Every finding on record at Charming Lakes Rehab

Based on observations, record reviews, and interviews, the facility failed to provide ADL care for fingernails for 3 residents, (Resident #68, Resident #6, and Resident #1), who were sampled for ADLs. The failure to provide ADL care caused harm to 1 Resident, (Resident #68). The findings included: A review of the facility’s policy for Activities of Daily Living (ADLs) effective 04/01/2022, revealed the purpose was to ensure all residents’ needs were met in a manner that promoted their quality of life and preferences. The procedure section included that the facility would provide residents with the appropriate treatment and services to maintain hygiene. This included bathing, dressing, grooming, and oral care. 1.A record review revealed that Resident #68 was admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction, Dementia, and Spastic Hemiplegia unspecified side The minimum data set (MDS) quarterly assessment dated [DATE] revealed he had severe cognitive impairment, and he was dependent on assistance for personal hygiene. Resident #68’s plan of care last revised on 02/03/25 noted that he had an activity of daily living, self-care performance deficit, that was related to a recent stroke, impaired mobility, and impaired communication. One documented intervention was to monitor, document, and report to the Doctor any changes or potential for improvement. During an observation on 08/18/25 at 2:32 PM, Resident #68 lied on his back with his head elevated in his bed. His hands were visible and most of his fingernails were approximately ¾ inch long. Dark brown/black sediment was on the middle fingernail of his right hand, and under the fingernail of the thumb on his left hand. On 08/19/25 at 4:00 PM the fingernails were observed again. The left hand was contracted. Four fingernails were visible, and they were all approximately the same length, ¾ inch long. The end of the pinky nail was not visible. Photographic evidence was obtained. When the resident was asked if he liked his fingernails long, he moved his head from the left to the right, which indicated he did not want long fingernails. An interview with Staff F, (a Licensed Practical Nurse), on 08/20/25 at 10:55 AM revealed that Resident #68 used to receive treatments for his left hand after it had been bleeding and leaking. When Staff F was asked to evaluate the condition of Resident #68’s fingernails, she touched Resident #68’s hand and attempted to turn the hand into a position for inspection. Resident #68 began to shake, and he pulled his hand away. Staff F said that his fingernails needed to be clipped. When asked who was responsible for clipping fingernails, Staff F said that the podiatrist came out to clip nails. She added that she tried to clip his fingernails a few weeks ago with the clippers from the activities room, and those nail clippers didn’t work. During a later interview with Staff F on 08/20/25 at 2:49 PM, when asked to locate documentation in the medical record about her attempt to cut Resident #68’s fingernails, Staff F could not find any documentation to support her statement. When asked how she followed up on the discovery about Resident #68’s injured hand, Staff F said that Staff G, the Nurse Practitioner (NP), came and viewed Resident #68’s fingernails she ordered Bactrim, an antibiotic tablet for his infection to the left big toe and to the left hand on 08/20/25. She also ordered a treatment to clean his hand with saline solution and to apply Nystatin Powder two times a day for 14 days on 08/20/25. Staff F said that “the nail was pretty much deep into the palm of his hand.” When asked if she thought that this hand injury could have been prevented, Staff F said with proper hand and nail care the injury could have been prevented. An interview later that day with Resident #68 at 4:19 PM revealed that his left hand was painful and that he wanted his nails to be cut. During an interview with the Activities Director (AD) on 08/20/25 at 2:58 PM, the AD said that the podiatrist only cut toenails. She said that fingernail care was performed by the nursing department and by the activities department. She added that nursing did the cutting. During a phone Interview on 08/20/25 at 4:20 PM, Staff G, (a Nurse Practitioner), said she performed her usual rounds earlier that morning. She said she reviewed Resident #68’s chronic systems which included medications, gastrostomy tube, and left big toe wound, and then she left the room. Staff G explained that Staff F told her Resident #68 had a problem with his left hand so they went into his room together. She said that they looked at the resident’s hand and saw that his fingernail dug into the palm of his left hand. The Nurse Practitioner said that she told the nurse to follow up and cut his fingernails. On 08/20/25 at 5:15 PM an interview was conducted with Staff S, (a CNA), who stated that Resident #68 was one of the residents in her assignment. She said Resident #68 did not talk; He communicated by nodding yes or no. She stated since the resident had Diabetes, she did not trim his fingernails or his toe nails. She stated the foot doctor trims toe nails and the nurses will trim his finger nails. She stated that at times Resident #68 touched his feces. She then stated that the nurse was aware Resident #68 had those behaviors. During an interview with the Administrator and DON on 08/21/25 at 4:17 PM, the DON said that they first found out about the hand injury on 08/20/25. A record review performed on 08/21/25 revealed that the most recent completed skin evaluation tool was completed on 08/06/25. It showed Resident #68 had an open area to left great toe. The surveyor's concern for the resident's long nails and injury to the palm of his hand was not identified until after the surveyor brought it to the attention of the LPN. The skin evaluation tool that was noted “in progress”, and dated 08/20/25, listed skin impairment to resident's left toe. It had no mention of the resident's fingernails or injury to his hand. 2. A record review revealed that Resident #6 was admitted to the facility on [DATE]. Her diagnoses included Muscle Weakness, and Type 2 Diabetes Mellitus. A Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status score of 13, which indicated that she was cognitively intact. This same MDS assessment documented that Resident #6 was dependent on assistance with personal hygiene. Her plan of care last revised on 07/14/25 noted that she had an ADL self-care performance deficit, and she required partial to moderate assistance with ADLs related to personal hygiene. During an observation on 08/18/2025 at approximately 3:00 PM, Resident #6 was lying in bed with her hands on top of the blanket. Her nails were very long. When asked if she liked her nails that long, Resident #6 said no. During an observation on 08/19/25 at 3:20 PM, Resident #6 was in bed with her hands crossed on top of her abdomen. There were 5 visible fingernails with lengths one half to three quarters of an inch past her fingertips. The nail portion above the fingertip had brown, black sediment underneath the nail. Brown/black sediment was also on the perimeter, top portion of some nails. During an interview with Staff J, (a CNA) on 08/20/2025 at 5:37 PM, the CNA said that she can not cut nails of any resident who was diagnosed with diabetes. She said that she did not report to a nurse manager the need for the resident's nails to be cut. In addition, the CNA said that her fingernails needed to be cleaned. Outside of the resident’s room, the CNA said that this resident was known to put her fingers in her feces. 3. A record review revealed that Resident #1 was admitted to the facility on [DATE]. Her medical history included the Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had a Brief Interview for Mental Status of 8, which indicated that she had cognitive impairment. A record review of Resident #1’s plan of care noted that her ADL self-care performance deficit was related to weakness, impaired mobility, some cognitive loss, and the loss of dexterity in her fingers. A listed intervention specified she needed maximum assistance for personal hygiene. During an observation on 08/20/25 at approximately 6:45 PM, Resident #1 was in her bed watching television. Her nails were long and the second digit of her left hand was pressing into the palm of her hand. Her fingers were contracted. [NAME] crusted looking patches of skin were on her palm. Red polish was on the upper half of her nails. There was no hand appliance on at that time. During an observation on 08/21/2025 at 9:17 AM, Resident #1 was in her bed and she was wearing an appliance on her left hand. Staff I removed the hand appliance and photographic evidence was obtained. The resident was asked if she wanted her fingernails cut and she said yes. Staff I was asked whose responsibility it was to clip the resident’s nails. Staff I said that she had cut them before, and that recently when she looked for the clippers she couldn’t find them. 4. During the tour on 08/18/25 at 11:58 AM, an interview was conducted with Resident #31’s spouse. He stated he has filed several grievances regarding care and for Resident #31 to get assistance to eat during meals. He is very concerned that his wife is not being encouraged to eat and drink by the staff. He stated that the facility mentioned the staff has been educated to assist his wife to eat. He stated he comes to visit every day and does help her with the meals; however, he is not sure if anyone is assisting when he is not at the facility. He also stated that Resident #31 appears thinner to him and dehydrated, she’s blind and has a hard time feeding herself. Record review documented Resident #31 was admitted on [DATE] with diagnoses to include Sequelae of Cerebral Infarction, Malignant Neoplasm of Colon, Adult Failure to Thrive, Generalized Muscle Weakness, Cognitive Communication Deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #31 had a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately cognitively impaired. Review of Section GG revealed that Resident #31 required setup or clean-up assistance for eating. Record review of the July Concern Log (Grievances) documented Resident #31’s spouse filed a grievance on 07/31/25 requesting assistance while eating for Resident #31. Further review of the Complaint/Grievance Report revealed the above grievance was resolved with education and the results were verbally communicated to family, who expressed satisfaction on 08/01/25. Record review of Resident #31 weight summary documented the following weights: 07/26/25 19:35 157.0 Lbs. 08/04/25 07:47 152.4 Lbs. 08/04/25 08:04 152.4 Lbs. 08/11/25 10:16 150.4 Lbs. During a breakfast dining observation on 08/19/25 at 8:13 AM, Resident #31 was in bed with the head of the bed raised and the breakfast tray in front of her on the over bed table. Breakfast consisted of scrambled eggs, hashbrown and oatmeal, 4oz container of milk (with a straw) and a foam cup of water with a lid and no straw. There were no staff in the room and Resident #31 was not eating anything on her breakfast tray. Continued observation at 8:22 AM did not show any staff in the room assisting Resident #31 with her meal which was100% untouched. At this time, an interview was conducted with Resident #31, who stated the food at the facility is okay and then grabbed the water foam cup and attempted to drink however was unable to since it had a lid and no straw. She then placed the foam cup back on the tray without drinking water. At 8:30 AM, the breakfast tray was taken out of the room. On 08/21/25 at 8:17 AM another breakfast observation was conducted for Resident #31, and no breakfast tray was observed in the room. Staff L, Certified Nursing Assistant (CNA) was asked to see Resident #31’s tray. Staff L removed the tray from the meal cart and noted that Resident #31 had eaten about 50% of her breakfast. She stated that she assisted the resident with her meal this morning. Staff L also stated that Resident #31 sometimes eats and sometimes does not, she needs encouragement.

Based on observations, interviews and record reviews, the facility failed to provide dining in a manner to preserve the dignity for 3 of 33 residents in the final sample, Residents #11, 14 and 9. The findings included:The facility’s policy, “Resident Rights – Right to Respect, Dignity and to have Personal Property” with a reference date of 04/01/22, did not address dignity during dining. 1. Resident #11 was admitted to the facility on [DATE]. According to the resident’s most recent complete assessment, a Significant Change Minimum Data Set (MDS), with a reference date of 05/21/25, Resident #14 had a Brief Interview for Mental Status (BIMS) score of 12, indicating that Resident #14 was moderately cognitively impaired. The assessment documented that the resident required partial/moderate assistance for eating. Resident #14’s diagnoses at the time of the assessment included: Arthritis, Parkinson’s disease, Seizure disorder, muscle weakness, Dysphagia. Resident #14’s care plan for Activities of Daily Living (ADLs) documented, “Resident has an ADL self-care performance deficit related to weakness, impaired mobility, tremors/Parkinson’s disease Date Initiated: 05/14/2024 Revision on: 06/04/2024 The goal of the care plan was documented as, “The resident will maintain or improve current level of function in ADLs through the review date. Date Initiated: 05/14/2024 Revision on: 06/04/2025 Target Date: 11/19/2025. Interventions to the care plan included: • EATING: The resident needs partial/mod assist of 1 when having tremors Date Initiated: 06/04/2024 During an observation of breakfast served to the residents in their rooms, on 08/20/25 at 8:33 AM, Resident #14 was sitting in a wheelchair on the left side of the resident’s bed facing the wall at the head of the bed. Staff N, CNA was noted to be assisting the resident by standing behind him and feeding him from over his right shoulder. 2. Resident #11 was admitted to the facility on [DATE]. According to the resident’s most recent complete assessment, a Significant Change MDS with a reference date of 08/10/25, Resident #11 was not assessed for cognition due to ‘resident is rarely/never understood’. The assessment documented that the resident required substantial/maximal assistance for eating. Resident #11’s diagnoses at the time of the assessment included: Gastro-esophageal reflux disease (GERD), Arthritis, Osteoarthritis, Aphasia, Seizure disorder, Dysphagia. Resident #11’s care plan for ADLs documented, “Resident has an ADL self-care performance deficit r/t Impaired balance, weakness, cognitive and communication deficit, traumatic brain injury, Cerebrovascular accident (CVA) subdural hematoma, contractures risk for decline in function. Date Initiated: 04/10/2023 Revision on: 08/21/2025. The goal of the care plan was documented as, “The resident will maintain or improve current level of function in ADLs through the review date. Date Initiated: 04/10/2023 Revision on: 08/18/2025 Target Date: 11/19/2025. Interventions to the care plan included: • EATING: The resident needs substantial/max assist x1. can feed self finger foods Date Initiated: 04/10/2023. During an observation of breakfast served to the residents in their rooms, on 08/20/25 at 8:33 AM, Resident #11 was positioned in a wheelchair at the resident’s left side of the bed with breakfast on an overbed table, while Staff O, CNA was standing over and to the resident’s left side to feed the resident. At the time of the observations of Resident #14 and Resident #11 being assisted by staff, Staff P, Licensed Practical Nurse/Unit Manager (LPN/UM), was asked to join the surveyor to make the observations. Staff P acknowledged the concerns at the time of the observations. 3. Record review for Resident #9 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses which included: Sequelae of Cerebral Infarction, Dysphagia, Dementia, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the Minimum Data Set (MDS) for Resident #9 dated 07/11/25 revealed in section C a Brief Interview for Mental Status (BIMS) score of 99, indicating that she was rarely/never understood. Review of section GG revealed Resident #9 was dependent on staff assistance for eating. During a lunch dining observation conducted on 08/21/25 at 1:02 PM, in the 200-unit hallway, it was noted Staff I, Certified Nursing Assistant (CNA) was in Resident #9’s room assisting with her lunch meal. Staff I was observed standing over Resident #9 while feeding the resident. Further observation of the room revealed an empty chair in the room by the window. At 1:13 PM, an interview was conducted with Staff I, who stated she has worked at the facility for 5 years. When asked if she should be standing to assist with meals, Staff I appeared confused, unsure of what to say and then asked the surveyor if she should sit or stand to assist with meals. Staff I was then asked again what the protocol is when a resident requires assistance with feeding. She then stated that she should sit because the resident might feel rushed to finish the meal. Then Staff I acknowledged that she was standing over Resident #9 while assisting with lunch and that was not per protocol.

Based on observations, interviews and record review, the facility failed to follow orders for fluid restrictions for 1 of 1 resident reviewed for Dialysis, Resident #3. The findings included:The facility's policy, ‘Fluid Restrictions' with a reference date of 05/2014 and a revision date of 09/2017, documented: A fluid restriction will be implemented only as part of a therapeutic diet prescription. The policy did not address fluids provided by staff for hydration. Resident #3 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment documented that Resident #15 required supervision or touching assistance for eating. Resident #3's diagnoses at the time of the assessment included: Hypertension, Peripheral Vascular disease (PVD), Diabetes Melitus, Psychotic disorder, Cerebral infarction, Muscle weakness, Dependence on Renal dialysis, Hypothyroidism. Resident #3's orders included;FLUID RESTRICTION - 1500 CC / day 720 ML by dietary, 260 ML 7-3, 260 ML 3-11, 260 ML 11-7 - every shift for nutrition 260 ml per shift by nursing - 07/07/25Resident #3's care plan for dehydration documented, The resident has dehydration risk for fluid restrictions, infections, diuretic use Date Initiated: 07/08/2025 Revision on: 8/18/2025. The goal of the care plan was documented as, The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Date Initiated: 07/08/2025 Target Date: 10/13/2025. Interventions to the care plan included: Monitor/document/report PRN any s/sx of dehydration. Date Initiated: 07/08/2025 Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal lab. Date Initiated: 07/08/2025 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 07/08/2025. Resident #3's care plan for nutrition documented, Resident has nutritional problem or potential nutritional problem related to End Stage Renal Disease, constipation, Hypertension, Peripheral vascular disease, Hypothyroidism, Gastroesophageal reflux disease, Chronic kidney disease, Cerebral infarction, Respiratory failure, Adjustment disorder, Hyperkalemia, eats out of facility, dialysis, fluid restrictions, history of non-compliance to diet, history of readmission, history of appetite stimulant use, Refused renal diet. Date Initiated: 05/30/2025 Revision on: 07/08/2025. Interventions to the care plan included: Fluid restrictions as ordered Date Initiated: 07/08/2025 Provide, serve diet as ordered. Monitor intake and record with each meal. Date Initiated: 04/17/2025. On 08/19/2025 at 11:22 AM Resident #3 was noted to be not in her room. At the time of the observation, there was a 20 ounce foam cup approximately 1/3 full of fluid (water) on her overbed table to the resident's left side of the bed. During an interview, on 08/19/25 at 11:35, with Resident #3, when asked about being aware of the fluid restrictions, Resident #3 stated, I have to watch my water intake because of the dialysis. If I get too much I would have to go to the hospital and get some taken off. When asked about the water on the overbed table, Resident #3 replied, I didn't drink it, I spilled some of it. It is for the middle of the night. On 08/20/25 at 8:30 AM, Resident #3 was not in her room. At the time of the observation, Resident #3's breakfast was on her overbed table and there was a 20 ounce Styrofoam cup of fluid (water) on the nightstand to the resident's left side of the bed. During an interview, on 08/20/25 at 3:15 PM, with Staff A, LPN, when asked about hydration provided to the residents, Staff A stated that 11-7 shift refreshes the fluids at the end of their shift and when they start doing coffee for breakfast they will be refilled. During an interview, on 08/21/25 at 6:50 AM, with Staff Q, CNA, when asked about providing fluids to Resident #3 during her shift (11PM to 7 AM), Staff Q replied, I never give her fluids. The nurse told me that she is on fluid restrictions, so I don't provide water at her bedside. Staff Q further stated that she worked on Monday night (08/18/25) and last night (Wednesday, 08/20/25). During an interview, on 08/21/25 at 6:53 AM with Staff P, LPN/Unit Manager, when the concern was brought to her attention, Staff P stated, she is noncompliant with her fluid restrictions. She has been educated about the risk, but if she gets her own from outside, we can't stop her. When asked about the risk associated with being noncompliant with the restrictions, Staff P stated, She is on dialysis, so they would have to remove more fluid because her kidneys would not be able to process the extra fluids. She could get swollen, she could have congestive heart failure, she can get fluid in her lungs.

Based on observations, interviews, and record reviews, the facility failed to provide nutrition via enteral feedings per physician orders for 1 of 3 residents (Resident #68), reviewed for enteral feeding. This had the potential to affect 3 residents who were dependent on enteral feeding for nutrition. The findings included:The facility's policy on Enteral Feeding and Nutrition, effective 04/01/22, was to ensure adequate parameters of nutrition and hydration status through the provision of physician ordered enteral feedings. It specified that the physician orders for enteral nutrition were based on recommendations of the Registered Dietitian. A record review revealed that Resident #68 was admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction, Dementia, Dysphagia following Cerebral Infarction, and Gastrostomy Status. The minimum data set (MDS) quarterly assessment dated [DATE] revealed he had severe cognitive impairment, and he received enteral feeding exclusively, also known as tube feeding, to meet his needs for nutrition. Resident #68's most recent weight was 116.2 lbs. His Body Mass Index was 18.2. This indicated that Resident #68 was underweight. A record review of Resident #68's care plan last revised on 11/26/2024, revealed a focus on tube feeding that was related to his diagnosis Dysphagia (difficulty swallowing). The quarterly assessment completed by the Registered Dietitian on 08/06/25 noted that Resident #68 was at risk for malnutrition and tube feeding complications; She calculated that the resident required 1800 Calories to be administered each day. This included 1240 milliliters of water that was a component in the 1500 milliliters of Glucerna 1.2 Cal formula. A doctor's order dated 11/26/24 was for an NPO (nothing by mouth) diet. A doctor's order dated 11/26/24 specified to administer Glucerna 1.2 Cal at a rate of 75 milliliters per hour for 20 hours. On at 2pm, off at 10am; until 1500ml infused. Another order for enteral feeding of Glucerna 1.2 dated 02/27/25 said to administer Glucerna 1.2 via PEG (percutaneous endoscopic gastrostomy) to run at 75 milliliters per hour via pump for 20 hours. Total volume to be infused 1500 milliliters/24 hours. Up at 2:00 PM and down at 10 AM. May stop for care and ADLs. There were 2 orders for enteral feeding. An observation of Resident #68 on 08/18/2025 at 12:10 PM during the initial screening process, revealed that the resident had physical signs of malnutrition. He was in bed wearing a loosely tied hospital gown. The enteral feeding pump was off. Severely depressed muscles in between the clavicle bones on his left shoulder were visible. Later that day, on 08/18/25 at 2:32 PM, the pump was on, and the resident's enteral feeding was in progress at 75 milliliters per hour. The 1000 milliliter plastic bottle appeared to be full. The hand-written date on the label was 08/18/25 and the time written on the label said was 2:00 PM. Approximately 50 milliliters was administered. The EntraFlo Pump digital display showed 49 milliliters was delivered since the pump was started (approximately 2:00 PM). Photographic Evidence Provided. An observation of Resident #68's enteral feeding on 08/19/25 at 10:07 AM revealed that the pump was turned off. The turn off time was scheduled at 10:00 AM. The 1000 milliliter bottle had dark black graduated lines printed along the right edge of the large rectangular label, revealed that the bottle still had approximately 800 milliliters left in the bottle. The date on the bottle was 08/19/25 and the start time was listed 4:00 A.M. Photographic Evidence Obtained. An observation of the digital readout of the amount of Glucerna 1.2 Cal that was delivered showed 1324 milliliters. This number was displayed 15 minutes prior to the shut off time. Considering there was 950 milliliters left in the bottle dated 08/18/25, 2:00 PM the difference is 374 milliliters that was delivered from the bottle dated 08/19/25 4:00 AM. A 1000 milliliter bottle minus 374 milliliters leaves 626 milliliters. There were 800 milliliters left in the bottle. The digital readout did not correlate with the observed amount of formula that was left in the bottle. A complete feeding of 1500 milliliters would have left 500 milliliters in the bottle after the 1000 milliliter bottle dated 08/18/25 was finished, and a new 1000 milliliter bottle was started. In the 20-hour feeding from 2:00 PM on 08/18/25, to 10:00 AM on 08/19/25, Resident #68 received approximately 300 milliliters too little formula. Photographic Evidence Obtained. During an observation of the enteral feeding pump connected to Resident #68 on 08/19/25 at 3:30 PM, the digital readout on the EntraFlo pump said 1324 milliliters was delivered. At 3:30 PM Resident #68 received 120 milliliters from the bottle of Glucerna 1.2 that was scheduled to start at 2:00 PM. Approximately 680 milliliters remained in the bottle of Glucerna that was dated 08/19/25, 4:00 AM. Photographic Evidence Obtained. During an observation of the enteral feeding pump connected to Resident #68 on 08/20/25 at 9:45 AM. The tube feeding was in progress at 75 milliliters per hour. The digital readout showed that 518 milliliters was delivered to the resident. The bottle of Glucerna 1.2 had a handwritten date 08/20/25, and time 2:00 AM. Approximately 600 milliliters remained in the bottle. If 518 milliliters was administered from a 1000 milliliter bottle, 482 milliliters would remain. The amount on the digital display did not reflect the observed approximation of 600 milliliters that remained in the bottle. Photographic Evidence Obtained. The amount of Glucerna 1.2 that was delivered from the bottle dated 08/20/25, 2:00 AM was 400 milliliters. The 800 milliliters that remained in the bottle dated 08/19/25, 4:00 AM was administered, plus 400 milliliters administered from the bottle dated 08/20/25, 2:00 AM equals 1200 milliliters. Resident #68 should have received 1500 milliliters in the 20-hour time period between 08/19/25 at 2:00 PM and 08/20/25 at 10 AM. Resident #68 received approximately 300 milliliters less than ordered. During an interview with Staff F on 08/20/25 at 10:52 AM, when asked how she knew when Resident #68 received enough of the Glucerna 1.2 Cal, she said that she turned the pump off at 10:00 AM, and then she turned the pump on at 2:00 PM. When asked how much formula he was supposed to receive everyday she answered Resident #68 received 75 milliliters for 20 hours or until 1500 milliliters was infused. When asked how she knew when 1500 milliliters was infused, Staff F read the digital display that showed 541 milliliters. She said 541 milliliters was the amount delivered. When asked if she ever saw a number 1500 milliliters on the digital display on the pump, Staff F said no.

Based on observations, interviews and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 sampled resident for respiratory care (Resident #24). The findings included:Review of the facility's policy titled, Tracheostomy Care with an effective date of 04/01/22 included in part the following: General Guidelines -Aseptic technique must be used: During cleaning and sterilization of reusable tracheostomy tubes. A mask and eyewear must be worn if splashes, spraying of blood or body fluids is likely to occur when performing this procedure. Clean the Removable Inner Cannula- Maintaining sterile field, pour equal parts hydrogen peroxide and normal Saline in one compartment of opened kit. Pour normal saline in another compartment. Put on sterile gloves. Secure the outer neck plate with non-dominate hand. Remove and discard gloves into appropriate receptacle. Wash hands and put on fresh gloves. Record review for Resident #24 revealed the resident was admitted to the facility on [DATE] with readmissions on 07/04/25 and 08/01/25, with diagnoses that included in part the following: Diffuse Traumatic Brain Injury and Tracheostomy Status. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #24 revealed in part the following orders:An order dated 06/19/24 to change trach collar every night shift and was discontinued 07/02/25.An order dated 06/19/24 to change trach inner cannula every day. Trach size:4UN65H inner cannula #4IC65 every night shift related to Tracheostomy Status and was discontinued on 07/02/25.An order dated 08/01/25 to change trach collar every night shift every 3 days.An order dated 08/06/25 to change trach inner cannula every day. Trach inner cannula size 4UN65H every night shift.In summary the resident did not have orders to change trach collar or to change trach inner cannula from 07/04/25 to 07/30/25 while the resident was in the facility. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #24 from 07/04/25 to 07/30/25 revealed there was no documentation of trach care. Review of the Progress Notes for Resident #24 from 07/04/25 to 07/30/25 revealed there was no documentation of trach care. Review of the Care Plan for Resident #24 dated 03/27/24 with a focus on the resident has a tracheostomy, resident puts his hands on tracheostomy frequently. The goals were for the resident to have minimal signs/symptoms of infection and for the resident to have clear and equal breath sounds bilaterally through the review date. The interventions included in part the following: Ensure that trach ties are secured at all times. Suction as necessary. On 08/18/25 at 12:42 PM an observation was made of Resident #24 who has a trach collar in place with suction set up at bedside. During an interview conducted on 08/18/25 at 12:45 PM with Resident #24 who was asked if staff perform trach care, he said they usually do it every day but not always. He said the nurse that he has today is good about doing it when she is working. On 08/20/25 at 12:15 PM an observation of tracheostomy care for Resident #24 performed by Staff A Licensed Practical Nurse (LPN) who was assisted by Staff B Licensed Practical Nurse/Wound Care Nurse (LPN/WCN). During the observation Staff A LPN performed suctioning, tracheostomy care that included: removing, cleaning and replacing outer cannula, replacing disposable inner cannula, removing and replacing trach ties. During the observation neither nurse wore any eye protection. Staff A LPN did apply sterile gloves but touched a plastic cover with both sterile gloved hands and touched the tip of the suction tubing prior to performing suctioning. During the suctioning a large mucus plug came out of the resident. Staff B LPN/WCN consistently had to give direction to Staff A LPN during all parts of the procedure including set up, suctioning, removing and cleaning outer cannula, replacing disposable inner cannula and replacing the trach ties. Staff A LPN continued to touch several items on the sterile field with contaminated sterile gloves and with non-sterile gloves. Staff A LPN cleaned the outer cannula and replaced the disposable inner canula with non-sterile gloves. During an interview conducted on 08/20/25 at 12:57 PM with Staff B LPN/WCN who was asked about Staff A LPN's performance of tracheostomy care for Resident #24, she said it was not good. Staff B LPN/WCN admitted he did not maintain a sterile field or use sterile technique while performing the procedures involved in tracheostomy care. During an interview conducted on 08/20/25 at 1:10 PM with Staff A LPN who was asked about his performance of tracheostomy care, he said he saw Staff B LPN/WCN in the hall on his way to this interview and knew it was not good. When asked about maintaining a sterile field maintaining a sterile gloved hand during the procedure, he admitted he did not. When asked about eye protection, he admitted that neither Staff B LPN/WCN nor himself had worn any eye protection during the procedure, but after thinking about it they should have worn eye protection. When asked when the last time he training for tracheostomy care , he said about 1 year ago when he was hired. During an interview conducted on 08/20/25 at 2:00 PM with the Director of Nursing (DON), who was asked how often trach care is provided, she said it should be every shift (three 8hour shifts per day). Upon record review for Resident #24 she acknowledged the resident did not have orders or documentation for trach care from 07/04/25 to 07/30/25.

Based on observations, interviews and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing, and administering of all drugs for, 7 of 9 residents reviewed for controlled substances (Residents #7, #104, #32, #14, #48, #69, and #85) and failed to establish a system of records of all controlled drugs to ensure discontinued controlled medications are removed from the medication carts for 2 of 9 residents reviewed for controlled medications (Residents #104 and #14). The findings included: 1. During an interview conducted on 08/19/25 at 9:51 AM with the Director of Nursing (DON) who was asked about medications, the DON stated all meds are secured at all times. When asked about what happens to controlled medications for residents who discharged or sent to the hospital, the DON stated the nurse on the med cart will remove the medication and give it to her. The DON said she is always on the floor daily and always asks nurses if they have any discontinued medications they need to give to her. Once she has the controlled medication that is discontinued or no longer in use, she stores them in her office in a locked file cabinet and they are destroyed with two people including herself and the Administrator or the Consultant Pharmacist. If it is her and the Administrator, the Consultant Pharmacist will sign off on the destruction of the medication and they keep a log of the destroyed medications. When asked if they audit the med carts to ensure controlled medications no longer in use or for residents no longer in the facility, she said she or the Consultant Pharmacist will periodically check the carts. On 08/20/25 at 4:00 PM a review of a south unit med cart for the 500 hall was performed with Staff D Licensed Practical Nurse (LPN) who had a medication cup with 11 pills in the top drawer. Review of the controlled meds and the Medication Monitoring/Control Record for the following residents revealed the following: Resident #48 Hydromorphone 2mg (23) was signed off on the Medication Monitoring/Control Record on 08/20/25 at 6:28 AM and not signed off on the Medication Administration Record (MAR). This was confirmed by Staff D LPN. Resident #14 Tramadol 50mg the resident had two Medication Monitoring/Control Records for the same medication, with one record showing the resident as given the medication on 08/17/25 at 1:30 AM however the medication was not documented on the MAR as the medication was discontinued on 08/12/25. During an interview conducted on 08/20/25 at 4:02 PM with Staff D LPN who was asked about the pills in the cup, she said she did not pull the pills. She said they must have been in the cart from the previous nurse. When asked what time she took over the med cart, she said it was at 7:00 AM this morning. When asked when a controlled medication is taken out to give to a resident where is this documented, she said it should be documented on the Medication Monitoring/Control Record and on the MAR. When asked about when the controlled medications are discontinued or the resident has been discharged or transferred out of the facility what is done with the controlled medications, she said they leave them in the cart until someone comes to pick them up. On 08/21/25 at 10:40 AM a review of a south unit med cart for the 600 hall was performed with Staff E Licensed Practical Nurse (LPN). Review of the controlled meds and the Medication Monitoring/Control Record for the following residents revealed the following: Resident #32 Tramadol Hcl 50mg (8) the Medication Monitoring/Control Record documented the medication was signed out seven times (07/25/25, 07/27/25, 07/28/25, 07/29/25, 07/31/25, 08/03/25, and 08/05/25) and none of these days the medication was signed out on the MAR. Resident #104 Alprazolam 0.5mg (6) the Medication Monitoring/Control Record documented the medication was signed out 4 times (07/25/25, 07/26/25, 0728/25, and 07/29/25) and none of these days the medication was signed out on the MAR. The medication had in fact been discontinued on 03/05/25 but had remained in the med cart. Resident #7 Fentanyl patch 50mcg (2) the Medication Monitoring/Control Record documented the medication was documented as signed out on 08/16/25 but was not documented on the MAR as administered. During an interview conducted on 08/21/25 at 11:00 AM with Staff E LPN who stated when a controlled medication is removed from the cart to be given to resident she will document the medication removal on the Medication Monitoring/Control Record and document the medication administration on the resident's MAR. Staff E LPN acknowledged Resident #32's Tramadol 50mg was not documented on the MAR but signed out on the Medication Monitoring/Control Record (07/25/25, 07/27/25, 07/28/25, 07/29/25, 07/31/25, 08/03/25, and 08/05/25). Staff E LPN also acknowledged Resident #104 Alprazolam 0.5mg was discontinued on 03/05/25 and had been documented as signed out on the Medication Monitoring/Control Record on 07/25/25, 07/26/25, 07/28/25, and 07/29/25 but not documented on the MAR as being administered on those dates. Staff E LPN acknowledged for Resident #7 the Fentanyl patch 50mcg (2) the Medication Monitoring/Control Record documented the medication was documented as signed out on 08/16/25 but was not documented on the MAR as administered. Record review for Resident #48 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Fibromyalgia, Generalized Anxiety Disorder. The Minimum Data Set (MDS) dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. a. Review of Physician’s Orders for Resident #48 revealed an order dated 06/18/25 for Hydromorphone HCl Oral Tablet 2 MG give 1 tablet by mouth every 6 hours as needed. b. Record review for Resident #104 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Mood Disorder Due to Known Physiological Condition with Mixed Features and Generalized Anxiety Disorder. The MDS dated [DATE] documented in Section C a BIMS score of 15 indicating a cognitive response. Review of Physician’s Orders for Resident #104 revealed an order dated 02/19/25 for Alprazolam Tablet 0.5 MG give 1 tablet by mouth every 12 hours as needed for Anxiety for 14 Days was discontinued on 03/05/25. c. Record review for Resident #7 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission to the facility on [DATE] with diagnoses that included in part the following: Multiple Sclerosis and Other Chronic Pain. The MDS dated [DATE] documented in Section C a BIMS score of 15 indicating a cognitive response. Review of the Physician’s Orders for Resident #7 revealed an order dated 06/27/25 for Fentanyl Patch 72 Hour 50 MCG/HR apply 1 patch transdermal every 72 hours for pain Rotate Site and remove per schedule. d. Record review for Resident #32 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Cerebal Palsy and Rheumatoid Arthritis. The MDS dated [DATE] documented in Section C a BIMS score of 13 indicating a cognitive response. Review of the Physician’s Orders for Resident #32 revealed an order dated 12/19/24 for Tramadol HCl Tablet 50 MG give 1 tablet by mouth every 12 hours as needed for pain. e. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Parkinsons Disease and Other Polyosteoarthritis. The MDS dated [DATE] documented in Section C a BIMS score of 12 indicating a moderate cognitive response. Review of the Physician’s Orders for Resident #14 revealed an order dated 08/15/24 for Tramadol HCl Tablet 50 MG give 1 tablet by mouth every 8 hours as needed and was discontinued on 08/12/25. 2. Record review for Resident #69 revealed an admission to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, Radiculopathy. Review of Resident #69’s Physician Orders dated 05/28/25 documented “Percocet (Oxycodone with Acetaminophen) 5-325 milligrams (mg) give one tablet every 4 hours as needed for pain (a controlled substance for pain)”. On 08/20/25 at 5:22 PM a medication storage observation was held on the North wing of the facility in which a controlled substance reconciliation was conducted for Resident #69. The medication monitoring/control record sheet documented Oxycod/APAP (Percocet) 5-325 mg was removed from the controlled substance locked box on 08/20/25 at 0042 (12:42 AM), 0822 (8:22 AM), and at 16:36 (4:36 PM). However, a review of the August Medication Administration Record (MAR) documented that Resident #69 was administered Percocet 5-325 mg tablet on 08/20/25 at 0822 and 1637; no entry was documented Resident #69 was administered the controlled substance on 08/20/25 at 0042. 3. Record review for Resident #85 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses included: Diabetes Mellitus due to Underlying condition with Diabetic Neuropathy, Generalized Muscle Weakness, Complete Traumatic Amputation at Level Between Knee and Ankle. Review of Resident #85’s Physician Orders dated 07/12/25 documented Tramadol (a controlled substance for pain) 50 mg, give one tablet every 6 hours as needed for moderate and severe pain. On 08/20/25 at 5:22 PM a medication storage observation was held on the North wing of the facility in which a controlled substance reconciliation was conducted for Resident #85. The medication monitoring/control record sheet documented Tramadol 50 mg was removed from the controlled substance locked box on 08/12/25 at 1855 (6:55 PM), and on 08/16/25 (unable to read the time). The next recorded date that the medication was removed from the locked box was on 08/19/25. Record review of the August MAR documented Resident #85 was never administered Tramadol 50 mg on 08/12/25; and the medication was administered twice on 08/16/25 at 0950 (9:50 AM) and at 1746 (5:46 PM). Further review revealed Resident #85 was administered Tramadol 50 mg on 08/17/25 at 1204 (12:04 PM), which was not documented as administered in Resident #85’s MAR.

Based on interviews and record review the facility failed to ensure adequate monitoring of behaviors and side effects for residents on psychotropic medications for 3 of 5 residents reviewed for unnecessary medications (Residents #24, #2, #3). The findings included:Review of the facility’s policy titled, “Antipsychotic Medication Use” with an effective date of 04/02/22 included in part the following: Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician. 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Urinary Tract Infection, Dementia, and Psychotic Disorder with Hallucinations Due to Known Physiological Condition. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. Review of the Physician’s Orders for Resident #2 revealed in part the following: An order dated 07/25/25 for Donepezil HCl Tablet 10 MG Give 0.5 tablet by mouth one time a day. An order dated 07/25/25 for Memantine HCl Tablet 10 MG Give 1 tablet by mouth at bedtime. An order dated 07/25/25 for Behaviors – Monitor for the Following: Sad Affect, Continuous crying, seems withdrawn, Mood Changes Document: \'N\' if none of the above observed. \'Y\' if any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and progress note findings every shift agitation (Active). An order dated 07/25/25 for Behaviors – Monitor for the following: Restlessness (Agitation), Hitting, Increase in Complaints, Spitting, Cussing, Racial Slurs, Elopement, Psychosis, Aggression, Refusing Care, Angry. Document: \'N\' if none of the above observed. \'Y\' if any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and progress note findings every shift An order dated 07/25/25 for Side Effects 1)Tardive dyskinesia 2)Hypotension 3)Sedation\/Drowsiness 4)Increased falls\/dizziness 4)Appetite changes\/weight change 5)Headache 6)Insomnia 7)Weakness 8)Visual Disturbances 9)Gastrointestinal disturbances 10)Other: see progress notes every shift for monitoring. Put in corresponding code. An order dated 07/26/25 for Antipsychotic Medication – Monitor for Dry Mouth, Constipation, Blurred Vision, Disorientation/Confusion, Difficulty Urinating, Hypotension, Dark Urine, Yellow Skin, Nausea/Vomiting, Lethargy, Drooling, Extrapyramidal Symptoms (Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement of Mouth of Tongue). Document: \'Y\' if monitored and none of the above observed. \'N\' if monitored and any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and progress note findings every day shift. An order dated 08/01/25 for Brexpiprazole (Rexulti )Oral Tablet 2 MG Give 1 tablet by mouth at bedtime. An order dated 08/02/25 for Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime. Review of the Medication Administration Record (MAR) for Resident #2 documented for side effects a code of “0” which has no indication according to the order. Review of the MAR for Resident #2 documented for behaviors was just a check mark not a “Y” or “N” to indicate if the resident had behaviors or not. Review of the Care Plan for Resident #2 dated 07/25/25 with a focus on the resident is on antipsychotic therapy at risk for side effects. The goal was for the resident to be/remain free of antipsychotic drug related complications. The interventions included in part the following: Monitor behavioral symptoms and side effects. During an interview conducted on 08/21/25 at 10:40 AM with Staff E Licensed Practical Nurse (LPN) who was asked about monitoring side effects and behaviors for psychotropic medications, she said they document in the MAR under the order. When asked about Resident #2 she acknowledged the documentation was not clear if the resident had side effects or behaviors. When asked about Resident #24 she acknowledged there were no orders for monitoring behaviors or side effects. During an interview conducted on 08/21/25 at 11:20 AM with Staff A Licensed Practical Nurse (LPN) who was asked about monitoring side effects and behaviors for psychotropic medications, she said they document in the MAR under the order. When asked about Resident #2 he acknowledged the documentation was not clear if the resident had side effects or behaviors. When asked about Resident #24 he acknowledged there were no orders for monitoring behaviors or side effects. 2 Record review for Resident #24 revealed the resident was admitted to the facility on [DATE], transferred to the hospital on [DATE] and returned to the facility on [DATE], and went out to the hospital again on 07/30/25 and returned to the facility on [DATE], with diagnoses that included in part the following: Diffuse Traumatic Brain Injury and Tracheostomy Status. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician’s Orders for Resident #24 revealed in part the following orders: An order dated 07/04/25 for Lorazepam Tablet 0.5 MG give 1 tablet by mouth two times a day. An order dated 07/10/25 for Duloxetine HCl Capsule Delayed Release Particles 30 MG give 2 capsule by mouth two times a day. In summary there were no orders to monitor behaviors or side effects for resident receiving psychotropic medications. Review of the MAR for Resident #24 from 08/01/25 to 08/17/25 revealed there was no documentation of monitoring behaviors or side effects. Review of Nursing Progress Notes for Resident #24 from 08/01/25 to 08/17/25 revealed there was no documentation of monitoring behaviors or side effects. Review of the Care Plan for Resident #24 dated 04/15/24 with a focus on the resident uses psychotropic medications antidepressant at risk for side effects. The goal was for the resident to be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions included in part the following: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN any adverse reactions of Psychotropic medications. 3. Record review for Resident #3 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses included: Adjustment Disorder with Mixed Disturbance of Emotions And Conduct; Unspecified Psychosis not due to a Substance or Known Physiological Condition; Major Depressive Disorder, Recurrent, Moderate; Mood Disorder due to Known Physiological Condition with Mixed Features; Generalized Anxiety Disorder. Review of Section C of the MDS dated [DATE] revealed that Resident #3 had a BIMS score of 15, which indicated that she was cognitively intact. Review of Resident #3’s Physician Orders dated 06/11/25 documented Divalproex Sodium 250 milligrams (ml) give 4 tablets by mouth at bedtime for anticonvulsant (a psychotropic medication used for mood disorder and anxiety).” Review of Resident #3’s Physician Orders dated 07/23/25 documented “Paroxetine HCl 20 mg, give 1 tablet by mouth one time a day for depression (a psychotropic medication)”. “Olanzapine 5 mg give 1 tablet by mouth at bedtime for psychotic disorder” and “Olanzapine 2.5 mg give 1 tablet by mouth one time a day for depression related to Unspecified Psychosis not due to A Substance or Known Physiological Condition (an antipsychotic medication). Review of Resident #3’s Physician Orders dated 07/30/25 documented “0-no behavior, 1-agitation, 2- combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes, every shift for <type the medication class>”. Further review of Resident #3’s Physician Orders revealed no orders to monitor side effects of the above psychotropic and antipsychotic medications. Review of the provider psych notes documented that on 07/23/25 Resident #3 was seen by Psych Health Associates for medication review and the provider recommended for Resident #3 to be monitor closely for side effects, sedation, or increase confusion; and a gradual dose reduction is not clinically indicated at this time due to the resident’s current psychiatric instability and ongoing needs for therapeutic support. Record review of the July and August Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed Resident #3 was administered all her medications, however, was not monitored for side effects for the psychotropic and antipsychotic medications.

Based on observations, interviews and record review the facility failed to secure medications at all times during 2 of 4 medication pass observations (Residents #73 and #45), failed to secure medications at all times for over the counter medications in 1 of 2 unit manager's offices (unit manager for south), and failed to store medications according to facility policy for 1 of 3 medication carts reviewed for medication storage (Med Cart 500 Hall). The findings included:Review of the facility's policy titled, Medication Storage with no date included in part the following: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the Florida Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or room that is accessible only to authorized personnel. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with the facility policy 1. During an interview conducted on [DATE] at 10:30 AM with Staff P Licensed Practical Nurse/Unit Manager (LPN/UM) in her office when an observation was made of approximately 36 bottles of over the counter medications and 1 enema solution were located on an open bookshelf in her office. When asked when she leaves her office does she lock the door, she replied no she just shuts the door. When asked about the approximate 36 bottles of medication and 1 enema solution located on an open bookshelf in her office, she said they were in the office when she moved into the office about a week or so ago. She added the medications were removed from the medication carts due to nurses marking a date on the medications and that is not their policy. When asked if the medications should be secured at all times she said yes, from now on I will lock my door when I leave my office. 2. On [DATE] at 4:00 PM a review of a south unit medication cart for the 500 hall was performed with Staff D Licensed Practical Nurse (LPN) who had a medication cup with 11 pills in the top drawer. During an interview conducted on [DATE] at 4:02 PM with Staff D LPN who was asked about the pills in the cup, she said she did not pull the pills. She said they must have been in the cart from the previous nurse. When asked what time she took over the med cart, she said it was at 7:00 AM this morning. During an interview conducted on [DATE] at 9:51 AM with the Director of Nursing (DON) who was asked about medications, the DON stated all medications are secured at all times. 3. During a medication pass observation for Resident #73 on [DATE] at 9:00 AM performed by Staff A Licensed Practical Nurse (LPN), he left 2 oral medications (gabapentin 300 MG, and Saccharomyces boulardii Capsule 250 MG) and 1 intravenous medication ( Cefepime HCl Intravenous Solution 2 GM/100ML) on the overbed table in front of the resident, out of his sight when the LPN went to put on a gown and gloves before administering the intravenous antibiotic.

Based on observations, interviews, policy review, and record review, the facility failed to provide pureed foods in appropriate consistency for 3 residents (Resident #30, Resident #78, Resident #76) on Dysphagia Puree texture diets and for one resident (Resident #108) who was on a diet with an order for nectar thickened fluids. This had the potential to affect 27 residents who were on mechanically altered diets. The findings included:A review of the policy on the Levels of the National Dysphagia Diet from the Nutrition Care Manual dated 2019 described the pureed diet as a homogenous, pudding-like consistency without particles, The General Guidelines for Thickened Liquids stated that all liquids should be thickened to the proper consistency, including soups, water, oral supplements, and all other beverages. 1.A record review revealed that Resident #30 was admitted to the facility on [DATE] with diagnoses that included Dysphagia (difficulty swallowing), Dementia, Muscle Weakness, and Lack of Coordination. A Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated that she had severe cognitive impairment. This MDS assessment revealed that she received a mechanically altered diet. A review of the medical records showed that Resident #30's diet order dated 02/07/25 was for a regular diet, with Dysphagia Puree texture, and Nectar thickened fluids. A record review revealed that Resident #78 was admitted to the facility on [DATE]. Her diagnoses included Multiple Sclerosis, Muscle Weakness, and Dysphagia, Oral Phase. Review of the Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed that Resident #78 had a Brief Interview for Mental Status of 12, which indicated that she had moderate cognitive impairment. This assessment also documented that Resident #78 was on a mechanically altered diet. A record review revealed that Resident #76 was admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, and Unspecified Dementia. The Minimum Data Set (MDS) significant change assessment dated [DATE] showed that Resident #76 was cognitively impaired. His most recent weight was 112 lbs on 08/12/25, and his Body Mass Index (BMI) was 16.5. This indicated he was severely underweight. His diet order dated 08/01/24 was for a Regular diet, with Dysphagia Puree texture, and Nectar thickened fluids. During an observation 08/19/25 at 5:10 PM Resident #30 was in the dining room. She received a plate of pureed foods. The pureed rice was lumpy. On 08/19/25 at 6:17 PM Resident #76 was receiving assistance with feeding while he was in bed. The pureed food was lumpy. The resident coughed several times. Photographic evidence obtained. When the surveyor entered the kitchen to examine the pureed foods, there were no pureed leftovers to examine. During observations on 08/20/25 at 12:36 PM, Resident #30, Resident #78, and Resident #76 were served plates of pureed foods. The pureed meat entree, and the pureed bread appeared lumpy. During an interview with the Kitchen Manager on 08/20/25 at 12:40 PM, a plate of pureed foods was requested. The Kitchen Account Manager and the surveyor tasted the pureed bread and the pureed meat. The pureed bread looked lumpy but it tasted smooth. The Kitchen Account Manager said the pureed meat could be smoother. It had sand like particles in it and it was not a homogenous texture. When the Kitchen Account Manager was shown photos from the dinner meal served on 08/19/25, she was asked if the rice appeared to be of a unified texture. The Kitchen Account Manager said that the pureed rice did not appear to be a uniform texture. 2.A record review of Resident #108 revealed that he was admitted on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease, Muscle Weakness, Dementia, and Dysphagia, Oropharyngeal Phase. The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #108 had a Brief Interview for Mental Status (BIMS) of 06, which indicated that he had severe cognitive impairment. This MDS assessment documented that Resident #108 was on a mechanically altered diet. His diet order dated 03/21/24 was for a Regular diet, with Dysphagia Advanced texture, and Nectar thickened fluids (consistency). During an observation on 08/19/25 at 5:51 PM in the resident's room, Resident #108 had a cup of thin coffee in a mug on his meal tray, and a large styrofoam cup of regular consistency water with a straw in it. The meal ticket on the tray said that he was to be served Nectar thick fluids. Photographic Evidence Obtained. During an interview with Staff K , (a CNA), on 08/19/25 at 6:00 PM, when asked if the water in the Styrofoam cup was regular thin water, Staff K answered yes. When asked if the coffee was regular texture, Staff K said that she thought thickener was added to the liquid and that it was too thin. She got more thickener to add to the coffee. She noticed that there was thickener on the bottom of the cup that was not mixed in thoroughly. Photographic evidence of a spoonful of the lump of unmixed powder from the bottom of the mug was obtained.

Based on observations, interviews and record reviews, the facility failed to ensure that potentially hazardous foods were held and reheated in a manner to prevent the growth of pathogens that cause foodborne illness and in a manner consistent with professional standards for food safety for 1 of 33 residents in the final sample, Resident #3. The findings included: The facility's policy, ‘Food: Preparation', with a reference date of 05/2014 and a revision date of 09/2027, did not address reheating potentially hazardous foods (PHF) from a resident's meal. Resident #3 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment documented that Resident #15 required supervision or touching assistance for eating. Resident #3's diagnoses at the time of the assessment included: Diabetes Melitus, Seizure disorder, Depression, Cerebral infarction, Muscle weakness, Need for assistance with personal care, Lack of coordination, Dependence on Renal dialysis. Resident #3's orders included:Hemodialysis every Monday, Wednesday, and Friday in house - 07/15/25. During an observation of breakfast served to the residents in their rooms, on 08/20/25 at 8:30 AM, Resident #3 was noted to be out of the room, while her breakfast tray - including scrambled eggs, toast, a half pint carton of milk, and a cup of orange juice - was noted to be on her overbed table. During an interview, on 08/20/25 at 8:33 AM, with Staff D, LPN (Licensed Practical Nurse), when asked about the resident's whereabouts, Staff D stated that the resident was at dialysis. When asked about the breakfast meal being left on the resident's overbed table, Staff D replied, They leave it there and they warm it when she gets back in the pantry (referring to the Certified Nursing Assistants (CNAs)). During an interview, on 08/20/25 at 9:01 AM, with Staff O, CNA, when asked how long Resident #3's dialysis treatments were, Staff O replied, She goes from 7:30 AM to 9:30 AM or so, no more than 2 hours. When asked about reheating the resident's breakfast, Staff O stated that she takes the meal to the pantry and heats it in the microwave in the unit pantry. When asked about the process for reheating potentially hazardous foods in a microwave, Staff O led this surveyor to the unit pantry and referred to a sign that was posted on the cabinet that instructed the staff in the following manner: Temperature limits for warming food:Potentially hazardous food = 135 F (degrees Fahrenheit)Poultry and stuffed meats = 165 FPork = 145 FRare roast beef = 130 Staff O then stated that she re-heats foods to 135 F. when asked about taking the temperature of the food, Staff O then began looking in the cabinets and drawers for the thermometer that was found in a drawer under the microwave. During an interview, on 08/20/25 at 9:07 AM, with Staff R, CNA, when asked about reheating food for the residents, Staff R stated that he uses the microwave oven that is in the unit pantry. Staff R led this surveyor to the unit pantry. Staff R was asked how to determine that the foods were reheated safely and Staff R stated that he takes the temperature. When asked what temperature to cook the food to, Staff R replied, 100-something. When asked about taking the temperature, Staff R stated that he uses a thermometer. Staff R then began looking in the cabinets and drawers, including the drawer that the thermometer was stored in, and struggled to find the thermometer. During an interview, on 08/20/25 at approximately 9:15 AM, the Food Service Manager was made aware of the concerns related to staff reheating potentially hazardous foods in a microwave oven and agreed that the instructions provided to the staff were inaccurate. The Food Service Manager stated that staff would be educated about reheating potentially hazardous foods.

Based on observations, and interviews, the facility failed to dispose of garbage and refuse appropriately. The findings included: Upon arriving to the facility, on 08/18/25 at 8:25 AM, it was noted that the trash dumpster appeared to be overflowing and there was an accumulation of trash and debris on the ground around the dumpster. At the time of the observation, the Director of Nursing (DON) was outside. Upon entering the facility, on 08/18/25 at 8:30 AM, the surveyor explained the concern to the DON to which the DON acknowledged. On 08/19/25 at approximately 8:00 AM, the dumpster area was visible through a window at the end of the 500 unit. It was noted that the accumulation of trash and refuse had not been cleaned up.

Based on record reviews, observations, and interviews, the facility failed to implement an effective infection control program related to 1. Not following local public health recommendations during an investigation of a possible Legionella outbreak. 2. Failed to ensure respiratory equipment was stored in a clean and sanitary manner for two of two observations. 3. Failed to ensure staff, including providers, used appropriate personal protective equipment (PPE) to prevent the transmission of an infectious pathogen for one resident (#5) of two residents sampled for transmission-based precautions. 4. Failed to display signage identifying the type of precautions that should be used for one resident (#3) of two sampled residents.Findings included: 1. Review of Resident #1’s clinical record showed the resident was admitted on [DATE] from an acute care facility. The record revealed the resident was admitted with diagnoses including but not limited to unspecified organism sepsis, acute and chronic respiratory failure with hypoxia, unspecified pneumonia, and unspecified chronic obstructive pulmonary disease (COPD). The resident was discharged to an acute care facility on 12/2/24 related to low oxygen saturation. During an interview on 8/7/25 at 1:42 a.m. the Executive Director (ED) reported Resident #1 was at this facility for 12 days and urine had tested positive for Legionella after being discharged . The ED stated the resident had been in and out of the hospital at least three times prior to being at this facility. The ED stated the Department of Health (DOH) had informed her of a suspected case (Legionnaires’ disease) and had conducted testing. The facility had reviewed the Water Management Plan and had implemented “some” of the recommendations made by the DOH. The ED stated she would have to look back to see what the other recommendations were. An interview was conducted on 8/7/25 at 1:28 p.m. with the Director of Maintenance (DM). The DM reported having read about Legionella, it was a bacteria in water faucets, shower heads, and could get into the (water) system. The DM reported working at this building for two years and had not done any (Legionella) testing during this time and had not done an assessment for the bacteria (Legionella). The DM stated he doesn’t necessarily monitor for Legionella and the reason for draining the water tanks was because at the last facility he was employed at it was done so he continued it. The DM stated every day water temps were taken, a couple rooms on the north side, couple rooms on the south side, a nutrition room and the two restrooms (near the lobby). He stated the temperatures are between 110° Fahrenheit (F) and 111°F and periodically takes temperatures at the mixing valve of 115-116°F and by the time it gets to where it goes it’s not that hot. The DM reported the facility had recirculation pumps which kept the water circulating (without areas of stagnation). The DM stated the lines to the showers and faucets were also kept circulating, and the DM doesn’t check temperatures in resident rooms. During the interview the ED asked the DM to report further, he stated he let the water run 10-15 minutes and changed all the aerators (in resident rooms). The ED reported quarterly flushing of the building was done, they did it in November or December, in March, and should have had a quarterly in April, May, or June. An observation was conducted on 8/7/25 at 2:00 p.m. with DM of the South side Boiler Room. The room contained two water heaters. The thermometer on the water heater furthest from the entry door showed a reading of 120°F (thermometer maxed at 120°F) and the thermometer closest to the door read 80 degrees. The reading of 80°F was confirmed by the DM who stated it may be due to resident showers. The DM stated the facility received water from the city and “sometimes” he received water information and would look for an example. The example was not provided by the end of the survey. An interview was conducted on 8/7/25 at 2:44 p.m. with the ED. The ED reported Resident #1’s AHCA form 3008 came in with a diagnosis of severe sepsis from an unknown source. The ED reported Resident #1 had tested positive (for Legionella) after discharging from the facility and returning to the acute care facility. The ED reported that the Department of Health (DOH) requested the facility complete a Legionella Environmental Assessment Form (LEAF) prior to the department’s arrival, which was completed on 3/13/25, and the county DOH visited the facility on 3/17/25. The ED stated the facility did not have any Legionella concerns as Legionella occurs when breathing in a hot mist and the facility did not have any areas of hot mist. She stated the facility did implement a revision of the Water Management Plan (WMP) as the previous one was generic and outdated. The facility had pulled up city and county water information to see what they were adding to the water and utilized the information to implement the new plan, had to personalize it the facility, did not have the background or current information from the city, or proof of where previous management had received the information from. She reported the DOH had recommended the facility have consultants from water experts, remediation testing and install micron biological point-of-use filters on sinks, showers, and faucets. “We didn’t go along with all the recommendations” because the facility had tested negative and “we felt it wasn’t necessary”. The ED stated the risk assessor named on the new WMP was a Maintenance / Life Safety consultant and he helped write the new plan and policy. She believes the new WMP was sent to the DOH the last week of July. Review of the DOH letter, dated 3/19/25, sent to the ED of this facility referenced “Legionnaires’ disease case associated with facility”. The letter was provided as a follow up to an on-site visit and discussions conducted on 3/17/24 during an investigation of a single confirmed case of Legionnaires’ disease who reported exposure at this facility between 11/20 and 12/2/24. The letter reported “investigating to determine possible sources of the illnesses, and to identify if anyone else has become ill from the disease. Legionnaires disease is caused by the Legionella bacteria that exist naturally in the environment. It can also be found and man-made water systems such as hot tubs, spas, cooling towers, hot water tanks, or large plumbing systems.” The letter informed the facility of onsite assessment “indicated conditions in the premise plumbing that could harbor and breed biofilms and Legionella bacteria” and made the following recommendations in addition to recommendations provided onsite: 1. Recommended obtaining professional consultation from a qualified water system expert for proper assessment and remediation of your water system. The remediation action plan must be reviewed by the county DOH and results of follow-up monitoring must be provided to the DOH. The letter showed attachments had been included of accepted remediation and maintenance guidelines. 2. Recommend post-remediation testing following a detailed plan that is submitted to the county's DOH along with results from each post remediation sampling event. Post remediation samples should be collected at least 48 hours after the water system or device has been restored to normal operating conditions through at least a six month period post remediation. - We recommend a sampling approach described in HICPAC guidance, in which environment samples are collected for culture at two week intervals for three months and if no Legionella is detected in cultures during three months of monitoring at two week intervals, continue to collect monthly for another three months. - a sampling approach may be adjusted over time based on trend data. DoH must be notified of any adjustments two of the established sampling plan. If Legionella is detected in one or more cultures you should: - review and modify the water management plan (WMP) - perform additional remediation, if indicated - implement a new six month period for post remediation follow-up sampling 3. Recommend that the facility either install 0.2 micron biological point-of-use filters on any showerheads or sink/tub faucets intended for use until remediation of your premise plumbing has occurred or restrict the use of showers to reduce the risk to guests during this investigation until remediation actions are completed. 4. Recommend that facility notify incoming residents in writing about the ongoing investigation of a case of Legionnaires’ disease with association to this facility. This provides residents an opportunity to make an informed decision based on their personal assessment of risk. 5. Recommend that notification of current residents also occur as soon as possible. Management should contact residents who visit the facility in the last four weeks (starting from date to present) to notify them about the ongoing investigation of Legionnaires disease cases associated with facility. This provides recent visitors the opportunity to seek medical care appropriately should they become ill with symptoms of pneumonia. If management is unable to do this, please let us know. 6. For maintenance of the premise plumbing system and to minimize growth of Legionella, domestic hot water should be stored at a minimum of 140° Fahrenheit (F) and delivered within a range of 105°F to 115°F to all points of delivery. Minimum temperatures of 122°F are required to prevent new growth of Legionella within hot water systems. 7. It is recommended that your facility monitor hot water temperatures at distal locations from the boilers/ hot water heaters. Annual inspections of the entire water system are advisable. They should include periodic draining, cleaning with a chlorine solution, and flushing of all water storage tanks to remove biofilm, scale, and sediment. The importance of maintaining complete documentation of the facility premise plumbing maintenance, water management efforts, and temperature logs cannot be overstated. 8. Report all possible cases of Legionnaires disease (staff or residents) immediately to the epidemiology department in county. (phone number and extension included). 9. Update your water safety management plan (WMP) for the prevention and control of Legionella. Provide FDOH (Florida Department of Health) with a copy of your updated facility WMP. Review of the DOH letter showed attachments of “Domestic Hot Water Systems: Emergency Management and Best Practices”, “Cooling Towers, HVAC systems, (and) Individual Air Condition Units” and referenced Centers of Disease Control and Prevention, American Industrial Hygiene Association (AIHA), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Environmental Protection Agency (EPA), and the Occupational Safety and Health Administration (OSHA). Review of the DOH sample results dated 5/1/25 showed they were collected on 3/17/25 showed the water samples taken from the south side water heaters, south side nutrition room, shower room [ROOM NUMBER], sink in room [ROOM NUMBER], in use shower, and the water main was negative, the swabs taken in the south side nutrition, room [ROOM NUMBER]’s sink and shower hose, room [ROOM NUMBER]’s sink, room [ROOM NUMBER]’s sink, and two shower rooms in use and not in use showed no Legionella pneumophila growth. An interview was conducted on 8/7/25 at 3:35 p.m. with the ED. The ED reported why the WMP took as long to conduct was they had a change in Regional Maintenance, didn’t get the results from testing until May then she was on leave, talking with the interim administrator, then the facility had another change in regional so it “went upwards”. An interview was conducted on 8/7/25 at 4:37 p.m. with the Director of Nursing (DON, who reported she had not spoken with the DOH, the previous Assistant DON and Infection Preventionist had spoken with them, the DON was kept “abreast” of the new WMP (formulation). An interview was conducted on 8/7/25 at 4:58 p.m. with the ED. The ED reported she believed in March the Activities Director had informed Resident Council that the DOH was testing for Legionella. The ED stated she had not called any families (regarding the Legionella investigation). Review of the current Annual Water Systems Risk Assessment was dated July 2025, 4 months after the facility had received the DOH recommendations. Review of the Water Systems Management Plan, dated July 2025, showed “This plan is targeted at responding to instances where water sample results are positive for the Legionella bacterium or where a patient from a facility has been identified as having Legionellosis.” Review of the Administrator (ED) job description showed the “primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to the residents at all times.” The Duties and Responsibilities of the Administrator include, ensure the planning, development, implementation, and monitoring of facility policies and procedures, and develop and implement a facility compliance program that meets state and federal requirements, ensure that a system for maintaining and improving buildings, grounds, and equipment is planned, implemented, and evaluated. 2. On 8/7/25 at 9:30 a.m. an observation of room [ROOM NUMBER] showed a blanket folded up under the Packaged Terminal Air Conditioner (PTAC). The resident in the bed next to the unit stated the blanket was due to water being on the floor and had been like that for a couple of months, then stated it was just a guess it could have been like that for four weeks. 3. On 8/7/25 at 9:35 a.m. an observation of a yellow organizer (caddy) containing Personal Protective Equipment (PPE) hanging from the door of room [ROOM NUMBER]. The observation showed a Transmission-based precaution sign for Contact Precautions attached to the yellow organizer. On 8/7/25 at 9:39 a.m. Staff C, Licensed Practical Nurse/Unit Manager (LPN/UM) dressed in yellow precaution gown and gloves before entering room [ROOM NUMBER]. The observation revealed a provider enter room [ROOM NUMBER] without PPE’s on and stand next to the bed speaking with Resident #5 as Staff C was standing on the opposite side of the bed dressed in PPE. Staff C left the room, after removing PPE, at 9:42 a.m. as the provider continued in the room without PPE’s on. Staff C stated if there was a caddy on the door all staff should be wearing PPE and confirmed the provider in the room was not wearing PPE and should have been. Review of Resident #5’s physician orders with an order date of 8/6/2025 revealed, “contact isolation precautions for esbl [Extended-spectrum beta-lactamase]/UTI [urinary tract infection].” 4. On 8/7/25 at 9:36 a.m. an observation was made of a nasal cannula tubing wrapped around an emergency tank in room [ROOM NUMBER]. The tubing was not stored in a plastic storage bag. On 8/7/25 at 9:37 a.m. an observation was made of nasal cannula tubing lying on the seat of a wheelchair in the 300-hallway diagonally from room [ROOM NUMBER]. On 8/7/25 at 9:46 a.m. Staff D, Certified Nursing Assistant (CNA) observed the cannula tubing lying in the wheelchair. The staff member reported not knowing whose cannula it was, it wasn’t the owners of the wheelchair as the owner did not wear oxygen. An interview was conducted on 8/7/25 at 4:24 p.m. with the Director of Nursing/Infection Preventionist (DON/IP). The DON stated if a caddy was on the outside of the door, stop and put on PPE before entering the room, the expectation for storing oxygen tubing was to be in a bag, and said a blanket on the floor to catch water was not appropriate. The DON stated she was made aware of the provider being in the isolation room without PPE (Resident #5’s room) and the provider had been educated. 5. On 8/7/25 at 9:35 a.m. Personal Protective Equipment (PPE) was observed hanging in a yellow organizer on the door of Resident #3’s room. There was no sign on the outside of the door indicating what kind of precautions. Review of Resident #3's medical record revealed he was readmitted to the facility on [DATE] with a diagnosis of: sepsis due to Escherichia Coli (E. Coli) and Enterocolitis due to Clostridium Difficile (C-Diff). Review of Resident #3’s physician orders included an order dated 7/29/25 for: contact isolation precautions for C-Diff infection. During an interview on 8/7/25 at 4:30 p.m. with the DON who is also the facility Infection Preventionist (IP), stated that a yellow organizer with PPE hanging outside of a door indicates the resident inside is on isolation precautions and PPE should be put on before entering the room. She stated that you should have a sign outside the door indicating what kind of isolation. The DON stated she educated the staff numerous times on isolation, hand washing and infection control and made rounds a couple of times a week to ensure the signs were there. The DON stated she has told staff not to move the signs. Review of the policy – Infection Control Prevention and Control Program, effective 2/21/23, reported “The facility shall establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” The general considerations included but not limited to: 1. The Infection Prevention and Control Program, associated programs, and policies and procedures are based on the facility assessment, incorporating accepted national standards and includes any facility or community risk. 2. The plan should be reviewed and updated as necessary, and a minimum of annually. 3. The facility has designated an Infection Preventionist. The Infection Preventionist is responsible for the oversight of the Infection Prevention and Control Program and works in collaboration with the facility Director of Nursing, Administrator, and Medical Director, and Quality Assurance Committee. The Infection Preventionist serves as resource to staff on infectious illness/disease, infection control and prevention practices, and affected facility processes and examples may include but are not limited to: - b. Implementation of isolation precautions; - c. Exposures; - d. Surveillance – facility and community-acquired infection findings; - e. Compliance and Performance monitors; - f. Results of environmental rounds; - g. Relevant changes in infection prevention and control policies and/or guidelines; - h. Infection related investigations; 4. The Quality Assurance Committee shall be responsible for overseeing and implementing the recommendation that result from the program. 5. All staff are responsible to follow policies, procedures, and expectations related to the program. The procedure portion of the policy included: 10. Resident/Family/Visitor Education and Screening: - a. Residents, family members, and visitors shall be provided information relative to the rationale for the isolation, behaviors required of them in in observing these precautions, and conditions for which to notify the nursing staff. - b. Information on various infectious diseases is available from our Infection Preventionist. - c. Isolation signage is used to alert staff, family members, and visitors of transmission based precautions. 13. Water Management - A water management program has been established as part of the overall infection prevention and control program. - Control measures and testing protocols are in place to address potential hazards associated with the facility’s water systems. - The Maintenance Director serves as the leader of the water management program. Review of a Facility Policy titled Isolation – Initiating Transmission Based Precautions with an effective date of 4/1/22 revealed: When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall post the appropriate notice on the room entrance door and on the front so that all personnel should be aware of precautions or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. (Photographic Evidence Obtained)

Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was unsteady on his feet, had a history of falling and age-related cognitive decline. Resident #1 was known to leave the facility every year on July 4th on a supervised leave of absence however on 07/04/2023, he did not go on his yearly supervised leave of absence. Resident #1 was able to exit the facility unsupervised through the front door which was equipped with a door alarm, a wander monitoring device alarm system and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #1 walked approximately 0.3 miles down a 2-lane road and was found on 07/04/2023 at approximately 7:12 p.m. sitting in a chair in the grass in front of a lake surrounded by bystanders. Staff arrived at Resident #1's location at approximately 7:12 p.m. The Resident was transported the hospital by Emergency Medical Services (EMS) and returned to the facility on [DATE] at 1:45 a.m. without injury. Resident #8 was a long-term resident who was confused, at risk for elopement, a known wanderer, known to push on doors, known to be exit seeking, and had a wander monitoring device on at the time of his unsupervised exit from the facility. Resident #8 was unsteady on his feet, had a history of falling, and age-related cognitive decline. On 07/05/2023 at approximately 9:40 a.m., Resident #8 was able to exit the facility without supervision through an exit door at the end of an uninhabited unit (the 600 hall). The door had an alarm and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was located on 07/05/2023 at approximately 9:42 a.m. on the sidewalk that wraps around the building and escorted back into the building unharmed. These failures created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and Resident #8 and resulted in the determination of Immediate Jeopardy on 07/04/2023. The findings of Immediate Jeopardy were determined to be removed on 07/27/2023 and the severity and scope was reduced to a E after verification of removal of Immediate Jeopardy. Findings included: Review of the facility floor plan showed a North Unit consisting of a nurse's station and the 100, 200 and 300 halls, and a South Unit consisting of a nurse's station and the 400, 500 and 600 halls. The front lobby with a reception area and the main entrance is in the middle of the two units. The facility main entrance is across a two-lane road from Lake [NAME] a 2,272 acre Fish Management Area with a maximum depth of 10 feet. According to https://myfwc.com/fishing/[NAME]/sites-forecasts/sw/lake-[NAME] Review of weather history in the Lakeland during the two-day period 7/4/2023 to 7/5/2023 revealed: July 4, 2023, and July 5, 2023, Max temp: 97 degrees Fahrenheit. Minimum temp: 80 degrees (wunderground.com) Review of Resident #1's Admission Record showed he was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, age related physical debility, limitation of activities due to disability, history of falling, age related cognitive decline, difficulty in walking, muscle weakness, unspecified lack of expected normal physiological development in childhood, and major depressive disorder. A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Resident Date (ARD)/target date of 04/09/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident was independent and needed setup help only for bed mobility and eating and needed supervision with setup help only for transfer and personal hygiene. Resident #1 was independent with no set up or physical help from staff for walk in room, walk in corridor, and locomotion on and off the unit. He needed limited assistance with one-person physical assist with dressing and toilet use. Section P Restraints and Alarms revealed Resident #1 used a wander/elopement alarm daily. An interview was conducted with Staff I, CNA, on 07/25/2023 at 1:51 p.m. She stated she was doing patient care and heard the alarm going off at the front door. She was working on the South unit/400 hall. She said it was not a wander monitoring device alarm, it was just the door alarm going off. No other staff came out to see why the alarm was going off. She said she went to the door, looked out of the glass window, turned the alarm off, and went back to the unit because she did not see anyone. A receptionist was not at the desk at this time. When Staff I, CNA, went back to the unit the phone rang at the nurse's station and she answered it. It was a man who said he was down the street from the facility and believed one of the residents had gotten out. She ran called for the nurse on her South Unit/400 hall. The person that called said Resident #1 had collapsed. She got in her car and went down the street. She went to the park and came back around and didn't see him, so she came back to the facility. She decided to go one more time and observed the nurses were down with Resident #1, so she came back. Staff G, Licensed Practical Nurse (LPN), was one of the nurses and she was not sure who the other nurse was. Resident #1 was found across the street from the fire station training center near the lake. She saw people were taking videos. Resident #1 was sitting on a lawn chair with a whole lot of people around. She said they had enough staff that day. Resident #1 walks around and he had a wander monitoring device on. Normally, a resident can get to where the receptionist sits in the front lobby, and the wander guard alarm would sound, and someone would have to input a code to turn it off. When they found him, he was transported to the hospital, and she didn't see him until a couple of days later. When Administration interviewed her about the incident, she told them she didn't hear the wander monitoring device sound going off at the front door. Staff I, CNA, stated you can hear the alarm sounding on South/400 unit, but you cannot hear the alarm sounding on the North Unit /300 hall and this is where Resident #1's room was located. Staff G, LPN, was one of the nurses that found Resident #1 by the lake. During an interview on 7/25/2023 at 3:05 p.m., Staff G, LPN, confirmed she worked on the day of the incident. At 3:30 p.m., Resident #1 was walking around. He was not happy. He usually says I love you to everybody and was very friendly. He said he was not ok on this day and wanted to go outside, so she took him outside. The wander monitoring device was on at the time. She took him outside from 3:30 p.m. to 4:45 p.m. and they sat out on the front porch. Staff G, LPN, stayed with him the entire time they were outside. The wander monitoring device alarm went off when he was near the front door prior to them going outside. Staff G, LPN, told Resident #1 to step back so she could put the code in, and then she was able to open the door. Other residents were outside. At 4:45 p.m., everyone came in to get ready for dinner. Around 7:10 p.m., the nurse assigned to Resident #1 said they found a patient by the lake, and they said it was Resident #1. She and that nurse ran to the car, and they rode together. Resident #1 was found by the lake right before the fire station training center on the opposite side of the street. He was sitting in a lawn chair near where people were fishing in the lake. Staff G, LPN, stated she was the first one to get out of the car. The bystanders were videoing them. When they attempted to ask Resident #1 questions, one of the bystanders said you are not allowed to talk to him. He had written on a piece of paper that Resident #1 was looking for a former coworker that he used to work with. Every 4th of July, she comes to get him, and she didn't come this time. He kept saying he wanted to go to a local restaurant to see the former coworker. She stayed until 911 came. Resident #1 came back the same night. Staff G, LPN, stated she didn't know how he got out. On that night, she was only there to help. She helped with admissions, she was not assigned to residents, and there were plenty of staff on duty. When she came back to the facility after EMS took Resident #1, they did a head count and got statements from everyone in the building. She called everyone to let them know what was going on, including the Director of Nursing (DON) and the Administrator. The last time she saw him was around 4:45 p.m. She did not remember if there was a sidewalk. Around 7:00 p.m., she was on the North unit and did not hear the alarm go off. Staff K, Registered Nurse (RN), was the nurse assigned to Resident #1 on the day of the elopement. During a telephone interview on 07/26/2023 at 9:49 a.m., Staff K, RN, confirmed Resident #1 was assigned to her on the day of the elopement. She saw him as she was completing medication pass and saw him in his room eating around 6:00 p.m. Ten minutes after coming back from her lunch break, she received a call from a lady stating she may have one of her patients up the road. She asked the staff to check for all patients. Resident #1 was the only patient they couldn't locate. She asked her if he was Resident #1 and she said yes. Staff K, RN, drove about 2 minutes up the road and observed Resident #1 sitting in a chair. The lady that called was there and another guy out there was extremely aggressive so she couldn't assess him. There were no noticeable injuries. No scratches or bruises. He stated at the start of the shift he wanted to go outside and Staff G, LPN, took him outside. Staff K, RN, reported she did not hear an alarm going off and she did not hear any alarm when she came back in from her lunch break. She stated she took a lunch break in her car in the parking lot and did not see the resident come out of the door. On 07/25/2023 at 2:40 p.m., Resident #1 was observed in his room standing next to the bed. A wander monitoring device was observed on his right leg. He stated he was hungry when asked how he was doing. The Staffing Coordinator was in the room with the resident at this time and she stated Resident #1 was on 1:1 supervision and she was scheduled to be with him at this time. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: May go out with responsible party (ordered 03/24/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/12/2023); Resident is 1:1 at all times every shift for safety (07/04/2023); Snack 3 times a day between meals (06/09/2022); Wander monitoring device- check for function each day every night shift for monitoring (03/25/2021) Wander monitoring device- check every shift for placement and monitoring (03/25/2021) Atorvastatin calcium tablet 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia; Tamsulosin HCL capsule 0.4 mg- give 1 capsule by mouth daily for benign prostatic hyperplasia (10/19/2022); Tramadol HCL capsule- give 1 capsule by mouth every 8 hours as needed for pain; and Trazodone HCL tablet- give 0.5 tablet by mouth daily related to major depressive disorder and give 1/2 tablet at bedtime (11/30/2022). During the time from when Resident #1 was last seen to when he was returned to the facility, he should have received atorvastatin calcium, tamsulosin, tramadol, and trazodone between 7:00 p.m. 7/4/2023 and 1:45 a.m. 7/5/2023. He should have received a snack during that time. Review of the Medication Administration Record (MAR) for July 2023 showed Resident #1 did not receive these medications or the snack as ordered on 07/04/2023. A review of the Treatment Administration Record (TAR) showed 6 in the box for checking the function of the wander monitoring device every night shift for monitoring and a 6 was in the box for checking the placement of the wander monitoring device every shift for monitoring on 07/04/2023. A review of Resident #1's Nursing Progress Notes revealed the following: On 07/04/2023 at 9:10 p.m., the writer spoke with a staff member from the local hospital taking care of Resident #1. The staff member stated, Resident is pleasantly confused at the moment. On 07/05/2023 at 1:45 a.m., the resident returned to the facility from the local hospital via stretcher with three attendants. The resident was alert and stated he will try to leave every chance he gets. Resident #1 was calling staff names, threatened to knock you down, I will hit you, and telling staff to get the hell away from me. The resident was placed on 1:1 for safety at this time. On 07/05/2023 at 2:21 a.m., the patient returned from the hospital at 145 a.m., he was not happy about coming back and stated he wanted to leave again. The patient is currently on 1:1 since his return and has been displaying negative behaviors such as yelling and cursing at the staff. On 07/07/2023 at 09:00 a.m., (Resident #1) eloped from facility the evening of 07/04/2023. The resident exited the facility through the front doors and proceeded to walk down the sidewalk as he reports in an effort to go to his favorite restaurant that he once worked at. Resident #1 has consistently been taken by friends to the July 4th parade in town where he's been a yearly fixture in handing out flags. This year however, the person that checked him out of the facility to do this annual tradition was out of town on vacation. Upon further investigation by staff, including social services, the resident has consistently stated his intent was to go to the restaurant he used to work at bussing tables to get something to eat and visit and then planned to go hand out flags at the parade. The writer went to question Resident #1 regarding events at his bedside where the resident pointed to pictures on his wall of him at the restaurant in question and also handing out flags at the July 4th celebration. Interventions have included one on one companionship, take out order from a local restaurant, and there are plans in place for next July 4th to take the resident out to enjoy watching fireworks although staff is working out the details as to the safest way to provide this annual expectation to meet his needs while ensuring his safety. The resident has not since tried to leave the facility and a care plan is now in place around this annual expectation. Resident #1 has since not attempted or expressed any want to leave, staff will continue to monitor and follow. Psychiatric care is also following the resident and have conducted a thorough evaluation since the elopement. Psychiatric care will also continue to monitor and follow. An observation of the path the resident may have taken revealed from the front door he turned left heading North after leaving the facility property. A two-lane road with a speed limit of 30 mph (miles per hour) separated the facility grounds from a grassy area that lead onto an asphalt sidewalk. The sidewalk with uneven cemented surfaces, potholes and cracks followed around the lake without barriers. The unprotected lake was approximately 10 feet away from the asphalt sidewalk. The resident was found across the road from the facility in a grassy area. Resident #1's Elopement Risk assessment dated [DATE] completed by Staff C, LPN, showed No was checked for attempt to wander off the unit and positions self by exit areas. Yes was checked for having a history of wandering or elopement. No was checked for attempts to leave the building or grounds without notifying staff, the resident was not able to negotiate environment safely and has a history of substance abuse and/or substance seeking behavior, repetitive verbalizations of I'm going home, and is ambulatory including wheelchair mobility and for not accepting his current residency in the facility. Yes was checked for having a diagnosis of Dementia, Alzheimer's and is able to negotiate environment safety. The assessment showed Resident #1 was not at risk for elopement at this time. The form also revealed a section that showed If there are 'Yes' answers, but the resident is not at risk explain why. The box for the section was blank. A Change in Condition dated 07/04/2023 showed the incident location was outside. Resident #1 left the facility. Staff were notified by anonymous bystanders that the resident was by the fire training center on the ground. The resident description section revealed, I don't want to be here anymore. I'm going to [a local restaurant]. The resident was transported to a local hospital and returned to the facility on 1:45 a.m. on 07/05/2023. Review of Resident #1's care plan revealed a focus area initiated on 03/26/2021 [Resident #1] is an elopement risk, wanders throughout facility independently related to dementia, disoriented to place, impaired safety awareness, and the resident wanders aimlessly at times. Interventions included 1:1 supervision at all times (07/05/2023), assess for elopement risk (03/26/2021), distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (03/26/2021), identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (03/26/2021), provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, picture and memory boxes (03/26/2021), psychiatric care evaluation as indicated (07/11/2023), and wander monitoring device (electronic monitoring device)- check placement every shift and function daily (03/26/2021). A review of the psychiatric care note written by Staff R, Advanced Registered Nurse Practitioners (ARNP), with a date of service date of 07/14/2023 showed patient was seen on 07/05/2023 for a telehealth follow up. He is currently taking Trazodone HCL Tablet 25 MG by mouth once a day for major depressive disorder. Patient seen today after eloping yesterday (July 4) from facility. He is alert and pleasantly confused. Appears in no acute distress. Patient reports he intended to have a meal at his favorite local restaurant. He reports he used to work at this restaurant. He stated he was planning to return after his meal. It was reported that the patient walked approximately 7 minutes and was spotted by nearby people who were watching fireworks. He was found sitting in a chair among the people watching fireworks. He was taken to the emergency room that evening to be evaluated. He was discharged later at approximately 1 a.m. on 07/05. Patient has returned and appears in good condition. No adverse effects or injuries noted or reported. No distresses or trauma observed related to the elopement. He denies increased anxiety or depression. Staff reports he remains pleasant and complaint with care. He is currently on one to one supervision for safety monitoring. During an interview on 07/25/2023 at 2:00 p.m., Staff Q, Receptionist, stated the door alarm and the wander monitoring device alarm had the same sound. Her shift ends at 4:00 p.m. daily. They have a part-time employee that works from 4:00 p.m. to 7:00 p.m. on Monday and Tuesday and another part-time employee that works 4:00 p.m. to 7:00 p.m. on Wednesday, Thursday, and Friday. The red alarm is a screamer, the door alarm was a beep. The front door had a high pitch sound, one beep, and a continuous beep until it was turned off. It will also beep if someone holds the door open too long. You must put a code in to turn the alarm off. An interview was conducted on 07/25/2023 at 2:35 p.m. with the Maintenance Director. He reported there were 8 exit doors in the facility, and they all had keypads. Three of the doors also had a wander monitoring device alarm, the front door is one of them. Residents would have to have a code to get through the doors. The Maintenance Director demonstrated how the doors were tested with his device and showed the front door was functioning properly. The Maintenance Director tested the door with the wander monitoring device and the alarm sounded when he was at the door. He said since the elopement that Screamer (very loud) alarms were put on a set of double doors that lead to the lobby, main entrance area. He said he checked the doors daily on weekdays, and according to the Administrator, the nursing staff check the doors on the weekend. The Alarmed and Exit Doors Daily Inspections log was reviewed at that time for the months of May 2023 and June 2023. It showed the doors were checked on weekdays but not checked on the weekend. During the observation the front door alarm was set off with a wander monitoring device by the Maintenance Director. The alarm could not be heard while standing on the North unit/300 hall. This was confirmed by the Maintenance Director. During an interview on 07/25/2023 at 3:29 p.m. with the Administrator and DON, the DON reported Staff G, LPN, contacted the DON and reported Resident #1 was out of the building and she was contacted by some bystanders. The resident was found about 7 minutes away from the facility if you walked. They both came to start the investigation. They called the police, the Power of Attorney (POA), the doctor, psychiatric care, and another outside agency. Interviews were completed with staff and residents. None of the staff reported he wanted to leave the facility that day or mentioned anything about leaving the facility. He walks back and forth all day. He had asked some about going out for fresh air. They went outside and came back in. Staff K, RN, took her lunch break around 6:10 p.m. and her car was facing the door. After her break, she came back in, went to the bathroom, and went back to the unit. Two phone calls came in about a missing resident. The DON stated Staff I, CNA, heard the alarm go off but she didn't see anyone. Resident #1 definitely went out of the front door. If you hold the door for 15 seconds, the door would open. He was a pretty smart guy and can probably read. He didn't verbalize he wanted to see fireworks. Resident #1 had on the wander monitoring device at the time he left the facility. It was removed in the hospital and brought back from the hospital when he returned. They tested the same wander monitoring device when he came back, and it was still working. We put it back on with a new bracelet. The wander monitoring device had an expiration date of 04/20/2025. In-services were started immediately after the incident. Maintenance came and checked the doors, and they were working fine. They set up 30-minute checks on all alarmed doors. The alarm company came out on 07/06/2023. They added screamers to the double doors to have a second alarm, because you cannot hear the alarm at the north Unit nursing station. The receptionist leaves at 4:30 p.m. or 5:00 p.m. Once the receptionist leaves, the nurse comes over and sets the alarm. There were no screamers when Resident #1 eloped. An enunciator will be placed at north unit nurse's station, it has been ordered, so alarms can be heard there. You must put a code in to enter or exit the facility. Visitors have to ring the bell. Prior to the incident, the receptionist buzzed everyone in and out. Now the nurse comes and sets the alarms to the front door after the receptionist leaves. The receptionist announces on the intercom that she is leaving for the day. Someone in charge, usually one of the nurses comes to lock the door. The nursing supervisors are the ones that come to turn on screamers. All nurses have keys to screamers. Resident #1 was placed on 1:1. The DON and ADON evaluated all residents for elopement. They checked wander monitoring devices, monitored Resident #1, and did a whole house audit. Staffing was good. No issue with staffing on that day. Staff were educated on the elopement procedure and drills. They did a drill each shift and did them weekly after the incident. During an interview on 07/27/23 at 9:55 a.m., the Administrator and DON reported training was provided on the elopement policy/procedure/protocol prior to July 4, 2023. Elopement audits and drills were completed. On 07/27/2023 12:08 p.m., the DON reported elopement education was completed upon hire. They do not have access to elopement training and elopement drills completed due to a change in systems approximately two months ago. Alarmed and Exit Doors Daily Inspections for the months of May 2023 and June 2023 were verified. The doors were not checked on the weekend. This was confirmed by the Administrator and DON. She stated as of July, nursing staff had been checking the doors on the weekend. 2. On 7/5/23 at approximately 9:40 a.m. Resident #8 was able to exit the facility without supervision through an exit door on an uninhabited hall (600) that was equipped with a door alarm. An interview conducted with the Activity Director on 07/26/2023 at 12:47 p.m. He stated he heard the alarm go off and the 600 area being announced by staff. Everyone jumped up and started moving. Everyone was looking. Staff scattered to their areas. He saw the Maintenance Director going down the 600 hall. The Activity Director went down the 500 hall; when he got to the 500 hall exit door it was locked so he ran toward the 600 side, and he didn't see anyone. The Activity Director stated he then went back to the 500 hall and opened the exit door and saw Resident #8 closer by the dumpster, he was smiling and giggling. He wheeled Resident #8 back into the facility and took him to the nursing station. The resident got out of the door on the end of the 600 hall and went down the sidewalk that surrounds the building towards the 500 unit. During an interview on 07/26/2023 at 12:21 p.m., the Maintenance Director stated on 7/5/2023 he was headed to the morning meeting, he exited the service hall, and heard the alarm going off. He checked the enunciator, and it showed the alarm was coming from the 600 hall. The exit door was open on the end of the 600 hall. He went outside and immediately ran to the front of the building, because there was more danger in the front of the building than the rear. He didn't see anyone. He then came in and headed back to the 600 hall and saw Resident #8 from the window sitting outside. Two other staff members were heading out to get him. Within two minutes they had him back inside. The Maintenance Director went back down the 600 hall, reset the doors and silenced the alarms. He was the first one to respond to the alarm. He immediately looked to see what hall the alarm was coming from. After the incident happened, they put a rope across the hall, caution signs, and wet floor signs. Resident #8 frequently pushes on the doors. He knows the door will open after 15 seconds. The resident was just sitting looking around at the trees. There's a sidewalk in the back parking lot area. Another staff member got to Resident #8 before he did. He went back to secure the doors after the resident was brought back into the facility. Observation of the outside area where the resident was found revealed an uneven cement sidewalk surface that wrapped around the facility's building connecting one entrance to the next. Adjacent to the sidewalk was approximately 5 feet of grassy terrain that led into a large area with trees, overgrown shrubs and standing water. Review of Resident 8's Admission Record showed he was admitted on [DATE] with diagnoses to include muscle weakness, difficulty in walking, unspecified lack of coordination, limitation of activities due to disability, other lack of coordination, history of falling, age related cognitive decline, age related physical decline, unspecified dementia, unspecified severity without behavioral disturbance, psychiatric disturbance, mood disorder, anxiety, unspecified cataract, and Alzheimer's Disease. A review of the quarterly MDS with an ARD/target date of 05/16/2023 revealed Resident #8 had a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident needed extensive assistance with two plus persons physical assist with bed mobility and transfers and needed supervision with one-person physical assist for locomotion on and off the unit. Resident #8 needed extensive assistance with one-person physical assist for dressing and personal hygiene. He needed supervision with setup help only for eating and he was total dependent with two plus persons physical assist for toilet use. Section P Restraints and Alarms revealed Resident #8 used a wander monitoring device daily. An observation and interview were conducted on 7/24/2023 at 10:05 a.m. of Resident #8 on 1:1 with CNA, Staff O. Resident #8 was observed to be dressed in day clothes, sitting in his wheelchair in front of an exit door at the end of the 400 hallway. Staff O, CNA stated she was on 1:1 with him because around 07/05/2023, he went past the nurses' station and pushed on the exit door to the 600 hall and was found outside by the dumpsters. She stated he always pushes on the doors. He used to be a lawyer and he thinks his car was parked in the parking lot and he says he had to go to work. Since he was admitted he has pretty much always pushed on the doors. You see he is sitting in front of this door, and I told him 'You can't push on the doors okay' and he told me 'Well yeah if I keep pushing on it the door will open, you see the sign.' A sign was observed on the door with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. The resident was observed to have a wander guard on his left ankle under his sock. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: 1:1 close observation every shift for safety (ordered 07/05/2023); May go out with responsible party (10/10/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/17/2023); (Company name) Hospice for diagnosis of metabolic encephalopathy (02/11/2022); Wander monitoring device- check for function each day every night shift for monitoring (07/29/2022); Wander monitoring device- place wander monitoring device on wheelchair (08/04/2022); and Wander monitoring device- check every shift for placement and monitoring (07/29/2022). A review of the Treatment Administration Record (TAR) for July 2023 showed that the function and placement of the wander monitoring device was checked every shift according to orders. A review of Resident #8's Nursing Progress Notes revealed the following: On 07/05/2023 at 9:40 a.m., the patient was found on the sidewalk next to the building after exiting out of the 600-hall door. The alarm was sounding and when staff investigated, they found the patient in his wheelchair on the sidewalk. The patient was frequently sitting at the doors down the halls and needed frequent redirection. Patient was subsequently put on 1 to 1 observation. The patient was alert to self which is normal. On 07/05/2023 at 1:00 p.m., Resident #8 eloped from the southside unit he resides on at approximately 9:30 a.m. Resident #8 was located at 9:42 a.m. Witness interviews indicate that he did not verbalize any desire to exit the building nor show any exit seeking behaviors toward staff. Resident interviews were performed, all of which stated they were unaware he'd eloped and did not visually observe him in the hall that morning as they were still in their rooms at the time. Staff interviews revealed Resident #8 was not observed entering the currently unoccupied 600 hall. The Maintenance Director observed the security panel that alerted him the exit door was breached. The Maintenance Director reported he found the resident outside on the sidewalk sitting in his wheelchair. There was no fall, no injuries documented, and skin was intact with no tears noted. <b[TRUNCATED]

Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was able to exit the facility unsupervised through the front door which was equipped with a door alarm, a wander monitoring device alarm system and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was a long-term resident who was confused, at risk for elopement, a known wanderer, known to push on doors, known to be exit seeking, and had a wander monitoring device on at the time of his unsupervised exit from the facility. Resident #8 was unsteady on his feet, had a history of falling, and age-related cognitive decline. On 07/05/2023 at approximately 9:40 a.m., Resident #8 was able to exit the facility without supervision through an exit door at the end of an uninhabited unit (the 600 hall). The door had an alarm and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was located on 07/05/2023 at approximately 9:42 a.m. on the sidewalk that wraps around the building and escorted back into the building unharmed. Nursing Elopement prevention policies were not followed regarding supervision of wandering residents and checking thoroughly for a resident elopement after an alarm is heard and before turning off the alarm. These failures created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and Resident #8 and resulted in the determination of Immediate Jeopardy on 07/04/2023. The findings of Immediate Jeopardy were determined to be removed on 07/27/2023 and the severity and scope was reduced to a E after verification of removal of Immediate Jeopardy. Findings included: Review of the facility floor plan showed a North Unit consisting of a nurse's station and the 100, 200 and 300 halls, and a South Unit consisting of a nurse's station and the 400, 500 and 600 halls. The front lobby with a reception area and the main entrance is in the middle of the two units. The facility main entrance is across a two-land road from Lake [NAME] a 2,272 acre Fish Management Area with a maximum depth of 10 feet. According to https://myfwc.com/fishing/[NAME]/sites-forecasts/sw/lake-[NAME] Review of weather history in the Lakeland during the two-day period 7/4/2023 to 7/5/2023 revealed: July 4, 2023, and July 5, 2023, Max temp: 97 degrees Fahrenheit. Minimum temp: 80 degrees (wunderground.com) An interview was conducted with Staff I, CNA, on 07/25/2023 at 1:51 p.m. She stated she was doing patient care and heard the alarm going off at the front door. She was working on the South unit/400 hall. She said it was not a wander monitoring device alarm, it was just the door alarm going off. No other staff came out to see why the alarm was going off. She said she went to the door, looked out of the glass window, turned the alarm off, and went back to the unit because she did not see anyone. A receptionist was not at the desk at this time. When Staff I, CNA, went back to the unit the phone rang at the nurse's station and she answered it. It was a man who said he was down the street from the facility and believed one of the residents had gotten out. She ran called for the nurse on her South Unit/400 hall. The person that called said Resident #1 had collapsed. She got in her car and went down the street. She went to the park and came back around and didn't see him, so she came back to the facility. She decided to go one more time and observed the nurses were down with Resident #1, so she came back. Staff G, Licensed Practical Nurse (LPN), was one of the nurses and she was not sure who the other nurse was. Resident #1 was found across the street from the fire station training center near the lake. She saw people were taking videos. Resident #1 was sitting on a lawn chair with a whole lot of people around. She said they had enough staff that day. Resident #1 walks around and he had a wander monitoring device on. Normally, a resident can get to where the receptionist sits in the front lobby, and the wander guard alarm would sound, and someone would have to input a code to turn it off. When they found him, he was transported to the hospital, and she didn't see him until a couple of days later. When Administration interviewed her about the incident, she told them she didn't hear the wander monitoring device sound going off at the front door. Staff I, CNA, stated you can hear the alarm sounding on South/400 unit, but you cannot hear the alarm sounding on the North Unit /300 hall and this is where Resident #1's room was located. Review of Resident #1's Admission Record showed he was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, age related physical debility, limitation of activities due to disability, history of falling, age related cognitive decline, difficulty in walking, muscle weakness, unspecified lack of expected normal physiological development in childhood, and major depressive disorder. Staff G, LPN, was one of the nurses that found Resident #1 by the lake. During an interview on 7/25/2023 at 3:05 p.m., Staff G, LPN, confirmed she worked on the day of the incident. At 3:30 p.m., Resident #1 was walking around. He was not happy. He usually says I love you to everybody and was very friendly. He said he was not ok on this day and wanted to go outside, so she took him outside. The wander monitoring device was on at the time. She took him outside from 3:30 p.m. to 4:45 p.m. and they sat out on the front porch. Staff G, LPN, stayed with him the entire time they were outside. The wander monitoring device alarm went off when he was near the front door prior to them going outside. Staff G, LPN, told Resident #1 to step back so she could put the code in, and then she was able to open the door. Other residents were outside. At 4:45 p.m., everyone came in to get ready for dinner. Around 7:10 p.m., the nurse assigned to Resident #1 said they found a patient by the lake, and they said it was Resident #1. She and that nurse ran to the car, and they rode together. Resident #1 was found by the lake right before the fire station training center on the opposite side of the street. He was sitting in a lawn chair near where people were fishing in the lake. Staff G, LPN, stated she was the first one to get out of the car. He had written on a piece of paper that Resident #1 was looking for a former coworker that he used to work with. Every 4th of July, she comes to get him, and she didn't come this time. He kept saying he wanted to go to a local restaurant to see the former coworker. She stayed until 911 came. Resident #1 came back the same night. Staff G, LPN, stated she didn't know how he got out. She helped with admissions, she was not assigned to residents, and there were plenty of staff on duty. When she came back to the facility after EMS took Resident #1, they did a head count and got statements from everyone in the building. She called everyone to let them know what was going on, including the Director of Nursing (DON) and the Administrator. The last time she saw him was around 4:45 p.m. She did not remember if there was a sidewalk. Around 7:00 p.m., she was on the North unit and did not hear the alarm go off. Staff K, Registered Nurse (RN), was the nurse assigned to Resident #1 on the day of the elopement. During a telephone interview on 07/26/2023 at 9:49 a.m., Staff K, RN, confirmed Resident #1 was assigned to her on the day of the elopement. She saw him as she was completing medication pass and saw him in his room eating around 6:00 p.m. Ten minutes after coming back from her lunch break, she received a call from a lady stating she may have one of her patients up the road. She asked the staff to check for all patients. Resident #1 was the only patient they couldn't locate. She asked her if he was Resident #1 and she said yes. Staff K, RN, drove about 2 minutes up the road and observed Resident #1 sitting in a chair. The lady that called was there and another guy out there was extremely aggressive so she couldn't assess him. There were no noticeable injuries. No scratches or bruises. He stated at the start of the shift he wanted to go outside and Staff G, LPN, took him outside. Staff K, RN, reported she did not hear an alarm going off and she did not hear any alarm when she came back in from her lunch break. She stated she took a lunch break in her car in the parking lot and did not see the resident come out of the door. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: May go out with responsible party (ordered 03/24/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/12/2023); Resident is 1:1 at all times every shift for safety (07/04/2023); Snack 3 times a day between meals (06/09/2022); Wander monitoring device- check for function each day every night shift for monitoring (03/25/2021) Wander monitoring device- check every shift for placement and monitoring (03/25/2021) Atorvastatin calcium tablet 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia; Tamsulosin HCL capsule 0.4 mg- give 1 capsule by mouth daily for benign prostatic hyperplasia (10/19/2022); Tramadol HCL capsule- give 1 capsule by mouth every 8 hours as needed for pain; and Trazodone HCL tablet- give 0.5 tablet by mouth daily related to major depressive disorder and give 1/2 tablet at bedtime (11/30/2022). During the time from when Resident #1 was last seen to when he was returned to the facility, he should have received atorvastatin calcium, tamsulosin, tramadol, and trazodone between 7:00 p.m. 7/4/2023 and 1:45 a.m. 7/5/2023. He should have received a snack during that time. Review of the Medication Administration Record (MAR) for July 2023 showed Resident #1 did not receive these medications or the snack as ordered on 07/04/2023. A review of the Treatment Administration Record (TAR) showed 6 in the box for checking the function of the wander monitoring device every night shift for monitoring and a 6 was in the box for checking the placement of the wander monitoring device every shift for monitoring on 07/04/2023. A review of Resident #1's Nursing Progress Notes revealed the following: On 07/04/2023 at 9:10 p.m., the writer spoke with a staff member from the local hospital taking care of Resident #1. The staff member stated, Resident is pleasantly confused at the moment. On 07/07/2023 at 09:00 a.m., (Resident #1) eloped from facility the evening of 07/04/2023. The resident exited the facility through the front doors and proceeded to walk down the sidewalk as he reports in an effort to go to his favorite restaurant that he once worked at. Resident #1 has consistently been taken by friends to the July 4th parade in town where he's been a yearly fixture in handing out flags. This year however, the person that checked him out of the facility to do this annual tradition was out of town on vacation. Upon further investigation by staff, including social services, the resident has consistently stated his intent was to go to the restaurant he used to work at bussing tables to get something to eat and visit and then planned to go hand out flags at the parade. The writer went to question Resident #1 regarding events at his bedside where the resident pointed to pictures on his wall of him at the restaurant in question and also handing out flags at the July 4th celebration. Interventions have included one on one companionship, take out order from a local restaurant, and there are plans in place for next July 4th to take the resident out to enjoy watching fireworks although staff is working out the details as to the safest way to provide this annual expectation to meet his needs while ensuring his safety. The resident has not since tried to leave the facility and a care plan is now in place around this annual expectation. An observation of the path the resident may have taken revealed from the front door he turned left heading North after leaving the facility property. A two-lane road with a speed limit of 30 mph (miles per hour) separated the facility grounds from a grassy area that lead onto an asphalt sidewalk. The sidewalk with uneven cemented surfaces, potholes and cracks followed around the lake without barriers. The unprotected lake was approximately 10 feet away from the asphalt sidewalk. The resident was found across the road from the facility in a grassy area. Resident #1's Elopement Risk assessment dated [DATE] completed by Staff C, LPN, showed No was checked for attempt to wander off the unit and positions self by exit areas. Yes was checked for having a history of wandering or elopement. No was checked for attempts to leave the building or grounds without notifying staff, the resident was not able to negotiate environment safely and has a history of substance abuse and/or substance seeking behavior, repetitive verbalizations of I'm going home, and is ambulatory including wheelchair mobility and for not accepting his current residency in the facility. Yes was checked for having a diagnosis of Dementia, Alzheimer's and is able to negotiate environment safety. The assessment showed Resident #1 was not at risk for elopement at this time. The form also revealed a section that showed If there are 'Yes' answers, but the resident is not at risk explain why. The box for the section was blank. A Change in Condition dated 07/04/2023 showed the incident location was outside. Resident #1 left the facility. Staff were notified by anonymous bystanders that the resident was by the fire training center on the ground. The resident description section revealed, I don't want to be here anymore. I'm going to [a local restaurant]. The resident was transported to a local hospital and returned to the facility on 1:45 a.m. on 07/05/2023. Review of Resident #1's care plan revealed a focus area initiated on 03/26/2021 [Resident #1] is an elopement risk, wanders throughout facility independently related to dementia, disoriented to place, impaired safety awareness, and the resident wanders aimlessly at times. Interventions included 1:1 supervision at all times (07/05/2023), assess for elopement risk (03/26/2021), distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (03/26/2021), identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (03/26/2021), provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, picture and memory boxes (03/26/2021), psychiatric care evaluation as indicated (07/11/2023), and wander monitoring device (electronic monitoring device)- check placement every shift and function daily (03/26/2021). Review of the care plans revealed a focus area initiated on 10/07/2022 [Resident #1] is/has potential to be verbally aggressive towards staff related to ineffective coping skills, limited impulse control inappropriate language use, refuses medications at times, history of elopement, will only allow name/id bracelet on his ankle, then takes it off when agitated, becomes agitated during 4th of July, and Memorial Day when he doesn't have someone take him out due to history of being very active handing out flags in the community. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness (10/07/2022), analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document (10/07/2022), assess resident's coping skills and support systems 10/07/2022), assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation (10/07/2022), and psychiatric care evaluation as indicated (07/11/2023. Review of Resident's #1 care plan revealed a focus area initiated on 02/17/2022 [Resident #1] has impaired cognitive function and/or impaired thought processes related to dementia diagnosis. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness (02/17/2022), ask yes/no questions in order to determine the resident's needs (02/17/2022), and communicate with the resident/resident's representative/caregivers regarding resident's capabilities and needs (02/17/2022). Engage the resident in simple, structured activities that avoid overly demanding tasks (02/17/2022) and keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (02/17/2022). Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated (02/17/2022). Review of the care plan revealed a focus area initiated on 04/05/2021 [Resident #1] is at risk for further falls related to confusion, gait/balance problems, episodes of incontinence, medication use, weakness, confusion, ambulates throughout unit wearing regular socks and refuses to have non-skid socks or tennis shoes put on for him at times. Interventions included anticipate and meet the resident's needs (04/05/2021), be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (04/05/2021), bed in low position (04/05/2021), and educate the resident and as needed the family on any individual fall reduction strategies (02/18/2022). Encourage resident to wear appropriate footwear/non-skid socks when ambulating (04/22/2021). Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (04/05/2021). Fall on 04/05/22 with ambulation, therapy evaluation, neurochecks, Xray lumbar spine, and encourage nonskid socks (04/06/2022). Medications as ordered and monitor for side effects (02/16/2022). Physical Therapy to evaluate and treat as ordered or as needed (04/05/2021). A review of the psychiatric care note written by Staff R, Advanced Registered Nurse Practitioners (ARNP), with a date of service date of 07/14/2023 showed patient was seen on 07/05/2023 for a telehealth follow up. He is currently taking Trazodone HCL Tablet 25 MG by mouth once a day for major depressive disorder. Patient seen today after eloping yesterday (July 4) from facility. He is alert and pleasantly confused. Appears in no acute distress. Patient reports he intended to have a meal at his favorite local restaurant. He reports he used to work at this restaurant. He stated he was planning to return after his meal. It was reported that the patient walked approximately 7 minutes and was spotted by nearby people who were watching fireworks. He was found sitting in a chair among the people watching fireworks. He was taken to the emergency room that evening to be evaluated. During an interview on 07/25/2023 at 2:00 p.m., Staff Q, Receptionist, stated the door alarm and the wander monitoring device alarm had the same sound. Her shift ends at 4:00 p.m. daily. The red alarm is a screamer, the door alarm was a beep. The front door had a high pitch sound, one beep, and a continuous beep until it was turned off. It will also beep if someone holds the door open too long. You must put a code in to turn the alarm off. An interview was conducted on 07/25/2023 at 2:35 p.m. with the Maintenance Director. He reported there were 8 exit doors in the facility, and they all had keypads. Three of the doors also had a wander monitoring device alarm, the front door is one of them. He said since the elopement that Screamer (very loud) alarms were put on a set of double doors that lead to the lobby, main entrance area. He said he checked the doors daily on weekdays, and according to the Administrator, the nursing staff check the doors on the weekend. The Alarmed and Exit Doors Daily Inspections log was reviewed at that time for the months of May 2023 and June 2023. It showed the doors were checked on weekdays but not checked on the weekend. During the observation the front door alarm was set off with a wander monitoring device by the Maintenance Director. The alarm could not be heard while standing on the North unit/300 hall. This was confirmed by the Maintenance Director. During an interview on 07/25/2023 at 3:29 p.m. with the Administrator and DON, the DON reported Staff G, LPN, contacted the DON and reported Resident #1 was out of the building and she was contacted by some bystanders. The resident was found about 7 minutes away from the facility if you walked. They both came to start the investigation. They called the police, the Power of Attorney (POA), the doctor, psychiatric care, and another outside agency. Interviews were completed with staff and residents. None of the staff reported he wanted to leave the facility that day or mentioned anything about leaving the facility. He walks back and forth all day. He had asked some about going out for fresh air. They went outside and came back in. Staff K, RN, took her lunch break around 6:10 p.m. and her car was facing the door. After her break, she came back in, went to the bathroom, and went back to the unit. Two phone calls came in about a missing resident. The DON stated Staff I, CNA, heard the alarm go off but she didn't see anyone. Resident #1 definitely went out of the front door. If you hold the door for 15 seconds, the door would open. He was a pretty smart guy and can probably read. He didn't verbalize he wanted to see fireworks. Resident #1 had on the wander monitoring device at the time he left the facility. They tested the same wander monitoring device when he came back, and it was still working. In-services were started immediately after the incident. Maintenance came and checked the doors, and they were working fine. They set up 30-minute checks on all alarmed doors. The alarm company came out on 07/06/2023. They added screamers to the double doors to have a second alarm, because you cannot hear the alarm at the north Unit nursing station. The receptionist leaves at 4:30 p.m. or 5:00 p.m. Once the receptionist leaves, the nurse comes over and sets the alarm. There were no screamers when Resident #1 eloped. An enunciator will be placed at north unit nurse's station, it has been ordered, so alarms can be heard there. You must put a code in to enter or exit the facility. Visitors have to ring the bell. Prior to the incident, the receptionist buzzed everyone in and out. Now the nurse comes and sets the alarms to the front door after the receptionist leaves. The receptionist announces on the intercom that she is leaving for the day. Someone in charge, usually one of the nurses comes to lock the door. The nursing supervisors are the ones that come to turn on screamers. All nurses have keys to screamers. Resident #1 was placed on 1:1. The DON and ADON evaluated all residents for elopement. They checked wander monitoring devices, monitored Resident #1, and did a whole house audit. Staffing was good. No issue with staffing on that day. Staff were educated on the elopement procedure and drills. They did a drill each shift and did them weekly after the incident. During an interview on 07/27/23 at 9:55 a.m., the Administrator and DON reported training was provided on the elopement policy/procedure/protocol prior to July 4, 2023. Elopement audits and drills were completed. On 07/27/2023 12:08 p.m., the DON reported elopement education was completed upon hire. They do not have access to elopement training and elopement drills completed due to a change in systems approximately two months ago. Alarmed and Exit Doors Daily Inspections for the months of May 2023 and June 2023 were verified. The doors were not checked on the weekend. This was confirmed by the Administrator and DON. She stated as of July, nursing staff had been checking the doors on the weekend. 2. On 7/5/23 at approximately 9:40 a.m. Resident #8 was able to exit the facility without supervision through an exit door on an uninhabited hall (600) that was equipped with a door alarm. An interview was conducted on 07/26/2023 at 12:29 p.m. with Staff M, CNA. She said on 7/5/2023 she served him breakfast around 8:00 a.m., picked up the tray, and the last time she saw him was after 9:00 a.m. He was down 400 hall next to the nurse. Staff M, CNA, stated she went into a room to provide patient care to another resident and heard the alarm going off. She looked on the board and saw the alarm was going off on the 600 hall. She looked and didn't see anything. At that time, they made an announcement to do a patient count. During an interview on 07/26/2023 at 12:11 p.m. with Staff L, LPN, she stated she was assigned to the resident that day. He likes to go back and forth. Around 9:20 a.m., she gave him medications and that was the last time she saw him. She was down the 400 hall passing medications when the alarm went off. She saw the Maintenance Guy and Housekeeping going down the 600 hall when the alarm went off. She continued finishing what she was in the middle of doing. She didn't see Resident #8 outside. After they wheeled him back in, she assessed him. He gravitated towards the doors with lights and guessed he was just going to see what was outside. He pushes on doors and jiggles the handles frequently. He had a wander monitoring device on which is why the alarm was going off. Everyone was busy, it was in the morning after breakfast. One of the CNAs took care of him before she gave him his medications. No one was on break, but everyone was busy with the residents. It was sunny and hot on that day. During an interview on 07/26/2023 at 12:37 p.m., Staff N, CNA, stated she was working on the floor on the day of the incident. She was giving a bed bath to another resident. She heard the alarm, came out of the room, and saw they were working on the doors. She saw the Maintenance Director working on the door around 9:50 a.m. She went back to finish the resident's bed bath. When she later went to nurses' station, the staff asked if she heard the alarm. She was assigned to stay with Resident #8 one on one that day at about 10:00 a.m. and she stayed with him until about 3:00 p.m. that day. An interview conducted with the Activity Director on 07/26/2023 at 12:47 p.m. He stated he heard the alarm go off and the 600 area being announced by staff. Everyone jumped up and started moving. Everyone was looking. Staff scattered to their areas. He saw the Maintenance Director going down the 600 hall. The Activity Director went down the 500 hall; when he got to the 500 hall exit door it was locked so he ran toward the 600 side, and he didn't see anyone. The Activity Director stated he then went back to the 500 hall and opened the exit door and saw Resident #8 closer by the dumpster, he was smiling and giggling. He wheeled Resident #8 back into the facility and took him to the nursing station. The resident got out of the door on the end of the 600 hall and went down the sidewalk that surrounds the building towards the 500 unit. During an interview on 07/26/2023 at 12:21 p.m., the Maintenance Director stated on 7/5/2023 he was headed to the morning meeting, he exited the service hall, and heard the alarm going off. He checked the enunciator, and it showed the alarm was coming from the 600 hall. The exit door was open on the end of the 600 hall. He went outside and immediately ran to the front of the building, because there was more danger in the front of the building than the rear. He didn't see anyone. He then came in and headed back to the 600 hall and saw Resident #8 from the window sitting outside. Two other staff members were heading out to get him. Within two minutes they had him back inside. The Maintenance Director went back down the 600 hall, reset the doors and silenced the alarms. He was the first one to respond to the alarm. He immediately looked to see what hall the alarm was coming from. After the incident happened, they put a rope across the hall, caution signs, and wet floor signs. Resident #8 frequently pushes on the doors. He knows the door will open after 15 seconds. The resident was just sitting looking around at the trees. There's a sidewalk in the back parking lot area. Another staff member got to Resident #8 before he did. He went back to secure the doors after the resident was brought back into the facility. Observation of the outside area where the resident was found revealed an uneven cement sidewalk surface that wrapped around the facility's building connecting one entrance to the next. Adjacent to the sidewalk was approximately 5 feet of grassy terrain that led into a large area with trees, overgrown shrubs and standing water. Review of Resident 8's Admission Record showed he was admitted on [DATE] with diagnoses to include muscle weakness, difficulty in walking, unspecified lack of coordination, limitation of activities due to disability, other lack of coordination, history of falling, age related cognitive decline, age related physical decline, unspecified dementia, unspecified severity without behavioral disturbance, psychiatric disturbance, mood disorder, anxiety, unspecified cataract, and Alzheimer's Disease. A review of the quarterly MDS with an ARD/target date of 05/16/2023 revealed Resident #8 had a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident needed extensive assistance with two plus persons physical assist with bed mobility and transfers and needed supervision with one-person physical assist for locomotion on and off the unit. Resident #8 needed extensive assistance with one-person physical assist for dressing and personal hygiene. He needed supervision with setup help only for eating and he was total dependent with two plus persons physical assist for toilet use. Section P Restraints and Alarms revealed Resident #8 used a wander monitoring device daily. An observation and interview were conducted on 7/24/2023 at 10:05 a.m. of Resident #8 on 1:1 with CNA, Staff O. Resident #8 was observed to be dressed in day clothes, sitting in his wheelchair in front of an exit door at the end of the 400 hallway. Staff O, CNA stated she was on 1:1 with him because around 07/05/2023, he went past the nurses' station and pushed on the exit door to the 600 hall and was found outside by the dumpsters. She stated he always pushes on the doors. He used to be a lawyer and he thinks his car was parked in the parking lot and he says he had to go to work. Since he was admitted he has pretty much always pushed on the doors. You see he is sitting in front of this door, and I told him 'You can't push on the doors okay' and he told me 'Well yeah if I keep pushing on it the door will open, you see the sign.' A sign was observed on the door with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. The resident was observed to have a wander guard on his left ankle under his sock. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: 1:1 close observation every shift for safety (ordered 07/05/2023); May go out with responsible party (10/10/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/17/2023); (Company name) Hospice for diagnosis of metabolic encephalopathy (02/11/2022); Wander monitoring device- check for function each day every night shift for monitoring (07/29/2022); Wander monitoring device- place wander monitoring device on wheelchair (08/04/2022); and Wander monitoring devic[TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement the care plan regarding a resident's call light for one (Resident #7) of 8 sampled residents. Findings included: A review of Resident #7's electronic record revealed she was admitted to the facility on [DATE], with diagnoses that include lack of coordination, abnormal posture, Chronic Pain Syndrome, Major Depressive Disorder, Anxiety and Traumatic Brain Injury. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. A review of the resident's care plan dated 2/18/19, with a revision date of 5/22/23 related to behavior due to anxiety, depression and insomnia revealed the resident Turns on call light repeatedly after staff has just exited the room; attention seeking. with interventions that included Anticipate and meet The resident's needs. initiated 2/8/19; Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. initiated 8/13/21. Observations of the 200 hall on 7/24/23 at 10:18 a.m. revealed the call light was on for Resident #7's room. Staff E, Housekeeper was noted to be in the doorway to the room mopping and said a few words in Spanish to the resident. Staff E completed the mopping, exited the room, and put the yellow caution sign in front of the door. Continued observations on 7/24/23 at 10:23 a.m., Staff B, Certified Nursing Assistant (CNA) was noted to walk down the hall and enter the room to the left of Resident #7's room. The CNA spoke to the resident in that room, exited the room, and walked down the hall past Resident #7's room toward the nurses station. Resident #7's call light was still illuminating above the room door. Staff B did not respond to the call light. On 7/24/23 at 10:27 a.m., while standing at the nurses station, a beeping sound could be heard. Observation of the call light system located behind the nurses station on the table identified Resident #7's room by illumination. At this time, Staff C, Licensed Practical Nurse (LPN) was standing at the nurses station with her medication cart and made no attempts to respond to the call light. Observations of the 200 hall continued from the 100 hall and the call light continued to illuminate over Resident #7's room and no one was noted to enter Resident #7's room. Observations on 7/24/23 at 10:30 a.m., revealed the call light was observed to go on above the room to the right of Resident #7's room. Both lights are noted to now be illuminated. At 10: 40 a.m., a staff person was noted to enter the room located to the right of Resident #7's room; however, no one was noted to respond to the call light for Resident #7's room and the light remained on. At this time, another staff person was noted to walk down the 200 hall, pass Resident #7's room and not respond to the call light. An interview with Staff B, CNA at this time revealed she was assigned to room [ROOM NUMBER]-213 and when call lights go on anyone was supposed to respond to call lights even if they were not assigned to the room. After the interview, Staff B was noted to proceed to walk down the 200 hall and not respond to Resident #7's call light. An interview on 7/24/23 at 10:43 a.m., with Staff C, LPN revealed she was assigned to the 200 hall and reported anyone could answer a call light. She said she was not aware that Resident #7's was on. An interview on 7/24/23 at 10:44 a.m., with Staff D, Minimum Data Set Coordinator (MDS Coordinator) revealed she was currently on the floor answering call lights and was just in the process of going to answer the light for Resident #7's room. She reported all staff could answer the call lights and if they were not able to assist the resident they were to notify nursing. An interview on 7/24/23 at 10:46 a.m., with Staff E, Housekeeping revealed all staff were supposed to answer call lights. When asked about assisting Resident #7 when she was in the room cleaning, she said she did not even realize the lights were on. She stated, [the resident] always puts her light on even if you have just helped her and most of the time it is for something little. An interview on 7/24/23 at 10:54 a.m., with the Director of Nursing (DON) revealed the expectation was that any staff member could answer the call lights and if they could not address the concern, they were to find someone that could. During observations of the 200 hall on 7/25/23 at 9:05 a.m., a call light could be heard at nurses station beeping and the call light was noted to be illuminated above Resident #7's room. Continued observation at this time, revealed a nurse was at her cart parked across the hall from Resident #7's room and two CNAs were standing and talking in the hall one room away from Resident #7's room. It was noted that when the CNAs completed their conversation and did not respond to Resident #7's call light. Inspection of the call light system at the nurses station revealed the button for Resident #7's room was illuminated. On 7/25/23 at 9:11 a.m., during an interview with the Nursing Home Administrator (NHA) she said all staff were to respond to call lights and get assistance if needed. She said Resident #7 always puts her light on even if a staff member just left the room. She reported that staff were still supposed to respond to the light. She reported the resident was care planned for using the call light too much. An interview on 7/25/23 at 9:12 a.m. with Staff F, CNA revealed he did not respond to Resident #7's call light right away because the resident always turned on her light. He said he knew he should respond to call light right away. Observations on 7/25/23 at 1:58 p.m. of Resident #7's room revealed she was in a room alone. During an interview with the resident she confirmed she pressed the call light often, and she pressed the call light when she needed something. The resident reported staff did not always come right away when she pressed the call light and she sometimes waited more than 30 minutes before a response.

Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment related to proper cleaning and maintenance in nine resident bathrooms (400, 401, 402, 403, 404, 405, 406, 407, and 409) out of ten bathrooms reviewed, two resident room baseboards (402 and 407) out of ten resident rooms observed, and one resident room wall (407) out of ten resident rooms observed. Findings included: An observation was made on 5/22/23 at 9:30 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet, a space between the base of the toilet and the floor was visible. The screws for the bowl base were rusted and dusty. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:40 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the toilet. On the window wall beneath the air conditioner the baseboard was not sticking to the wall. The baseboard was protruding past the air conditioner. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:45 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the toilet. On the window wall beneath the air conditioner the baseboard was protruding past the air conditioner, not attached to the wall. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:50 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. There was a gap between the toilet base and floor. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:02 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black substance around half of the toilet base. There was a gap between half of the base and floor, that had no caulking. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:15 a.m., in resident room [ROOM NUMBER] and the bathroom. The bathroom toilet had a brown substance at the base of the toilet. On the window wall the baseboard was protruding past the air conditioner. The baseboard was not sticking to the wall. The wall of the resident's over bed light to 407 B was a hole, directly next to the headboard. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:33 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. There was a gap between the toilet base and floor. The screws for the toilet base were rusted and had dust build up on them. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:38 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the top of the tank of the toilet. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:45 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. (Photographic Evidence Obtained.) On 5/25/23 at 1:10 p.m. an interview was conducted with the District Housekeeping/Laundry Manager (DM) stating there is a department head assigned to all rooms. The department heads are supposed to speak to the resident's and/or families and observe the physical plant for any needs of attention. During the interview, an observation was made with the DM in room [ROOM NUMBER] bathroom. When the DM noted the toilet base, she stated oh yes, that could probably be scrubbed, oh goodness, I think that the seal is gone. Maintenance would take care of that part. Continued observations with the DM into the hallway outside of room [ROOM NUMBER] and noted the baseboard protruding past the air conditioning unit. DM stated we should have noted this while mopping was being done and inform Maintenance. DM stated the expectations are for the housekeepers to clean and scrub to the best of their ability and notify their supervisor or Maintenance of any repairs that need or if they are unable to remove a substance. On 5/25/23 at 1:31 p.m. an interview was conducted with the Nursing Home Administrator (NHA), regarding the toilet bases, baseboards, and the hole in the resident room's wall. The NHA stated, oh yes, that needs to be caulked. NHA continued to state there is a lot of maintenance that is needed here, we have a lot to do. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 4/1/22 and revised on 3/10/23, showed: The purpose: to develop and implement a preventative maintenance program that promotes a safe, functional, and comfortable environment for all residents. Procedure: 1. The facility's maintenance program is based on regular and routine maintenance designed to maintain a safe, comfortable, operating environment. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, significant event reviews, life safety requirements, and/or experience. 3. This should include but is not limited to: a. Essential mechanical, electrical, life safety and patient care equipment; b. Well lighted and well-ventilated rooms and common areas; c. Resident furniture such as bed-side cabinet or drawer spaces; d. Maintain comfortable sound levels; e. Secure handrails; f. Effective pest control; g. Maintain nurse call system; h. Maintain comfortable and safe temperature level between 71-81 degrees Fahrenheit; i. Kitchen/Dietary Equipment; j. Therapy Equipment; 4. The Maintenance Director should maintain a system for routine audits of each of the areas above.

Based on record review, staff interviews, and review of the facility's policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR's) were completed accurately for 5 of 6 residents reviewed, (#60, #18, #68, #16 and #1). Findings included: A review of Resident #60's admission record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder. A review of current physician orders for Resident #60 dated 05/05/23 showed the resident was receiving Mirtazapine 7.5 MG (Milligrams) by mouth daily for depression. A minimum data set (MDS) dated [DATE], section I, showed the resident had a diagnosis of depression. A review of a level I PASARR for Resident #60 dated 12/20/22 revealed no diagnosis were checked. A review of Resident #18's admission record dated 05/23/23revealed the resident was admitted to the facility on [DATE] with diagnoses to include Major depressive disorder, Vascular Dementia with behavioral disturbance, and Mild cognitive impairment. A review of a level I PASARR for Resident #18, dated 5/23/17 showed upon admission no diagnosis were checked to indicate Resident #18 had any diagnoses of Mental illness or suspected mental illness. A review of Resident #68's record showed the resident was admitted to the facility on [DATE]. A review of Resident #68's Medication Administration Record (MAR) dated 05/25/23 showed the resident was receiving an antipsychotic medication, Depakote 500mg for encephalophagy, a disease of the brain, Levetiracetam oral solution for seizures, and Trazodone HCI oral tablet 50mg daily for depression, effective 1/18/23. An MDS dated [DATE], Section I showed active diagnoses of a neurological diagnosis Aphasia, Cerebrovascular accident (CVA) a psychiatric diagnoses were not indicated. A review of resident #68's PASARR showed upon admission no diagnosis were checked to indicate Resident #68 had any diagnoses of mental illness or suspected mental illness. On 05/24/23 at 11:11 a.m. an interview was conducted with the Social Services Director (SSD). She stated the PASARRs should have been checked to indicate mental diagnoses present upon admission. She stated their process is review PASARRs on admission, but they had not gotten around to it. She stated the DON (Director of Nursing) should be completing them because she did not have access. She stated either way, they should have been reviewed and corrected. On 05/24/23 at 11:13 a.m., an interview was conducted with the Regional Clinical Nurse. She stated they were putting a plan in place to review all the PASARRs in all their facilities to make sure they were accurate. She stated when the residents are admitted to the facility, they come with PASARRs completed from the hospital that are often inaccurate. She stated it was their responsibility to ensure they were updated to match the admitting diagnoses. A review of a facility policy titled, PASARR, dated 04/01/22, showed the facility shall insure each resident in a nursing facility it's screened from a mental disorder (MD) or intellectual disability(ID) prior to admission and that individuals identified with MD or ID are evaluated to receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate state designated authority. The facility should ensure that individuals with a mental disorder or intellectual disability continues to receive care and services they need in the most appropriate setting when a significant change in their status occurs. 39438 A review of the Admission Record for Resident #16 showed she was admitted on [DATE] with diagnoses of autistic disorder, dementia in other diseases classified elsewhere, unspecified severity, with agitation, anxiety disorder, mood disorder due to known physiological condition with mixed features, and major depressive disorder and the resident was not assessed for PASARR Level II. The PASARR Level I assessment dated [DATE] indicated a related condition of autism and no other qualifying mental health diagnoses. Section I Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed Resident #16 had diagnoses to include depression, bipolar, and autistic disorder. A review of the Admission Record for Resident #1 showed she was admitted on [DATE] with diagnoses of anxiety disorder, schizoaffective disorders, and major depressive disorder and the resident was not assessed for PASARR Level II. The PASARR Level I assessment dated [DATE] indicated diagnoses to include anxiety disorder, depressive disorder, and schizophrenia and showed that a Level II PASARR evaluation was not required. Section I Active Diagnoses of the MDS dated [DATE] showed Resident #1 had diagnoses to include anxiety disorder, depression, and schizophrenia.

Based on observations, interviews and facility policy review, the facility did not ensure an effective pest control system was in place in 1 of 3 halls (300) during 3 of 4 days of survey (05/22/23, 05/23/23 and 05/24/23). Findings included: During multiple facility tours, observations were made of live and dead pests/flying insects to include cockroaches in resident's rooms in hall 300 as follows: on 05/22/23 at 9:50 AM room [ROOM NUMBER] an observation was made of a dead cockroach on the floor. On 05/22/23 at 10:14 a.m. room [ROOM NUMBER] was observed with a dead cockroach On 05/23/23 at 01:07 p.m., an observation was made of flying insects landing on the resident's food (bed B.) in room [ROOM NUMBER]. On 05/23/23 at 01:13 room [ROOM NUMBER] was observed with a live cockroach and flies. The residents confirmed on-going issues with insects and pests. On 05/23/23 at 01:15 p.m., A live insect in the appearance of a spider was observed on the floor in room [ROOM NUMBER]. The residents confirmed on-going pest concerns. On 05/23/23 at 01:20 p.m., a live cockroach was observed in room [ROOM NUMBER]. On 05/23/23 at 01:26 p.m., a live bug/insect was observed on resident #302's bed. On 05/24/23 at 08:47 a.m., an observation was made of a live cockroach in room [ROOM NUMBER]. On 05/24/23 at 08:50 a.m., an observation was made of a live cockroach in room [ROOM NUMBER]. On 05/24/23 at 08:52 a.m., an observation was made of a live cockroach in room [ROOM NUMBER]. On 05/23/23 at 01:07 p.m., an interview was conducted with Staff E, Certified Nursing Assistant (CNA). She stated she had been at the facility a few months. She said, Yes, I have seen roaches, and ants. I just shoos them away if they are on resident's space. She stated she notifies someone such as a nurse. The CNA observed flies on the resident's tray in room [ROOM NUMBER] and shooed them away. On 05/23/23 at 01:17 p.m., an interview was conducted with Staff F. She stated she seen pests like gnats and flies. She said, it is on-going issue especially with cockroaches. She stated the expectation was to report to the Director of Maintenance (DOM) so they can spray. On 05/23/23 at 01:28 p.m., an interview was conducted with Staff G, CNA. Staff G said, Yes, we have cockroaches. When I see them, I sweep them away and I write it down in the book at the nurses station and also let the maintenance head know. On 05/24/23 at 09:17 a.m., an interview was conducted with the DOM. He stated a pest control company comes out twice a month and they review pest control logs in both north and south nurse's units. He stated they treat specific areas that are documented in the book, and other areas and including exterior and entry ways. The DOM stated he heard there were reports of cockroaches sightings in hall 300. He stated pest control services was scheduled to return and that he would have them treat the areas of concern. 05/24/23 10:32 a.m., an interview was conducted with the Nursing Home Administrator (NHA) as she presented the facility's pest control policy. She stated she had walked the halls and noted one bug. She stated she would be changing the pest control service company because it was obvious their pest control program as not working. She stated she did not know there was an on-going problem. She stated she would review the logs, discuss with the DOM and the contracted pest control service technician. A review of a facility policy titled, Pest Control, dated 04/01/22 showed facility wide pest control strategies are developed emphasizing kitchens, cafeterias, laundries, central supply, loading docks, construction activities, and other regions prone to pest infestation. Procedures showed ongoing measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice, and rats. General measures are taken to decrease pests including the elimination of cracks and crevices, proper lighting and ventilation, use of screens on windows and doors, and use of self-closing doors. A contract with a pest control company may be elected to assure regular inspections and the application of chemical pesticides. The facility will contract for routine pest control services by a credentialed pest control specialist. The pest control contractor shall have knowledge of pest control treatment methods for healthcare facilities. Regular inspections by the local and county sanitation departments are part of the pest control program. The facility will follow applicable state and local regulations unregular pest control. 46973

Based on interviews, record review and review of facility policy, the facility did not ensure one resident (#60) of one reviewed had access to his personal funds. Findings included: On 05/22/23 at 10:17 a.m., an interview was conducted with Resident #60. He stated he had been asking how much money was in his account and no one could give him that information. He stated he had requested a statement without success. Resident #60 stated he did not know what happened to his money upon admission. A review of Resident #60's admission record showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of a document for Resident #60, titled, Resident Fund Management Service, dated 02/06/23, showed an incomplete form that did not show accountability of the resident's funds. On 05/23/23 at 12:18 p.m., an interview was conducted with Staff I, the Human Resource Director, and Resident Accounts Manager. Staff I stated this resident did not have any funds that she knew of. Staff I presented a statement showing the resident had a zero balance in his account. On 05/23/23 at 12:20 p.m., an interview with was conducted with the Nursing Home Administrator (NHA). She stated their policy was to send residents financial statements every 3 months. She stated if the resident had money at the facility, any amount, they would mail them statement. On 05/24/23 at 02:02 p.m., a follow up interview was conducted with Resident #60. He stated it would not make sense that his account had a zero balance. Resident #60 said, I had money when I was at [name of facility]. They should have sent my money here. The resident stated he was confident he had money somewhere. On 05/24/23 at 02:24 p.m. an interview was conducted with the Social Services Director (SSD). She stated she did not know anything about this resident's funds concerns but would investigate. The SSD reported that she had contacted the other facility and had left two voicemails. A review of a social services progress note for Resident #60 dated 05/25/23 showed, SSD met with resident in regard to his money that was located in a safe with his name on it that came from [name of previous facility]. SSD informed the resident of the amount and that it would be deposited in his trust account. On 05/25/23 at 09:02 a.m., The SSD stated they had located Resident #60's money. She said, It was in the safe the whole time. His money was here, and no one knew about it. The SSD stated she did not know who had put the money in the safe and why it was not accounted for per their procedures. She stated she did not know how much it was but would find out and update Resident #60. On 05/25/23 at 09:32 a.m., an interview was conducted with Staff I. She stated if the resident brought in cash, someone should have gone to get him a money order so they can deposit the money. She stated social services would normally do this. Staff I said, someone should have documented that the money and his personal belongings were in the safe. On 05/25/23 at 09:40 a.m., a follow up interview was conducted with the NHA, DON (Director of Nursing) and The Regional Clinical Nurse. The DON stated if nursing would have received the resident's wallet it would have been inventoried. A review of the inventory sheet revealed these items were not indicated. The DON stated the resident was originally admitted in December. The DON said, We should have accounted for it. The NHA stated this was before her time, and she could not speak of the process. She said, I would expect a resident to have access to their personal belongings and personal funds. She stated Resident #60 should have had his money this whole time. On 05/25/23 at 11:10 a.m. the NHA stated they did not have a policy on personal funds/personal belongings, but they exercise the Resident's Rights and Responsibilities expectations. She said, However, I would expect staff to complete a full inventory when the resident comes in. If they are alert and oriented ask them what they would like with their belongings. If something needs to be secured, we put it in the safe. We should keep an inventory of what is in the safe and SSD should have a copy. A review of an undated document titled Resident's Rights and Responsibilities, showed the resident has a right to know in advance what charges the facility may impose against your personal funds. Choose to deposit your personal funds with the facility in which the facility must act as a fiduciary and hold, safeguard and manage your funds. Earn interest on any funds in excess of $100.00 that is deposited with the facility. Choose not to deposit your personal funds with the facility. Receive full complete and separate accounting of your funds according to acceptable accounting principles. Receive financial statements at least quarterly and upon request.

Based on interviews with family member, facility staff and Hospice staff, the facility failed to notify the parties involved in care, of a change in condition (CIC) for one of four residents reviewed, Resident #333. Findings included: On [DATE] at 11:02 a.m., an interview was conducted with Resident #333's family member. The family member stated they had been out to dinner and decided to stop by the facility to visit the resident. The family member stated when they arrived, they became aware that Resident #333 had died . The family said, We walked into the facility's lobby, signed in and walked into the room and no one said anything. When we got to the room, the door was shut, we knocked and no one said anything, the Responsible Party peeked inside and saw people in the room. He stated he thought they were just taking care of her. She stated when they finally came out of the room, he walked in and sat by the resident's bedside, still unaware she was gone. The family member stated the nurse (Staff A, LPN, Licensed Practical Nurse) stated the resident had just passed away and stated Hospice was supposed to notify the family. The family member stated no one at the facility had spoken to the family all day on [DATE] or on [DATE]. The family member stated they did not know the resident had declined so rapidly. She stated the family was aware she was under Hospice care, but she was still stable, alert, and oriented. The family member stated she would have hoped someone would have alerted them of the decline. A review of Resident #333's admission record showed the resident was admitted on [DATE] with diagnoses to include unspecified cirrhosis of liver and Type 2 Diabetes Mellitus without complications. A review of the resident's physician orders, active as of [DATE], showed the resident was admitted to the facility under [name of hospice] consult for continuation of care related to terminal diagnosis of cirrhosis of liver. The order showed the resident required an intermediate level of care. A review of resident #333's progress notes revealed the following: -[DATE] 11:03 p.m. Patient was found unresponsive, hospice was called. The patient was pronounced diseased at 6:17 p.m. on [DATE]. Hospice notified family. Funeral home picked up body at 7:44 pm. Note was entered by Staff A, LPN. -[DATE] 5:51 a.m. BSL (blood sugar level) was 33 mg/dL (Milligrams per deciliters, unit of measuring the concentration of glucose in the blood). Glucagon given. offered juice BS currently at 41. -[DATE] 5:39 a.m. Resident is showing signs of hypoglycemia BSL at 58 mg/dL. -[DATE] 4:39 a.m. Resident is alert , she presents with hypoglycemia BSL at 41. MD (Medical Doctor) notified. Orders received to administer Glucagon and monitor. BSL remains low at 62 mg/dL . Placed call to [name of hospice]. Patient Care Coordinator and Registered Nurse (RN) advised of Hypoglycemia diagnosis. -[DATE] at 11:23 p.m. Nurse notified the ARNP (Advanced Registered Nurse Practitioner) and Resident #333's doctor her BSL was 62 mg/dL. An order was given to give Glucagon and recheck blood sugar. Resident was alert and informed of situation. Review of hospice records showed Hospice was notified of Resident #333's low BSL on [DATE] and a nurse came to the facility and assessed the resident. The hospice note showed, Left note to call [name of Hospice] with any concerns. The review of resident #333's Electronic Medical Record (EMR) showed Resident #333 had low blood sugar levels documented from [DATE] to the time of her death [DATE]. The review showed the family was not notified of the change in condition for the resident. The review further showed Resident #333 was last assessed by a Hospice nurse on [DATE] at 11:45 a.m. to 1:15 p.m. An interview was conducted with the Hospice nurse who last assessed Resident #333 on [DATE] at 2:27 p.m. She stated at the time she left, the resident was alert, at baseline and was in no distress. She stated she spoke with the nurse at the facility and was not made aware of any blood sugar concerns. She stated she had seen these resident during prior visits and she was herself. This nurse stated she completed routine care and educated the staff on calling with any change in condition., A copy of Record of death and mortician's receipt showed resident died on [DATE] at 6.17 p.m. The receipt showed Hospice was notified of death. On [DATE] at 01:12 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA) she stated she remembered the resident. She had worked with her on [DATE] during the first shift, 7 a.m. to 3 p.m. She stated on that day Resident #333 did not get out of bed. Staff B said, She was sick, she was looking ill, looking pale. She didn't move, she would normally turn herself in bed. She didn't get out of bed, I gave her a bed bath and tried to offer her snack pudding, she had two bites. She did not want to eat anything. This was not like her. I Kept checking in on her all shift. I knew she was not feeling well. I told the nurse, she had a basin by her chin so if she had to throw up it would be right there. Staff B stated she last saw the resident around 2:30 p.m. She had checked to if she needed to be changed before she left. Staff B said, I fixed her blanket. She didn't want anything to drink. An attempt to reach the nurse who worked the 7 a.m. to 3 p.m. shift on [DATE] was unsuccessful. On [DATE] at 10:05 a.m., an interview was conducted with [name of Hospice] representative. She stated Hospice received a call on [DATE] around 6:09 p.m. and was notified Resident #333 had died . She stated they sent their Chaplain who responded to the facility at 6:46 p.m. The Hospice representative stated on [DATE] the resident had received a regular visit and on [DATE] at 6:09 p.m. they received a call from the facility stating the resident had expired. She stated they had not received any other calls from the facility indicating a change in condition. She said, if they had called with a CIC, we could not have sent a Chaplain. We could have sent a nurse. A chaplain responded because the resident had already passed on. There were no other calls. She stated the nurse who assessed the resident last would have initiated their change in condition protocol if they felt the resident was showing signs and symptoms of imminent decline. She stated that would have included contacting the family and hospice physician. She stated the nurse's visit on [DATE] was standard and the resident was at baseline at the time. The Hospice representative stated the chaplain could not call the family, because the family was already at the facility. The Hospice Representative said, I Can't speak to the facility's process of reporting. They learned of the death before Hospice. I would expect they would follow their procedures. On [DATE] at 12:57 p.m., an interview was conducted with Staff A, LPN Agency. She confirmed she worked with the resident on [DATE] during her 3 p.m. to11 p.m. shift. She said, upon arrival on my shift, I did my rounds around 4 p.m., I do not remember passing meds to her, but I remember she was not in any distress, she was resting. She stated sometime around 6 p.m. during dinner time, one of the aides reported the resident did not want to eat. Staff A stated she assessed the resident and noted she didn't get a pulse. She stated she called the facility's weekend supervisor and Hospice and notified them the resident had died . Staff A stated she believed Hospice notified the family, but she was not sure. She stated the previous nurse had said the resident was on comfort measures only and had not indicated the resident was on comfort measures only. Staff A stated she did not call Resident's #333's family during her shift. On [DATE] at 01:24 p.m., an interview was conducted with Staff C, CNA. She confirmed she worked second shift 3 p.m. to 11 p.m. on [DATE] and was assigned to Resident #333 the day she died . Staff C stated at the beginning of the shift the resident was not in pain that she could see. Staff C said, she did not speak much. She answered yes or no or just nodded. I changed her and gave her a bed bath. Staff C stated the last time she saw Resident #333 was dinner time, between 5 p.m. and 5:30 p.m. The resident did not eat. She took a couple bites. She would normally eat and drink. The CNA said, Not this day. She refused. Right after I wiped her face, I noticed she was a little pale, and appeared unwell. I called the nurse, she looked at her and then she left to make a call. Another aide came then we cleaned her. We were in the room when three family members came. When they entered the room, we left. I don't know if she was still breathing at this time. Record review and interview showed on [DATE] at 5:51 a.m. Resident #333 had a BSL of 33. Record review showed no evidence a call was made to the doctor or Hospice or family. Record review showed no nursing notes documented on [DATE] from 7 a.m. to 3 p.m. Staff B, CNA confirmed Resident #333 was sick. Review of record did not show a change in condition documented, or contact with family, physician, and hospice. On [DATE] at 02:52 p.m., an interview ws conducted with the facility's Regional Clinical Nurse. She said, I see there are some concerns related to documentation. I spoke with the weekend supervisor. She stated she was notified the resident was not doing well. she stated she contacted the physician. She could not remember the date or the time. There is no evidence of this. It was not documented. The Regional Clinical Nurse stated staff should have documented if any contact was made with the family, physician, or Hospice. She said, I would expect a change in condition to be filled out and documentation to show that the family and physician were notified. She stated the physician was called and he pronounced the resident, I understand it is not documented. The Regional Clinical stated they should have made note of the date and time of notification. She said, I cannot speak of why they did not. A review of a facility policy titled, Nursing - Change in Condition, dated [DATE], showed a purpose to identify and communicate changes in condition to the physician and other employees to implement interventions to prevent further deterioration and possibly prevent hospitalization . Procedure: all staff are encouraged to promptly report any changes in condition to the charge nurse supervisor our director of nursing/assistant director of nursing or designee immediately. This may include but is not limited to a significant change in the resident's physical, mental our psychosocial condition such as deterioration in health, mentor of psychosocial status. Life threatening conditions, or clinical complications. Circumstances that may require a need to alter treatment this may include new treatment and/or discontinuation of current treatment due to adverse consequences, acute condition, or worsening of her chronic condition. (7.) The resident's family/legal representative/healthcare agent should be notified about the change in condition as required. A review of a facility policy titled, Hospice Care, dated [DATE], showed the center supports the patient/resident's right to a dignified existence and self-determination. The center will assist the patient/resident/and/legal representative in arranging Hospice services. When Hospice are provided in center, the center should meet the following: The center should immediately notify the hospice when the patient/resident experiences a significant change in condition including physical, mental, social, or emotional change, clinical changes suggest a need to alter the plan of care and patient/resident death.

Based on interviews and record review the facility failed to ensure adequate assistance to prevent a fall with injury for one (Resident #3) of two residents reviewed for falls with injury. Resident #3 rolled off her bed onto the floor during incontinence care, sustaining a fracture. Findings included: Facility incident logs and reportable event logs for October 2022 through December 2022 were reviewed. There was an entry of injury of unknown source, event date 12/18/2022 documented for Resident #3 on the reportable event log. A fall was documented for Resident #3 on the incident log, date 12/16/2022. An interview was conducted with Resident #3 on 12/28/2022 at 12:51 p.m. in her room. She was observed seated in a wheelchair in her room between her bed and the door. She was dressed and wearing socks and pull-on sneakers and playing a game on an electronic tablet. Her bed was positioned at neutral height, bed was made, and there was a quarter rail on the door-facing side of the bed that was in lowered position. Regarding the events listed on the facility logs, Resident #3 said, I broke my toe. She stated it was the big toe on her right foot. Regarding how her toe had been broken she said, I fell out of bed. She said, one of the guys was changing my diaper and I rolled out of bed. The resident stated she did not know the name of the staff person who was changing her, but she thought maybe he was in training, and she had not seen him since. She could not provide the date when the fall occurred and could not provide any information about whether anyone had assessed her for injury immediately after the fall. Resident #3 stated that later (again she could not provide a date) she had pain and bruising of her right hand and right foot, x-rays were ordered of both, nothing was broken in her hand, but the big toe was broken on her right foot. She said therapy had ordered a boot for her foot, but she did not have it yet. She said her foot hurt. She stated she had asked for a bed rail on the other side of her bed but was told she was not allowed to have one. She stated Staff A, Certified Nursing Assistant (CNA) had asked her about the incident and did not buy her story. Staff A, CNA was interviewed on 12/28/2022 at 1:04 p.m. She confirmed she knew about Resident #3's fall and injury. She stated she did not recall the date but said, I came into work that morning and her roommate was in the room with her and said to me come here I need to tell you something. She said I want you to know that [Resident #3] was on the floor the previous night. Staff A stated she went immediately and got the Assistant Director of Nursing (ADON) and they both returned to the room and the ADON questioned Resident #3. Staff A stated Resident #3 reported to them she fell on the floor out of the bed and the male CNA picked her up and put her back in the bed. Staff A stated after Resident #3 made that statement, she asked the nurse from night shift (Staff D) if she was aware of the fall and Staff D stated she was told by the male CNA that the resident was hanging off the side of the bed. Regarding how/when x-rays were ordered of Resident #3's hand and foot Staff A said, I want to say it was a Saturday [she could not recall date]. The resident went into the restroom, and was complaining that her foot was hurting her. I asked her to take her sock off and I noticed that her foot was red. Staff A stated a nurse (Staff E) assessed and ordered an x-ray. Staff A stated she was not involved any further after that and did not have any additional information. She stated she gave her statement to the ADON and the ADON would have more information. Review of Resident #3's medical record was conducted. The admission record revealed diagnoses that included rheumatoid arthritis, anxiety disorder, need for assistance with personal care, history of falling, lack of coordination, osteoporosis, and muscle spasm. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which meant the resident was cognitively intact. The MDS revealed the resident required extensive physical assist of two persons for bed mobility. The care plan revealed Resident #3 required assist with Activities of Daily Living (ADL) related to weakness and impaired balance/gait and interventions included, Bed Mobility: The resident requires extensive assistance of 1-2 staff to turn and reposition in bed, 2 for moving toward head of bed. The care plan revealed Resident #3 was at risk for falls related to gait/balance problems, incontinence, medication use, and multiple chronic conditions and that the resident had fallen related to poor balance, weakness, and impulsivity. The task list for CNAs for Resident #3 revealed a section titled Safety which included, Monitor the resident every shift and prn (as needed) for safety. The resident is taking meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. The task list included a section tiled, Bed Mobility which included, Bed in low position .The resident requires extensive assistance of 1-2 staff to turn and reposition in bed, 2 for moving toward head of bed. The task list included a section titled, Toileting which included, The resident requires limited to extensive assist from 1 staff for toileting, 2 if weak or tired. Review of CNA task documentation for night shift 12/16/2022 revealed care tasks documented by Staff B, CNA, including bowel and bladder care. Review of progress notes in Resident #3's medical record revealed no notes about the fall on 12/16/2022 until an entry with effective date 12/16/2022 1:08 p.m. tiled Interdisciplinary Team (IDT) note authored by the facility Director of Nursing (DON) which read: Plan of care review. Fall 12/16/2022. 11-7 shift while transferring with caregiver. fall lowered to floor while transferring 12/16/22. therapy evaluation. Education provided to sit down slowly to take her time, descend slowly. And not complete quickly. [Resident #3] was referred to therapy for evaluation. Following this note were additional entries related to the fall and injury: Effective Date 12/16/2022 1:31 p.m. Nursing Progress Note authored by Staff C, Registered Nurse (RN): Resident advised nurse that she slipped from her bed onto the floor, during the night. Full assessment completed by RN; no injury noted. No adverse reaction noted. Resident was able to move all lower and upper extremities independently. Resident denied pain. MD (medical doctor) notified no new orders received. POA (power of attorney) - resident's sister [name and contact] notified. Staff continues to monitor resident frequently. Effective Date 12/18/2022 2:41 p.m. Nursing Progress Note authored by Staff E, RN: Resident has reported hand and toe injury to CNA and nurse on 12-18-2022 on 7-3 shift. Nurse has completed assessment on resident and has spoken to NP (nurse practitioner) and x-rays have been ordered for hand and toe. Effective Date 12/18/2022 4:20 p.m. Nursing Progress Note authored by Staff E, RN: Nurse has spoken to family member (sister) and made her aware of resident injury after fall, and has made family member aware that resident will be having x-rays completed STAT (immediately). Effective Date 12/19/2022 2:27 p.m. Nursing Progress Note: Writer contacted Psych ARNP (advanced registered nurse practitioner) to notify of patient's recent fall. New order from Psych ARNP for [labs] .Writer contacted [family member] and notified her of new labs. Writer also notified [family member] of new order for boot to right foot at all times and new order for podiatry consult . Effective date 12/19/2022 3:12 p.m. Nursing Progress Note authored by Staff C, RN: Resident is alert w/ (with) confusion. Resident advised staff that she rolled out of bed. X-ray completed of resident's right great toe. Results - subtle fracture of the toe. No swelling or skin issues noted. Resident denied pain or discomfort. Staff will continue to monitor resident. Review of assessments in Resident #3's medical record did not reveal any nursing assessments or change in condition assessments immediately post-fall on 12/16/2022. The first assessment found was a change in condition assessment with effective date 12/16/2022 1:08 p.m. authored by Staff C, RN. It documented the situation as, Resident advised nurse that she slipped out of her bed onto the floor during the night shift. The following summary was included, Full assessment completed by RN; no injury noted. No adverse reaction noted. Resident was able to move all lower and upper extremities independently. Resident denied pain. MD notified no new orders received. POA notified. Staff continues to monitor resident frequently. An interview was conducted with Staff B, CNA on 12/28/2022 at 4:37 p.m. The Nursing Home Administrator (NHA) was present during the interview. Regarding the circumstances surrounding Resident #3's fall on 12/16/2022 Staff B stated, I was doing my last rounds [confirmed date was 12/16/2022 and shift was night shift] I think around a few minutes to 6 in the morning and I offered to change her. I asked her which side was best for her to turn and she told me the side where I was standing because she has a rail to hold on to. Staff B confirmed he was standing on the left side of the bed (side facing door & also on the side that had the rail). Staff B stated the bed height was mid-level, not lowered and not too high because the bed could not go all the way up. Staff B stated the bed would have been waist height on him and stated he was 5 feet 6 inches tall. Staff B stated he changed and cleaned Resident #3 while she was in the bed and rolled onto her left side and facing him. Regarding his technique he stated, I always roll the sheet from the other side so I have a draw sheet to pull while they are rolling back into position. I always have them roll toward me and clean from there. Staff B stated, I told her to roll onto her back (after incontinence care was completed) but she went so fast I did not have time to pull the draw sheet and she rolled off the other side of the bed. He stated she rolled off the bed feet and legs first. Staff B stated, From my same spot I held onto her waist then lowered the bed all the way down so her foot was on the floor, and I eased her gently on the floor with her back against the bed with legs outstretched in front of her. Staff B confirmed that Resident #3 was completely on the floor with her bottom seated on the floor, back against the bed, legs out in front of her. Staff B confirmed the resident did not hit her head at any point. Staff B stated, I asked her if she was hurt, she said no, I asked if she wanted me to get anybody and she said no she was fine and then she started making moves to get back into the bed and I assisted her back on the bed sitting on edge of bed. I asked her then if she was hurting and if she wanted me to get anyone. She said she was fine she just wanted to lay down, I helped her to lay down. Staff B confirmed after he assisted Resident #3 back into bed he reported to the nurse (he did not know name of nurse) and stated the nurse asked him if the resident hit the floor and he told her no and explained what happened. Staff B stated the nurse told him she would check on Resident #3. Staff B did not know any details about nursing assessments of the resident after the fall. He stated after he told the nurse, Resident #3 was pressing her call light and said she wanted water, he brought her water and asked if she was hurting and she said she was fine, and he went on to care for other residents. Staff B stated, I went back to check on her around 6:45 a.m. before I left, and she said she was fine. Regarding whether anyone at the facility had asked him about the fall, Staff B stated someone from the facility (NHA interjected that it was the DON) called me that same morning (12/16/2022) and asked me to come in and give a statement, I did and I told her the same thing I just told you. Regarding how a CNA would know how much assistance a resident needed for bed mobility, Staff B stated they've trained me to go in Kardex and if two assist you get another person. Staff B stated, at that time (time of the fall) I was not too sure about how to use the Kardex well because the next day was when I really asked and the DON took me through the process of how to check the computer to know what is needed for the care. Regarding findings when he consulted Kardex for Resident #3, Staff B stated, I think she was supposed to be two assist or something. Staff B stated, She (the DON) explained that since I was new that should not happen again and let me know to make sure to check the Kardex (medical patient information system) and if two assist I should get another CNA to assist. Staff B stated the DON also educated him that if a resident was on the floor he should call the nurse and not get the resident up off the floor until the nurse did an assessment. An interview was conducted on 12/18/2022 at 3:30 p.m. with the NHA and ADON. The ADON stated she interviewed Resident #3 on 12/19/2022 after the findings of the toe fracture had occurred. The ADON stated Resident #3 reported she had fallen out of bed prior (fall on 12/16/2022) and when she fell out of bed she remembered she grabbed the bed frame and maybe that was where she hit her hand, she did not know if she hit her foot. The ADON stated she did not ask the resident for any details on what exactly occurred during the provision of care and the fall. The ADON stated she had interviewed Resident #3's roommate on 12/29/2022 and the roommate reported the aide was doing care and Resident #3 rolled out of the bed and was on the floor in between their beds. The ADON stated she did not ask the roommate for any additional details. The ADON stated she interviewed Staff B, CNA on 12/19/2022 and said, From talking with the CNA I learned that he was doing peri care in the bed alone, she's an assist of one, patient rolled over and kept rolling, he said he was able to lower her to the floor. The ADON stated Staff B told her he immediately reported it to Staff E, RN and Staff E told her she assessed the resident and there was no bruising or swelling. Regarding if the assessment happened while the resident was on the floor the ADON stated she did not know how the resident was returned to bed and did not know if an assessment by a nurse happened while the resident was on the floor. The ADON reviewed the notes and assessments in Resident #3's medical record during the interview and confirmed there was nothing documented in the record by Staff E, rather the documentation there had been completed by Staff C, RN. The NHA stated facility protocol after a fall was not to move a resident until they were assessed. The NHA and ADON could not provide further details and stated the DON had handled things and they would reach out to the DON for additional information. The ADON followed up later and provided documentation of a written statement gathered from Staff B on 12/16/2022 and documentation of in-service provided to Staff B on 12/19/2022 on Always check the Kardex before providing any type of resident care. Remember to properly position the resident during care and after to ensure that all patient safety needs are met. Always notify the nurse before moving the resident if they fall. No additional information was provided. A telephone interview was conducted with Staff C, RN on 12/28/2022 at 5:25 p.m. Regarding Resident #3's fall on 12/16/2022, Staff C stated, I wasn't the nurse assigned to that resident. I was at the nurse's station when the CNA came to tell [Staff E, RN], the resident was sitting at the side of the bed with her feet hanging off the bed and he assisted her feet back in the bed. Both of us walked to her room to make sure she was okay and she was lying on her back in the bed. We spoke to her and asked if everything was okay. She didn't have a fall so we didn't do an assessment. Regarding whether Resident #3 was ever on the floor Staff C stated,No she just had her feet off the bed. Regarding whether Staff C had documented anything about the fall she stated, It wasn't my patient so I don't usually do documentation so I couldn't say yes or no on that one. Staff C stated she had spoken with the ADON and DON about it afterwards because the resident reported, after the event, that she had a fall. Staff C stated, The resident never reported to myself or [Staff E] that she had a fall. I heard that the morning after, the resident reported way in the day maybe 9 or 10 that she had a fall. Regarding facility policy/protocol post-fall Staff C stated, If someone falls the CNA is not to touch the resident, leave in place, get the nurse, the nurse goes in and assesses and if resident is transferable we then transfer back to the bed or the wheelchair, then have to report to DON, MD, POA, do skin assessment, pain assessment, neuro-checks if unwitnessed, have to do thorough fall documentations. Regarding whether she knew about Resident #3's broken toe Staff C stated, I was told she had a broken toe, have no idea where the broken toe came from, I just know as a nurse it was brought to my attention that she had the broken toe and I was to assess her for pain which I have been doing when I care for her. Attempts were made to reach Staff E, RN for telephone interview and she did not respond. Undated facility policy titled Falls and Fall Risk, Managing was reviewed. Policy revealed: Definition According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Undated facility procedure titled Transferring Residents was reviewed. It revealed: As with every ADLs the resident must be transferred according to the plan of care. The nurse makes and assessment on admission and obtains orders for evaluation by the Therapy Department related to safe transfers. The therapy department will determine the transfer status. As with all ADLS, Instructions consist of two parts. This will be noted in the ADL transfer section of the nursing instructions. You must follow the instructions. You can give more help if needed but NEVER less. If you feel the resident does not need as much help, have nurse or therapy reassess. Follow the plan until it is change in writing. Undated facility procedure titled, Assisting Residents with ADLS: All Resident Tasks Consist of 2 Parts was reviewed. It revealed the following definitions: Bed mobility: How the resident moves from a lying to sitting position, sitting to lying position and side to side Toileting: how resident's elimination needs are taken care of such as bringing to toilet, placing a bed pan or urinal, providing incontinent care, colostomy care or foley care. Resident may appear to toilet self but if he/she needs help with cleaning up, straightening out closes or personal hygiene related to the task such as handwashing or wiping, it is considered extensive. Extensive assistance: Resident participates in some way even if minimal .(check to see if 2 staff are required)

Based on interviews with the facility's nursing and administrative staff, a family member, Resident #11's physician, review of clinical records and facility policies and procedures, it was determined that the facility failed to promote the rights for one (#11) of nine sampled residents related to the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Of 109 facility residents, 62 were identified by the facility to have current Full Code orders. The facility failed to honor an Advance Directive order executed by Resident # 11. The facility failed to follow their policy and procedures regarding identification of the end-of-life wishes prior to conducting CPR for Resident #11, who was identified as having Full Code orders and not ensuring that his rights were protected and CPR wishes honored. On [DATE], Resident #11, a [AGE] year-old male, was found to be unresponsive, pupils fixed and dilated, Cheyne-Stokes respiration noted (abnormal pattern of breathing), and absent of pulse. The facility staff failed to validate Resident#11's code status immediately and conducted comfort measures. The facility failed to honor Resident #11's expressed wishes and violated his right to receive treatment. The facility's failure to follow their policies and procedures represented a system wide failure. Failure of the facility staff to correctly implement advance directives resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of a D. Findings included: A review of Resident #11's clinical record revealed a hospital History and Physical (H&P) for a date of admission of [DATE]. The history of present illness documented that the patient was a [AGE] year-old male, who was brought from a nursing home. The reason was for shortness of breath. Oxygen was low, he was alert and oriented, and he had a history of [REDACTED]. The plan was for palliative care recommendations to include care and placement. Hospice reported that they had set up transport to a Long Term Care facility in Lakeland A review of Resident #11's facility admission record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident was admitted directly from Hospice under the services of a hospice/attending physician. The responsible party listed for the resident was his sister/POA (Power of Attorney). The responsible party information was corroborated by a document for General Durable Power of Attorney for Finance, Property and Health Care dated and signed by the resident on [DATE], which indicating authority to the resident's sister. A review of Resident #11's Admission Notification form dated [DATE] revealed multiple [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A review of the resident's admission physician orders dated [DATE] included a signed physician's order for a Full Code dated [DATE]. The initial plan of care/admissions orders and Hospice Certification dated [DATE] also indicated that the resident was a Full Code. A review of the admission MDS (Minimum Data Set) assessment completed on [DATE] revealed the facility attempted to conduct the Brief Interview for Mental Status (BIMS) with Resident #11 but he was unable to recall any information and scored 0 points, indicating severe cognitive impairment. The resident's overall expectation was to remain in the facility (section Q0300A). A review of the Baseline Care Plan and Summary dated [DATE] revealed the resident's discharge plan was to stay long term in the facility with interventions to include provide service to improve abilities and advance directives of full code. A review of the Acknowledgement of Advance Directives Discussion form completed by phone between the POA/sister and the Social Service Director on [DATE] indicated that the resident's wishes were to be provided with Cardiopulmonary Resuscitation. A review of progress notes for Resident #11 from Hospice on [DATE] revealed the patient was seen at the facility where he resided. He was pleasant, exhibits no signs or symptoms of pain. Emotional support provided. A review of the facility nursing notes dated [DATE] for 7:00 A.M. to 3:00 P.M. shift revealed: Resident resting comfortably in bed easily aroused. Vitals signs obtained within normal ranges. No signs or symptoms of distress noted. Medications administered via patent peg tube. Peg tube was flushed with 200 ml of H20 (water), all of which was well tolerated. Will continue to monitor. A review of the nursing progress note dated [DATE] for 7:00 A.M. to 3:00 P.M. was identical to the previous entry of [DATE]. An Interdisciplinary Progress Note, dated [DATE], indicated the following: IDT (interdisciplinary team) met with the resident's family via phone, Hospice was invited to attend, however, did not show up. Resident was in bed resting quietly, no complaints or concerns. Family member was agreeable with current P[NAME] (plan of care.) No additional documentation was present in the record post this IDT note, this includes no record of the resident expiring or any events leading up to the death of the resident. Upon entry to the facility on [DATE] at 9:00 AM, a list of resident discharges was requested and provided. Resident #11 was documented as expired on [DATE]. An interview on [DATE] at 9:24 a.m. with the Nursing Home Administrator (NHA) and Corporate Nurse confirmed that there was no documentation in the clinical record for Resident #11 related to his death. A telephone interview on [DATE] at 10:47 A.M. was conducted with the Assistant Director of Nursing (ADON) via telephone. She provided the following details of the event on [DATE] involving Resident #11: On [DATE], I was in the Unit Manager's office when Staff Member K came in stating that Resident#11 was having trouble breathing. The Unit Manager asked Staff Member K if she had assessed the resident, and Staff Member K told her that his O2 stats were at 35%. The Unit Manager went down with Staff Member K to the resident's room. Staff Member K said, I do not know what to do. Staff Member K had put a breathing treatment on the resident. Staff Member C had stated to Staff Member K that the resident had a lot of mucus and something white coming from his mouth. The Unit Manager told Staff Member K to get the suctioning machine. This occurred after lunch. The lunch trays were passed, and I believe that the trays had been picked up as well. I was waiting in the Unit Manager's office for her to return. It took a while, and I figured that the Unit Manager should have been back in about 5 minutes. I went down to Resident#11's room to see if they needed help. The Unit Manager, the ARNP, and Staff Member C were in the room when I entered. At that time, the Unit Manager was suctioning the patient, and the ARNP was assessing the patient. The ARNP said to call Hospice. The first time I was in the room, Staff Member K was not in the room. Staff Member K had Resident#11's chart. Before I left the room, I asked, What is the code status? Staff Member K said DNR and held the chart against her body. I left the room to get a suction connector. I grabbed a new suction machine from the storage room, which is located outside of the building, in a shed. I brought it into the room. The resident had chain respiration, in and out. Thinking he was a DNR, after bringing up a mucus plug, I told the aides to clean the resident. We are calling Hospice, the physician, and appropriate parties. We thought he had stopped breathing and were just providing comfort measures. I took the suction supplies that I used and threw them out. As I walked out of the room, I told the CNA to clean the resident. The Unit Manager and ARNP left the room before me. I walked passed the Unit Managers office and she was on the phone. I had just sat down and the Unit Manager had the chart and said, He is a full code! I yelled, we will run the code. The Unit Manager ran. I grabbed the crash cart and told Staff Member I to call the code. The ARNP was on the phone with the attending physician when all of this occurred. I said run the code; let the attending physician know he is a full code. I gave the DON the Code Blue documentation nurses note so that she could scribe. The Unit Manager was giving chest compressions, and Staff Member K was at the head of the bed. I had hooked the Ambu bag to the oxygen, and Staff Member K was giving rescue breaths. After Staff Member B got to the room, we couldn't read any vital signs. EMS was with the resident for a while. The attending physician did show up while the Unit Manager was still doing compressions. A second EMS team showed up and they were unable to revive the resident. Staff Member K told the whole team that Resident #11 was a DNR. An interview with the North Side Unit Manager conducted on [DATE] at 9:53 A.M. provided the following information in relation to Resident #11's expiration: On [DATE], I was called by Staff Member K to access Resident #11. I was told his oxygen saturation was at 35% and that he was a DNR (do not resuscitate). This was said in my office, and the DON was present. When I went to assess the resident, he had a breathing treatment running. I told Staff Member K he needed more than an [MEDICATION NAME] treatment, oxygen saturations were low. I told Staff Member K to grab the suction from the crash cart. I suctioned mucus from the resident, removed a mucous plug; his breathing was at 30% after suctioning. I told Staff Member K to go to his chart, call Hospice, and let them know about the change in condition. Staff Member (K) came back from the nursing station with Resident #11's chart. The resident was unstable with a loose pulse. After he was deceased , I told the aides to clean him, and I stepped away. I went back to the nurse's station, pulled his chart, and I was going to call the family. At that time, I noticed he was a Full Code and not a DNR. As I left the nurses' station, I passed my office and told the Assistant Director of Nursing (ADON) that Resident #11 was a Full Code and not a DNR. I began CPR, I believe the DON was scribing while I was doing chest compressions until the paramedics relieved me. Someone called the attending physician while I was doing the chest compressions. The attending physician showed up while the paramedics were here. The paramedics administered different medications (cardio medications). At that time, someone made the paramedics aware that the physician present was the resident's attending physician. The attending physician eventually called the time of death because the resident could not be resuscitated. The Unit Manager was asked if she looked at the resident's chart and she responded, yes. I pulled the chart from the nursing station, saw that he was a Full Code, and saw the orders in front of the chart. The only time I checked the code status was after I had left the resident's room to call next of kin. I began the chest compressions after I saw that the resident was not a DNR but a Full Code. An interview with Staff K, Licensed Practical Nurse (LPN) on [DATE] at 9:12 a.m. revealed she was as a LPN for only a few months at this facility, her regular shift was 7:00 a.m. to 3:00 p.m. She confirmed she was passing out medications on [DATE] between 1:00 p.m. to 1:30 p.m. and went to the nurses' station to start charting. Staff C, Certified Nursing Assistant (CNA) informed her Resident #11 was having breathing problems, and needed suctioning. She took her medication cart to Resident's room, put the blood pressure cuff and pulse ox (oximeter) on the resident, and noted he had labored breathing. She administered his breathing treatment and his oxygen saturation was at thirty-eight percent. She stated, she ran out and called the Unit Manager, Registered Nurse (RN). Staff K then went to get the suctioning machine and gave it to Unit Manager, RN, and Unit Manager started the suctioning on Resident #11 and his breathing was still labored. She stated the Unit Manager called code blue when patient was non-breathing and struggling. She confirmed the Unit Manager asked her to get the chart for Resident #11. Staff K said the resident was a Full Code. Staff K, LPN stated, at some point, he stopped breathing. She believed it was Unit Manager that verified code status. She stated that she did not verify the resident's code status. She said, I knew he was a full code. She confirmed that she brought the chart to verify next of kin and did not bring the chart to verify code status. She stated that she provider her (Unit Manager) the next of kin's name. Unit Manager told Staff K to call Hospice. She called Hospice at 1:30 p.m. She stated that when she went back to the resident's room the Unit Manager had started chest compressions, and then she (Staff K) did the Ambu bag breathing until EMS (Emergency Services) arrived. She confirmed the Unit Manager called the family. She said, I believe I did the documentation in the medical record. She (Staff K) confirmed that she called Hospice before compressions had started and informed them that their patient (Resident #11) had gone into respiratory distress. She confirmed that compressions continued until EMS arrived. She could not recall an exact timeline of events. This surveyor asked Staff K if she looked at the chart. She stated that she honestly did not know who pulled the wrong chart. Staff K confirmed the Director of Nursing (DON) her that she (Staff K) pulled the wrong chart and gave it to the Unit Manager. She stated the DON said that she gave the Unit Manager Resident #20's chart not Resident #11's chart. Staff K said, I told her that I did not. A telephone interview conducted on [DATE] at 9:07 A.M. with the attending physician's ARNP related to Resident #11's expiration on [DATE] revealed the following details: I only had seen the resident one time prior to the event of [DATE]. What I do remember was that he had [MEDICAL CONDITION], history of dysphagia, he had a PEG tube, and he was treated for [REDACTED]. I do not have my notes in front of me, but that was what I can remember in regards to his condition prior to the event of [DATE]. I was at the facility on [DATE]. I was just coming down the hall when the Unit Manager told me that a patient was under respiratory distress and requested I go in and see him real quick. Because she said he was in respiratory distress, I rushed to the room to see what was going on. When I got to the room the patient, (Resident #11) had just been given a breathing treatment. I went to assess him and the patient was cyanotic at that point, having Cheynes-stokes. He was in respiratory distress from what I saw. As I continued to assess, the Unit Manager was suctioning him at the bedside. I got report from both the Unit Manager and Staff Member K. I was under the impression that the patient was a Hospice patient, DNR, and that we were just doing comfort measures. At that point, I just proceeded to treat his symptoms, he was cyanotic. The Unit Manager had suctioned the patient and pulled out a huge mucus plug. I had the tube feed on hold, listened to his lung sounds, and pretty much just performed an assessment. The Unit Manager was the person who informed me that the patient was a DNR. It was the ARNP's understanding at that time that it was comfort measures only. That was the plan. I was just there to treat the symptoms and to make sure the patient was comfortable. I verified who the attending physician was based on the Hospice Company the patient was under. Just like anytime with any of this physician's patients, if anything was abnormal, I always call him to give him a quick report. We consult one another and then we go from there. I told the staff to call Hospice; and I spoke with the physician regarding the situation. After we suctioned him, his oxygen saturation didn't seem to come up. At that point we really couldn't get a blood pressure, his pulse was very, very, faint, he was still having the same type of breathing .sputum coming up. I noticed he might be imminent so I just made sure the facility followed proper protocol by calling the doctor, which I had, and they called Hospice. After that, I pretty much just continued with my rounds at that point. I know that the Unit Manager went to call the daughter. Apparently, based on the information that I received after the fact, the conversation the Unit Manager had with the daughter and the kind of questioning from the daughter made her question the resident's code status. It was that point the Unit Manager went and looked for the code status in the chart. While I was with a patient, I noticed that they called a code. I was not sure what was going on. After seeing my patient, I saw that they were back in Resident #11's room doing a full code on him. I called the attending physician and said There must be some confusion; they are running a full code right now on the patient. I asked a staff member that was on the floor, what was going on and they told me that the patient was actually a full code. The attending physician arrived while they were doing the code, probably after 2:00 PM. I am not sure. Everyone was under the impression, including myself, that he was a Hospice patient, DNR, comfort measures only. After he passed, the Unit Manager went to check the chart. She noticed that he was not a DNR but a Full Code, then they called the code. That is exactly what happened. After everything had happened, the daughter had arrived at the facility and the attending physician introduced me to them, but I didn't speak to them. Hospice had spoken to them and the daughter had spoken to the DON or ADON at that time so I really didn't have a conversation with her. The ARNP indicated that the facility did not follow proper protocol of confirming code status prior to withholding CPR. An interview on [DATE] at 2:32 PM with Resident #11's attending physician revealed he was also the Hospice physician. Resident #11's physician provided the following information: Resident #11 was my patient prior to coming to the facility while in Hospice. I actually had him transferred to this facility so that his family could be closer to him since they resided in the Tampa area. Resident #11 had a primary [DIAGNOSES REDACTED]. I was not in the building when this incident occurred. I was called by my Advanced Registered Nurse Practitioner (ARNP) because she was concerned over all the commotion surrounding the event. I was told by my ARNP that everyone in the room thought the resident was a DNR; everyone was saying he was a DNR. Initially they did not start CPR in a timely manner. They did not start CPR when they should have. They should have immediately started CPR; there was a delay in starting CPR. They should have started the CPR at the moment that he was expiring. The time delay was from the time he expired to the time the Unit Manager went to the front desk, looked at the resident's chart and noticed no DNR, and then they started CPR. No one had laid eyes on any actual DNR paper. Certified Nursing Assistants (CNA's) had begun cleaning the resident when the Unit Manager finally looked at the chart. It was about ,[DATE] minutes, it was not until then that the chest compressions were started. I know Staff Member K, the Unit Manager, the DON, and my ARNP were in the room. When I spoke with my ARNP, she told me that multiple times it was said, He is a DNR. When the Unit Manager found out the resident was not a DNR then CPR started. I do not understand why there was a lapse and why didn't they check the resident's chart beforehand? I know from what my ARNP told me that Staff Member K had the chart in the room and had said DNR. Everyone in the room said he was a DNR. They need to realize just because you are a Hospice patient, it does not mean that you are automatically a DNR. The Unit Manager informed me that the resident was not a DNR after the fact. The family was in on that day. Myself along with the DON, the Unit Manager, the Social Worker from Hospice, and my ARNP met with them. I did not inform them that there had been a delay in CPR. It was my understanding that the staff here provided that information. The Nursing Home Administrator, DON and the Unit Manager had informed the family of the delay in CPR. The resident was so weak that he most likely would have been transported to the hospital and intubated. An interview was held with Staff Member B, Registered Nurse on [DATE] at 2:20 P.M. She provided the following details related to Resident #11's event: I was in my office when they called a code to Resident #11's room. I grabbed the code cart, and I went running down the hall. When I went in to Resident#11's room, I saw the Unit Manager doing chest compressions. Staff Member K had the Ambu bag, and the code cart was inside the room. The ADON was giving orders to make copies of the chart, somebody was calling EMS, and someone was outside of the room doing something with a suctioning machine. I went to the side of the bed to see if the Unit Manager or Staff K needed relief. They said they were doing fine. The Fire Department came in and placed the leads. Compressions were stopped while the leads were being placed. After the leads were on Resident #11 the Fire Department told the Unit Manager to continue with compressions and an IV line was put in place. When EMS came in, I stepped out of the room. A telephone interview conducted with Staff Member D, C.N.A., on [DATE] at 4:43 P.M. revealed the following information related to Resident #11 expiring on [DATE]: She had not worked on Resident#11 before; I had just come off my break when all the commotion had started. I knew that he was having breathing problems and was on oxygen (O2). I was told to call 911. The Unit Manager told Staff Member I, C.N.A, and myself to clean him up, and wipe him down before she left the room. He had already stopped breathing and been pronounced. The ADON and the Unit Manager left the room. Shortly thereafter was when they reported the code. I did not think you could start CPR after someone was pronounced, but they did. I did not see anything afterwards because they closed the door after they started the code. On [DATE] at 2:32 PM, Staff Member I, C.N.A., provided the following details related to the event involving Resident #11: On the day of the incident, Staff Member D came to get me to help her clean the resident. A whole wipe down, change briefs, change gown and change the bed sheets. He had already expired when I cleaned him. A lot of commotion happened afterwards, I left the room. The ADON, who was in the office with the Unit Manager, told me to call Code Blue. When I called the Code Blue, I said the room number then Code Blue, three times on the overhead. That is when everyone rushed into the room. I saw EMS come in. A telephone interview with Resident #11's sister/POA on [DATE] at 9:49 A.M. revealed that she had just visited her brother an hour prior to his passing. She attended a care plan meeting at 1:00 P.M and visited with her brother. He appeared just fine. She had not made it back to Tampa when she received a telephone call from the Unit Manager stating that my brother had passed suddenly. I asked if he responded to CPR and she abruptly said she had to hang up. I went back to the facility at about 3:00 PM and saw that he was being taken out of the facility. I met with the Hospice team who provided emotional support. I did not speak with the NHA or the DON. An interview on [DATE] at 10:34 a.m. with the DON revealed she was in the Administrator's office when she heard a code blue paged with Residents #11's room number. She went into Resident #11's room. She confirmed CPR was being performed by Unit Manager and was unable to confirm if Staff K was assisting. She confirmed the ADON and Staff B, RN were present and both crash carts were in the Resident's room. She confirmed that she said, Did someone call 911, the physician and family? She stated that someone said yes and she did not know who answered because there were so many people in the room. She asked for the chart, someone gave me the chart and then she looked and saw he was a full code. She stated that she verified that he was a full code once she got the chart. She scribed the vital signs, that were being yelled out and at the time, EMS arrived. She observed EMS arrived approximately 2:06 p.m. Unit Manager continued with CPR until relieved by EMS. A second crew of EMS came; they hung IVs and put a line in him. She left the room and confirmed Attending Physician went into the resident room. She stated the Unit Manager told her that Staff K brought her the wrong chart. The DON said, I said what do you mean she brought the wrong chart? She stated Unit Manager reported, The chart that they brought me said DNR. Unit Manager told her she called a full code after she looked at the chart. The DON looked at the chart after CPR was started which is the time she came into the room. She did not see a DNR order. The DON was asked to provide the Code Blue Documentation Nurses Note used to scribe for the full code initiated on Resident #11. The DON reported that she could not find the Code Blue documentation. She was asked if she had documented evidence of the time the Code Blue was called, when CPR was started, when resuscitation was terminated, the names of the team members that were present during the code and the times that notification was provided to the required parties. The DON confirmed that she did not have the Code Blue Documentation where this information should have been documented. The DON reported she and the Nursing Home Administrator (NHA) had obtained statements from everyone involved and the Unit Manager said Staff K had brought the wrong chart. Staff K denied that she had brought the wrong chart. The DON confirmed she did not request a statement or interview from the ARNP. The DON reported that she did not speak with the family. She confirmed a timeline was created and it was determined that there were approximately 2 minutes from the time staff member (Staff K) said that Resident #11 was a DNR and the full code was called. Unit Manager looked at the wrong chart that was brought to her, which had a DNR goldenrod. The DON confirmed that the Unit Manager did not look at Resident #11's chart until the resident stopped breathing. The Unit Manager realized it was a wrong chart when she looked at the name on the chart. This is when she looked at the correct chart and called the code. The investigation reflected Staff K told the Unit Manager that Resident #11 was having trouble breathing. The Unit Manager went to the resident's room and said he needed suctioning at 1:50 p.m. Unit Manager and Staff K suctioned him, the ADON was there as well. Unit Manager left the room when out to the nurses' station with a resident clinical record. She realized it was the wrong chart, got the right chart and called the full code. On [DATE] at 9:18 A.M., the NHA and Corporate Nurse were asked to review Resident #11's medical record along with the surveyor. They confirmed that the medical record did not contain any record of notification to Resident #11's family or hospice, there was no physician order to release the body and there was no nursing documentation of the events that surrounded Resident #11's expiration. On [DATE] at 9:24 PM, the NHA and Corporate Nurse indicated that the expectation was to document in the medical record any situation that occurred with a resident. On [DATE] at 9:36 A.M., the Nursing Home Administrator (NHA), in the presence of the Corporate Nurse, recalled hearing the Code called on [DATE]. The response was quick, and the ARNP was on-site and oversaw the Code. The Unit Manager suctioned the patient, and the patient became unresponsive at 1:53 P.M. The chart was checked, and CPR was initiated at 1:55 PM. The Unit Manager performed CPR for about ,[DATE] minutes, according to her statement. She stated, she never stopped CPR, and 911 called it. I will have to check the soft record for the correct timeline for times; EMS arrived while the Unit Manager was giving compressions. Paramedics took over and initiated Advanced Cardiac Life Support (ACLS). The ARNP called the attending physician who came on-site. The attending physician called the time of death at 2:41 P.M. on [DATE]. I did not speak with the family. I believe my staff spoke to the family. A review of the facility policy and procedure for Advanced Directives-Admissions/Social Services with a date of (MONTH) 30, 2014 revealed: Policy: The Facility Social Service Staff will abide by the resident advance directives, if known. Procedure: Social Services (and/or admissions staff) must be fully informed of Federal and Individual States' laws and regulations regarding advance directives. Facility is responsible for maintaining a copy of state specific regulations on file in the facility. Upon admission, Social Services must communicate residents, family members or responsible parties of: a) Their right to make choices concerning health care and treatments, including self-sustaining treatments b) Determine whether the resident has advanced directive and, if not, determine whether the resident wishes to establish an advance directive, c) Define and clarify medical issues and present the information regarding relevant healthcare issues to the resident or his/her legal representative d) Identify and assess medical issues where life-sustaining treatments are potential options and implement choices related to health care decisions Social services and or Admissions staff must complete advanced directive discussion document (CNS-036), which must be part of the resident's file confirming the parties were appropriately informed and an advanced directive, if one exists, was obtained or was identified as to its location. It is important to note that it is not to be construed that an advanced directive is required. An advanced directive is the choice of the resident. a) Indicate the resident's wishes to provide or withhold CPR. b) Check for possession of document as indicated. c) Fill in type of document and location of document if they are not available. d) Indicate names of persons to act as a primary decision-maker, with position held and phone number. e) Obtain signature from resident/responsible party and facility representative. f) Document discussion. Upon completion of Advanced Directives Discussion Document, Social Services will notify Nursing who will notify the Physician of the resident's wishes. Notification will be documented in the resident's clinical record. Nursing may refer to policy SS-123 Advanced Directives- Nursing. A review of the facility policy and procedure titled Advance Directives- Nursing with an effective date of [DATE] revealed: Policy: The facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Procedure: Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social services will provide these for the clinical record. Nursing staff must use a means of identification for those residents who have a DNR in the medical records through advance directives and written orders from the attending physician. Nursing staff must be aware of other advance directives regarding residents' wishes before certain treatments are initiated. Follow these steps

Based on resident clinical record review, staff interviews, family interview, physician interview, and review of facility's policies and procedures, it was determined that the facility personnel failed to immediately provide emergency basic life support for Resident #11 upon [MEDICAL CONDITION] in accordance with Resident's Advance Directives and a physician's order. Furthermore, the facility failed to ensure that services being provided met the professional standards of quality relating to the initiation of Cardiopulmonary Resuscitation (CPR), and failed to follow the facility's policies and procedures relating to CPR and the resident's documented wish for CPR for one (#11) of nine sampled residents, of 62 total residents identified as having Full Code orders. On [DATE], Resident #11, a [AGE] year-old male, was assessed to be in respiratory distress. The facility staff failed to confirm Resident #11's accurate code status and initiated comfort measures without validating Resident #11's code status. The resident admitted to the facility with a signed physician's order that indicated Full Code status. The facility failed to follow their policies and procedures related to Cardiopulmonary Resuscitation (CPR) and Advance Directives - Nursing. The facility's failure to provide immediate CPR for Resident #11 represented a system wide failure. This failure resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of a D. Findings included: A review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR), effective date of [DATE], Document Name: N-302, Revision Date: [DATE], revealed: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a physician's order for a DNR. Procedure: In the event of [MEDICAL CONDITION], immediately call for assistance. Two staff members are to verify the current order for code status. Using the paging system and call Code Blue to room number_, three times (or location of event). In the absence of a physician's order for DNR the facility will immediately begin CPR. CPR is continued until life support systems are available, or it may be discontinued if: The resident responds. The physician orders CPR to be discontinued Notify the physician and resident representative/legal representative Document in the medical record. The forms included with the policy and procedure were the, The Code Blue Documentation Nurses Note Page 1 of 1, effective date of ,[DATE] N-305 Attachment A - Emergency Procedures - Code Blue Documentation Form, and Code Blue Quality Assurance Drill form. A review of the facility policy and procedure titled Advance Directives- Nursing with an effective date of [DATE] revealed: Policy: The facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Procedure: Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social services will provide these for the clinical record. Nursing staff must use a means of identification for those residents who have a DNR in the medical records through advance directives and written orders from the attending physician. Nursing staff must be aware of other advance directives regarding residents' wishes before certain treatments are initiated. Follow these steps in an emergency situation: a. If a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered. b. If there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately. Page Code Blue to summon anyone in the facility who has been certified to administer CPR. At the same time, call emergency paramedic support. The attending physician also must be notified. c. If a DNR order has been entered (and this has also been verified by checking the resident's chart), CPR will not been administered. All normal comfort measures will be administered and the attending physician must be called. Assure physician's order are in correct format. a. No action regarding withholding of life support measures will be implemented prior to the entry of an appropriate written order by the attending physician in the resident's medical record (unless emergency DNR/CPR orders are activated). This order will be entered on the resident's chart. b. Orders must be specific, i.e. Do not resuscitate or Do not initiate respirators, etc. c. No order will be entered until consent of the resident or appropriate substitute decision-maker(s) has been obtained, preferably in writing after discussion with the attending physician. d. If the order required withholding life support measures such as respirations, or IV or tube feeding, the order is in accordance with his best medical judgement, that the resident is in a terminal condition and that he has considered the resident's wishes as expressed by the resident or through the appropriate substitute decision-maker(s) or the resident's next of kin. e. Staff must also notify the attending physician and the Administrator if a resident verbally expresses a desire to change or revoke his/her advance directives. In the event there is clear written documentation on an Advanced Directive form by the resident that they do not wish CPR performed and the physician is not immediately available to write the DNR order, the following will occur: a. Two licensed personnel may take a telephone order from the physician. b. Both licensed personnel will sign and note the order according to the Do Not Resuscitate policy. c. The physician must co-sign the order. A review of Resident #11's clinical record revealed an admission date of [DATE]. The resident admitted directly from a Hospice in Jacksonville under the services of Attending Physician. A review of Resident #11's Admission Notification form dated [DATE] revealed multiple [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. The Admission MDS (minimum data set assessment) completed on [DATE] revealed the resident scored a 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's overall expectation was to remain in the facility (section Q0300A). The clinical record indicated the responsible party for Resident #11 was his POA (power of attorney)/Sister. The General Durable Power of Attorney for Finance, Property and Health Care agreement was dated and signed by Resident #11 on [DATE] and filed in the clinical record indicating authority to the resident's sister. Further review of the clinical record revealed an Acknowledgement of Advance Directives Discussion form completed by phone between the POA/Sister and the Social Service Director on [DATE]. The form indicated that the resident's wish was to be provided with CPR. A review of the resident's clinical record included a signed physician's order for a Full Code dated [DATE]. The initial plan of care, and Hospice Certification dated [DATE] indicated that Resident #11 was a Full Code. A review of the Baseline Care Plan and Summary dated [DATE] revealed the resident's discharge plan was to stay long term in the facility with interventions to include provide service to improve abilities and advance directives of full code. An interview with Staff K, Licensed Practical Nurse (LPN) on [DATE] at 9:12 a.m. revealed she was as a LPN for only a few months at this facility, her regular shift was 7:00 a.m. to 3:00 p.m. She confirmed she was passing out medications on [DATE] between 1:00 p.m. to 1:30 p.m. and went to the nurses' station to start charting. Staff C, Certified Nursing Assistant (CNA) informed her Resident #11 was having breathing problems, and needed suctioning. She took her medication cart to Resident's room, put the blood pressure cuff and pulse ox (oximeter) on the resident, and noted he had labored breathing. She administered his breathing treatment and his oxygen saturation was at thirty-eight percent. She stated, she ran out and called the Unit Manager, Registered Nurse (RN). Staff K then went to get the suctioning machine and gave it to the Unit Manager, RN, and the Unit Manager started the suctioning on Resident #11 and his breathing was still labored. She stated the Unit Manager called Code Blue when patient was non-breathing and struggling. She confirmed the Unit Manager asked her to get the chart for Resident #11. Staff K said the resident was a Full Code. Staff K, LPN stated, at some point, he stopped breathing. She believed it was Unit Manager that verified code status. She stated that she did not verify the resident's code status. She said, I knew he was a full code. She confirmed that she brought the chart to verify next of kin and did not bring the chart to verify code status. She stated that she provided her (Unit Manager) the next of kin's name. The Unit Manager told Staff K to call Hospice. She called Hospice at 1:30 p.m. She stated that when she went back to the resident's room the Unit Manager had started chest compressions, and then she (Staff K) did the Ambu bag breathing until EMS (Emergency Services) arrived. She confirmed the Unit Manager called the family. She said, I believe I did the documentation in the medical record. She (Staff K) confirmed that she called Hospice before compressions had started and informed them that their patient (Resident #11) had gone into respiratory distress. She confirmed that compressions continued until EMS arrived. She could not recall an exact timeline of events. The surveyor asked Staff K if she looked at the chart. She stated that she honestly did not know who pulled the wrong chart. Staff K confirmed the Director of Nursing (DON) her that she (Staff K) pulled the wrong chart and gave it to the Unit Manager. She stated the DON said that she gave the Unit Manager Resident #20's chart, not Resident #11's chart. Staff K said, I told her that I did not. An interview with the Unit Manager, RN on [DATE] at 9:53 a.m. revealed on [DATE], Staff K, LPN called her to assess Resident #11. She (Staff K) told her (Unit Manager) Resident #11's oxygen saturation was at 35% and that he was a DNR. She was provided this information in her office with DON present. She stated when she went to assess Resident #11, he had a breathing treatment running. She told Staff K he needed more than [MEDICATION NAME] treatment and the oxygen saturations were low. She told Staff K to grab the suction from the crash cart. She (Unit Manager) suctioned mucus from the resident and removed a mucous plug. She stated Resident #11's breathing was at 30% after suctioning. She then told Staff K to go to his chart and call Hospice, to let them know about the change in condition for the resident. Staff K came back from the nurses' station with Resident #11's chart and the resident was unstable with a loose pulse. Unit Manager, RN confirmed that after Resident #11 was deceased , she told the aides to clean him and she stepped away. She went back to the nurses' station and pulled his chart. She was going to call the family, at that time. She stated that she noticed Resident #11 was a Full Code and not a DNR. She stated she left the nurses' station, passed her office and told the Assistant Director of Nursing (ADON) that Resident #11 was a Full Code and not a DNR. She confirmed she began CPR. She stated that she believed the DON was scribing while she was doing chest compressions until the paramedics relieved her. She knew someone called the Attending Physician, while she was doing the chest compressions. She confirmed the Attending Physician showed up while the paramedics were there and the paramedics administered different cardio medications. She stated, at that time, someone made the paramedics aware Attending Physician was the resident's primary physician. She confirmed the Attending Physician, called time of death because the resident could not be resuscitated. The Unit Manager confirmed she looked at the chart and stated Yes, she pulled the chart from the nurses' station and saw Resident #11 was a Full Code. She saw the physician's order that reflected Full Code status in front of the clinical chart for Resident #11. She confirmed the only time she checked the code status was after she had left the resident's room to call his next of kin. She stated she began the chest compressions after she saw that the resident was not a DNR but a Full Code. Review of the Hospice progress notes for Resident #11 provided the notations of his condition on [DATE], prior to being found in [MEDICAL CONDITION], Patient seen at the facility where he resides. He is pleasant, exhibits no signs or symptoms of pain. Emotional support provided. A review of the Nursing notes dated [DATE] for 7:00 a.m. to 3:00 p.m. reflected, Resident resting comfortably in bed easily aroused. Vitals signs obtained within normal ranges. No signs or symptoms of distress noted. Medications administered via patient peg tube. Peg tube was flushed with 200 ml (milliliters) of H20 (water), all of which was well tolerated. Will continue to monitor. A review of the Nursing progress note dated [DATE] for 7:00 a.m. -3:00 p.m. shift was identical to the previous entry on [DATE]. An Interdisciplinary progress note, dated [DATE], indicated the following, IDT (interdisciplinary team) met with the resident's family via phone, Hospice was invited to attend, however, did not show up. Resident is in bed resting quietly, no complaints or concerns. Family member is agreeable with current P[NAME] (plan of care). The clinical record was silent in regards to the event related to Resident #11's respiratory distress and circumstances surrounding the death event on [DATE]. A telephone interview conducted with Staff D, CNA on [DATE] at 4:43 p.m. revealed she had not worked with Resident #11 before [DATE]. She stated that she had just come off her break when all the commotion had started. She knew that Resident #11 was having breathing problems and was on O2 (oxygen). She stated she was told to call 911. Unit Manager, RN told Staff I, CNA and Staff D to clean Resident #11 up, and wipe him down before she (Unit Manager) left the room. Staff D confirmed Resident #11 stopped breathing and had been pronounced dead. She stated the ADON and Unit Manager left the room and shortly after they left, was when a code was called. She said, I did not think you could start CPR after someone was pronounced, but they did. She confirmed she did not see anything afterwards because the door was closed after they started the code. On [DATE] at 2:32 p.m. and interview with Staff I, CNA revealed on [DATE] that Staff D, CNA came to get her to help clean Resident #11. They were to do a whole wipe down, change the briefs, and change the gown and bed sheets. She confirmed Resident #11 had already expired when she cleaned him on [DATE]. She confirmed there was a lot of commotion afterwards and she left the room. She stated the ADON, who was in the office with Unit Manager, told her to call Code Blue. She stated when she called the Code Blue, she said the room number, then Code Blue three times on the overhead. At that point, everyone rushed into the resident's room and EMS (Emergency Services) personnel entered the room. An interview on [DATE] at 2:20 p.m. with Staff B, RN revealed she was in her office when a code was called for room [ROOM NUMBER]. She stated she grabbed the code cart, and ran down the hall towards the room. She stated she went into Resident #11's room and saw Unit Manager doing chest compressions. Staff K had the Ambu bag and the code cart was inside the room. The ADON was giving orders to make copies of chart, somebody was calling EMS, and someone was outside of the room doing something with a suctioning machine. Staff B stated she went to the side of the bed to see if Unit Manager and K needed relief and they said they were doing fine. The Fire Department came in and placed the leads, compressions stopped while the leads were placed, and after the leads were on Resident #11, the Fire Department told Unit Manager to continue with compressions, IV (intravenous) line went in. EMS came in and Staff B confirmed she stepped out of the room. A telephone interview on [DATE] 10:47 a.m. was conducted with the Assistant Director of Nursing (ADON) via telephone. She stated on [DATE] she was in the Unit Manager's office when Staff K came into her office and said Resident #11 was having trouble breathing. Unit Manager asked Staff K if she had assessed Resident #11. Staff K told her that his 02 stats (statistics) were at 35%. Unit Manager accompanied Staff K to the resident's room. Staff K said, I do not know what to do! Staff K had put a breathing treatment on him. Staff C, CNA told Staff K that Resident #11 had a lot of mucus and something white was coming from his mouth. Unit Manager told Staff K to get the suctioning machine. The ADON confirmed this occurred after lunch trays were passed and picked up. The ADON waited in the Unit Manager's office for her to return. It took longer than 5 minutes so she went down to Resident#11's room to see if they needed help. Unit Manager the ARNP and Staff C were in the room when she entered the room. At that time Unit Manager was suctioning the patient, the ARNP was assessing the resident and told staff to call Hospice. The ADON confirmed at first Staff K was not in the room. Staff K entered the room and had Resident #11's chart. The ADON said, Before I left the room I said, what is the code status. The ADON stated Staff K said DNR and was holding the chart against her body. The ADON left the room to get a suction connector. The ADON grabbed a new suction machine from the storage room, which was located outside of the building, in a shed. The ADON brought it into the room. She confirmed that Resident #11 had chain respiration, in and out. She confirmed she thought he was a DNR, after bringing up a mucous plug. She stated she told the aides to clean the resident and facility staff was calling Hospice, the physician and appropriate parties. She stated the team thought Resident #11 had stopped breathing, and were just providing comfort measures. She took the suction supplies that she used and threw them out as she walked out of the room. She confirmed that she told the CNA to clean the resident. Unit Manager and ARNP left the room before her. She stated she walked passed the Unit Manager's office and she was on the phone. The ADON said that she had just sat down and Unit Manager had Resident #11's chart and said, He is a full code! The ADON said, We will run the code. The Unit Manager ran to Resident's room. The ADON grabbed the crash cart. The ADON stated she told Staff I to call the code. She confirmed the ARNP (Advanced Registered Nurse Practitioner) was on the phone with the Attending Physician when all of that occurred. ADON asked ARNP to let Attending Physician know he is a full code. She gave the DON the Code Blue Documentation Nurses Note so that she could scribe. The ADON confirmed that Unit Manager was giving chest compressions, Staff K was at the head of the bed, the ADON had hooked the Ambu bag to the oxygen, and Staff K gave rescue breaths. She stated that after Staff B, RN entered the room; they could not read any vital signs. EMS worked on Resident #11 for a while. The attending physician arrived, while Unit Manager was still doing compressions. A second EMS team showed up at that time and they were unable to revive Resident #11. The ADON stated that Staff K told the whole team that Resident #11 was a DNR. An interview on [DATE] at 10:34 a.m. with the DON revealed she was in the Administrator's office when she heard a Code Blue paged with Residents #11's room number. She went into Resident #11's room. She confirmed CPR was being performed by the Unit Manager and was unable to confirm if Staff K was assisting. She confirmed the ADON and Staff B, RN were present and both crash carts were in the Resident's room. She confirmed that she said, Did someone call 911, the physician and family? She stated that someone said yes and she did not know who answered because there were so many people in the room. She asked for the chart, someone gave me the chart and then she looked and saw he was a full code. She stated that she verified that he was a full code once she got the chart. She scribed the vital signs, that were being yelled out and at the time, EMS arrived. She observed EMS arrived approximately 2:06 p.m. Unit Manager continued with CPR until relieved by EMS. A second crew of EMS came; they hung IVs and put a line in him. She left the room and confirmed Attending Physician went into the resident room. She stated the Unit Manager told her that Staff K brought her the wrong chart. The DON said, I said what do you mean, she brought the wrong chart? She stated Unit Manager reported, The chart that they brought me said DNR. Unit Manager told her she called a full code after she looked at the chart. The DON looked at the chart after CPR was started which is the time she came into the room. She did not see a DNR order. The DON was asked to provide the Code Blue Documentation Nurses Note used to scribe for the full code initiated on Resident #11. The DON reported that she could not find the Code Blue documentation. She was asked if she had documented evidence of the time the Code Blue was called, when CPR was started, when resuscitation was terminated, the names of the team members that were present during the code and the times that notification was provided to the required parties. The DON confirmed that she did not have the Code Blue Documentation where this information should have been documented. The DON reported she and the Nursing Home Administrator (NHA) had obtained statements from everyone involved and the Unit Manager said Staff K had brought the wrong chart. Staff K denied that she had brought the wrong chart. The DON confirmed she did not request a statement or interview from the ARNP. The DON reported that she did not speak with the family. She confirmed a timeline was created and it was determined that there were approximately 2 minutes from the time staff member (Staff K) said that Resident #11 was a DNR and the full code was called. The Unit Manager looked at the wrong chart that was brought to her, which had a DNR goldenrod. The DON confirmed that the Unit Manager did not look at Resident #11's chart until the resident stopped breathing. The Unit Manager realized it was a wrong chart when she looked at the name on the chart. This is when she looked at the correct chart and called the code. The investigation reflected Staff K told the Unit Manager that Resident #11 was having trouble breathing. Unit Manager went to the resident's room and said he needed suctioning at 1:50 p.m. the Unit Manager and Staff K suctioned him, the ADON was there as well. The Unit Manager left the room when out to the nurses' station with a resident clinical record. She realized it was the wrong chart, got the right chart and called the full code. A telephone interview conducted on [DATE] at 9:07 a.m. with Staff O, ARNP revealed she had seen Resident #11 one time before prior to the event of [DATE]. She stated she remembered the condition of the resident prior to [DATE] was that he had [MEDICAL CONDITION], history of dysphagia, he had a feeding tube, and he was treated for [REDACTED]. She confirmed she was at the facility on [DATE]. She stated she was coming down the hall and had just seen a patient when the Unit Manager told her that Attending Physician's patient was under respiratory distress. She requested that she go in and see him (Resident #11) real quick because he was in respiratory distress. She said she rushed to the room to see what was going on and when she arrived Resident#11, had just been given a breathing treatment. She then assessed Resident #11 and determined he was cyanotic at that point, having Cheynes-stokes respiration noted (abnormal pattern of breathing). She confirmed he was in respiratory distress. She stated at that point, she continued to assess and Unit Manager was suctioning at bedside. She received report from both, Unit Manager, RN and Staff K, LPN. She stated that based on the report that was given to her, she was under the impression that the patient was a Hospice patient, had a DNR and that they were doing comfort measures only. She stated, at that point, she proceeded to treat his symptoms, as he was cyanotic. Unit Manager had suctioned the resident and pulled out a large mucus plug and she (ARNP) put the tube feed on hold, listened to his lung sounds, continued the assessment. The ARNP confirmed Unit Manager was the person who informed her Resident #11 was a DNR. She confirmed the plan was to provide comfort measures only. She stated that she was just there to treat the symptoms and to make sure the patient was comfortable. She asked them (facility staff) what Hospice company the resident was under, and was told name of the Hospice company. She knew Attending Physician was with that Hospice and if anything was going abnormal with one of his patients, she always called Attending Physician to give him a quick report. She confirmed they (attending physician and ARNP) consult one another and that she contacted Attending Physician about the situation. She told the facility staff to call Hospice. She confirmed after Resident #11 received suction that his oxygen saturation did not come up, they were unable to get a blood pressure and his pulse was very, very faint. She stated Resident #11 continued to have the same type of breathing with sputum coming up. At that point, she noticed Resident #11 was imminent and made sure the facility followed proper protocol. She called the doctor and the facility called Hospice. She continued her rounds. She knew Unit Manager went to call the daughter. The ARNP was made aware following the respiratory distress event on [DATE] that the questioning from the daughter previewed Unit Manager to look at the resident's code status. She went and looked for the code status in the chart at that point. She stated while she continued her rounds she noticed that they (facility staff) called a code. She saw they (facility staff) were in the room that she had just been in with Resident#11. She confirmed that at that point they were doing a full code on him. She said she called Attending Physician and said, There must be some confusion. They are running a full code right now on the patient. She confirmed she was under the impression that Resident #11 was a DNR. ARNP asked a staff member on the floor, what was going on and ARNP said, They told me that the patient was actually a full code. She confirmed Attending Physician arrived after 2:00 p.m. while they were performing the Code Blue. She stated that everyone including herself was under the impression Resident #11 was a Hospice patient, DNR, comfort measures only. She stated that after Resident #11 passed the Unit Manager checked the chart and noticed he was not a DNR but a full code. The facility then called the code. She said, That is exactly what happened. She confirmed following the passing of Resident #11 the daughter arrived and Attending Physician, introduced her to the family, and Hospice, the DON or ADON met with the family. The ARNP said, No, when asked if she thought the facility followed the appropriate protocol to confirm code status before attempting anything. An interview with Attending Physician on [DATE] at 2:32 p.m., confirmed he was Resident #11's primary physician and the Hospice physician. He confirmed Resident #11 was his patient while in the Hospice in Jacksonville; he had him transferred to this facility, so that his family could be closer to him because they reside in the Tampa area. He confirmed Resident #11's admission [DIAGNOSES REDACTED]. Further review of the clinical record revealed a hospital History and Physical (H&P) for a date of admission at a hospital in Jacksonville was dated [DATE]. The history of present illness documented that the resident was brought from a nursing home. The reason was for shortness of breath, oxygen was low, he was alert and oriented, and he had a history of [REDACTED]. The plan was for palliative care recommendations to include care and placement. Hospice reported that they had set up transport to a Long Term Care facility in Lakeland. The Attending Physician stated he was not in the building when the respiratory distress event occurred. He confirmed that he was called by his ARNP because she (ARNP) was concerned over the commotion surrounding the event. The Attending Physician stated the ARNP reported that everyone in the room thought Resident #11 was a DNR, and everyone was saying he was a DNR. He stated, initially they (the facility staff) did not start CPR in a timely manner. He stated they did not start CPR when they should have. He said, They should have immediately started CPR, there was a delay in starting CPR. They should have started CPR at the moment that he was expiring. He confirmed the time delay was from the time Resident #11 expired to the time the facility staff member (Unit Manager) went to the front desk, looked at Resident #11's chart and noticed no DNR was in place. Then the facility staff started CPR. He stated that no one had laid eyes on an actual DNR paper. He confirmed the CNAs had begun cleaning Resident #11 when Unit Manager, had finally looked at the chart. He stated the delay was about ,[DATE] minutes; it was not until then that the chest compressions started. He confirmed that Staff members H, K, DON, and his ARNP were in the room. He confirmed his ARNP told him that He is a DNR was said multiple times. He stated, when Unit Manager found out Resident #11 was not a DNR then she started CPR. He said, I do not understand why there was a lapse, and why didn't they check the resident's chart beforehand. He continued that he knew from what his ARNP told him that Staff K had the chart in the room and had said DNR, and everyone in the room said he was a DNR. He said, They need to realize just because you are a Hospice patient, it does not mean that you are automatically a DNR. He confirmed Unit Manager informed him that Resident #11 was not a DNR after the fact. He stated the resident was so weak that he most likely would have been transported to the hospital and intubated. The Attending Physician confirmed he met with the family on that day ([DATE]), along with his ARNP, the DON, Unit Manager, and the Social Worker from Hospice. He did not inform them that there had been a delay in CPR. He understood the facility staff, to include the Nursing Home Administrator (NHA), DON and Unit Manager, notified the family of the delay in CPR. A family interview conducted via telephone on [DATE] at 9:49 a.m. revealed that Resident #11's POA/Sister had just visited Resident #11 an hour prior to his passing. She attended a care plan meeting at 1:00 p.m. and visited with her brother. She stated he appeared just fine. She had not made it back to Tampa when she received a telephone call from Unit Manager that her brother had passed suddenly. The POA/Sister asked if Resident #11 responded to CPR, and she (Unit Manager) abruptly s

Based on interviews with the facility's nursing and administrative staff, a family member, an attending physician, an Advanced Registered Nurse Practitioner (ARNP), and a review of clinical and hospital records, facility policies and procedures and job descriptions, it was determined that facility administration failed to utilize resources effectively and efficiently to protect the rights for one (#11) of 9 sampled residents related to the resident's right to receive cardiopulmonary resuscitation (CPR) in the case of a cardiopulmonary arrest. Facility administration failed to ensure that the policies and procedures were implemented to verify and immediately initiate life saving measures in accordance with Resident #11's advance directive wishes and physician orders. On [DATE], Resident #11, a [AGE] year-old male, was found to show signs of respiratory distress with a pulse oximetry of 35%. The facility staff failed to validate Resident#11's code status immediately and provided comfort measures only until the resident ceased pulse and respirations. Facility staff provided post mortem cleaning of the resident before they became aware of the resident's Full Code status and called a Code Blue to initiate CPR. The facility's failure to follow their policies and procedures represented a system wide failure. Failure of the facility staff to ensure that the resident's expressed wishes related to advanced directives and the right to receive end of life treatment, were honored and protected, resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of a D. Findings included: A review of the undated job description for the Executive Director 1 (also known as the Nursing Home Administrator, NHA), reflected a hire date of [DATE]. The primary purpose of the job position was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. The job function indicated the Executive Director was responsible for the day-to-day clinical and administrative actions of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. The Executive Director will provide leadership to all the facility staff in meeting the goal of providing quality resident care. Duties and responsibilities included but not limited to: · Recruit, hire and, provide orientation/training for a sufficient number of qualified staff to carry out facility programs and services. · Interpret and ensure implementation of governing board policies and procedures. · Maintain a guide implementation of facility policies and procedures in compliance with corporate state, federal, and other regulatory guidelines. · Ensure a safe, clean and comfortable environment for residence, visitors and staff. · Maintain a file for and monitor incident reports. · Maintain effective relationships and open communication with residents, families, staff, contractors and the outside community. · Adhere to facility policies and procedures and participates in facility quality improvement and safety programs. · Attend to overall operation of the facility. Review resident complaints and grievances and make written reports of actions taken. Discuss such actions with resident family as appropriate. A review of the job description for the Divisional Director of Clinical Services (also known as the Director of Nursing), (July (YEAR)) reflected a hire date of [DATE]. The primary purpose was to plan, coordinate and manage the nursing department. The job function indicated the Divisional Director of Clinical Services was responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Duties and responsibilities included but not limited to: · Oversee the nursing staff for the provision of quality and appropriate resident/patient care that meets or exceeds company and regulatory standards. · Schedule and performs rounds to monitor and evaluate the quality and appropriateness of nursing care. · Maintain administrative authority, responsibility and accountability for the proper charting and documentation of care, medications and treatments. · Hire nursing staff, oversee the provision of orientation/training by a qualified Director of Education and retains qualified staff to carry out nursing programs and services. Reviews employee performance and conducts periodic performance appraisals timely. · Evaluate current and potential residents and patients to determine and maintain living centers ability to provide appropriate level of care. · Maintain regular ongoing communication with the living center's Medical Director to identify educational needs for staff and provide quality care and services to meet the needs of residents. · Adhere to the Company policies and procedures and participate in quality improvement and safety programs. · Must stay in compliance with all state, federal, and government agencies. · Conduct oneself with the highest degree of honesty and integrity in every interaction. A family interview conducted via telephone on [DATE] at 9:49 a.m. revealed that Resident #11's POA/Sister had just visited Resident #11 an hour prior to his passing. She attended a care plan meeting at 1:00 p.m. and visited with her brother. She stated he appeared just fine. She had not made it back to Tampa when she received a telephone call from Unit Manager that her brother had passed suddenly. The POA/Sister asked if Resident #11 responded to CPR, and she (Unit Manager) abruptly said she had to hang up. She went back to the facility about 3:00 p.m. and saw that he was being taken out. She met with the Hospice team who provided emotional support. She confirmed that she did not speak with the NHA or the DON. On [DATE] at 9:18 A.M., the NHA and Corporate Nurse were asked to review Resident #11's medical record along with the surveyor. The NHA and Corporate Nurse confirmed that the medical record did not contain any record of events that surrounded Resident #11's change in condition or death that occurred on [DATE]. They also confirmed that the clinical record did not contain notification to Resident #11's family or hospice of the resident's death, and there was no physician order to release the body. On [DATE] at 9:24 PM, the NHA and Corporate Nurse indicated that the expectation was to document in the medical record any situation that occurred with a resident. On [DATE] at 9:36 A.M., the NHA, in the presence of the Corporate Nurse, recalled hearing the Code Blue that was called on [DATE]. He stated, the response was quick, and the ARNP was on-site and oversaw the Code. The Unit Manager suctioned the patient, and the patient became unresponsive at 1:53 P.M. The chart was checked, and CPR was initiated at 1:55 PM. The Unit Manager performed CPR for about ,[DATE] minutes, according to her statement. She stated, she never stopped CPR, and 911 called it. I will have to check the soft record for the correct timeline for times; EMS arrived while the Unit Manager was giving compressions. Paramedics took over and initiated Advanced Cardiac Life Support (ACLS). The ARNP called the attending physician who came on-site. The attending physician called the time of death at 2:41 P.M. on [DATE]. I did not speak with the family. I believe my staff spoke to the family. An interview on [DATE] at 10:34 a.m. with the DON revealed she was in the Administrator's office when she heard a code blue paged with Residents #11's room number. She went into Resident #11's room. She confirmed CPR was being performed by Unit Manager and was unable to confirm if Staff K was assisting. She confirmed the ADON and Staff B, RN were present and both crash carts were in the Resident's room. She confirmed that she said, Did someone call 911, the physician and family? She stated that someone said yes and she did not know who answered because there were so many people in the room. She asked for the chart, someone gave me the chart and then she looked and saw he was a full code. She stated that she verified that he was a full code once she got the chart. She scribed the vital signs, that were being yelled out and at the time, EMS arrived. She observed EMS arrived approximately 2:06 p.m. Unit Manager continued with CPR until relieved by EMS. A second crew of EMS came; they hung IVs and put a line in him. She left the room and confirmed Attending Physician went into the resident room. She stated the Unit Manager told her that Staff K brought her the wrong chart. The DON said, I said what do you mean she brought the wrong chart? She stated Unit Manager reported, The chart that they brought me said DNR. The Unit Manager told her she called a full code after she looked at the chart. The DON looked at the chart after CPR was started which is the time she came into the room. She did not see a DNR order. The DON was asked to provide the Code Blue Documentation Nurses Note used to scribe for the full code initiated on Resident #11. The DON reported that she could not find the Code Blue documentation. She was asked if she had documented evidence of the time the Code Blue was called, when CPR was started, when resuscitation was terminated, the names of the team members that were present during the code and the times that notification was provided to the required parties. The DON confirmed that she did not have the Code Blue Documentation where this information should have been documented. The DON reported she and the Nursing Home Administrator (NHA) had obtained statements from everyone involved and the Unit Manager said Staff K had brought the wrong chart. Staff K denied that she had brought the wrong chart. The DON confirmed she did not request a statement or interview from the ARNP. The DON reported that she did not speak with the family. She confirmed a timeline was created and it was determined that there were approximately 2 minutes from the time staff member (Staff K) said that Resident #11 was a DNR and the full code was called. Unit Manager looked at the wrong chart that was brought to her, which had a DNR goldenrod. The DON confirmed that the Unit Manager did not look at Resident #11's chart until the resident stopped breathing. The Unit Manager realized it was a wrong chart when she looked at the name on the chart. This is when she looked at the correct chart and called the code. The investigation reflected Staff K told the Unit Manager that Resident #11 was having trouble breathing. The Unit Manager went to the resident's room and said he needed suctioning at 1:50 p.m. Unit Manager and Staff K suctioned him, the ADON was there as well. The Unit Manager left the room when out to the nurses' station with a resident clinical record. She realized it was the wrong chart, got the right chart and called the full code. A review of Resident #11's clinical record revealed an admission date of [DATE]. The resident was admitted directly from a Hospital in Jacksonville under the services of an Attending Physician. A review of Resident #11's Admission Notification form dated [DATE] revealed multiple [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. The Admission MDS (minimum data set assessment) completed on [DATE] revealed the resident scored a 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's overall expectation was to remain in the facility (section Q0300A). A review of the Baseline Care Plan and Summary dated [DATE] revealed the resident's discharge plan was to stay long term in the facility with interventions to include provide service to improve abilities and advance directives of full code. The clinical record indicated the responsible party for Resident #11 was his POA (power of attorney)/Sister. The General Durable Power of Attorney for Finance, Property and Health Care agreement was dated and signed by Resident #11 on [DATE] and filed in the clinical record indicating authority to the resident's sister. Further review of the clinical record revealed an Acknowledgement of Advance Directives Discussion form completed by phone between the POA/Sister and the Social Service Director on [DATE]. The form indicated that the resident's wish was to be provided with CPR. A review of the resident's clinical record included a signed physician's order for a Full Code dated [DATE]. The initial plan of care, and Hospice Certification dated [DATE] indicated that Resident #11 was a Full Code. Review of the Hospice progress notes for Resident #11 provided the notations of his condition on [DATE], prior to being found in [MEDICAL CONDITION], Patient seen at the facility where he resides. He is pleasant, exhibits no signs or symptoms of pain. Emotional support provided. A review of the Nursing notes dated [DATE] for 7:00 a.m. to 3:00 p.m. reflected, Resident resting comfortably in bed easily aroused. Vitals signs obtained within normal ranges. No signs or symptoms of distress noted. Medications administered via patient peg tube. Peg tube was flushed with 200 ml (milliliters) of H20 (water), all of which was well tolerated. Will continue to monitor. A review of the Nursing progress note dated [DATE] for 7:00 a.m. -3:00 p.m. shift was identical to the previous entry on [DATE]. An Interdisciplinary progress note, dated [DATE], indicated the following, IDT (interdisciplinary team) met with the resident's family via phone, Hospice was invited to attend, however, did not show up. Resident is in bed resting quietly, no complaints or concerns. Family member is agreeable with current P[NAME] (plan of care). The clinical record was silent in regards to the event related to Resident #11's respiratory distress and circumstances surrounding his death on [DATE]. A telephone interview conducted on [DATE] at 9:07 A.M. with the attending physician's ARNP related to Resident #11's expiration on [DATE] revealed the following details: I only had seen the resident one time prior to the event of [DATE]. What I do remember was that he had [MEDICAL CONDITION], history of dysphagia, he had a PEG tube, and he was treated for [REDACTED]. I do not have my notes in front of me, but that was what I can remember in regards to his condition prior to the event of [DATE]. I was at the facility on [DATE]. I was just coming down the hall when the Unit Manager told me that a patient was under respiratory distress and requested I go in and see him real quick. Because she said he was in respiratory distress, I rushed to the room to see what was going on. When I got to the room the patient, (Resident #11) had just been given a breathing treatment. I went to assess him and the patient was cyanotic at that point, having Cheynes-stokes. He was in respiratory distress from what I saw. As I continued to assess, the Unit Manager was suctioning him at the bedside. I got report from both the Unit Manager and Staff Member K. I was under the impression that the patient was a Hospice patient, DNR, and that we were just doing comfort measures. At that point, I just proceeded to treat his symptoms, he was cyanotic. The Unit Manager had suctioned the patient and pulled out a huge mucus plug. I had the tube feed on hold, listened to his lung sounds, and pretty much just performed an assessment. The Unit Manager was the person who informed me that the patient was a DNR. It was the ARNP's understanding at that time that it was comfort measures only. That was the plan. I was just there to treat the symptoms and to make sure the patient was comfortable. I verified who the attending physician was based on the Hospice Company the patient was under. Just like anytime with any of this physician's patients, if anything was abnormal, I always call him to give him a quick report. We consult one another and then we go from there. I told the staff to call Hospice; and I spoke with the physician regarding the situation. After we suctioned him, his oxygen saturation didn't seem to come up. At that point we really couldn't get a blood pressure, his pulse was very, very, faint, he was still having the same type of breathing .sputum coming up. I noticed he might be imminent so I just made sure the facility followed proper protocol by calling the doctor, which I had, and they called Hospice. After that, I pretty much just continued with my rounds at that point. I know that the Unit Manager went to call the daughter. Apparently, based on the information that I received after the fact, the conversation the Unit Manager had with the daughter and the kind of questioning from the daughter made her question the resident's code status. It was at that point the Unit Manager went and looked for the code status in the chart. While I was with a patient, I noticed that they called a code. I was not sure what was going on. After seeing my patient, I saw that they were back in Resident #11's room doing a full code on him. I called the attending physician and said There must be some confusion; they are running a full code right now on the patient. I asked a staff member that was on the floor, what was going on and they told me that the patient was actually a full code. The attending physician arrived while they were doing the code, probably after 2:00 PM. I am not sure. Everyone was under the impression, including myself, that he was a Hospice patient, DNR, comfort measures only. After he passed, the Unit Manager went to check the chart. She noticed that he was not a DNR but a Full Code, then they called the code. That is exactly what happened. After everything had happened, the daughter had arrived at the facility and the attending physician introduced me to them, but I didn't speak to them. Hospice had spoken to them and the daughter had spoken to the DON or ADON at that time so I really didn't have a conversation with her. The ARNP indicated that the facility did not follow proper protocol of confirming code status prior to withholding CPR. An interview with Attending Physician on [DATE] at 2:32 p.m., confirmed he was Resident #11's primary physician and the Hospice physician. He confirmed Resident #11 was his patient while residing in Jacksonville; he had him transferred to this facility, so that his family could be closer to him because they reside in the area. He confirmed Resident #11's admission [DIAGNOSES REDACTED]. The Attending Physician stated he was not in the building when the respiratory distress event occurred. He confirmed that he was called by his ARNP because she (ARNP) was concerned over the commotion surrounding the event. The Attending Physician stated the ARNP reported that everyone in the room thought Resident #11 was a DNR, and everyone was saying he was a DNR. He stated, initially they (the facility staff) did not start CPR in a timely manner. He stated they did not start CPR when they should have. He said, They should have immediately started CPR, there was a delay in starting CPR. They should have started CPR at the moment that he was expiring. He confirmed the time delay was from the time Resident #11 expired to the time the facility staff member (Unit Manager) went to the front desk, looked at Resident #11's chart and noticed no DNR was in place. Then the facility staff started CPR. He stated that no one had laid eyes on an actual DNR paper. He confirmed the CNAs had begun cleaning Resident #11 when the Unit Manager, had finally looked at the chart. He stated the delay was about ,[DATE] minutes; it was not until then that the chest compressions started. He confirmed that Staff members H, K, DON, and his ARNP were in the room. He confirmed his ARNP told him that He is a DNR was said multiple times. He stated, when Unit Manager found out Resident #11 was not a DNR then she started CPR. He said, I do not understand why there was a lapse, and why didn't they check the resident's chart beforehand. He continued that he knew from what his ARNP told him that Staff K had the chart in the room and had said DNR, and everyone in the room said he was a DNR. He said, They need to realize just because you are a Hospice patient, it does not mean that you are automatically a DNR. He confirmed Unit Manager informed him that Resident #11 was not a DNR after the fact. He stated the resident was so weak that he most likely would have been transported to the hospital and intubated. The Attending Physician confirmed he met with the family on that day ([DATE]), along with his ARNP, the DON, Unit Manager, and the Social Worker from Hospice. He did not inform them that there had been a delay in CPR. He understood the facility staff, to include the Nursing Home Administrator (NHA), DON and Unit Manager, notified the family of the delay in CPR. An interview with Staff K, Licensed Practical Nurse (LPN) on [DATE] at 9:12 a.m. revealed she was as a LPN for only a few months at this facility, her regular shift was 7:00 a.m. to 3:00 p.m. She confirmed she was passing out medications on [DATE] between 1:00 p.m. to 1:30 p.m. and went to the nurses' station to start charting. Staff C, Certified Nursing Assistant (CNA) informed her Resident #11 was having breathing problems, and needed suctioning. She took her medication cart to Resident's room, put the blood pressure cuff and pulse ox (oximeter) on the resident, and noted he had labored breathing. She administered his breathing treatment and his oxygen saturation was at thirty-eight percent. She stated, she ran out and called the Unit Manager, Registered Nurse (RN). Staff K then went to get the suctioning machine and gave it to Unit Manager, RN, and Unit Manager started the suctioning on Resident #11 and his breathing was still labored. She stated the Unit Manager called code blue when patient was non-breathing and struggling. She confirmed the Unit Manager asked her to get the chart for Resident #11. Staff K said the resident was a Full Code. Staff K, LPN stated, at some point, he stopped breathing. She believed it was Unit Manager that verified code status. She stated that she did not verify the resident's code status. She said, I knew he was a full code. She confirmed that she brought the chart to verify next of kin and did not bring the chart to verify code status. She stated that she provider her (Unit Manager) the next of kin's name. Unit Manager told Staff K to call Hospice. She called Hospice at 1:30 p.m. She stated that when she went back to the resident's room the Unit Manager had started chest compressions, and then she (Staff K) did the Ambu bag breathing until EMS (Emergency Services) arrived. She confirmed the Unit Manager called the family. She said, I believe I did the documentation in the medical record. She (Staff K) confirmed that she called Hospice before compressions had started and informed them that their patient (Resident #11) had gone into respiratory distress. She confirmed that compressions continued until EMS arrived. She could not recall an exact timeline of events. This surveyor asked Staff K if she looked at the chart. She stated that she honestly did not know who pulled the wrong chart. Staff K confirmed the Director of Nursing (DON) her that she (Staff K) pulled the wrong chart and gave it to the Unit Manager. She stated the DON said that she gave the Unit Manager Resident #20's chart not Resident #11's chart. Staff K said, I told her that I did not. An interview with the Unit Manager, RN on [DATE] at 9:53 a.m. revealed on [DATE], Staff K, LPN called her to assess Resident #11. She (Staff K) told her (Unit Manager) Resident #11's oxygen saturation was at 35% and that he was a DNR. She was provided this information in her office with DON present. She stated when she went to assess Resident #11, he had a breathing treatment running. She told Staff K he needed more than [MEDICATION NAME] treatment and the oxygen saturations were low. She told Staff K to grab the suction from the crash cart. She (Unit Manager) suctioned mucus from the resident and removed a mucous plug. She stated Resident #11's breathing was at 30% after suctioning. She then told Staff K to go to his chart and call Hospice, to let them know about the change in condition for the resident. Staff K came back from the nurses' station with Resident #11's chart and the resident was unstable with a loose pulse. Unit Manager, RN confirmed that after Resident #11 was deceased , she told the aides to clean him and she stepped away. She went back to the nurses' station and pulled his chart. She was going to call the family, at that time. She stated that she noticed Resident #11 was a Full Code and not a DNR. She stated she left the nurses' station, passed her office and told the Assistant Director of Nursing (ADON) that Resident #11 was a Full Code and not a DNR. She confirmed she began CPR. She stated that she believed the DON was scribing while she was doing chest compressions until the paramedics relieved her. She knew someone called the Attending Physician, while she was doing the chest compressions. She confirmed the Attending Physician showed up while the paramedics were there and the paramedics administered different cardio medications. She stated, at that time, someone made the paramedics aware Attending Physician was the resident's primary physician. She confirmed the Attending Physician, called time of death because the resident could not be resuscitated. The Unit Manager confirmed she looked at the chart and stated Yes, she pulled the chart from the nurses' station and saw Resident #11 was a Full Code. She saw the physician's order that reflected Full Code status in front of the clinical chart for Resident #11. She confirmed the only time she checked the code status was after she had left the resident's room to call his next of kin. She stated she began the chest compressions after she saw that the resident was not a DNR but a Full Code. On [DATE] at 2:32 PM, Staff Member I, C.N.A., stated that on the day of the incident, Staff Member D came to get me to help clean Resident #11. A whole wipe down, change briefs, change gown and change the bed sheets. He had already expired when I cleaned him. A lot of commotion happened afterwards, I left the room. The ADON, who was in the office with the Unit Manager, told me to call Code Blue. When I called the Code Blue, I said the room number then Code Blue, three times on the overhead. That is when everyone rushed into the room. I saw EMS come in. A telephone interview conducted with Staff D, CNA on [DATE] at 4:43 p.m. revealed she had not worked with Resident #11 before [DATE]. She stated that she had just come off her break when all the commotion had started. She knew that Resident #11 was having breathing problems and was on O2 (oxygen). She stated she was told to call 911. Unit Manager, RN told Staff I, CNA and Staff D to clean Resident #11 up, and wipe him down before she (Unit Manager) left the room. Staff D confirmed Resident #11 stopped breathing and had been pronounced dead. She stated the ADON and Unit Manager left the room and shortly after they left, was when a code was called. She said, I did not think you could start CPR after someone was pronounced, but they did. She confirmed she did not see anything afterwards because the door was closed after they started the code. A telephone interview on [DATE] at 10:47 a.m. was conducted with the Assistant Director of Nursing (ADON) via telephone. She stated on [DATE] she was in the Unit Manager's office when Staff K came into her office and said Resident #11 was having trouble breathing. Unit Manager asked Staff K if she had assessed Resident #11. Staff K told her that his 02 stats (statistics) were at 35%. Unit Manager accompanied Staff K to the resident's room. Staff K said, I do not know what to do! Staff K had put a breathing treatment on him. Staff C, CNA told Staff K that Resident #11 had a lot of mucus and something white was coming from his mouth. Unit Manager told Staff K to get the suctioning machine. The ADON confirmed this occurred after lunch trays were passed and picked up. The ADON waited in the Unit Manager's office for her to return. It took longer than 5 minutes so she went down to Resident#11's room to see if they needed help. Unit Manager, the ARNP, and Staff C were in the room when she entered. At that time, Unit Manager was suctioning the patient, the ARNP was assessing the resident and told staff to call Hospice. The ADON confirmed, at first Staff K was not in the room. Staff K entered the room and had Resident #11's chart. The ADON said, Before I left the room I said, what is the code status. The ADON stated Staff K said DNR and was holding the chart against her body. The ADON left the room to get a suction connector. The ADON grabbed a new suction machine from the storage room, which was located outside of the building, in a shed. The ADON brought it into the room. She confirmed that Resident #11 had chain respiration, in and out. She confirmed she thought he was a DNR, after bringing up a mucous plug. She stated she told the aides to clean the resident and facility staff was calling Hospice, the physician and appropriate parties. She stated the team thought Resident #11 had stopped breathing, and were just providing comfort measures. She took the suction supplies that she used and threw them out as she walked out of the room. She confirmed that she told the CNA to clean the resident. Unit Manager and ARNP left the room before her. She stated she walked passed the Unit Manager's office and she was on the phone. The ADON said that she had just sat down and Unit Manager had Resident #11's chart and said, He is a full code! The ADON said, We will run the code. The Unit Manager ran to Resident's room. The ADON grabbed the crash cart. The ADON stated she told Staff I to call the code. She confirmed the ARNP (Advanced Registered Nurse Practitioner) was on the phone with the Attending Physician when all of that occurred. ADON asked ARNP to let Attending Physician know he is a full code. She gave the DON the Code Blue Documentation Nurses Note so that she could scribe. The ADON confirmed that Unit Manager was giving chest compressions, Staff K was at the head of the bed, the ADON had hooked the Ambu bag to the oxygen, and Staff K gave rescue breaths. She stated that after Staff B, RN entered the room; they could not read any vital signs. EMS worked on Resident #11 for a while. The attending physician arrived, while Unit Manager was still doing compressions. A second EMS team showed up at that time and they were unable to revive Resident #11. The ADON stated that Staff K told the whole team that Resident #11 was a DNR. An interview was held with Staff Member B, Registered Nurse on [DATE] at 2:20 P.M. She provided the following details related to Resident #11's event: I was in my office when they called a code to Resident #11's room. I grabbed the code cart, and I went running down the hall. When I went in to Resident #11's room, I saw the Unit Manager doing chest compressions. Staff Member K had the Ambu bag, and the code cart was inside the room. The ADON was giving orders to make copies of the chart, somebody was calling EMS, and someone was outside of the room doing something with a suctioning machine. I went to the side of the bed to see if the Unit Manager or Staff K needed relief. They said they were doing fine. The Fire Department came in and placed the leads. Compressions were stopped while the leads were being placed. After the leads were on Resident #11, the Fire Department told the Unit Manager to continue with compressions and an IV line was put in place. When EMS came in, I stepped out of the room. A review of the f

Based on interviews and record review the facility failed to obtain a follow up physician ordered laboratory value, a serum [MEDICATION NAME] level, for one (resident #2) of three residents sampled. The physician ordered the lab testing to be completed to determine therapeutic blood levels, after a significant increase of medication. The failure to obtain the follow up lab work resulted in a hospitalization for a change in status and [MEDICATION NAME] toxicity. Findings included: A progress note for resident #2, dated 09/13/12 and signed by a nurse practitioner (ARNP), stated he was assessed with [REDACTED]. Review of the physician orders [REDACTED]. Review of a laboratory report, dated 09/18/12, revealed the [MEDICATION NAME] level was 5.30. It was flagged as low with the reference range as 10.00 to 20.00 ug per ml. A hand written notation on the lab report stated "Increase [MEDICATION NAME] ([MEDICATION NAME]) to 150 mg (6 ml) at 8:00 a.m. and 10:00 p.m. and 100 mg (4 ml.) at 2:00 p.m. Repeat Dilatin level in two weeks." The hand written note was signed by the ARNP. Review of the monthly physician orders [REDACTED]. Review of the record revealed no lab work was obtained on October 2, 2012. Further review of the medical record for resident #2 revealed that he was readmitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. He was [AGE] years old. A change of condition note, dated 10/09/12, stated the resident had slurred speech and facial drooping. He was lethargic. He was transferred to the hospital at 4:35 p.m. for evaluation. Review of the hospital physician's evaluation, dated 10/9/12 at 10:50 p.m., revealed that the serum [MEDICATION NAME] level was 37.6. The impression list stated "[MEDICATION NAME] toxicity". He was admitted to the hospital for further evaluation.

Based on record review and interview the facility did not have a behavioral monitoring record for the month of September, 2012, for the [MEDICATION NAME] medication being given since 09/03/12 to one of three residents sampled (#1). Findings include: Record review did not find a behavioral monitoring record completed for [MEDICATION NAME] medication prescribed for resident #1 since 09/03/12 through 09/30/12. The resident was prescribed [MEDICATION NAME] 0.5 mg four times per day for anxiety per order of 09/03/12. This order was changed on 09/07/12 to [MEDICATION NAME] 0.5 mg. every 12 hours for anxiety and [MEDICATION NAME] sprinkles was added at 125 mg. twice a day for mood after a psych consult. The first behavior monitoring form was started on 10/01/12 following distressed behavior exhibited by the resident on 09/29/12 and 09/30/12. Interview at various times with the Administrator on 10/03/12 from 3:30 p.m. to 4:30 p.m. related that when the staff increased monitoring for resident #1 a facility Resident Safety Check Form, effective 01/2007, should have been added to the behavior monitoring record and documented. Record review revealed that this procedure was not completed for 09/29/12 to 09/30/12 for the increased monitoring of the resident for his distressed behavior. The Administrator related the facility does not have a specific policy for this but shared verbally the procedure and shared a copy of the Resident Safety Check Form. Interview with the Administrator and DON on 10/03/12 from 11:35 a.m. to 11:50 a.m. regarding resident #1 related the following timeline of events on 09/29/12 to 09/30/12: From 11:00 p.m. to 4:25 a.m. resident #1 was wandering in his wheel chair around the unit and building. He was combative and agitated and exit seeking. Resident was aggressive with all staff on the 11-7 shift on 09/29/12 to 09/30/12. The resident would not go to bed in his room stating that there were snakes in his room. He had been placed in his bed by his aide, employee A, but was observed up and standing at his door afterwards and was coaxed back into his wheel chair. He would not stay in his room due to seeing snakes. He was up in his wheel chair wandering around the facility. He was agitated and yelling, cursing staff. Banging and kicking on exit doors which were locked. Resident wears a wanderguard also. Staff repeatedly tried to redirect him unsuccessfully. His aide told the LPN, employee B, that the resident's medications were not working. Staff closed the fire doors in the 400 and 600 halls to prevent the resident from wandering into residents' rooms. He started going into an unlocked storage room on the unit he lived and was removed several times. The DON related that the facility staff informed each other of his agitation and behavior and were each monitoring their assigned areas if he was in their vicinity. Record review of 23 staff interviews conducted by the facility regarding the above time line verified the interview of the Administrator and the DON. The facility interviewed all staff on the 09/29/12 11-7 shift and the 09/30/12 7-3 shift. Record review finds resident's [DIAGNOSES REDACTED]. Record review of Medication Administration Record [REDACTED]

Based on interviews and record review the facility failed monitor Dilatin levels by obtaining a follow up a physician ordered laboratory value a serum [MEDICATION NAME] level, for one (resident #2) of three residents sampled. The physician ordered the lab testing to be completed after finding a sub-therapeutic [MEDICATION NAME] level and then a significant increase of [MEDICATION NAME]. The failure to obtain the follow up lab work resulted in a hospitalization for a change of mental status and Dilatin toxicity. Findings included: Review of the medical record for resident #2 revealed that he was readmitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. He was [AGE] years old. The resident received [MEDICAL CONDITION] tube feedings. A progress note, dated 09/13/12 and signed by a nurse practitioner (ARNP), stated he was assessed with [REDACTED]. Review of the physician orders [REDACTED]. Review of a laboratory report, dated 09/18/12, revealed the [MEDICATION NAME] level was 5.30. It was flagged as low with the reference range as 10.00 to 20.00 ug per ml. A hand written notation on the lab report stated " Increase [MEDICATION NAME] (Dilatin) to 150 mg (6 ml) at 8:00 a.m. and 10:00 p.m. and 100 mg (4 ml.) at 2:00 p.m. Repeat [MEDICATION NAME] level in two weeks." The hand written note was signed by the ARNP. Review of the monthly physician orders [REDACTED]. On 10/04/12 the ARNP visited. She noted that the resident had two falls that morning, with no injuries. The assesment and plan section stated: 1.[MEDICAL CONDITIONS], continue [MEDICATION NAME], monitor levels/recent increase". She added a soft waist belt for safety. Review of the record revaled no [MEDICATION NAME] level lab work was obtained on October 2, 2012. A change of condition note, dated 10/09/12, stated the resident had slurred speech and facial drooping. He was lethargic. He was transferred to the hospital at 4:35 p.m. that day for evaluation. Review of the hospital physician's evaluation, dated 10/9/12 at 10:50 p.m., revealed that the serum [MEDICATION NAME] level was 37.6. The impression list stated "[MEDICATION NAME] toxicity". He was admitted to the hospital for further evaluation.