shake with breakfast for several weeks. I asked the kitchen staff, and they told me they don't have any. They are always running out of supplies in the kitchen, and she rarely has what is listed on the meal ticket. 3. On 2/6/24 at 10:00 a.m., in an interview the Dietary Director verified the facility had no health shakes for the residents and said the supply company did not supply the health shakes they ordered. She said, We have been out since yesterday. She also confirmed they ran out of salt packets. She said we are currently using a [brand name] supplement in place of the health shakes until they have a supply. That is the problem, we order them but the supply company does not have them so we don't get them delivered. On 2/6/24 at 10:15 a.m., in an interview with the Registered Dietitian (RD) said I have worked at the facility for 2 1/2 years and feel the portion size at meals is adequate to meet the resident needs. She said they use consistent size scoops. I have not noticed a weight loss trend in the facility. 4. Review of the clinical record for Resident #799 revealed a physician's order dated 7/18/23 for health shakes with each meal for abnormal weight loss. The Resident's weight record revealed on 12/4/23 Resident #799's weight was 132.8 pounds (lbs.). On 1/4/24 the recorded weight was 126.2 lbs., a 6.6 lbs. weight loss in two months. On 2/6/24 at 12:30 p.m., in an interview Resident #799's family member said, I come daily to feed my mother lunch. The facility runs out of shakes all the time. She is supposed to get one for every meal, but she doesn't always get them. I bring my own ensure and ice cream for her and I feed her every day for lunch. On 2/6/24 at 12:30 p.m., the resident's lunch tray was observed and did not include a health shake or substitution. 5. Review of Resident #750's clinical record revealed a physician ordered dated 1/16/24 for house shakes or equivalent with meals for weight loss. Review of the weight record for Resident #750 revealed an admission weight of 122.2 lbs. on 12/18/23. On 2/5/24 the resident's recorded weight was 114 lbs., a loss of 8.2 lbs. On 2/6/24 at 12:24 p.m., in an interview the Dietary Director, said residents did not receive [brand name] supplement as a substitution for the health shakes because the facility did not have the [brand name] supplement. On 2/6/24 at 1:20 p.m., in an interview the RD said Resident #750 was on weekly weights and ate 75% of meals. He sometimes took the shakes, with an intake range of 50 to 100%. The RD said the resident triggered for weight loss on 1/15/24 so she added the shakes. The RD said if the resident does not receive the ordered shakes, it would 100% affect the weights. The RD said, I was not aware there was a problem with the shakes. I found out last week they did not have the shakes for one day.

Based on observation, review of the clinical record, resident, resident representative and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #999, #900, and #899) of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: The facility policy, Nursing-Activities of Daily Living (ADL's) documented, The facility shall ensure a resident is given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . 1. Review of the clinical record revealed Resident #999 was 82 had an admitted [DATE], with diagnoses including Parkinson's disease, sepsis, muscle weakness and need for assistance with personal care. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 1/18/24 documented Resident #999 required maximum assistance of one for showers/bathing. The MDS noted Resident #999's cognitive skills for daily decision making was intact with a Brief Interview for Mental Status (BIMS) score of 13. Review of the Certified Nursing Assistant (CNA) documentation for January 2024 revealed that Resident #999 preferred showers on the 3:00 p.m., to 11:00 p.m., shift on Mondays and Thursdays. The record showed a shower was documented on 1/18/24. No other showers were documented from admission on 1/11/24 through discharge 1/22/24. One bed bath was documented on 1/19/24. The clinical record did not document a reason for the missed scheduled showers on 1/11/24, 1/15/24 and 1/22/24. On 2/7/24 at 9:00 a.m., the Director of Nursing (DON) confirmed the CNA documentation documented only one shower was provided to Resident #999 during the 12 days he resided at the facility. 2. Review of the clinical record revealed Resident #900 had an admitted [DATE], with diagnoses including rheumatoid arthritis, muscle weakness and need for assistance with personal care. The Admission Minimum Data Set (MDS) with an ARD of 12/5/23 documented Resident #900 required maximum assistance of 1 for showers/bathing. The MDS noted the residents cognitive skills for daily decision making were intact with a BIMS score of 15. On 2/7/24 at 8:45 a.m., in an interview Resident #900 said sometimes I get my showers, it depends on who is working. Some CNAs are better than others. Review of the CNA documentation for January 2024 revealed that Resident #900 preferred showers on the 7:00 a.m., to 3:00 p.m., shift on Tuesdays and Fridays. The CNA documentation showed the resident received one scheduled shower on 1/30/24. She received a bed bath on 1/11/24, 1/16/24, and 1/25/24. There was no documentation recorded on scheduled shower days on 1/2/24, 1/5/24, 1/12/24, 1/19/24, and 1/26/24. 3. Review of the clinical record revealed Resident #899 had an admitted [DATE], with diagnoses including Alzheimer's disease, anxiety, need for assistance with personal care and muscle weakness. The Quarterly MDS with an ARD of 1/11/23 documented Resident #899 required was dependent on staff for showers/bathing. The MDS noted the residents' cognitive skills for daily decision making were severely impaired with a BIMS score of 03. On 2/6/24 at 9:05 a.m., in an interview Resident #899's family representative said, I'm here every day and I don't think she is being showered as often as she is supposed to. Her hair is greasy and does not look right. I know they are not providing oral care. Her dentures are dirty, and food is caked on them. She is often soaked with urine when I get here. Resident #899 was observed in her bed, her hair was uncombed and greasy. Review of the CNA documentation for January Resident #899 revealed the resident preferred showers on Monday and Thursday on the 7:00 a.m. to 3:00 p.m., shift. The CNA documentation recorded Resident #899 received a bed bath on 1/1/24, 1/4/24, 1/8/24, 1/11/24, 1/18/24, 1/22/24, 1/25/24. There was no documentation on the scheduled shower day on 1/15/24, 1/29/24. The resident received a shower on the 3:00 p.m., to 11:00 p.m., shift on 1/2/24 and 1/11/24. The CNA documentation revealed no documentation of oral care on the 7:00 a.m. to 3:00 p.m., shift on 1/3/24, 1/5/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/24/24, 1/28/24 and 1/29/24. No oral care was documented on the 3:00 p.m. to 11:00 p.m., shift on 1/5/24, 1/7/24, 1/17/24 and 1/27/24. On 2/6/24 at 9:35 a.m., in an interview CNA Staff B said, We give showers every day, it is on the assignment sheet. If the resident doesn't want it, I do a bed bath and tell the nurse. On 2/6/24 at 10:40 a.m., in an interview CNA Staff C said, We are to turn the residents every two hours and I tell the nurse if I see anything. We offer fluids and fill the ice cups every shift, someone is assigned. There is a shower list at the desk and showers are in the CNA Care Kardex (Provides instruction for care), if a resident refused a shower I would try again and if they still refuse, I let the nurse know.

Based on observation, review of manufacturer recommendations, staff and resident interviews, the facility failed to maintain 1 of 2 sit to stand lifts used to transfer residents in safe operating condition. The findings included: The [brand name] Instruction for Use Manual of the sit to stand lift specified Periodic testing to be carried out at weekly intervals . Adjustable width chassis function: Open and close the chassis legs to check for full and efficient movement. The manual specified the transfer shall be performed with the chassis legs closed, as this will be easier when maneuvering. On 2/6/24 at 9:00 a.m., in an interview Resident #900 said the [brand name] sit to stand Lift was not working, the legs do not close, and I am afraid the staff will drop me. I was dropped at another facility and fractured my back. The Lift remote is broken too, it has been broken for several weeks. On 2/6/24 at 9:15 a.m., CNA Staff A was observed pushing a sit to stand lift down the halls from Unit A to Unit B with the legs of the lift in open position. CNA Staff A said the legs of the lift did not close. She said the lift has been broken for approximately two weeks but it was still being used to transfer residents. She said, We just can't close the legs. CNA Staff A said the lift remote was broken therefore you must manually push the buttons to work the lift. She said she had written in the Maintenance Log at the nursing desk, the lift required repair and said, sometimes it takes a while for maintenance to fix things. Review of the maintenance log for Unit A, B and C did not show a repair request for the broken sit to stand lift. On 2/6/24 at 9:35 a.m., in an interview CNA Staff B said, the lifts are broken frequently, and it takes a long time for Maintenance to make the repairs. I know the [brand name] lift has been broken for several weeks now but we use it to get the residents out of bed. On 2/6/24 at 1:10 p.m., in an interview the Maintenance Director said the lifts were last yearly inspection of the lifts was done on 5/15/23 by a contracted company. The repairs are made by a special technician who comes upon request. The Maintenance Director said he checks the maintenance logbook daily and the broken sit to stand lift was not logged in. He said he just found out about the broken lift today and has sent a repair request to the technician who will come in three days. The Maintenance Director provided documentation of the last technician report for a sit to stand lift dated 12/13/22. He said, There is a communication problem here sometimes. I can't call for a repair if I don't know it is broken. Review of the Inspection Report for the [brand name] sit to stand Lift was dated 5/15/23. Review of the technician report for Lift was dated 12/13/22. The Maintenance Director said there is a communication problem here sometimes. I can't call for a repair if I don't know it is broken. I had them remove the broken lift. On 2/6/23 at 2:51 p.m., the Maintenance Director said there were six different lifts in use in the facility but only two sit to stand lifts. He said, I can tell you the [brand name] sit to stand lifts were never repaired because I did not know they were broken.

Based on observation and staff interviews, the facility failed to ensure insulin vials and pens were properly labeled and dated when opened, in medication carts for 1 (C wing) of 3 wings reviewed. Without an open date on the insulin there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: On 8/16/23 at 9:00 a.m., during an observation of medication cart #3 on the C wing with Registered Nurse (RN) Staff A the following was observed: 1. One open bottle of Glargine insulin for Resident #950 without a date of when it was opened. The pharmacy label documented to discard after 28 days. Photographic evidence obtained. 2. One open bottle of Glargine Insulin in the medication with no resident identification label and no open date. Photographic evidence obtained. 3. One open bottle of Aspart insulin for Resident #800 without a date of when it was opened. The findings were verified by RN Staff A. 4. One Aspart insulin pen for Resident #850 without a date of when it was opened. The findings were verified by RN Staff A. On 8/16/23 at 9:30 a.m., during an observation of medication cart #1 on the C wing with Licensed Practical Nurse (LPN) Staff B the following was observed: 5. One open bottle of Glargine insulin for Resident #799 with an open date of 6/23/23. The Pharmacy label specified to discard the medication 28 days after opening. 6. One open bottle of Lispro insulin for Resident #900 without a a date of when it was opened. The pharmacy label documented to discard after 28 days. The findings were verified by LPN Staff B. 7. One open bottle of Glargine Insulin for Resident #700 with an expiration date of 8/2/23 on the label. Resident #700 was discharged from the facility on 8/2/23. The findings were verified by LPN Staff B. On 8/16/23 at 3:07 p.m., the Administrator said the facility had no policy specific to insulin storage but staff should follow the pharmacy recommendations.

Based on observation, record review, review of the facility's policies, staff, and resident interview the facility failed to have documentation of analysis of falls to implement appropriate interventions to prevent avoidable falls and fall related injuries for 3 residents (#17, #48, #76) of 4 residents reviewed who sustained falls at the facility. The findings included: A review of the facility policy and procedure, Falls Policy, revised 7/29/2022 stated, The intent of this policy is to ensure the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls. The policy further states, all residents will have a comprehensive fall risk assessment on admission, quarterly, annually and with significant change in condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each resident. The care plan will be reviewed following each fall, quarterly, annually and with each significant change. The facility fall guidelines stated if a fall occurs the following actions will be taken, evaluate the resident including neuro-checks, pain assessment, range of motion, skin, joint, extremities and vital signs. Neuro-checks x (for) 72 hours will be initiated for all unwitnessed falls. Once resident is stabilized nurse will conduct a Fall Huddle will all staff working on that hallway. Interventions must be initiated. Enter residents name on 24-hour report for minimum of 72 hours for follow up charting on every shift. 1. Review of the clinical record showed resident #76 had an admitted [DATE] and had severe cognitive impairment. Review of fall documentation showed resident #76 sustained a fall at the facility on 8/30/22, 9/5/22, 11/18/22. Review of the progress notes revealed documentation on 11/18/22 at 10:55 a.m., the Certified Nursing Assistant (CNA) notified the nurse the resident was agitated and trying to get out of bed repeatedly. While checking for the resident's PRN (as needed) order the CNA approached her and said the resident had fallen. The nurse documented when she entered the room the resident was sitting upright on the floor mat, leaning her left side against the right side of the bed. The resident was transferred to bed. A care plan intervention for resident #76 was last updated 9/9/22 which included a therapy evaluation for positioning in wheelchair. On 11/28/22, at 10:21 a.m., resident #76 was sitting in bed and stated she was, not so good today, I fell and hit my head today, people came and looked at it. Resident pointed to swelling lump on forehead. Resident noted to have large golf ball size lump in right center of her forehead with abrasion present. On 11/28/22, at 12:21 p.m., resident #76 daughter was at the bedside and said the nurse practitioner and hospice agency were planning to put a different mattress on the bed with sides. The clinical record lacked documentation of implementation of post fall assessment, updated interventions or neuro-checks after the fall on 11/28/22. On 11/28/22 at 3:22 p.m., resident #76 progress note stated, resident is complaining of a headache, Tylenol and Tramadol given. On 12/1/22 at 11:21 a.m., Licensed Practical Nurse (LPN), Staff I said she was assigned to resident #76. She said routine care for unwitnessed fall included neuro-checks (neurological checks) for 72 hours or send the resident out, alert the CNA what to watch for. Staff I said she was not aware Resident #76 had a fall. After reviewing the progress notes, LPN Staff I verified neurological checks were not initiated on 11/28/22 after the resident sustained a fall and hit her head. She said Resident #76 was taking Plavix (blood thinner) and should have had neuro-checks started. On 12/1/22 at 11:46 a.m., the Director of Nursing (DON) said taking Plavix would put Resident #76 at increased risk for bleeding after the fall. She said neurological checks should have been initiated immediately. The DON said she will be contacting the physician. 41155 2. Review of the clinical record for Resident #17 revealed a readmitted [DATE]. The record contained a quarterly minimum data set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #17 required extensive assistance of 1 with toileting, and supervision and assistance of 1 with ambulation in her room. The MDS identified Resident #17 was occasionally incontinent of bowel and bladder and was not on a toileting program. On 9/11/22 at 5:30 a.m., Resident #17 was found on the floor in her room. The Event Details form documented, the nurse heard the closed room door rattling and slowly opened it to find the resident on the floor behind the door, kicking the door in distress, saying I fell , and I'm hurt. Resident has a large hematoma on right side of head, small amount of bleeding in hair. Resident complains of acute back pain. The resident was transferred to the local hospital emergency room where she was diagnosed with a T 11 (thoracic spine) compression fracture and anterior wedge compression fracture T 12. The resident had surgical repair of the fracture on 9/12/22. The care plan initiated 10/31/20 (revised 8/25/22), identified Resident #17 was at risk for falls related injury as determined to generalized weaknesses, anemia, and muscle weakness. The interventions included assist for toileting and transfers as needed and place call bell within easy reach. Complete review of the clinical record failed to reveal documentation of a fall assessment and the facility was not able to provide one at the time the survey completed. On 11/28/22 at 10:30 a.m., Resident #17 said she fell and fractured her back while at the facility. She said she was not sure when she fell but said it was recently. Resident #17 said sometimes it takes more than 15 minutes before staff answer her call light. She said she had back pain due to breaking her back in the fall. On 11/30/22 at 2:23 p.m., the Director of Nursing (DON) said we met with the interdisciplinary team every morning and reviewed falls and updated the care plan. The care plan for Resident #17 documented on 2/27/18 to observe for appropriate footwear, use nonskid socks. On 10/10/22 the care plan was updated again to encourage to wear nonskid socks when not in bed. The DON said Resident #17 was readmitted to the facility on [DATE] after a fall at home, she was here for therapy, and she was doing well. The resident was taking care of herself and was going to discharge back home in a few days, but she fell and broke her back. The DON confirmed there was no documentation of an investigation into the cause of the residents fall to implement appropriate interventions to prevent further falls. On 12/1/22 8:24 a.m., Certified Nursing Assistant (CNA) Staff A said before her fall, Resident #17 used to get things done herself we would supervise her. When walking to the bathroom or in the hall we supervised her, she was going to be discharged home. CNA Staff A said, now she can do things on her own, but we supervise her for safety. On 12/1/22 at 8:36 a.m., Resident #17 said the night she fell , she couldn't reach the call light. The door was closed and it was dark. She said she got up unassisted and tripped over the bedside table, fell and hurt herself. It took over 15 minutes form for someone to come and get her off the floor. 3. A review of the clinical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. The record showed a quarterly MDS dated [DATE] documented the resident had a BIMS score of 15, indicating intact cognition. The MDS documented the resident required extensive assistance of 1 with bed mobility, transfers, toileting, dressing, and personal hygiene. The MDS documented the Resident was frequently incontinent of bowel and bladder and was not on a toileting program. The care plan initiated 2/27/18 identified the resident was at risk for fall related injury due to poor sitting and standing balance, unsteady gait, and dementia. The interventions included to observe for appropriate footwear; use nonskid socks, remind resident to request assistance prior to ambulation and or transfers, remind resident to lock brakes on wheelchair. Complete review of the clinical record failed to reveal documentation of a fall assessment and the facility was not able to provide one at the time the survey completed. On 10/9/22 at 2:37 p.m., Resident #48 was found on the floor. The Event Details form documented; Resident observed lying on bathroom floor. Resident sent to emergency room for further evaluation. A nursing progress noted dated 10/9/22 at 3:25 p.m., documented the resident observed lying on floor. Resident stood up in bathroom and loss her balance and fell on floor. Denies pain or discomfort. Able to move all extremities without discomfort. Some skin discoloration noted on arms and abdomen. Resident did not hit her head. Her legs are weak. Resident was educated about keeping socks or shoes on feet when going to the bathroom. A nursing progress note dated 10/9/22 at 7:48 p.m., documented the resident complained of pain to left elbow. New order received to obtain x-ray of left elbow. On 10/10/22 at 1:09 p.m., the nursing progress note documented post fall, resident complained of left elbow pain, area noted swollen, slight red. X-ray was still pending. The physician issued an order to send the resident to the emergency room for evaluation. The resident was transferred to the local hospital emergency room where she was diagnosed with a left olecranon (part of the ulna that creates a hinge for elbow movement) fracture and was admitted to the hospital. On 11/28/22 at 1:58 p.m. Resident #48 was observed sitting in a wheelchair in her room. The resident had a sling on her left arm. Resident #48 said she had a fall in the bathroom a few months ago and had a fracture in the left shoulder. She said she had fallen and pointed to the middle of the room, floor. Resident #48 said she did not know how she fell , and said I had to use the bathroom. She said she did not know if she had used the call light. On 11/30/22 at 11:37 a.m., in an interview the DON, said she had no documentation of what interventions were in place when the resident fell and she did not have documentation of an investigation of the fall. 11/30/22 at 1:29 p.m., the DON said Resident #48 was working with therapy at the time of the fall and was independent with her care needs. The DON said the care plan was the documentation that the care plan interventions were in place at the time of the fall.

Based on record review, review of policies and procedures, resident and staff interviews, the facility failed to monitor the weight and implement intervention to prevent ongoing weight loss for 1 (Resident #50) of 4 sampled residents identified with significant weight loss. Resident #50 experienced a 7.6% significant weight loss in 46 days and continued to lose weight without appropriate interventions and monitoring. The findings included: The facility's weight and measuring height policy with an effective date of 3/22/22 noted, Guidance and best practice . Significant weight changes are considered significant changes in condition and require facility staff assessment/intervention .Facility staff will notify the charge nurse and Registered Dietician of 5% gain or loss . notify physician of weight change . Review of the clinical record indicated Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, and unspecified severe protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/31/22 noted the resident's cognition was intact. The resident was coded as having been 67 inches tall and weighed 144 pounds. The resident was receiving a regular diet. Review of Resident #50's care plan initiated edited on 9/1/22 noted the resident was at risk for malnutrition related to but not limited to advanced age, abnormal labs, inadequate oral intake, history of failure to thrive, anorexia, cachexia (Complex syndrome causing ongoing muscle loss), and Chron's disease (Chronic inflammatory disease of the intestines). The goal was to maintain adequate nutritional status as evidenced by maintaining weight and no signs or symptoms of malnutrition. The interventions included to administer nutritional support as ordered, report to the physician signs and symptoms of malnutrition, significant weight loss. Review of the Nutritional Review with an effective date of 11/21/22 revealed documentation the resident's weight was down significantly for one month and stable for three and six months. The Registered Dietitian documented the resident had fair oral intake, she will add health shakes 120 milliliters twice a day and will obtain weekly weights. Resident #16's orders did not list the health shakes and weekly weight. On 11/28/22 at 10:03 a.m., Resident #50 said he has lost weight in the last month, adding, I am skin and bone. Review of the weights and vitals summary revealed the following weights documented for Resident #50: 9/2/22: 148.2 lbs. (pounds). 10/18/22:140.6 lbs. (a significant weight loss of 7.6% in one month). 11/30/22:135.0 lbs. On 11/30/22 at 9:49 a.m., a phone interview was conducted with the Registered Dietitian (RD). The RD said Resident #50 experienced a 7.6 pounds weight loss from September 2, 2022, to October 18, 2022, and lost another 5.6 pounds as of 11/30/22. The RD identified the weight loss as severe and said Resident #50 should be on weekly weights and supplements. The RD said she documented her recommendations and findings on her notes on 11/21/22 but did not inform the physician of the weight loss. She said, I missed this one completely. The Dietitian said she assessed the resident and recommended health shakes and nursing had not contacted the physician to order the shakes as of now. She verified the nursing staff did not obtain weekly weights for Resident #50 as per her recommendation. On 11/30/22 at 10:10 a.m., the Director of Nursing (DON) said she was not aware of Resident #50's significant weight loss. The DON said when a resident experiences significant weight loss, the expectation is to put interventions in place to encourage weight gain.

Based on record review, staff interviews and policy review the facility failed to ensure timely report of injuries of unknown origin to the State Survey Agency for 1 (Resident #84) of 4 residents reviewed. The findings included: A review of the facility, Policy, Procedures and Information, with an effective date of 4/1/2022 stated, it will be the policy of this facility to ensure that all alleged violations of Federal or State laws, which involve . injuries of undetermined source.not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/Abuse coordinator/designee. Appropriate agencies will be notified in accordance with existing laws. An injury of unknown source is an injury that was not observed by any person and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incidence of injuries over time. On 11/28/22 at 11:03 a.m., Resident #84 was observed lying on her left side, facing the window, her arm exposed to air. A large approximately 3-inch skin tear was observed on her right arm with a small bruise just below it. Resident #84 was awake with eyes open but did not respond to simple questions. On 11/28/22 at 3:14 p.m., Resident #84 was observed with a dated and initialed dressing to her right forearm. On 11/29/22, a clinical record review noted resident #84 was admitted on [DATE]. Resident #84 diagnoses included Dementia, Muscle weakness, and routine healing of a right hip fracture. An event report dated 11/27/22 noted, resident found with skin tear to left forearm in bed. On 12/01/22 at 11:46 a.m., the Director of Nursing (DON) confirmed she could not tell by the information in the risk report how the skin tear occurred and said the resident was not able to assist with care and express how the injury occurred. The DON said the injury should have been reported and investigated.

Based on record review, staff interviews and policy review the facility failed to have documentation of investigation of an injury of unknown origin for 1 (Resident #84) of 4 sampled residents. The findings included: A review of the facility Policy, Procedures and Information with an effective date of 4/1/2022 stated, it will be the policy of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse, injuries of undetermined source .not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/Abuse coordinator/designee. Appropriate agencies will be notified in accordance with existing laws. An injury of unknown source is an injury that was not observed by any person and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incidence of injuries over time. On 11/28/22 at 11:03 a.m., Resident #84 was observed lying on her left side, facing the window, her arm exposed to air. A large approximately 3-inch skin tear was observed on her right arm with a small bruise just below it. Resident #84 was awake with eyes open but did not respond to simple questions. On 11/28/22 at 3:14 p.m., Resident #84 was observed with a dated and initialed dressing to her right forearm. On 11/29/22, a clinical record review noted resident #84 was admitted on [DATE]. Resident #84 diagnoses included Dementia, Muscle weakness, and routine healing of a right hip fracture. An event report dated 11/27/22 noted, resident found with skin tear to left forearm in bed. On 12/01/22 at 11:46 a.m., the Director of Nursing (DON) confirmed she could not tell by the information in the risk report how the skin tear occurred and said the resident was not able to assist with care and express how the injury occurred. The DON confirmed she did not investigate the event and that currently it was day five since the skin tear was identified. The DON said the injury should have been investigated.

Based on record review, and staff interviews, the facility failed to ensure ongoing monitoring for complications, coordination and response to the dialysis center's multiple requests for weight monitoring for 1 (Resident #96) of 1 sampled resident receiving dialysis. The findings included: A review of clinical record for Resident #96 showed a date of admission of 4/26/2022, and readmission of 11/15/22 with diagnoses including end stage renal disease, and dependence on renal dialysis (procedure to remove waste products an excess fluid from the blood). The physician orders included to check the resident's weight before and after dialysis. The care plan initiated on 11/19/22 documented the resident needed hemodialysis related to renal failure. The interventions included to obtain weight per protocol. A review of the clinical record revealed the facility used a Dialysis Hand off Communication report to coordinate with the dialysis center. The form included a section to document pre and post dialysis weight. On 10/26/22 the dialysis center documented on the form, We need the weight: Please report weight to dialysis. On 10/27/22 the dialysis center documented on the form, Please weigh. On 10/31/22 the dialysis center documented on the form, Can you please weigh and report weight to dialysis. On 11/2/22 the dialysis center documented on the form, Please weigh and report to dialysis. The dialysis communication forms revealed no documentation of pre-dialysis weights on 10/26/22, 10/27/22, 10/31/22, 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/11/22, 1/17/22, 11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22. On 11/2/22, 11/3/22, 11/10/22, 11/11/22, 11/18/22, 11/28/22, 11/30/22 the dialysis communication form did not note the nursing staff evaluated Resident #96 upon return from dialysis. On 12/1/22 at 10:45 a.m., dialysis Registered Nurse (RN) Staff M said pre-dialysis weights were important, and the dialysis center did not always get Resident #96's pre-dialysis weight. On 12/1/22 at 12:04 p.m., Licensed Practical Nurse (LPN) Staff C verified the lack of documentation of pre-dialysis weight for Resident #96 on 10/26/22, 10/27/22, 10/31/22, 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/11/22, 1/17/22, 11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22. On 12/1/22 at 12:19 p.m., the Director of Nursing (DON) said the nurse was responsible to ensure pre and post dialysis weights are obtained and communicated to the dialysis center, as they to not have access to the facility's electronic clinical record. The DON verified the lack of documentation Resident #96 was evaluated by the facility nurse upon return from dialysis on 11/2/22, 11/3/22, 11/10/22, 11/11/22, 11/18/22, 11/28/22, and 11/30/22.

Based on record, review of policies and procedures, resident and staff interviews, the facility failed to notify the physician of a significant weight loss for 1 (Resident #50) of 2 residents reviewed for nutrition. The findings included: Review of weighting and measuring height policy with an effective date of 3/22/22 indicated the following: Significant weight changes are considered significant changes in condition and require facility staff assessment/intervention. Significant weight change is defined as: 1 month 5% weight loss/gain - 3 months 7.5% and 6 months 10% Severe loss/gain is defined as 1 month greater 5% - 3 months greater than 7.5% and 6 months greater than 10%. Facility staff will notify physician of weight change. Notify physician of significant changes. On 11/28/22 at 10:03 a.m., Resident #50 said he has lost weight in the last months, adding I am skin and bone. Review of the clinical record indicated Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, and hypertension. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/31/22 noted the resident's cognition was intact. The resident was coded as having been 67 inches tall and weighed 144 pounds. The resident was receiving a regular diet. Review of the weights and vitals summary revealed the following weights documented for Resident #50: 9/2/22: 148.2 lbs. (pounds). 10/18/22:140.6 lbs. (a significant weight loss of 7.6% in one month). 11/30/22:135.0 lbs. On 11/30/22 at 9:49 a.m., in a telephone interview the Registered Dietitian (RD) stated Resident #50 experienced a 7.6 lbs. weight loss from September 2, 2022, to October 18, 2022, and lost another 5.6 pounds as of 11/30/22. The RD stated she did not inform the Physician nor asked the Charge Nurse to do so. She stated, I missed this one completely. On 12/1/22 at 10:50 a.m., the Administrator stated it was her expectation for the attending physician to see a resident and explore further interventions when a resident had a significant weight loss to increase or maintain the resident's weight.

Based on record review and interview, the facility failed to honor advanced directives and administered cardiopulmonary resuscitation to 1 (Resident #1) of 3 sampled residents against the resident's expressed wished. The facility failed to have a process to verify advanced directives. On [DATE] Registered Nurse (RN) Staff A instructed RN Staff B to start Cardiopulmonary resuscitation (CPR) against Resident #1's expressed wishes when he was found without a pulse or respiration. Along with the physical trauma such as broken ribs, lung bruising, damage to internal organs, if Resident #1 was revived, he may likely have to be put on life-support to keep him alive. Individuals who receive CPR may suffer from serious long-term consequences like brain damage from oxygen deprivation. Resident #1 would likely suffer serious psychosocial harm, from the experience. The Immediate Jeopardy started on [DATE]. On [DATE] at 3:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and was provided the Immediate Jeopardy template. The Immediate Jeopardy ended on [DATE] at 5:30 p.m. The scope and severity of the citation was reduced to D. The findings included: The facility's policy for Cardiopulmonary Resuscitation revised on [DATE] read, CPR will be attempted on any resident who clinically exhibits no palpable pulse and/or discernible respirations. UNLESS a. A signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g., Advanced Directive, in the medical record, etc.). The signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (i) A yellow form. (ii) Telephonic, with verification of 2 nurses or (iii) Any other acceptable written physician order [MEDICAL RECORD OR PHYSICIAN ORDER] OR b. A medical director instructs otherwise, as per Florida Statute 401.45; OR c. Obvious clinical signs of irreversible death exist (e.g., severe rigor mortis, dependent lividity, decapitation, decomposition, etc.). The policy did not include a procedure to verify the Resident's advanced directives related to CPR when a resident is found without a pulse or respiration. On [DATE] review of the clinical record revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] for rehabilitation services. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. On [DATE] Resident #1 signed a Do Not Resuscitate Order (DNR) that read, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. On [DATE] the attending physician signed the Do Not Resuscitate Order that read, I, the undersigned physician licensed pursuant to Chapter 458 or 459, F.S. (Florida Statutes) am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. The medical record face sheet was updated on [DATE] to reflect the DNR status. Review of the progress notes revealed on [DATE] at 11:26 p.m., RN Staff B documented . was interrupted by CNA (Certified Nursing Assistant) who made this nurse aware of Patient status in said room. Upon entering room patient was pale, and unresponsive to touch and sound. Patient had no resp [respiration], noted, and unarosable [sic] to sterum [sic] rub. No heart rate, or blood pressure noted at this time. CPR started until code status was verified by yellow form. Patient a DNR and CPR stopped immediately. A review of the facility's investigation showed on [DATE] at approximately 11:30 p.m., a Certified Nursing Assistant (CNA) found Resident #1 unresponsive in his room. RN Staff A and RN Staff B assessed Resident #1 and found he had no pulse or respiration. RN Staff A instructed RN Staff B to start CPR without checking the code status. RN Staff B initiated CPR. RN Staff A went to the nurse's station and activated Emergency Medical Services (EMS). EMS arrived at the facility at approximately 11:35 p.m. and took over. RN Staff A was at the nurse's station making copies of paperwork for EMS when she noticed a DNR status on Resident #1's face sheet. She provided the documentation of DNR status to EMS and CPR stopped at that time. On [DATE] at 1:38 p.m., in a telephone interview RN Staff A said she instructed RN Staff B to start CPR because Resident #1 was young and healthy. She said when he was found unresponsive, it was unexpected. She said he was doing well in therapy. On [DATE] at 1:50 p.m., in a telephone interview RN Staff B said she and Staff A entered Resident #1's together. She asked RN Staff A about the code status. She said RN Staff A left the room, came back, and told her Resident #1 was a full code and instructed her to start CPR. In a statement dated [DATE] RN Staff A wrote to the Director of Nursing (DON) I am writing regarding the issue we discussed earlier. Last night at approximately 11:30, CNA discovered resident in [room #] unresponsive, called for help & (RN Staff B) and I both responded and assessed patient. I assumed in error that this patient would be a full code as relatively young and healthy and quickly got crash cart, called the code, and called 911. When printing face sheet after EMS arrived noticed DNR status and we stopped code. RN Staff A and RN Staff B failed to follow the facility's policy and verify the code status before starting CPR. On [DATE] at 5:10 p.m., in an interview the RN Staff Educator said if a resident is found without pulse or respiration the procedure is to: Page a code blue to the location to get as many nurses as possible. One nurse stays with the patient. Initiate CPR unless there is a yellow DNR form or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] If CPR is initiated, CPR ceases after a valid DNR is found. The nurses are expected to look at the following documents to determine the resident's code status: The Medication Administration Report, bring up the documents uploaded in the computer or the DNR book to determine the code status. She said if they cannot verify the code status for example if the computer is down, the nurses are to initiate CPR until the code status is verified. She said on the day of the incident, RN Staff A verified the code status while RN Staff B started CPR. She verified based on the facility's investigation RN Staff A and RN staff B did not follow the facility's policy. The RN Staff Educator said the facility did not have a written procedure with steps to follow to verify the code status when a resident is found without a pulse or respiration. On [DATE], the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included the following immediate actions which were verified as implemented before the survey exit: A review of the facility's updated procedure dated [DATE] noted an emergency procedure which directs 2 nurses to verify the code status in a DNR binder located at each nurse's station. On [DATE] The Social Worker and the DON audited all residents advance directive and physicians orders for code status along with residents' care plans. Certified Nursing Assistants (CNA) care plans were audited by social services and the DON to ensure accuracy on [DATE]. On [DATE] Social Service assessed and interviewed residents for any possible resident rights violations. Residents with a BIMS score greater than 8 were interviewed. On [DATE] the Unit Managers or Nursing Supervisors physically assessed residents with BIMS score less than 8 for any signs and symptoms of possible quality of life or resident rights violations. On [DATE] the DON and Nursing Supervisors audited the clinical record of all residents admitted in the past 30 days for compliance with the admission process including notification of attending physician, review of admitting orders including code status and ensure professional standards were followed. On [DATE] The DON and Nursing Supervisor audited all clinical records to ensure compliance with delivery of quality of care. On [DATE] the Signature Clinical Consultant (SCC) instructed all management staff on the advance directive policy and procedure, admission/physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the facility completed all nurses on the Advanced Directives Policy and Procedure, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Education regarding the policies included in the orientation process for all newly hired nursing staff members. No newly hired nursing employee will be allowed to work until education has been obtained. On [DATE] the Human Resource department or Staff Development Coordinator (SDC) audited all personnel files for CPR certification. On [DATE] the SDC educated all nurses present at the facility on the updated CPR policy and procedure to include the quickest method identification of the code status using the DNR book. On [DATE] the SDC completed education of 100% of working nursing staff on the new procedure regarding CPR, including the quickest method of identification of code status using DNR book before initiating CPR to honor residents expressed advanced directives. The facility verified understanding through a post-test. The facility conducted mock drills on all shifts starting on [DATE] to demonstrate and evaluate the nurses' understanding of the procedure to follow when a resident is found without a pulse or respiration.

Based on record review and staff interview the facility failed to utilize its resources effectively to ensure each resident's resuscitation wishes were honored. The facility administration failed to implement written procedures to ensure residents' wishes for advanced directives were honored. There were 34 residents in the facility with wishes not to be resuscitated. These actions resulted in Immediate Jeopardy that started on [DATE] when 1 (Resident #1) of 3 residents reviewed received Cardiopulmonary Resuscitation (CPR) against the resident's expressed wishes. The facility's failure to honor residents' wishes not to be resuscitated would likely result in the resident experiencing major physical trauma including broken ribs, lung bruising, internal bleeding, and damage to the airway and internal organs. If a resident were revived against their wished, they may likely have to be put on life-support to stay alive. Individuals who receive CPR may suffer from serious long-term consequences like brain damage from oxygen deprivation. Residents would likely suffer serious psychosocial harm from the experience. On [DATE] at 2:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the Immediate Jeopardy template. The Immediate Jeopardy ended on [DATE] at 5:30 p.m. The scope and severity of the citation was reduced to D. The findings included: The Administrator's job description signed on [DATE] read Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. The Director of Nursing's job description signed on [DATE] included . Verify that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives . The facility's policy for Cardiopulmonary Resuscitation revised on [DATE] read, CPR will be attempted on any resident who clinically exhibits no palpable pulse and/or discernible respirations. UNLESS a. A signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g., Advanced Directive, in the medical record, etc.). The signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (i) A yellow form. (ii) Telephonic, with verification of 2 nurses or (iii) Any other acceptable written physician order [MEDICAL RECORD OR PHYSICIAN ORDER] OR b. A medical director instructs otherwise, as per Florida Statute 401.45; OR c. Obvious clinical signs of irreversible death exist (e.g., severe rigor mortis, dependent lividity, decapitation, decomposition, etc.). The policy did not include a procedure to verify the Resident's advanced directives related to CPR when a resident is found without a pulse or respiration. A review of Resident #1's record on [DATE] showed he was admitted to the facility on [DATE]. Resident #1 had a valid DNR dated [DATE]. A review of the facility's investigation showed on [DATE] at approximately 11:30 p.m., a Certified Nursing Assistant (CNA) found Resident #1 unresponsive in his room. RN Staff A and RN Staff B assessed Resident #1. Resident #1 had no pulse or respiration. RN Staff A instructed RN Staff B to start CPR without checking the code status. RN Staff B initiated CPR. RN Staff A went to the nurse's station and activated Emergency Medical Services (EMS). EMS arrived at the facility at approximately 11:35 p.m. and took over. RN Staff A was at the nurse's station making copies of paperwork for EMS when she noticed a DNR status on Resident #1's face sheet. She provided the documentation of DNR status to EMS and CPR stopped at that time. On [DATE] at 12:30 p.m., in an interview the facility's Staff Development Coordinator (SDC) said the policy for CPR was revised on [DATE] by their corporate office. She started in-services for the nurses in the facility on the revised policy. A review of the in-services dated [DATE], [DATE], [DATE] and [DATE] failed to reveal documentation RN Staff B was educated on the new policy. On [DATE] at 5:10 p.m., the RN Staff Development Coordinator (SDC) said she did not do a formal in-service but spoke to the nurses 2 to 3 at a time during their shift and the training did not include verification of understanding of the policy but answered any questions the nurses had. She said a total of 27 of approximately 41 nurses were educated. She said although the facility also conducted a mock drill on [DATE] it included a situation where a resident was a full code and 2 nurses verified the code, CPR was not provided since the resident regained consciousness. The scenario did not include a DNR resident. A review of this mock code blue drill showed it was conducted on [DATE] at 12:45 p.m., revealed 8 nurses participated in the mock drill. RN Staff A and RN Staff B did not participate in the mock code blue drill to demonstrate their understanding of the facility's policy when a resident is found without a pulse or respiration. The SDC said she did not in-services 100% of the staff since it was a policy change, and not a corrective action following an event. The facility Director of Nursing was not available during the survey to interview about the event. On [DATE], the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included the following immediate actions which were verified as implemented before the survey exit. On [DATE] at 11:00 a.m., in an interview the Administrator discussed the removal plan and said the Administrative staff was in-serviced on the new policy and procedure. The facility has started mock drills on each shift on [DATE]. Weekly Quality Assurance and Performance Improvement meetings on [DATE].

Based on interview and record review the facility failed to accurately assess and document 1 (Resident #282's) cardiac and respiratory status of 3 residents surveyed resulting in the resident expiring without clear documentation of the resident's physical status and the staff's actions in not performing Cardiopulmonary resuscitation (CPR) on the resident when he had requested to have full resuscitation initiated if he was found in cardiac, and respiratory arrest. The facility failed to provide effective assessment and nursing services resource management to promote and ensure the health all facility residents. The facility failed to provide nursing and medical services resulting in a continuation of the systems' failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to Advance Directives, notification of the physician regarding condition changes, and the implementation of full code in the absence of a Do Not Resuscitate (DNR). This failure resulted in death to a resident and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The findings included: 1. During a review of Resident #282's record on [DATE], noted he was an [AGE] year old male, admitted to the facility from Fawcett Hospital on [DATE]. Review of the hospital record documenting the resident was treated for [REDACTED]. Review of Resident #282's History and Physical (H&P), dated [DATE] documented "He is a functional quadriplegic as he cannot feed himself, toilet himself or get out of bed." He was dehydrated and malnourished. He was being treated for [REDACTED]. The hospital record documented Resident #282 was a Full Code. Full Code means if the resident was be found unresponsive, his wish is to have cardiopulmonary resuscitation attempted to revive him. During a review of Resident #282's record on [DATE] noted he was assessed at admission by a Licensed Practical Nurse (LPN) on [DATE]. The assessment documented the resident was a total assist with Activities of Daily Living (ADLs). He was incontinent and had an ostomy in place. He was assessed to have a regular heartbeat with [MEDICAL CONDITION]. He was assessed to have normal respirations with no [MEDICAL CONDITION], Apnea, Pneumonia, [MEDICAL CONDITIONS], or [MEDICAL CONDITIONS]. He had a Percutaneous Endoscopic Gastrostomy (PEG) Tube on admission, running Glucerna 1.5 at 70 centimeters/hour (cc/hr). He was to receive flushes of 200 cc every eight hours to his PEG Tube. During a review of Resident #282's nurse's note dated [DATE], he had no [MEDICAL CONDITION] and no respiratory issues. The nursing note written by the 7:00 a.m.-3:00 p.m. nurse documented the resident was alert with confusion and he was administered pain medication by the nurse. The nursing note dated [DATE] at 7:45 p.m., documented the resident was "moaning and groaning." The resident was administered pain medication at that time. The nurse documents the resident is extensive assist with activities of daily living and transfers. During a review of the nursing note dated [DATE], noted there was no documentation of an assessment of the resident's cardiac and respiratory condition. At 6:00 a.m. on [DATE], the nurse documents the resident is nonverbal and resting quietly. At 3:45 p.m., on [DATE], the nurse documents the resident's vitals as, "99.9 (temperature) 66 (heart rate) 18 (pulse) and ,[DATE] (blood pressure)." At 10:00 p.m. on [DATE], the nurse documents, "Resident alert. Resting in bed. PEG tube patent. Running Glucerna 1.5 at 70 cc/hr. As needed suctioning was ordered. Resident was found to be gurgling. Resident was suctioned with a positive effect. Vitals ,[DATE] (blood pressure) 24 (pulse) 64 (heart rate) and 99.0 (temperature). Will continue to monitor. Call light in reach." During a review of Resident #282's nurse's notes for [DATE], revealed no documentation of an assessment of the resident's cardiac or respiratory status. A nursing note dated [DATE] at 12:30 a.m., documented "This nurse was called into room as Certified Nursing Assistant (CNA) was making rounds. Patient found in the bed without a pulse. Supervisor called into the room to verify. Physician called and notified of death. Daughter called by the supervisor and notified. Awaiting phone call back from daughter regarding funeral home. At 1:00 a.m. on [DATE], the same nurse documents, "Son and Family member came in to see patient. Phone call made to funeral home." 2. Review of the facility's policy for "CPR-Code Blue" effective ,[DATE] documented "It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. Procedure Open the airway: 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart association guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the Emergency code documentation from to document the event." 3. During an interview on [DATE] at 10:45 a.m., Resident #282's daughter stated her father had declined in health a week or two before being put in the hospital on [DATE]. She stated he was not eating and had a tube placed in his stomach two days before being discharged from the hospital. She stated he was eating while he was at the nursing home. She stated her brother was feeding her father when he would go into visit him. She was asked about her father's wishes for end of life care. She stated "Daddy would joke about it and say if I'm gonna die, he wanted everything done for him that could be done." 4. During an interview on [DATE] at 11:10 a.m., Resident #282's primary physician stated he had spoken to the resident's son when the resident was admitted to the facility. He stated the family wanted Resident #282 to be a full code. He stated he had assessed the resident and had found no issues with the resident's respiratory status. He stated he had gone into the resident's room and found the resident's son feeding the resident. He told the son not to feed him at that time because he was not able to swallow food well. The physician stated the nurse had called him around 9:00 p.m. on [DATE], stating the resident needed suctioning. He was asked if there were any issues with aspiration of his tube feeding or respiratory difficulties. He stated the resident needed suctioning because he was having oral secretions due to the resident receiving a tube feeding. He stated he did give an order for [REDACTED]. He was told the resident was cold when they found him. He stated at that time, to call the funeral home. 5. During an interview on [DATE] at 12:20 p.m., the Administrator stated the nursing staff had failed to report to the DON that they had not performed CPR on Resident #282. She stated "The DON was reviewing the resident's chart after discharge on [DATE] and found he was a full code and CPR was not preformed according to policy." She stated she initiated a full investigation on [DATE]. She called Adult Protective Services and initiated an adverse incident 1 day reporting. The 3 nurses who failed to follow the facility's policy were suspended from working. Written statements were obtained from all staff involved in the incident. All staffs were in-serviced on the policy of full code status of the residents. Staff not on shift was sent a letter they could not work until they had received in-services on DNR policies. An audit was conducted of the current residents in the facility as to their status of DNR. The Sheriff's office was notified and a report was given to law enforcement. 6. During a telephone interview on 6/ ,[DATE] at 12:30 p.m., Staff A, the Registered Nurse (RN) supervisor, who was involved in the incident, stated the resident had been suctioned around 9:30 p.m., earlier in evening. She stated he was having oral secretions and once he was suctioned he was clear and had no respiratory distress. Staff A stated the color of the secretions pulled from Resident #282's throat were thick, yellow to white in color. She stated she was called into the room on [DATE] around 12:15 a.m., and found Resident #282 had no pulse or respirations. "His pupil was dilated and he was cold and stiff." Staff A, RN Supervisor, stated she made the decision not to perform CPR on Resident #282 because he was too far gone. She stated the 11:00 p.m.-7:00 a.m. nurse had called the resident's primary physician after he had expired. She stated she overheard her tell the physician the resident had passed and he was found cold and without vitals. She stated the physician had told the nurse to notify the funeral home and family. She was asked if she had been oriented in the policy of the facility regarding full code status. She stated she was oriented at general orientation when she had started to work at the facility. She was asked what the policy at the facility was for a full code. She stated "You start CPR and call 911." 7. During a telephone interview on [DATE] at 8:50 a.m., Staff E, the CNA who found Resident #282 unresponsive, stated he came on shift at 11:00 p.m. on [DATE]. He checked to ensure the resident was clean and dry at around 11:05 p.m. Between 11:30 p.m. and 12:00 p.m., he is not sure of the time; he went back in the resident's room and found he was not responsive. He stated he touched his throat and shook the resident and shouted at him. He then placed his finger under the resident's nose and determined he was not breathing. At that time he called for the nurses and went to get the crash cart. He stated the Licensed Practical Nurse (LPN) assigned to the resident did find the resident to be a full code. He stated the Registered Nurse (RN) supervisor made the decision not to do CPR. He was asked how the resident felt when he touched him. He stated "He was a bit warm." Staff E then stated he was completely unresponsive and he was not breathing. Staff E was asked why he had not filled out an incident report or reported the incident to the Director of Nursing (DON) or the Administrator. Staff E stated "I did not think I had done anything wrong. Looking back in hindsight I would have reported what had happened." 8. During a telephone interview on [DATE], at 9:02 a.m., the facility's Medical Director stated he was made aware of the issue on [DATE] when the Administrator found out about it. He stated he had reviewed the resident's chart and found that he was a sick person who should have been made a DNR. He stated he felt nursing staff had not followed the policy of the facility to start CPR on a resident who was a full code and calling EMS. He stated if Resident #282 was found to be thermally cold he would assume CPR would not be administered at that time. He stated in reviewing the chart he found a lack of documentation. He stated "There were a lot of holes." 9. During an interview on [DATE], at 10:05 a.m., Staff B, an LPN, stated she had assessed the resident around 9:30 p.m., and found he had gurgling sounds in the back of his throat. She stated she obtained an order from the primary physician to suction Resident #282. She stated the supervisor suctioned him and obtained a dark brown sputum from the back of his throat. She stated "I kept checking on him until 11:00 p.m. I auscultated (listened to) his lungs and he sounded clear. He had a temp of 99 when I checked at 11:00 p.m. I told the oncoming nurse she needed to call the physician and let him know he had a temperature. I don't remember what (Staff C) responded back to me." 10. During a telephone interview on [DATE], at 9:46 a.m., Staff C, LPN stated around 12:15 a.m. on [DATE], she was passing medications and the CNA called her to room [ROOM NUMBER] stating Resident #282 was not breathing. She stated she called for the nursing supervisor and checked the resident's chart and found he was a full code. She stated "I yelled down the hall to go ahead and start CPR." She stated "When I got to the room the supervisor said, what are you going to do that for. He's been gone." Staff C stated Resident #282 was yellow in color, cold and had no pulse when she initially assessed him. She stated she called the physician and reported the resident was found without a pulse and cold. She was told by the physician to call the funeral home. She was asked about reporting the incident. She stated "I did not think about reporting or doing an incident report. I thought the nursing supervisor would have reported it to the DON." 11. During a telephone interview on [DATE], at 11:00 a.m., Staff D, an LPN, stated she was passing medications and stopped to go and assist with the Code in room [ROOM NUMBER]. She stated it was approximately 12:30 a.m., on [DATE]. She stated Staff A, RN Supervisor, Staff E and CNA were in the room when she arrived. She stated the crash cart was in the room. Staff D stated "Staff A said we are not going to start CPR because it's too late he's already gone." She stated she and Staff C, another LPN looked at each other. But they did not question the supervisor about her decision. She stated she never touched or assessed Resident #282. 12. A review of the Medication Administration Record [REDACTED] 13. A review of the facility's policy for incident reporting documents "An incident report is to be completed for all falls, bruises and skin tears of known or unknown origin, resident to resident altercations, resident to employee altercations, medication errors or any other atypical occurrence. The following procedures will be implemented to effectively deal with incidents: 1. Incident and occurrence will be reported to the department supervisor. 2. Incident/Occurrence report will be completed by the charge nurse or the shift nurse that the incident/occurrence occurred. 3. Incident/Occurrence Investigation Form initiated by the Charge Nurse with completion by the DON/designee. 4. Charge Nurse/designee will add interventions to the care plan as needed." During an interview on [DATE], at 12:45 p.m., the Administrator verified the nurses involved with not performing CPR on Resident #282 were aware they were not following the policy of the facility in not performing CPR. She stated this should have been reported to the Administrator and the DON when it occurred. 14. A plan of correction provided by the facility on [DATE] was reviewed to verified implementation effectiveness. The plan included: A. The team reviewed the documentation of the in-services provided to 36 licensed staff who worked on all shifts in the facility. 5 licensed staff was sent letter telling them they could not work at the facility until the in-service was completed. Interviews were conducted with staff in all areas of the facility and over different shifts to ensure staff was aware of the policies. B. Residents were interviewed as to their Code status and verified with the documentation of the facility. The facility documented that every resident's code status was reviewed with the resident or their legal representative. The staff was observed calling resident's representatives and verifying Code status. C. A mock code was observed at the facility at 3:30 p.m., on [DATE]. Staff was observed to initiate CPR and EMS services for a staff member posing as a resident who was a full code. Documentation of mock codes was reviewed. Mock codes were documented as being done by the facility on all shifts. D. The facility's Allegation of Compliance was reviewed and accepted and the Immediate Jeopardy was removed on [DATE], at the exit conference. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses; had not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on facility record review and staff interviews, the facility failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #282) of the 3 residents' records reviewed. The facility failed to provide end of life care when the resident and his family had requested the resident be resuscitated if found in cardiac and respiratory arrest. The facility staff failed to coordinate services to follows policy and procedures in initiating Cardiopulmonary Resuscitation (CPR) and notifying Emergency Medical Services (EMS) resulting in the resident expiring without an attempt to revive. The facility failed to provide coordination of the notification of the physician regarding condition changes and the notification of administration when resident's rights were not honored and policy and procedures not followed, resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff demonstrating an understanding of facility expectations. This failure created a situation resulting in the death to a resident and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE], was identified on [DATE]. The findings included: 1. During a review of Resident #282's record on [DATE], noted he was an [AGE] year old male, admitted to the facility from Fawcett Hospital on [DATE]. Review of the hospital record documenting the resident was treated for [REDACTED]. Review of Resident #282's History and Physical (H&P), dated [DATE] documented "He is a functional quadriplegic as he cannot feed himself, toilet himself or get out of bed." He was dehydrated and malnourished. He was being treated for [REDACTED]. The hospital record documented Resident #282 was a Full Code. Full Code means if the resident was be found unresponsive, his wish is to have cardiopulmonary resuscitation attempted to revive him. During a review of Resident #282's record on [DATE] noted he was assessed at admission by a Licensed Practical Nurse (LPN) on [DATE]. The assessment documented the resident was a total assist with Activities of Daily Living (ADLs). He was incontinent and had an ostomy in place. He was assessed to have a regular heartbeat with [MEDICAL CONDITION]. He was assessed to have normal respirations with no [MEDICAL CONDITION], Apnea, Pneumonia, [MEDICAL CONDITIONS], or [MEDICAL CONDITIONS]. He had a Percutaneous Endoscopic Gastrostomy (PEG) Tube on admission, running Glucerna 1.5 at 70 centimeters/hour (cc/hr). He was to receive flushes of 200 cc every eight hours to his PEG Tube. The nursing note dated [DATE] at 7:45 p.m., documented the resident was "moaning and groaning." The resident was administered pain medication at that time. During a review of the nursing note dated [DATE], noted there was no documentation of an assessment of the resident's cardiac and respiratory condition. At 6:00 a.m. on [DATE], the nurse documents the resident is nonverbal and resting quietly. At 3:45 p.m., on [DATE], the nurse documents the resident's vitals as, "99.9 (temperature) 66 (heart rate) 18 (pulse) and ,[DATE] (blood pressure)." At 10:00 p.m. on [DATE], the nurse documents, "Resident alert. Resting in bed. PEG tube patent. Running Glucerna 1.5 at 70 cc/hr. As needed suctioning was ordered. Resident was found to be gurgling. Resident was suctioned with a positive effect. Vitals ,[DATE] (blood pressure) 24 (pulse) 64 (heart rate) and 99.0 (temperature). Will continue to monitor. Call light in reach." During a review of Resident #282's nurse's notes for [DATE], revealed no documentation of an assessment of the resident's cardiac or respiratory status. A nursing note dated [DATE] at 12:30 a.m., documented "This nurse was called into room as Certified Nursing Assistant (CNA) was making rounds. Patient found in the bed without a pulse. Supervisor called into the room to verify. Physician called and notified of death. Daughter called by the supervisor and notified. Awaiting phone call back from daughter regarding funeral home. At 1:00 a.m. on [DATE], the same nurse documents, "Son and Family member came in to see patient. Phone call made to funeral home." 2. Review of the facility's policy for "CPR-Code Blue" effective ,[DATE] documented "It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. Procedure Open the airway: 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart association guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the Emergency code documentation from to document the event." 3. During an interview on [DATE] at 10:45 a.m., Resident #282's daughter stated her father had declined in health a week or two before being put in the hospital on [DATE]. She stated he was not eating and had a tube placed in his stomach two days before being discharged from the hospital. She stated he was eating while he was at the nursing home. She stated her brother was feeding her father when he would go into visit him. She was asked about her father's wishes for end of life care. She stated "Daddy would joke about it and say if I'm gonna die, he wanted everything done for him that could be done." 4. During an interview on [DATE] at 11:10 a.m., Resident #282's primary physician stated he had spoken to the resident's son when the resident was admitted to the facility. He stated the family wanted Resident #282 to be a full code. He stated he had assessed the resident and had found no issues with the resident's respiratory status. He stated he had gone into the resident's room and found the resident's son feeding the resident. He told the son not to feed him at that time because he was not able to swallow food well. The physician stated the nurse had called him around 9:00 p.m. on [DATE], stating the resident needed suctioning. He was asked if there were any issues with aspiration of his tube feeding or respiratory difficulties. He stated the resident needed suctioning because he was having oral secretions due to the resident receiving a tube feeding. He stated he did give an order for [REDACTED]. He was told the resident was cold when they found him. He stated at that time, to call the funeral home. 5. During a telephone interview on 6/ ,[DATE] at 12:30 p.m., Staff A, the Registered Nurse (RN) supervisor, who was involved in the incident, stated the resident had been suctioned around 9:30 p.m., earlier in evening. She stated he was having oral secretions and once he was suctioned he was clear and had no respiratory distress. Staff A stated the color of the secretions pulled from Resident #282's throat were thick, yellow to white in color. She stated she was called into the room on [DATE] around 12:15 a.m., and found Resident #282 had no pulse or respirations. "His pupil was dilated and he was cold and stiff." Staff A, Registered Nurse (RN) Supervisor, stated she made the decision not to perform CPR on Resident #282 because he was too far gone. She stated the 11:00 p.m.-7:00 a.m. nurse had called the resident's primary physician after he had expired. She stated she overheard her tell the physician the resident had passed and he was found cold and without vitals. She stated the physician had told the nurse to notify the funeral home and family. She was asked if she had been oriented in the policy of the facility regarding full code status. She stated she was oriented at general orientation when she had started to work at the facility. She was asked what the policy at the facility was for a full code. She stated "You start CPR and call 911." 6. During an interview on [DATE] at 12:20 p.m., the Administrator stated the nursing staff had failed to report to the DON that they had not performed CPR on Resident #282. She stated "The DON was reviewing the resident's chart after discharge on [DATE] and found he was a full code and CPR was not preformed according to policy." She stated she initiated a full investigation on [DATE]. She called Adult Protective Services and initiated an adverse incident 1 day reporting. The 3 nurses who failed to follow the facility's policy were suspended from working. Written statements were obtained from all staff involved in the incident. All staffs were in-serviced on the policy of full code status of the residents. Staff not on shift was sent a letter they could not work until they had received in-services on DNR policies. An audit was conducted of the current residents in the facility as to their status of DNR. The Sheriff's office was notified and a report was given to law enforcement. 7. During a telephone interview on [DATE] at 8:50 a.m., Staff E, the Certified Nurse Assistant (CNA) who found Resident #282 unresponsive, stated he came on shift at 11:00 p.m. on [DATE]. He checked to ensure the resident was clean and dry at around 11:05 p.m. Between 11:30 p.m. and 12:00 p.m., he is not sure of the time; he went back in the resident's room and found he was not responsive. He stated he touched his throat and shook the resident and shouted at him. He then placed his finger under the resident's nose and determined he was not breathing. At that time he called for the nurses and went to get the crash cart. He stated the Licensed Practical Nurse (LPN) assigned to the resident did find the resident to be a full code. He stated the Registered Nurse (RN) supervisor made the decision not to do CPR. He was asked how the resident felt when he touched him. He stated "He was a bit warm." Staff E then stated he was completely unresponsive and he was not breathing. Staff E was asked why he had not filled out an incident report or reported the incident to the Director of Nursing (DON) or the Administrator. Staff E stated "I did not think I had done anything wrong. Looking back in hindsight I would have reported what had happened." 8. During a telephone interview on [DATE], at 9:02 a.m., the facility's Medical Director stated he was made aware of the issue on [DATE] when the Administrator found out about it. He stated he had reviewed the resident's chart and found that he was a sick person who should have been made a DNR. He stated he felt nursing staff had not followed the policy of the facility to start CPR on a resident who was a full code and calling EMS. He stated if Resident #282 was found to be thermally cold he would assume CPR would not be administered at that time. He stated in reviewing the chart he found a lack of documentation. He stated "There were a lot of holes." 9. During an interview on [DATE], at 10:05 a.m., Staff B, an LPN, stated she had assessed the resident around 9:30 p.m., and found he had gurgling sounds in the back of his throat. She stated she obtained an order from the primary physician to suction Resident #282. She stated the supervisor suctioned him and obtained a dark brown sputum from the back of his throat. She stated, "I kept checking on him until 11:00 p.m. I auscultated (listened to) his lungs and he sounded clear. He had a temp of 99 when I checked at 11:00 p.m. I told the oncoming nurse she needed to call the physician and let him know he had a temperature. I don't remember what (Staff C) responded back to me." 10. During an interview on [DATE], at 12:45 p.m., the Administrator verified the nurses involved with not performing CPR on Resident #282 were aware they were not following the policy of the facility by not performing CPR. She stated this should have been reported to the Administrator and the DON when it occurred. 11. During a telephone interview on [DATE], at 9:46 a.m., Staff C, LPN stated around 12:15 a.m. on [DATE], she was passing medications and the CNA called her to room [ROOM NUMBER] stating Resident #282 was not breathing. She stated she called for the nursing supervisor and checked the resident's chart and found he was a full code. She stated "I yelled down the hall to go ahead and start CPR." She stated "When I got to the room the supervisor said, what are you going to do that for. He's been gone." Staff C stated Resident #282 was yellow in color, cold and had no pulse when she initially assessed him. She stated she called the physician and reported the resident was found without a pulse and cold. She was told by the physician to call the funeral home. She was asked about reporting the incident. She stated "I did not think about reporting or doing an incident report. I thought the nursing supervisor would have reported it to the DON." 12. During a telephone interview on [DATE], at 11:00 a.m., Staff D, an LPN, stated she was passing medications and stopped to go and assist with the Code in room [ROOM NUMBER]. She stated it was approximately 12:30 a.m., on [DATE]. She stated Staff A, RN Supervisor, Staff E and CNA were in the room when she arrived. She stated the crash cart was in the room. Staff D stated "Staff A said we are not going to start CPR because it's too late he's already gone." She stated she and Staff C, another LPN looked at each other. But they did not question the supervisor about her decision. She stated she never touched or assessed Resident #282. 13. Review of the facility's policy for incident reporting documented "An incident report is to be completed for all falls, busies and skin tears of known or unknown origin, resident to resident altercations, resident to employee altercations, and medication errors or any other atypical occurrence. The following procedures will be implemented to effectively deal with incidents. 1. Incident and occurrence will be reported to the department supervisor. 2. Incident/Occurrence report will be completed by the charge nurse or the shift nurse that the incident/occurrence occurred. 3. Incident/Occurrence Investigation Form initiated by the Charge Nurse with completion by the DON/designee. 4. Charge Nurse/designee will add interventions to the care plan as needed." 14. A plan of correction provided by the facility on [DATE] was reviewed to verified implementation effectiveness. The plan included: A. The team reviewed the documentation of the in-services provided to 36 licensed staff who worked on all shifts in the facility. 5 licensed staff was sent letter telling them they could not work at the facility until the in-service was completed. Interviews were conducted with staff in all areas of the facility and over different shifts to ensure staff was aware of the policies. B. Residents were interviewed as to their Code status and verified with the documentation of the facility. The facility documented that every resident's code status was reviewed with the resident or their legal representative. The staff was observed calling resident's representatives and verifying Code status. C. A mock code was observed at the facility at 3:30 p.m., on [DATE]. Staff was observed to initiate CPR and EMS services for a staff member posing as a resident who was a full code. Documentation of mock codes was reviewed. Mock codes were documented as being done by the facility on all shifts. D. The facility's Allegation of Compliance was reviewed and accepted and the Immediate Jeopardy was removed on [DATE], at the exit conference. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses; had not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on facility record review and staff interviews, the facility Administrator failed to effectively attain and maintain the highest practicable physical and medical well-being, resulting in a resident's death regarding the facility processes for 1 (Resident #282) of 3 residents' records reviewed. The facility administration failed to identify the inappropriate facility process integrity of staff not coordinating medical services care, reporting an adverse incident when a resident did not have Cardiopulmonary Resuscitation (CPR) and died without the Administrator and the Director of Nursing being notified. The facility Administrator failed to ensure implementation of policy and procedures to initiating CPR and notifying Emergency Medical Services (EMS) resulting in the resident expiring without an attempt to revive. The facility Administrator failed to ensure coordination of the notification of the physician regarding condition changes and the notification of administration when resident's rights were not honored and policy and procedures not followed, resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff demonstrating an understanding of facility expectations. This failure created a situation resulting in the death to a resident and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE], was identified on [DATE]. The findings include: 1. During a review of Resident #282's record on [DATE], noting admission to the facility from Fawcett Hospital on [DATE]. Review of the hospital record documenting the resident was treated for [REDACTED].#282 was a Full Code. Full Code means if the resident was be found unresponsive, his wish is to have cardiopulmonary resuscitation attempted to revive him. During a review of Resident #282's nurse's notes for [DATE], revealed no documentation of an assessment of the resident's cardiac or respiratory status. A nursing note dated [DATE] at 12:30 a.m., documented "This nurse was called into room as Certified Nursing Assistant (CNA) was making rounds. Patient found in the bed without a pulse. Supervisor called into the room to verify. Physician called and notified of death. Daughter called by the supervisor and notified. Awaiting phone call back from daughter regarding funeral home. At 1:00 a.m. on [DATE], the same nurse documents, "Son and Family member came in to see patient. Phone call made to funeral home." 2. Review of the facility's policy for "CPR-Code Blue" effective ,[DATE] documented "It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. Procedure Open the airway: 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart association guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the Emergency code documentation from to document the event." 3. During an interview on [DATE] at 10:45 a.m., Resident #282's daughter stated her father had declined in health a week or two before being put in the hospital on [DATE]. She stated he was not eating and had a tube placed in his stomach two days before being discharged from the hospital. She stated he was eating while he was at the nursing home. She stated her brother was feeding her father when he would go into visit him. She was asked about her father's wishes for end of life care. She stated "Daddy would joke about it and say if I'm gonna die, he wanted everything done for him that could be done." 4. During an interview on [DATE] at 11:10 a.m., Resident #282's primary physician stated he had spoken to the resident's son when the resident was admitted to the facility. He stated the family wanted Resident #282 to be a full code. He stated he had assessed the resident and had found no issues with the resident's respiratory status. He stated he had gone into the resident's room and found the resident's son feeding the resident. He told the son not to feed him at that time because he was not able to swallow food well. The physician stated the nurse had called him around 9:00 p.m. on [DATE], stating the resident needed suctioning. He was asked if there were any issues with aspiration of his tube feeding or respiratory difficulties. He stated the resident needed suctioning because he was having oral secretions due to the resident receiving a tube feeding. He stated he did give an order for [REDACTED]. He was told the resident was cold when they found him. He stated at that time, to call the funeral home. 5. During a telephone interview on 6/ ,[DATE] at 12:30 p.m., Staff A, the Registered Nurse (RN) supervisor, who was involved in the incident, stated the resident had been suctioned around 9:30 p.m., earlier in evening. She stated he was having oral secretions and once he was suctioned he was clear and had no respiratory distress. Staff A stated the color of the secretions pulled from Resident #282's throat were thick, yellow to white in color. She stated she was called into the room on [DATE] around 12:15 a.m., and found Resident #282 had no pulse or respirations. "His pupil was dilated and he was cold and stiff." Staff A, RN Supervisor, stated she made the decision not to perform CPR on Resident #282 because he was too far gone. She stated the 11:00 p.m.-7:00 a.m. nurse had called the resident's primary physician after he had expired. She stated she overheard her tell the physician the resident had passed and he was found cold and without vitals. She stated the physician had told the nurse to notify the funeral home and family. She was asked if she had been oriented in the policy of the facility regarding full code status. She stated she was oriented at general orientation when she had started to work at the facility. She was asked what the policy at the facility was for a full code. She stated "You start CPR and call 911." 6. During an interview on [DATE] at 12:20 p.m., the Administrator stated the nursing staff had failed to report to the DON that they had not performed CPR on Resident #282. She stated "The DON was reviewing the resident's chart after discharge on [DATE] and found he was a full code and CPR was not preformed according to policy." She stated she initiated a full investigation on [DATE]. She called Adult Protective Services and initiated an adverse incident 1 day reporting. The 3 nurses who failed to follow the facility's policy were suspended from working. Written statements were obtained from all staff involved in the incident. All staffs were in-serviced on the policy of full code status of the residents. Staff not on shift was sent a letter they could not work until they had received in-services on DNR policies. An audit was conducted of the current residents in the facility as to their status of DNR. The Sheriff's office was notified and a report was given to law enforcement. 7. During a telephone interview on [DATE] at 8:50 a.m., Staff E, the CNA who found Resident #282 unresponsive, stated he came on shift at 11:00 p.m. on [DATE]. He checked to ensure the resident was clean and dry at around 11:05 p.m. Between 11:30 p.m. and 12:00 p.m., he is not sure of the time; he went back in the resident's room and found he was not responsive. He stated he touched his throat and shook the resident and shouted at him. He then placed his finger under the resident's nose and determined he was not breathing. At that time he called for the nurses and went to get the crash cart. He stated the Licensed Practical Nurse (LPN) assigned to the resident did find the resident to be a full code. He stated the Registered Nurse (RN) supervisor made the decision not to do CPR. He was asked how the resident felt when he touched him. He stated "He was a bit warm." Staff E then stated he was completely unresponsive and he was not breathing. Staff E was asked why he had not filled out an incident report or reported the incident to the Director of Nursing (DON) or the Administrator. Staff E stated "I did not think I had done anything wrong. Looking back in hindsight I would have reported what had happened." 8. During a telephone interview on [DATE], at 9:02 a.m., the facility's Medical Director stated he was made aware of the issue on [DATE] when the Administrator found out about it. He stated he had reviewed the resident's chart and found that he was a sick person who should have been made a DNR. He stated he felt nursing staff had not followed the policy of the facility to start CPR on a resident who was a full code and calling EMS. He stated if Resident #282 was found to be thermally cold he would assume CPR would not be administered at that time. He stated in reviewing the chart he found a lack of documentation. He stated "There were a lot of holes." 9. During an interview on [DATE], at 12:45 p.m., the Administrator verified the nurses involved with not performing CPR on Resident #282 were aware they were not following the policy of the facility by not performing CPR. She stated this should have been reported to the Administrator and the DON when it occurred. 10. During a telephone interview on [DATE], at 9:46 a.m., Staff C, LPN stated around 12:15 a.m. on [DATE], she was passing medications and the CNA called her to room [ROOM NUMBER] stating Resident #282 was not breathing. She stated she called for the nursing supervisor and checked the resident's chart and found he was a full code. She stated "I yelled down the hall to go ahead and start CPR." She stated "When I got to the room the supervisor said, what are you going to do that for. He's been gone." Staff C stated Resident #282 was yellow in color, cold and had no pulse when she initially assessed him. She stated she called the physician and reported the resident was found without a pulse and cold. She was told by the physician to call the funeral home. She was asked about reporting the incident. She stated "I did not think about reporting or doing an incident report. I thought the nursing supervisor would have reported it to the DON." 11. During a telephone interview on [DATE], at 11:00 a.m., Staff D, an Licensed Practical Nurse (LPN), stated she was passing medications and stopped to go and assist with the Code in room [ROOM NUMBER]. She stated it was approximately 12:30 a.m., on [DATE]. She stated Staff A, RN Supervisor, Staff E and CNA were in the room when she arrived. She stated the crash cart was in the room. Staff D stated "Staff A said we are not going to start CPR because it's too late he's already gone." She stated she and Staff C, another LPN looked at each other. But they did not question the supervisor about her decision. She stated she never touched or assessed Resident #282. 12. Review of the facility's policy for incident reporting documented "An incident report is to be completed for all falls, busies and skin tears of known or unknown origin, resident to resident altercations, resident to employee altercations, and medication errors or any other atypical occurrence. The following procedures will be implemented to effectively deal with incidents. 1. Incident and occurrence will be reported to the department supervisor. 2. Incident/Occurrence report will be completed by the charge nurse or the shift nurse that the incident/occurrence occurred. 3. Incident/Occurrence Investigation Form initiated by the Charge Nurse with completion by the DON/designee. 4. Charge Nurse/designee will add interventions to the care plan as needed." 13. The facility Administration failed to provide end of life care when Resident #282 and his family had requested the resident be resuscitated if found in cardiac and respiratory arrest. The facility Administrator failed to ensure staff followed policy and procedures in initiating Cardiopulmonary Resuscitation (CPR) and notifying Emergency Medical Services (EMS) resulting in the resident expiring without an attempt to revive. The facility failed to provide coordination of services resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff had demonstrated understanding of facility expectations in the implementation of full code in the absence of a DNR, calling EMS, the notification of the physician regarding condition changes and the notification of administration when resident's rights were not honored and failure to follow policy and procedures. Cross reference to F155, F278 and F309. During a review of the facility's Administrator's position description, signed on [DATE], noted expectations including: Summary: ? Lead and direct the overall operation of the facility in accordance customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilities including: ? Management duties including, but not limited to, hiring, training and developing,coaching and counseling, and terminating department staff, as deemed necessary. ? Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach and discipline as needed. ? Develop an environment that allows for creative thinking, problem solving,and empowerment in the development of facility management team. ? Oversee regular rounds to monitor deliver of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed. 14. A plan of correction provided by the facility on [DATE] was reviewed to verified implementation effectiveness. The plan included: A. The team reviewed the documentation of the in-services provided to 36 licensed staff who worked on all shifts in the facility. 5 licensed staff was sent letter telling them they could not work at the facility until the in-service was completed. Interviews were conducted with staff in all areas of the facility and over different shifts to ensure staff was aware of the policies. B. Residents were interviewed as to their Code status and verified with the documentation of the facility. The facility documented that every resident's code status was reviewed with the resident or their legal representative. The staff was observed calling resident's representatives and verifying Code status. C. A mock code was observed at the facility at 3:30 p.m., on [DATE]. Staff was observed to initiate CPR and EMS services for a staff member posing as a resident who was a full code. Documentation of mock codes was reviewed. Mock codes were documented as being done by the facility on all shifts. D. The facility's Allegation of Compliance was reviewed and accepted and the Immediate Jeopardy was removed on [DATE], at the exit conference. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses; had not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on facility staff interviews and record reviews, the facility failed to honor a formulated Advance Directive (AD) as requested by the resident and resident's family of 1 (Resident #282) of the 3 residents' records reviewed. This resulted Resident #282 not receiving resuscitation when found to be without a pulse and respirations. The facility failed to follow their policy and procedure in starting Cardiopulmonary Resuscitation (CPR) and calling Emergency Medical Services (EMS). The facility staff failed to implement CPR when the resident's wishes and policy and procedures were known by staff and failed to immediately report to administration. The facility failed to ensure staff honored resident's AD resulting in ongoing systems' failure regarding facility approaches and all staff having demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to AD and CPR, the implementation of full code in the absence of a Do Not Resuscitate (DNR) and notification of the physician regarding condition changes. This failure created a situation which resulted in death to a resident and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE]; was identified on [DATE]. The findings included: 1. During a review of Resident #282's record on [DATE], noted he was an [AGE] year old male, admitted to the facility from Fawcett Hospital on [DATE]. Review of the hospital record documenting the resident was treated for [REDACTED]. Review of Resident #282's History and Physical (H&P), dated [DATE] documented "He is a functional quadriplegic as he cannot feed himself, toilet himself or get out of bed." He was dehydrated and malnourished. He was being treated for [REDACTED]. The hospital record documented Resident #282 was a Full Code. Full Code means if the resident was be found unresponsive, his wish is to have cardiopulmonary resuscitation attempted to revive him. During a review of Resident #282's record on [DATE] noted he was assessed at admission by a Licensed Practical Nurse (LPN) on [DATE]. The assessment documented the resident was a total assist with Activities of Daily Living (ADLs). He was incontinent and had an ostomy in place. He was assessed to have a regular heartbeat with [MEDICAL CONDITION]. He was assessed to have normal respirations with no [MEDICAL CONDITION], Apnea, Pneumonia, [MEDICAL CONDITIONS], or [MEDICAL CONDITIONS]. He had a Percutaneous Endoscopic gastrostomy (PEG) Tube on admission, running Glucerna 1.5 at 70 centimeters/hour (cc/hr). He was to receive flushes of 200 cc every eight hours to his PEG Tube. The nursing note dated [DATE] at 7:45 p.m., documented the resident was "moaning and groaning." The resident was administered pain medication at that time. The nurse documents the resident is extensive assist with activities of daily living and transfers. During a review of the nursing note dated [DATE], noted at 6:00 a.m. on [DATE], the nurse documents the resident is nonverbal and resting quietly. At 3:45 p.m., on [DATE], the nurse documents the resident's vitals as "99.9 (temperature) 66 (heart rate) 18 (pulse) and ,[DATE] (blood pressure)." At 10:00 p.m. on [DATE], the nurse documents "Resident alert. Resting in bed. PEG tube patent. Running Glucerna 1.5 at 70 cc/hr. As needed suctioning was ordered. Resident was found to be gurgling. Resident was suctioned with a positive effect. Vitals ,[DATE] (blood pressure) 24 (pulse) 64 (heart rate) and 99.0 (temperature). Will continue to monitor. Call light in reach." During a review of Resident #282's nurse's notes for [DATE], revealed no documentation of an assessment of the resident's cardiac or respiratory status. A nursing note dated [DATE] at 12:30 a.m., documented "This nurse was called into room as Certified Nursing Assistant (CNA) was making rounds. Patient found in the bed without a pulse. Supervisor called into the room to verify. Physician called and notified of death. Daughter called by the supervisor and notified. Awaiting phone call back from daughter regarding funeral home." At 1:00 a.m. on [DATE], the same nurse documents, "Son and Family member came in to see patient. Phone call made to funeral home." 2. Review of the facility's policy for "CPR-Code Blue" effective ,[DATE] documented "It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. Procedure: Open the airway: 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart association guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the Emergency code documentation from to document the event." 3. During an interview on [DATE] at 10:45 a.m., Resident #282's daughter stated her father had declined in health a week or two before being put in the hospital on [DATE]. She stated he was not eating and had a tube placed in his stomach two days before being discharged from the hospital. She stated he was eating while he was at the nursing home. She stated her brother was feeding her father when he would go into visit him. She was asked about her father's wishes for end of life care. She stated "Daddy would joke about it and say if I'm gonna die, he wanted everything done for him that could be done." 4. During an interview on [DATE] at 11:10 a.m., Resident #282's primary physician stated he had spoken to the resident's son when the resident was admitted to the facility. He stated the family wanted Resident #282 to be a full code. He stated he had assessed the resident and had found no issues with the resident's respiratory status. He stated he had gone into the resident's room and found the resident's son feeding the resident. He told the son not to feed him at that time because he was not able to swallow food well. The physician stated the nurse had called him around 9:00 p.m. on [DATE], stating the resident needed suctioning. He was asked if there were any issues with aspiration of his tube feeding or respiratory difficulties. He stated the resident needed suctioning because he was having oral secretions due to the resident receiving a tube feeding. He stated he did give an order for [REDACTED]. He was told the resident was cold when they found him. He stated at that time, to call the funeral home. 5. During a telephone interview on 6/ ,[DATE] at 12:30 p.m., Staff A, the Registered Nurse (RN) supervisor, who was involved in the incident, stated the resident had been suctioned around 9:30 p.m., earlier in evening. She stated he was having oral secretions and once he was suctioned he was clear and had no respiratory distress. Staff A stated the color of the secretions pulled from Resident #282's throat were thick, yellow to white in color. She stated she was called into the room on [DATE] around 12:15 a.m., and found Resident #282 had no pulse or respirations. "His pupil was dilated and he was cold and stiff." Staff A, RN Supervisor, stated she made the decision not to perform CPR on Resident #282 because he was too far gone. She stated the 11:00 p.m.-7:00 a.m. nurse had called the resident's primary physician after he had expired. She stated she overheard her tell the physician the resident had passed and he was found cold and without vitals. She stated the physician had told the nurse to notify the funeral home and family. She was asked if she had been oriented in the policy of the facility regarding full code status. She stated she was oriented at general orientation when she had started to work at the facility. She was asked what the policy at the facility was for a full code. She stated "You start CPR and call 911." 6. During an interview on [DATE] at 12:20 p.m., the Administrator stated the nursing staff had failed to report to the DON that they had not performed CPR on Resident #282. She stated, "The DON was reviewing the resident's chart after discharge on [DATE] and found he was a full code and CPR was not preformed according to policy." She stated she initiated a full investigation on [DATE]. She called Adult Protective Services and initiated an adverse incident 1 day reporting. The 3 nurses who failed to follow the facility's policy were suspended from working. Written statements were obtained from all staff involved in the incident. All staffs were in-serviced on the policy of full code status of the residents. Staff not on shift was sent a letter they could not work until they had received in-services on DNR policies. An audit was conducted of the current residents in the facility as to their status of DNR. The Sheriff's office was notified and a report was given to law enforcement. 7. During a telephone interview on [DATE] at 8:50 a.m., Staff E, the CNA who found Resident #282 unresponsive, stated he came on shift at 11:00 p.m. on [DATE]. He checked to ensure the resident was clean and dry at around 11:05 p.m. Between 11:30 p.m. and 12:00 p.m., he is not sure of the time; he went back in the resident's room and found he was not responsive. He stated he touched his throat and shook the resident and shouted at him. He then placed his finger under the resident's nose and determined he was not breathing. At that time he called for the nurses and went to get the crash cart. He stated the Licensed Practical Nurse (LPN) assigned to the resident did find the resident to be a full code. He states the Registered Nurse (RN) supervisor made the decision not to do CPR. He was asked how the resident felt when he touched him. He stated "He was a bit warm." Staff E then stated he was completely unresponsive and he was not breathing. Staff E was asked why he had not filled out an incident report or reported the incident to the Director of Nursing (DON) or the Administrator. Staff E stated "I did not think I had done anything wrong. Looking back in hindsight I would have reported what had happened." 8. During a telephone interview on [DATE], at 9:02 a.m., the facility's Medical Director stated he was made aware of the issue on [DATE] when the Administrator found out about it. He stated he had reviewed the resident's chart and found that he was a sick person who should have been made a DNR. He stated he felt nursing staff had not followed the policy of the facility to start CPR on a resident who was a full code and calling EMS. He stated if Resident #282 was found to be thermally cold he would assume CPR would not be administered at that time. He stated in reviewing the chart he found a lack of documentation. He stated "There were a lot of holes." 9. During an interview on [DATE], at 10:05 a.m., Staff B, an LPN, stated she had assessed the resident around 9:30 p.m., and found he had gurgling sounds in the back of his throat. She stated she obtained an order from the primary physician to suction Resident #282. She stated the supervisor suctioned him and obtained a dark brown sputum from the back of his throat. She stated, "I kept checking on him until 11:00 p.m. I auscultated (listened to) his lungs and he sounded clear. He had a temp of 99 when I checked at 11:00 p.m. I told the oncoming nurse she needed to call the physician and let him know he had a temperature. I don't remember what (Staff C) responded back to me." 10. During an interview on [DATE], at 12:45 p.m., the Administrator verified the nurses involved with not performing CPR on Resident #282 were aware they were not following the policy of the facility by not performing CPR. She stated this should have been reported to the Administrator and the DON when it occurred. 11. During a telephone interview on [DATE], at 9:46 a.m., Staff C, LPN stated around 12:15 a.m. on [DATE], she was passing medications and the CNA called her to room [ROOM NUMBER] stating Resident #282 was not breathing. She stated she called for the nursing supervisor and checked the resident's chart and found he was a full code. She stated "I yelled down the hall to go ahead and start CPR." She stated "When I got to the room the supervisor said, what are you going to do that for. He's been gone." Staff C stated Resident #282 was yellow in color, cold and had no pulse when she initially assessed him. She stated she called the physician and reported the resident was found without a pulse and cold. She was told by the physician to call the funeral home. She was asked about reporting the incident. She stated "I did not think about reporting or doing an incident report. I thought the nursing supervisor would have reported it to the DON." 12. During a telephone interview on [DATE], at 11:00 a.m., Staff D, an LPN, stated she was passing medications and stopped to go and assist with the Code in room [ROOM NUMBER]. She stated it was approximately 12:30 a.m., on [DATE]. She stated Staff A, RN Supervisor, Staff E and CNA were in the room when she arrived. She stated the crash cart was in the room. Staff D stated "Staff A said we are not going to start CPR because it's too late he's already gone." She stated she and Staff C, an other LPN looked at each other. But they did not question the supervisor about her decision. She stated she never touched or assessed Resident #282. 13. Review of the facility's policy for incident reporting documented "An incident report is to be completed for all falls, busies and skin tears of known or unknown origin, resident to resident altercations, resident to employee altercations, and medication errors or any other atypical occurrence. The following procedures will be implemented to effectively deal with incidents. 1. Incident and occurrence will be reported to the department supervisor. 2. Incident/Occurrence report will be completed by the charge nurse or the shift nurse that the incident/occurrence occurred. 3. Incident/Occurrence Investigation Form initiated by the Charge Nurse with completion by the DON/designee. 4. Charge Nurse/designee will add interventions to the care plan as needed." 14. A plan of correction provided by the facility on [DATE] was reviewed to verified implementation effectiveness. The plan included: A. The team reviewed the documentation of the in-services provided to 36 licensed staff who worked on all shifts in the facility. 5 licensed staff was sent letter telling them they could not work at the facility until the in-service was completed. Interviews were conducted with staff in all areas of the facility and over different shifts to ensure staff was aware of the policies. B. Residents were interviewed as to their Code status and verified with the documentation of the facility. The facility documented that every resident's code status was reviewed with the resident or their legal representative. The staff was observed calling resident's representatives and verifying Code status. C. A mock code was observed at the facility at 3:30 p.m., on [DATE]. Staff was observed to initiate CPR and EMS services for a staff member posing as a resident who was a full code. Documentation of mock codes was reviewed. Mock codes were documented as being done by the facility on all shifts. D. The facility's Allegation of Compliance was reviewed and accepted and the Immediate Jeopardy was removed on [DATE], at the exit conference. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses; had not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on record review, observation and interviews, the facility failed to supervise a resident at risk for falls to prevent the resident from getting out of her chair, exiting the facility and sustaining a fall with injury for 1 (Resident # 133) of 1 sampled residents reviewed for falls. The findings include: During a review of Resident #133's clinical record and incident/occurrence report noted on 5/26/14 at 9:45 p.m., the resident was found sitting on the floor in the activity room and had a small hematoma on the left side of her head. The resident's care plan, dated 4/16/14, under the Problem of at risk for fall related injury related to poor safety awareness and Dementia, was updated on 5/26/14 to include the use of a wheelchair alarm to alert staff of the resident's self transfers. During a review of Resident #133's clinical record, a nurses note indicated on 5/28/14 at 8:05 p.m., the resident was found on the ground outside the facility near the entry way. The nurse noted the resident had sustained a hematoma to her head, a bruise to her left shoulder, and there was a small amount of blood on the resident's nose. The resident was assisted back into the facility and the resident's physician was notified. Resident #133's physician gave an order to send the resident to the hospital for a Computerized Tomography (CT) scan of her head. The nurse noted the resident returned from the hospital at approximately 11:00 p.m., with a [DIAGNOSES REDACTED]. A CT scan is a pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them in pictures. During an intervew on 6/13/14, at 9:18 a.m., the Administrator stated Resident #133 eloped from the facility on 5/28/14 at 8:00 p.m., and was reported to be out front of the facility on the side walk near a bench. She stated a visitor saw the resident lying there and notified the receptionist who sent someone to get a nurse. The Administrator stated Resident #133 was already trying to get up and was assisted to a chair. She stated the resident did have a scrape on her shoulder and forehead; was brought back into the facility and staff notified the resident's physician, who sent her to the emergency room (ER) for evaluation. The Administrator stated that based on the interviews she conducted it was determined the nurse (Staff J) and Certified Nursing Assistant (Staff I CNA) were not present on their assigned hallway to monitor the residents. She stated one of the other CNAs working on that hallway reported upon her return to the hallway she heard the exit door alarm sounding and found the resident's wheelchair nearby with the wheelchair alarm sounding. The CNA reported when she looked outside she saw Resident #133 was already being assisted by a nurse. The Administrator stated the 2 staff assigned to the resident that evening (Staff J and Staff I) no longer worked at the facility. During a telephone interview on 6/13/14 at 10:24 a.m., Staff J Registered Nurse, stated Resident #133 had gotten up and ambulated without assist the night before. Staff J stated the resident would wheel herself around in her wheelchair, but had never been observed trying to get out the door. Staff J stated at 7:15 p.m., she did leave the unit to go on supper break but she communicated to one of the other nurses working on the unit and to the CNA (Staff I) who was assigned to the hallway where Resident #133 resided. Staff J stated she returned to the unit at 7:45 p.m., but does not recall seeing the resident or hearing any alarms. Staff J stated she did go into the family room where staff had gathered for a party to look for Staff I. Staff J stated right around this time she was notified Resident #133 had been found outside the facility. On 6/13/13 at 10:17 a.m., an attempt was made to contact Staff I for interview but was unsuccessful.. During an observation on 6/13/14 at 11:43 a.m., Resident #133 was sitting in the dining room in her wheelchair with a sensor alarm attached. Resident #133 was observed with a resolving yellow/purple bruise extending across the right forehead and an small healing abrasion on top of the nose. The resident did not respond appropriately to questions and was unable to be interviewed. During an intervew on 6/13/14 at 11:44 a.m., Staff P, Registered Nurse (RN), confirmed the bruising on Resident #133's forehead and scrape on her nose was from a fall face down occurring on the evening of 5/28/14. Staff P stated the resident did go to the emergency room (ER) for a CT scan which was negative. Staff P stated the resident was at risk for falls and had alarms, but had not attempted to elope before this event. Staff P stated she heard there had been a staff retirement party on 5/28/14 in the evening, but usually staff take turns getting their food. Staff P stated the resident may have been more confused as she did have a UTI. During an intervew on 6/13/14 at 1:23 p.m., the Director of Nursing (DON), confirmed the door alarm had been functional and staff were not properly supervising Resident #133 when she exited the facility without being observed and sustained an injury.

Based on observation, interviews, and record review, the facility failed to provide sufficient nursing staff to assure a resident at risk for falls was being monitored in accordance with the plan of care by not responding to a chair sensor alarm and exit door alarm resulting in a fall with injury for 1 (Resident #133) of 1 sampled residents reviewed for falls. The facility failed to have sufficient staff to meet the needs of residents by not responding to call lights in a timely manner for 6 (Residents #162, #279, #277, #161, #79, and #225) of 19 sampled residents interviewed and to provide sufficient staff for 4 (Residents #206, #108, #65, and #283) of 8 dependent residnets during a supper meal. This impacted a total of 10 (Residents #162, #279, #277, #161, #79, #225, #206, #108, #65, and #283) of 27 residents reviewed. The findings include: 1. During a review of Resident #133's clinical record and incident/occurrence report noted on 5/26/14 at 9:45 p.m., the resident was found sitting on the floor in the activity room and had a small hematoma on the left side of her head. The resident's care plan, dated 4/16/14, under the Problem of at risk for fall related injury related to poor safety awareness and Dementia, was updated on 5/26/14 to include the use of a wheelchair alarm to alert staff of the resident's self transfers. During a review of Resident #133's clinical record, a nurses note indicated on 5/28/14 at 8:05 p.m., the resident was found on the ground outside the facility near the entry way. The nurse noted the resident had sustained a hematoma to her head, a bruise to her left shoulder, and there was a small amount of blood on the resident's nose. The resident was assisted back into the facility and the resident's physician was notified. Resident #133's physician gave an order to send the resident to the hospital for a Computerized Tomography (CT) scan of her head. The nurse noted the resident returned from the hospital at approximately 11:00 p.m., with a [DIAGNOSES REDACTED]. A CT scan is a pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them in pictures. During an interview on 6/13/14, at 9:18 a.m., the Administrator stated Resident #133 eloped from the facility on 5/28/14 at 8:00 p.m., and was reported to be out front of the facility on the side walk near a bench. She stated a visitor saw the resident lying there and notified the receptionist who sent someone to get a nurse. The Administrator stated Resident #133 was already trying to get up and was assisted to a chair. She stated the resident did have a scrape on her shoulder and forehead; was brought back into the facility and staff notified the resident's physician, who sent her to the emergency room (ER) for evaluation. The Administrator stated that based on the interviews she conducted it was determined the nurse (Staff J) and Certified Nursing Assistant (Staff I CNA) were not present on their assigned hallway to monitor the residents. She stated one of the other CNAs working on that hallway reported upon her return to the hallway she heard the exit door alarm sounding and found the resident's wheelchair nearby with the wheelchair alarm sounding. The CNA reported when she looked outside she saw Resident #133 was already being assisted by a nurse. The Administrator stated the 2 staff assigned to the resident that evening (Staff J and Staff I) no longer worked at the facility. During a telephone interview on 6/13/14 at 10:24 a.m., Staff J Registered Nurse, stated Resident #133 had gotten up and ambulated without assist the night before. Staff J stated the resident would wheel herself around in her wheelchair, but had never been observed trying to get out the door. Staff J stated at 7:15 p.m., she did leave the unit to go on supper break but she communicated to one of the other nurses working on the unit and to the CNA (Staff I) who was assigned to the hallway where Resident #133 resided. Staff J stated she returned to the unit at 7:45 p.m., but does not recall seeing the resident or hearing any alarms. Staff J stated she did go into the family room where staff had gathered for a party to look for Staff I. Staff J stated right around this time she was notified Resident #133 had been found outside the facility. On 6/13/13 at 10:17 a.m., an attempt was made to contact Staff I for interview but was unsuccessful.. During an observation on 6/13/14 at 11:43 a.m., Resident #133 was sitting in the dining room in her wheelchair with a sensor alarm attached. Resident #133 was observed with a resolving yellow/purple bruise extending across the right forehead and an small healing abrasion on top of the nose. The resident did not respond appropriately to questions and was unable to be interviewed. During an interview on 6/13/14 at 11:44 a.m., Staff P, Registered Nurse (RN), confirmed the bruising on Resident #133's forehead and scrape on her nose was from a fall face down occurring on the evening of 5/28/14. Staff P stated the resident did go to the emergency room (ER) for a CT scan which was negative. Staff P stated the resident was at risk for falls and had alarms, but had not attempted to elope before this event. Staff P stated she heard there had been a staff retirement party on 5/28/14 in the evening, but usually staff take turns getting their food. Staff P stated the resident may have been more confused as she did have a UTI. During an interview on 6/13/14 at 1:23 p.m., the Director of Nursing (DON), confirmed the door alarm had been functional and staff were not properly supervising Resident #133 when she exited the facility without being observed and sustained an injury. 2. Duiring resident intervews on 6/9/14 and 6/10/14, multiple residents answered "No" to the question "Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?" a. Resident #162 stated on 6/9/14 at 4:42 p.m., "Sometimes I have to wait 25 minutes. Most of the time it is during the night." b. Resident #279 stated on 6/9/14 at 5:18 p.m., "No, especially on weekends and nights there are no staff visible in the hallways." c. Resident #277 stated on 6/10/14 at 9:26 a.m., "Some of the Certified Nursing Assistants (CNA) make you wait forever. I do not remember their names." d. Resident #161 stated on 6/10/14 at 9:19 a.m., "No, particularly on the weekends." It depends. "Can roll a ball down the hall and not hit anybody." Will wait "20 minutes or more" when rings bell for help; has to wait for the appropriate person, will be told someone is on break and will turn off the light and leave room. Resident #161 stated she "turns it back on which annoys the staff." e. Resident #79 stated on 6/10/14 at 10:36 a.m., he has to "wait 30 minutes, day shift and weekends." f. Resident #225 stated on 6/9/14 at 1:03 p.m., "Sometimes I have to wait an hour." The resident stated frequently "it takes a long time for them to answer the light." During an interview on 6/12/14 at 12:17 p.m., the Director of Nursing (DON), reported call lights were not being answered in a timely manner. The DON stated she had discussed the issue with call light response at the last resident council meeting and has started doing audits on each unit to address this concern. 3. During an observation of the 200 Hall assisted dining room, on 6/11/14 at 5:20 p.m., 8 residents needed assistance eating. There were 2 Certified Nnursing Assistants (CNA) and a family were in the room. Resident #206 was observed sitting ata table with her puree dinner meal in front of her and 5 other residents. 2 CNAs were assisitng 4 residents to dine. Staff stated there was not enough staff to assist all the residents at once. They were doing the best they could. Resident #108 sat at the same table without her tray. Her tray was on the counter behind her. Staff stated she plays with food and, "not enough staff to feed the others." Resident #65 sat with 3 other residents who could feed themselves at another table. No staff was available to assist him. Resident #65 had puree diet with honey thick liquids tray in front of him. Resident #65 indicated he could not feed self by nodding no when asked if he could eat by himself. Resident #283 sat at a table by herself with a family member assisting to dine. The daughter stated mother has been losing weight. Another family member, who is Power of Attorney(POA), requested she assist their mother because he does not feel staff feed her. During an interview on 6/11/14 at 5:40 p.m., Resident #283's family member stated she just started to come a day ago. Resident #283 has been at facility about a month. During an interview on 6/11/14 at 5:25 p.m., Certified Nurse Assistant (CNA), Staff R, reported there are usually 3 CNA here, but today is someone's day off. During an interview on 6/11/14 at 5:30 p.m., CNA Staff S stated Resident #206 used to be able to feed herself. She stated she is not sure of an exact date when she stopped feeding herself, but it is about 2 months. The Staff Q, a nurse was assigned to 200 Hall assisted dining room. The Director of Nursing (DON) was asked who was assigned to assist in 200 Hall assisted dining room. When asked the DON directed Staff Q to go to her assignment.