Every finding on record at Community Convalescent Center

Based on observations, record review and interviews, the facility failed to coordinate an outside medical appointment for one resident (#1) out of three residents reviewed for medical appointments.Findings include: On 04/08/2026 at 10:23 AM, Resident #1 was observed lying down in bed dressed in his nightgown. Resident #1 stated he has vertigo and was supposed to be seen by an Ear Nose and Throat (ENT) Specialist. He stated on the day transportation came to the facility to take him he was not ready because no one at the facility informed him about the appointment. He stated this happened about a month ago. The facility told him they would reschedule his appointment, but it never happened. Review of Resident # 1 admission Record dated 04/08/2026 revealed he was admitted to the facility originally on 10/10/2023 and readmitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, heart failure, unspecified, chronic kidney disease, stage 3A, Review of an order summary dated 04/08/2026 revealed an Ear Nose and Throat appointment on 2/11/2026 at 11 [NAME] 04/08/2026 at 2:17 PM, an interview was conducted with Staff A, Registered Nurse, RN. Staff A stated Resident # 1 had an Ear Nose and Throat (ENT) appointment on 2/11/2026 for vertigo, but the appointment had to be rescheduled. Staff A stated the staff in Medical Records is responsible for scheduling appointments. Staff A stated she did not know if Resident #1's appointment was ever rescheduled for him to be seen by the (ENT). On 04/08/2026 at 2:36 PM, an interview was conducted with Staff B, Certified Nurse Assistant, (CNA)/ Medical Records. Staff B stated she has worked at the facility since 2022. Staff B stated the Nurse Practitioner informed her that Resident #1 wanted to see the Ear Nose and Throat Doctor. Staff B stated she was not made aware that Resident #1's appointment needed to be rescheduled. Staff B stated the Nurse Practitioner came to her on Monday (4/6/26) to ask her if she had rescheduled Resident #1's (ENT) appointment. She stated she told the Nurse Practitioner that she would get to it but she did not reschedule it because she did not have time. On 04/08/2026 at 2:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated his expectations are appointments should be followed up on timely. Review of the facility policy titled, Transportation Services, dated 02/2025, showed policy, The facility will arrange for transportation services when needed to ensure that each resident receives a complete continuum of service consistent with the plan of care. Procedure 2. The individual that identifies the need for transportation service shall notify the Medical Records Designee/ Designee of the need and provide the following information: a. Resident, name , date/ time of appointment, and reason for the appointment. B. if the date/time of appointment is in less than 72 hours, the individual scheduling the appointment shall try to re-schedule the appointment for a date/ time greater than 72 hours.

Based on observations, interviews and record review the facility failed to ensure sufficient kitchen staff for four out of eight days reviewed.Findings Included:During an observation on 08/24/2025 at 9:23 a.m., three staff members Staff P, Cook, Staff Q, Certified Nursing Assistant (CNA) and Staff R, Dietary Aide were observed in the kitchen area.Review of the punch detail report for dietary staff for 07/24/2025 thru 08/25/2025 revealed:08/24/2025 one cook and one dietary aide clocked in for the morning shift.08/22/2025 one cook and one dietary aide clocked in for the afternoon shift.08/18/2025 one cook and one dietary aide clocked in for the afternoon shift.08/17/2025 one cook and one dietary aide clocked in for the afternoon shift.Review of Staff Q, CNA and Staff N, CNA punch detail report dated 07/24/2025 thru 08/25/2025 revealed, Staff Q, CNA worked as a dietary aide 4.25 hours and Staff N, CNA worked as a dietary aide 16.00 hours.During an interview on 08/24/2025 at 11:09 a.m. Staff P, Cook, stated I was the only person in the kitchen this morning. This is normal when I work. People are scheduled off and they don't cover the position. Staff R, Dietary Aide just started and is in training. When we are short in the kitchen, they will send a CNA to help. I served breakfast on Styrofoam, and some residents got plastic ware because I did not have anyone to do the dishes. Breakfast was served late this morning because I did not have help in the kitchen.During an interview on 08/24/2025 at 1:59 p.m., Staff N, CNA stated she was called in to work at 10:30 a.m. this morning. We always work short on the floor because kitchen staff call off and they take CNAs off the floor. When they pull me from the floor to work in the kitchen, they don't cover my assignment, and it causes residents to not get showers. If state was not here, they would not have called me in to fill in on the floor.During an interview on 08/25/2025 at 9:50 a.m., Staff S, Food Services Manager (Interim Certified Dietary Manager) stated she was not sure if the kitchen was fully staffed. She was asked to come and cover because the Dietary Manager is out. She would have to check with the Nursing Home Administrator to confirm how many staff the kitchen had and if it is fully staffed. She thinks they are interviewing for kitchen positions as well.During an interview on 08/27/2025 at 12:30 p.m., the Staffing Coordinator stated CNA's have had to fill in in the kitchen. But it's not frequent. If they need help in the kitchen, and if they let her know ahead of time and she will make sure there is staff to be able to help in the kitchen. They called her on Sunday 08/24/2025 and asked if the aides can go in the kitchen. Most of the time we have an overflow with aides on the weekends. If a CNA is moved from the floor to the kitchen the supervisor is responsible for adjusting the assignments on the floor. She is not responsible for the kitchen staff schedule; the Dietary Manager is the one who does that schedule and takes calls for call outs.During an interview on 8/27/2025 at 5:25 p.m., Staff Q, CNA stated she is asked to help in the kitchen a few times a month. I was most recently pulled from the floor to work in the kitchen on 8/21 and 08/24. When I cover in the kitchen no one covers my assignments on the floor. During an interview on 08/27/2025 at 2:45 p.m., the Nursing Home Administrator (NHA) stated on Sunday (08/24/2025) they had call outs in the kitchen, so they used a CNA from the floor to help in the kitchen. She stated when they have call outs in the kitchen the Dietary Manager is responsible for getting coverage or they should come in and cover the shift. CNA's are pulled from the floor to help in the kitchen. CNAs are not given any additional training when working in the kitchen because they are only helping with tray service. They already do tray service on the floor so they would not need any additional training. If kitchen staff are not coming into their shift this would cause a delay in meal services to residents.Review of the facility policy titled Staffing, dated August 2024 revealed.The projected staffing plans are reevaluated on an ongoing basis and response to changes in the facility, resident population, or other circumstances. Staffing is monitored on an ongoing basis through reviews conducted by the facility. The facility administrator and director of nursing should evaluate staffing on a daily basis. Ongoing Monitoring 1. Monitor open positions and call offs throughout the day and respond to staffing needs as needed. 2.Evaluate the adequacy and appropriateness of facility specific projected staffing plans throughout the day.

Based on observation, interviews and record review the facility failed to provide a clean and sanitary environment in the kitchen related to undated, unlabeled food items, properly disposing of food items, and following hand hygiene practices for staff. Findings Included: On 8/24/2025 at 9:21 a.m., an initial tour of the facility’s kitchen revealed Staff P, Cook, preparing breakfast plates, and Staff Q, Certified Nursing Assistant (CNA) plating trays. Food trays on a meal cart were observed with Styrofoam containers. A three compartment sink behind the cook side of the meal service line was observed with dirty pots and pans. On the sink was a bag of boiled eggs and bags of pancakes. Clean plate covers next to an open trashcan near the dish washing area. (photographic evidence obtained) On 8/24/25 at 9:24 a.m., an observation of Staff P, [NAME] doing multiple tasks in between plating breakfast without proper glove and hand hygiene being taken was made. On 8/24/25 at 9:25 a.m., an observation of the kitchen’s dishwashing temperature log had multiple dates missing: 8/2/25, 8/9/2025, 08/10/25, 8/16/25, 8/18/25. For the date on the dishwashing temperature log of 8/22/25 at 9:25 a.m., the breakfast and lunch temperature check was already filled out. On 8/24/25 at 9:28 a.m., an observation of the walk in fridge revealed, no temperature log. An observation of the Inside of the walk in fridge revealed 1 open gallon of milk, prepared fruit bowls with an open mouth hole as coverings, a food service tray with clear cups with red and yellow liquids, a silver dish with a clear plastic covering, a clear container with a blue lid, and a clear container with a green lid all undated and unlabeled. On the top of a gray metal rack there was a box of “Smoked Ham and Water Product”, an opened package of sliced ham wrapped in plastic wrap, underneath on the second shelf was a gray food service tray with clear cups with an orange liquid covered with slitted lids. On the same shelf a metal container with two cantaloupes were observed with white and gray bio growth. On another gray metal rack was a clear container with a white substance with black hand writing “made 04/18”, a white block wrapped in plastic wrap, a brown bag secured with rubber bands, a clear bag of lettuce, a box of cucumbers with several cucumbers showing soft, sunken spots, covered in fuzzy white and green bio growth, a box of tomatoes with several tomatoes showing soft, sunken spots covered in black and white bio growth, and three boxes of raw chicken in bags with “08/21” hand written on the box. (photographic evidence obtained) On 8/24/25 at 9:30 a.m., an observation of the walk-in freezer revealed the freezer door was frozen shut. The floor within the freezer had a thick slippery ice build-up. Many items in the walk-in freezer were observed opened, unlabeled and not dated, such as tater tots, pie crusts, and breakfast sausage patties. (photographic evidence obtained) On 08/24/2025 at 9:40 a.m., an observation of the dry storage area revealed an open white bag of tortilla chips, two open clear and blue bags of uncooked pasta, an open lidless liquid thickener carton, an open bottle of soy sauce all undated with no open date. On the floor of the dry storage room underneath a metal was a brown dried substance. (photographic evidence) On 08/24/2025 at 11:40 a.m., an observation of the first floor nourishment room revealed on top of the fridge was a pink and white box of meal replacement shakes. Inside of the refrigerator several items were identified to be undated with no resident information. Items included a clear bottle with a red and yellow label, a clear jar with a purple lid, several gray and brown grocery bags with containers inside, a yellow bag with a clear container with the date “08/3/2025”, clear cups with a sticky brown substance, and an open clear container with a black label, and a white bag with a Styrofoam container with green and white bio growth on an unidentifiable item. An observation of the freezer revealed a clear cup with a white label, and a red and white candy wrapper. (photographic evidence obtained) On 08/24/2025 at 11:50 a.m., an observation of the second floor nourishment room revealed on top of the fridge a brown box with an open undated blue box. Inside the refrigerator was three unlabeled yogurts, an open clear bottle with a blue label, a yellow bag with a container inside, a can of soda with brown writing, an open undated carton of liquid thickener, and three clear zip lock bags with black writing “8/23” with a clear and white separating liquid. On 08/24/2025 at 3:50 p.m., an observation of Staff X, Dietary Aide revealed her cutting cucumbers. Behind her was a box of cucumbers with several cucumbers showing soft, sunken spots, covered in fuzzy white and green bio growth. On 08/25/2025 at 9:50 a.m., an observation of a brown box with coffee was observed on a metal shelf next to a red handled bucket with a clear liquid and a blue rag. On 08/26/2025 at 1:30 p.m., an observation of the dish machine area revealed a brown insect stuck to the wall. Underneath the dish machine on a metal wire rack there were food particles. An observation of the garbage disposal revealed black winged insects stuck to a hose. In the sink of the garbage disposal there was food particles. Black bio growth was observed on the wall and sink of the dish area. Underneath the clean side of the dish machine was an unpainted, peeling wall with a brown and black build up. Review of the facility’s Food Temperature logs for August revealed: On 08/02, 08/03, 08/05, 08/06, 08/07, 08/08, 08/11, 08/12, 08/13, 08/14, 08/19, 08/20, and 08/22 dinner temperatures were not recorded. On 08/01, 08/04, 08/09, 08/10, 08/15, 08/16, and 08/17 the food temperature logs were blank. There were no temperature logs for 08/18, 08/23 or 08/24. The facility was asked to provide four weeks of kitchen cleaning logs. This was not provided during the time of the survey. On 8/24/25 at 9:54 a.m., an interview with Staff P, [NAME] revealed the chicken stored in the walk-in fridge was pulled in preparation for todays lunch. On 8/24/25 at 1:20 p.m., Staff X, Dietary Aide, was on the prep line and was observed changing tasks during the tray prep line and performing no hand wash in between tasks. [NAME] line staff was observed scratching their head, and picking items up off of the floor, and proceeding to continue line prep duties without a glove change or hand wash. A bin of single-serve milk cartons was also viewed sitting on the prep line with no ice to keep them cool while lunch was being plated on trays. On 08/24/2025 at 4:00 p.m., Staff X, Dietary Aide, stated the cucumbers she was cutting did have bio growth on them and were soft to the touch. “I am cutting off the bad parts and washing them really well. Yes, I am going to serve them for dinner tonight.” On 08/24/2025 at 4:03 p.m., the Nursing Home Administrator stated she would have to look to see what the policy is for food storage and when food should be discarded. “We will call someone to go get new cucumbers and discard of those.” On 8/25/25 at 9:59 a.m., Staff W, Dietary Aide was observed doing a temperature check on the low-temperature dishwasher. Staff W, Dietary Aide took off her gloves after running the dishes and began to do a temperature check on the dishwasher without a hand-wash after completing a dish run-through. Staff S, Dietary Aide stated only dietary aids do the temperature dish check, and that new staff have not yet been educated on performing temperature checks on the dishwasher. On 8/26/25 at 11:25 a.m., Staff V, Cook, was observed performing the temperature check of foods and the tray prep line for lunch. During this observation is was noted that Staff V, [NAME] was performing multiple different tasks, i.e., cooking food on the stove and going back to plating food, performing temperature checks on foods in between plating lunch trays with no hand hygiene in-between. Staff P, [NAME] was also observed assisting in tray line and changing tasks with no hand hygiene being performed or gloves being worn. Staff S, Food Service Manager was observed performing tasks to assist Staff V, [NAME] with getting foods ready to be served without completing hand hygiene in-between every task. On 8/26/25 at 2:58 p.m., an interview with Staff V, [NAME] revealed that a in service education pertaining to the storing of food items was completed back in “May or June,” and a large focus was on labeling and dating food items as they come into the facility and are used. Staff V, [NAME] mentioned that if an item does not have a label it needs to be thrown away, and that if an item was dated back in April, it needs to be thrown out. Staff V, [NAME] revealed that if there is raw chicken stored in the walk-in fridge, it needs to be thrown out in three days. Staff V, [NAME] revealed that the kitchen has a daily, weekly, and monthly cleaning schedule. They used to do a deep cleaning once a month but is unsure what happened to do that. Staff V, [NAME] mentioned that hand hygiene needs to be performed after completing each task before moving on to the next task. Staff V, [NAME] explained that if a box of food is old or has bio growth on it the entire box should be discarded and not served. During an interview on 08/27/2025 at 10:43 a.m., Staff Y, CNA stated dietary is the one who is responsible for the fridge in the nourishment rooms. They have a temp log they keep but dietary is responsible for the fridge and cleaning it out. During an interview on 08/27/2025 at 10:54 a.m., Staff Z, CNA stated dietary is responsible for cleaning the nourishment rooms. On 8/27/25 at 2:45p.m., an interview was conducted with the Nursing Home Administrator, Regional Dietitian, Staff S, Food Service Manager, and Dietician revealed the NHA stated dishes are expected to be ran after every meal, all seven days of the week. Staff S, Food Service Manager explained it is the duty of the food service manager to do daily checks during morning walk-through of the dishwashing, fridge, freezer, and temperature logs to ensure that they are being completed on a daily and timely basis, and that all kitchen cleaning and temperature logs should be put into the file after they are completed. We were not able to locate any cleaning logs for the month of August. Dating and labeling expectations for open containers is all foods get a date and are labeled when they first come into the facility, and immediately after they are opened. This process goes for all items in the fridges, freezers, and dry storage areas, and if an item is not labeled it is to be discarded. Raw meat are to be pulled no more than 3 days before they are going to be prepared and put into the fridge either in their container or on a sheet pan. If there are contaminated or foods with bio growth in the fridges, freezers, or dry storage they are to be thrown away, not washed, skinned and served. Food items in the fridge or freezer are not to be near any raw meats, and should have coverings with no holes. All staff in the kitchen are to wash their hands prior to each shift, and in between each change of task. All staff are responsible for cleaning the nourishment rooms. Nourishment rooms should be gone through weekly to ensure they are clean and items are being discarded. A review of the facility’s safe handling, storage, and reheating of food from visitors or outside source- Policy & Procedure revealed that “Residents will be assisted in properly storing and safely consuming food items brought into the facility for residents by visitors.” . “When food items are intended for later consumption, the nursing staff will: 1. Ensure the food item(s) are in sealed container, stored in the nourishment room/pantry refrigerator label with the current date and name of the resident. 2. Food will be stored for up to 3 days and then discarded.” . “Temperatures will be logged” . “Food and Nutrition Services department is responsible for cleaning the refrigerator weekly. Nursing staff will check the refrigerator daily for temperature, expired food, and is responsible for cleaning up spills on an as needed basis.” A review of the facility’s Cleaning and Sanitizing Policy and Procedure revealed that “The facility promotes a safe, clean and sanitary environment for its employees, residents and visitors. The food and Nutrition Services team maintains clean and sanitary kitchen facilities. Walls, floors, ceiling, equipment, dishware and utensils are clean and/or sanitized and in good, working order.” . “The Food Service Manager will review the completed Food and Nutrition Services Master and Cleaning Schedule to ensure all kitchen equipment in the operation is included.” . “The Food and Service Manager or designee will inspect kitchen sanitation Daily, Weekly, and Monthly using the Kitchen Sanitization Checklist.” . “The Food Service Manager will train new staff on proper cleaning techniques and appropriate cleaning agents to use.” . “Food and Nutrition Services staff will follow appropriate procedures for cleaning and sanitizing kitchen equipment.” . “Record dish machine temperatures and chemical saturation PPM three (3) times daily using the Dish machine Log to ensure dishes are clean and sanitized.” . “Ensure no cross contact occurs; change gloves and wash hands when working from dirty to clean.” . “Cover trashcans with a lid when not in use and when taking them to the dumpster.” A review of the facility’s Dish Machine Policy & Procedure indicated “To monitor dish machine temperatures and chemical saturation (parts per million [PPM]) for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes.” . “Record wash and rinse temperatures under appropriate meal and column initial.” A review of the facility’s Hand Washing and Glove Use Policy & Procedure revealed “Hand washing is a vital role in infection control, reducing the surface microorganisms on our hands.” . “Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food sources, following contact with unsanitary surfaces, and before wearing gloves.” . “Gloves should be changed frequently, single use task.” . “Hands must be washed between changing gloves.” A review of the facility’s Storage Policy & Procedure revealed “To store food and dishware in a safe manner.” Dry Storage Procedure instructed to “Label products with delivery dates indicating the month and year of the product was received. Discard food by expiration or use by date.” . “Store baking ingredients and cereal in original containers or plastic containers with lids and label include the expiration or use by date.” . “Never store scoops in ingredient bins or ice machines. Always place in a separate container.” . “Pour contents of opened canned goods into plastic containers with label and date and place into refrigerator storage.” . “Dry goods may be placed in plastic bags and sealed or placed in plastic containers with label including expiration or use by date.” Refrigerator Storage Procedure instructed to “Store raw meat away from vegetables and cooked foods. Raw and/or thawing meat must be stored on the bottom shelves of the unit to prevent dropping on other foods.” . “Label products with delivery date indicating month and year the product was received.” . “Discard refrigerated leftovers after 72 hours.” . “Cover all pre-dished items with plastic wrap or foil to prevent off-flavors, drying, and/or cross-contamination.” . “Label all prepared items with the product name, preparation date and use by date.” . “Record temperatures of all refrigeration units during each shift, every day using the Refrigerator Log.” Freezer Storage Procedure states to “Label products with delivery date indicating month and year the product was received.” … “Label all prepared items with the product name, preparation date and use by date.” … “Record temperatures of all freezer units during each shift, every day using the Freezer Log.” A review of the facility’s Preparation Policy and Procedure revealed “To conserve nutritive value, enhance flavor, and prevent foodborne illness.” … “Wash hands properly and as often as needed. Note: Wash hands prior to putting on gloves and after taking off gloves.” … “Change gloves: With each new task.” … “Discard foods: Contaminated”

Based on record review and interviews the facility failed to update the facility-wide assessment to determine emergency plans, staff competencies needed for care of residents with different types of acuities and specific staffing needs for each shift.Findings Included: Review of the facility assessment dated [DATE] revealed there was not a section for emergency plans, staff competencies needed for care of residents with different types of acuities and specific staffing needs for each shift.During an interview on 08/27/2025 at 12:30 p.m., the Staffing Coordinator stated she staffs the facility daily to meet the needs of the residents based off of the daily census. She was unsure what the facility assessment was.During an Interview on 08/27/2025 at 2:06 p.m., the Nursing Home Administrator stated she just updated the facility assessment in July when she first got to the building so she would have a snapshot of the building. The facility assessment asses every aspect of the facility, residents, services, and list any employees and tracks their length of employment. It also includes any services we provide and how many residents need those services. You use the assessment to identify if there are any areas that need improvement. The facility did not provide a policy related to this cite.

Based on observations, record reviews, and interviews the facility failed to implement an effective Infection Control program related to ensuring meal carts were closed when unattended not offering residents hand hygiene prior to meals on one (100-high) of 4 hallways and two dining rooms observed, failed to remove red-stained towel from under one (#114) of one dialysis resident, failed to ensure sharps container was managed in a manner promoting safety, and failed to ensure one of one laundry room was clean. Findings included: An observation on 8/24/25 at 9:12 A.M. of a meal tray cart on the first floor was opened and contained multiple unused food trays. The food is contained in Styrofoam trays. An additional meal cart was observed at 9:15 A.M. on second floor was opened and contained multiple unused food trays. The food to be served to the residents are contained in foam take out trays. A tour of the Laundry Room on 8/27/25 at 1:00 P.M. revealed a personal cell phone on the table for folding linens. The wall air conditioning unit accordion panels behind the table for folding linens had dust and the unit was running. A floor fan facing toward the table for folding linens was resting on two black milk crates and on running high speed. There was dust wrapping the cage of the fan. In the room with 3 dryers, dryer number (#) 2 was not working and clothes were inside the dryer. The vents under dryer #1 and dryer #3 contained small balls of lint in the corners. The other room had 2 washers. The blue washer (#1) was running, while the other washer (#2) was not running. The front of the washer #2 contained three uncleanable porous foam tubes with crusty unknown substances on under the door of the washer. In front of washer #2 contained a folded wet and soiled blanket. There was a soiled folded blanket sitting on milk crate behind the washers next to drainage area. There was a rusty and uncleaned flap above the door on washer #2. The floor around both washers were dirty, unkept, and contained water stains. An interview with Staff E on 8/27/25 at 1:00 P.M. was conducted. He said the wall air conditioning unit accordion panels behind the table for folding linens are cleaned every week. He said the room where the staff folds the laundry is cleaned every morning. He said that dryer #2 is not working and maintenance has ordered the part. He said the front of the washer #2, the three uncleanable porous foam tubes has been there since before he started. He said he was unaware of the blanket behind the washers. He said the blanket in front of the washer was placed there because there is a leak under the floor of washer #2. An interview with Staff F on 8/27/25 at 1:05 P.M. was conducted. She said she cleans the floor fan facing toward the table for folding linens with a toothbrush to remove the dust. She said she is using dryer #2 as storage for clean clothes because her table where she folds clothes is full and she didn’t want to stop the dryer with the wet linens. An interview with Staff G on 8/27/25 at 1:19 P.M. was conducted. He said he started here on 7/8/25. He said he noticed the porous foam tubes on washer #2 after he started working here. A review of the facility policy titled, “Infection Prevention and Control Program” effective in October 2021, reads “The Infection Prevention and Control Program (IPCP) is comprehensive program that addresses detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement and personnel. The goals of the IPCP are to: a: Provision of a safe sanitary, and comfortable environment; b: Decrease the risk of infection and communicable diseases development and transmission to residents, volunteers, visitors, individuals providing services under a contractual arrangement and personnel; d: Identify and correct problems relating to infection control and prevention practices.” The major activities of the program are: a: Surveillance of infections and communicable diseases; b: Antibiotic Stewardship; c: Implementation of infection control and prevention measures; d: Prevention of Infection and Communicable Diseases. On 8/24/25 at 9:28 a.m. an observation was conducted on the 100-high hallway showing meal trays with foam food containers and utensils placed directly onto paper napkins. The observation showed staff leaving the cart open and unattended in the hallway outside of room [ROOM NUMBER] while other meal trays were delivered. On 8/24/25 at 2:17 p.m. an observation showed a wheeled cart with 3 shelves contained 4 meals brought to the 100-high hallway. The meal trays contained covered plates and cups while eating utensils were left open to the environment and unattended while staff passed the meal trays. On 8/24/25 at 11:23 a.m. Resident #114 was observed with a towel stained with bright red spots under the left upper arm. The resident stated the dialysis site had started bleeding the other day. The dressing on the resident’s left upper arm was white without staining. The resident reported dialysis time was on Monday, Wednesday, and Fridays. On 8/24/25 at 4:32 p.m. Resident #114 was observed with fingernails extending approximately ½ inch past fingertips. The fingernails appeared to be dirty with unknown substance. On 8/26/25 at 12:21 p.m. Resident #114 reported wanting to keep fingernails long and staff do not offer hand hygiene before meals. Review of Resident #114s comprehensive assessment, dated 5/25/25 revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating an intact cognition. On 8/26/25 at 12:31 p.m. the meal cart for 100-high arrived on the hall, Staff L, Certified Nursing Assistant (CNA) was sitting behind the nursing station and at 12:32 p.m. Staff O, CNA came out of a resident’s room on the hallway. On 8/26/25 at 12:41 p.m. Staff K, Licensed Practical Nurse (LPN) began checking trays in the meal cart. On 8/26/25 at 12:44 p.m. Staff L, CNA was observed delivering a meal tray to a resident in room [ROOM NUMBER] without offering hand hygiene to the resident and Staff O delivered a tray to a resident in room [ROOM NUMBER] without offering hand hygiene. On 8/24/25 at 11:10 a.m., a sharps container attached to a treatment cart parked next to the nursing station on the first floor was overfilled with syringes. The observation showed syringes were sticking out of the container. The sharps container label read “Do not fill above this line”. The contents of the container was clearly above the line. Review of the facility policy - Hand Hygiene effective October 2021 did not address providing residents with hand hygiene. Photographic evidence was obtained.

Based on record reviews and interviews, the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use. On review, the monitoring was not completed for four months. A review of the Antibiotic Stewardship Book on 8/27/25 at 1:40 P.M. revealed the antibiotic surveillance for August 2025 was missing. A review of May, June, and July 2025 revealed the surveillance forms are incomplete. The forms did not have the required information based on policy. The forms contained spaces for required documentation to be completed. The book did not contain mapping of infections throughout the building for months May 2025 through August 2025. An interview with the Director of Nursing (DON) on 8/27/25 at 2:25 P.M. was conducted. She said she is the facility's dedicated Infection Preventionist. She said the Antibiotic Stewardship Policy is reviewed annually. She said she uses McGeer's Criteria form and mapping for surveillance of infections. She could not locate a copy of the form. She said her expectation is that the nurse fills out the top form and she fills out the bottom portion. She said she hasn't educated the nurses on properly filling out the forms. She said she could not locate the surveillance documentation for August 2025. The DON said she always starts making the surveillance list at the end of the month, and then she documents on the facility map where each infection is located. She said she hasn't educated the staff on infection control. She said the interdisciplinary team reviews Antibiotic Stewardship in Quality Assurance meetings monthly but could not provide evidence of discussion for May, June, and July 2025. She could not locate a copy of the point prevalence rate for May, June, and July 2025. She said she doesn't allow physicians to write antibiotic orders prophylactically. A review of the facility's policy Antibiotic Stewardship - Tracking: Monitoring Antibiotic Prescribing, Use, and Resistance, effective in April 2017, revealed the procedure is Residents will have complete clinical assessment documentation at the time of the antibiotic prescription. Audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the facility or a transferring facility. Antibiotic prescribing elements will be addressed for the presence: 1. Dose; 2. Route; 3: Duration; 4. Start Date; 5. End Date; 6: Planned days of therapy; 7. Indication. The policy revealed community acquired infection antibiotic prevalence data will be monitored and information presented during the monthly Quality Assurance and Performance Improvement Committee meeting, by the Infection Preventionist. The policy revealed by tracking antibiotic usage of those residents admitted into the facility, the total risk of individuals at risk for complications from antibiotic use can be followed. The policy revealed when providing point prevalence rates, the Infection Preventionist will obtain census information from the electronic documentation system and generate a midnight census report for the date in question. New antibiotic starts will be monitored by the Infection Preventionist as part of their surveillance activities.

Based on observations, interviews, and facility policy review, the facility failed to provide activities on three out of four days observed.Findings included:On 08/24/2025 at10:30 a.m., and 1:30 p.m., an observation was made revealing no activities were conducted throughout the day as scheduled.On 08/25/2025 at 9:30 a.m.,10:30 a.m., 11:15 a.m., 1:40 p.m. and 3:30 p.m., observations were made revealing no activities were conducted throughout the day as scheduled.Review of an Activity Calendar for the month of August of 2025, revealed on 8/24/2025 activities were scheduled at 10:30 a.m. for Pokeno 2, 1:30p.m. Blackjack, and 3:30 p.m. [Church]. On 8/25/25 activities were scheduled at 9:30 a.m. Room Visits 1,2 10:30 a.m. Movement and Music. 11:15 a.m. Sing a Long. 1:45 p.m. Bingo 1. 3:30 p.m. Movie Monday. On 08/26/2025 at 9:30a.m. Room Visits 1,2 10:30 a.m. Trivia, 1:45 p.m. [Church], 2:30 p.m. Blackjack 2, and 4:00 p.m. Game Time.On 08/27/2025 at 10:41 a.m., an interview was conducted with the Director of Nurses (DON). The DON said activities were not conducted because the Activity Director has been out since last Friday. She said the person they had assigned to cover activities had called out and there was no one to conduct activities.On 08/27/2025 at 4:00 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA said when the Activity Director is out there should be someone covering activities for the residents. If staff were aware the person assigned to activities had called off, then there should have been someone pulled to conduct activities for the residents.Review of the facility policy titled, Activities Overview Effective Date October 2021, revealed policy: Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs, The Activity Programs will reflects individual needs and provide/promote the following: Activity will be provided at a frequency to meet the individual needs of the residents.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, the facility failed to ensure residents were offered the COVID Vaccine for three (Resident #3, #88, and #119) of five residents sampled.Review of Resident #3 records showed the resident was not offered the COVID Vaccine. Review of Resident #88 and #119 records showed the resident was offered the COVID Vaccine and no documentation that indicated the resident received the COVID Vaccine.An interview with the Director of Nursing (DON) on 8/27/2025 at 2:25 P.M. was conducted. She said she is the facility's dedicated Infection Preventionist. She said she is waiting on a new code from Florida Shots. She said she hasn't checked any of the residents' immunization status. She said her expectation is the residents are offered Influenza, Pneumonia, and COVID vaccine every 5 years. She said she hasn't educated any residents at the facility, but there should be a form the staff completes when the education is provided.Review of the facilities policy titled, Immunizations - Pneumococcal, Influenza, and Other Recommended Vaccinations effective in December 2024, reads, Influenza vaccine will be administered by a licensed nurse who is following the facility's protocol to obtain an order on admission for the administration of an annual influenza vaccine injection. Immunization will be offered from October to March. The Infection Prevention Coordinator/DON will coordinate the Influenza and Pneumococcal immunizations. All residents, regardless of age and medical condition, will be offered the COVID-19 primary series vaccinations and all eligible and recommended boosters unless there is documented evidence of prior administration, documented medical contraindication, refusal, or no order. The Procedure section of the policy reads, 1. COVID-19 primary series and any boosters - Document dates and types in the immunization tab in the medical record. 2. Obtain consent for immunization or immunization declination on the Pneumococcal and Annual Influenza Vaccination Information and Request Form; and on the COVID-19 Vaccination or boosters on the vaccination consent or declination forms. 3. Obtain a physician order for all vaccines to include Influenza, COVID-19, or booster and the Pneumococcal (if indicated) immunization. 6. Document the administration of the vaccination in the electronic medical record.

Based on record reviews and interviews, the facility failed to ensure residents were offered the Influenza vaccine annually and offered the Pneumococcal Vaccine for four (Resident #3, #88, #110, and #119) of five residents sampled. Review of Resident #3, #88, and #119 records showed the resident was not offered the Influenza Vaccine. Review of Resident #110 records showed the resident was offered the Influenza Vaccine and no documentation that indicated the resident received the Influenza Vaccine.Review of Resident #88 and #119 records showed the resident was not offered the Pneumococcal Vaccine. Review of Resident #3 records showed the resident was offered the Pneumococcal Vaccine and no documentation that indicated the resident received the Pneumococcal Vaccine.An interview with the Director of Nursing (DON) on 8/27/2025 at 2:25 P.M. was conducted. She said she is the facility's dedicated Infection Preventionist. She said she is waiting on a new code from Florida Shots. She said she hasn't checked any of the residents' immunization status. She said her expectation is the residents are offered Influenza, Pneumonia, and COVID vaccine every 5 years. She said she hasn't educated any residents at the facility, but there should be a form the staff completes when the education is provided. Review of the facilities policy titled, Immunizations - Pneumococcal, Influenza, and Other Recommended Vaccinations effective in December 2024, reads, Influenza vaccine will be administered by a licensed nurse who is following the facility's protocol to obtain an order on admission for the administration of an annual influenza vaccine injection. Immunization will be offered from October to March. The Infection Prevention Coordinator/DON will coordinate the Influenza and Pneumococcal immunizations. The facility will continue to offer vaccines to unvaccinated persons and newly admitted residents all throughout the Influenza season as recommended. The Procedure section of the policy reads, 2. Obtain consent for immunization or immunization declination on the Pneumococcal and Annual Influenza Vaccination Information and Request Form. The Influenza vaccination will be offered annually, and a new request form will be signed annually, and a new physician order will be obtained. 3. Obtain a physician order for all vaccines to include Influenza, COVID-19, or booster and the Pneumococcal (if indicated) immunization. 6. Document the administration of the vaccination in the electronic medical record.

Based on observations, interviews, and record review, the facility failed to provide a building in good repair, related to cleanliness, holes in walls, bio growth and unpainted walls in two wings (100 East, 200 East) of the four facility wings toured. Findings included: During a tour of the facility on 08/24/2025 at 9:30 a.m., it was observed, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had a peeling ceiling, room [ROOM NUMBER] had a hole in the wall and unpainted wall, room [ROOM NUMBER] had an unpainted wall, room [ROOM NUMBER] had no baseboards and unpainted walls, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had an unpainted wall and bio growth on the window sill.During a tour of the facility on 08/27/2025 at 1:23 p.m., it was observed, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had a peeling ceiling, room [ROOM NUMBER] had a hole in the wall and unpainted wall, room [ROOM NUMBER] had an unpainted wall, room [ROOM NUMBER] had no baseboards and unpainted walls, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had a hole in the wall, room [ROOM NUMBER] had an unpainted wall and bio growth on the window sill. During an interview with the Maintenance Director (MD) on 08/26/25 at 11:15 a.m., the MD stated, I have previously worked in long term care facilities and have an extensive background in facility maintenance. The MD said it is the MD's responsibility to maintain the building, all the equipment and the items in the facility, including mechanical and electrical. I had planned to do a comprehensive room-to-room review; however, I had not gotten that done to date. Residents can report issues with their rooms to any staff member. Once reported, the staff puts the work order into the electronic reporting system. The MD said a notification is alerted to the cell phone that there is a work order in the electronic reporting system. From there the MD prioritizes as to what gets fixed first. The system allows the MD to prioritize based on the MD experience. Once the prioritization is determined, then we just start at the top or request items from a vendor for repair and then make the necessary repairs. During a tour on 08/26/2025 at 2:10 p.m. with the MD, of rooms,122, 218, 223, 224, 225, 227, 228 and 229, the MD stated, I have no answer for the issues with the rooms.During a tour on 08/27/25 at 3:15 p.m. with the MD of room [ROOM NUMBER], the MD stated, we do not currently have any resolution to fixing the ceiling or moving the residents out of the area. Review of an unsigned undated document named, work orders open and in progress, showed only one room [ROOM NUMBER], was identified as having wall damage. Review of an undated, unsigned, job description titled Maintenance Director, showed the Maintenance Director is responsible for the overall maintenance of the facility and provides direction for all activities related to plant operations. The maintenance director ensures the facility, equipment and utilities are maintained in good working order and facility grounds are properly maintained in accordance with the facility policies and state and federal regulations.The essential Duties and Responsibilities showed:Perform minor repairs and supervise the day-to-day repair, improvement and preventative maintenance of the facility to ensure that machines continue to run smoothly, building systems operate efficiently, or the physical condition of facility does not deteriorate.Make job assignments and set priorities. Review of the facility's policy and procedure, dated 08/2024 titled Physical Environment, showed the facility will provide a safe, clean, comfortable, and home-life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide residents with needed services. All essential mechanical, electrical, and resident care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. (Photographic Evidence Obtained)

Based on observation, record review, and interview the facility failed to ensure the medication error rate was less that 5.00%. Thirty medication administration opportunities were observed and two errors were identified for one (#17) of five residents observed. These errors constituted a 6.67% medication error rate.Findings included: On 8/26/25 at 9:13 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #17. The staff member dispensed the following medications:- Amolodipine 5 milligram (mg) oral tablet- Buspirone 5 mg oral tablet- Famotidine 10 mg over the counter (otc) tablet - 2 tablets- Ferrous sulfate 325 mg otc tablet- Polyethylene glycol 3350 1 capful powder- Potassium chloride Extended Release (ER) 20 milliequivalents (meq)- Senna 8.6 mg otc tablet- Sodium Chloride 1 gm, 15.4 grain otc tabletThe staff member reported having to see about changing the resident's lactobacillus tablet to the house probiotic and change the docusate from capsule to tablet. The staff member confirmed dispensing 9 medications. Staff I received order from provider (who was in the facility) to change docusate from capsule to tablet and lactobacillus to saccharomyces. The staff member changed the orders in the electronic medication profile and administered the 9 medications to the resident. On 8/26/25 at 9:36 a.m. Staff I electronically signed the medications had been administered. Review of Resident #17s August 2025 Medication Administration Record (MAR) showed an order dated 8/13/25 and discontinued on 8/26/25 at 9:33 a.m. for Docusate Sodium Oral Capsule - Give one tablet by mouth every 12 hours for constipation. The MAR showed Staff I had documented 9 other/see nurse's notes. An order for Docusate Sodium Oral tablet 100 mg - Give 1 tablet by mouth every 12 hours for constipation was ordered on 8/26/25 at 9:32 a.m and scheduled to begin at 9 p.m. on 8/26/25. The order for Resident #17s Floranex (Lactobacillus) was ordered on 8/13/25 for two times a day (9 a.m. and 5 p.m.) for probiotic and showed the medication was a otc medication provided by the facility and pharmacy was not to send. The order was discontinued on 8/26/25 at 9:30 a.m. and Staff I had documented 9. An order was written on 8/26/25 at 9:30 a.m. for Saccharomyces boulardii - one capsule by mouth two times a day for gastrointestinal (GI) upset. The order was scheduled to begin on 8/26 at 5:00 p.m. An interview was conducted on 8/27/25 at 8:31 a.m. with the Director of Nursing (DON). The observation of Resident #17s medication administration was reviewed and the DON stated both medications should have been given after the orders were changed. Review of the policy - Medication Administration Orals, dated 11/17, revealed the policy was to administer oral medications in an organized, accurate, and safe manner. The procedure included the instructions for staff to:5. Review and confirm medication orders for each individual resident on the medication administration record PRIOR to administering medication.6. Perform hand hygiene.7. Pour the correct number of tablets or capsules into the medication cup, taking care to avoid touching any medication unless wearing gloves.

Based on record reviews and interviews, the facility failed to ensure the grievance process was followed for one resident (#45) and Resident Council members out of three residents reviewed for grievances. Findings included: On 8/27/25 at 1:13 p.m., an interview with Resident #45 revealed that the resident has been missing three pairs of cargo pants, has had a second pair of pants discolored/damaged from laundry, and complains that staff is not taking his soiled linens daily to be washed. Resident #45 expressed that the facility has yet to replace the damaged and lost items despite advising Resident #45 that they will be replaced and creating a grievance for each occasion. A review of Resident #45's admission record revealed an original admission date of 2/15/2024, and a re-admission date of 8/14/2025 with diagnosis to include type 2 diabetes, and chronic kidney disease. Review of the facility's Grievance Log dated from August 2024-August 2025 showed two documented grievances for Resident #45 in regard to laundry. A review of Resident #45's Grievance/Concern Report dated 11/23/2024 initiated by Resident #45, revealed Resident #45 reported three pairs of cargo pants are missing. The conclusions for grievance dated 11/23/24 revealed a hand written note stating Unable to locate 3 pairs of cargo pants. The grievance report was not checked off on whether the issue was resolved or not. The Date Assigned for this grievance was 11/25/24, and Date Resolved By is empty. A review of Resident #45's Grievance/Concern Report dated 2/26/25 , revealed one pair of green pants were sent to the laundry and came back a rust color. Resident #45 expressed Certified Nursing Assistant (CNA) staff are not taking dirty clothes to the soiled linen room daily. The facility noted the follow-up plan was for the laundry supervisor to check the chemicals in the washing machine, and for CNAs to remove soiled linens from the resident's room. The conclusions for grievance dated 2/26/25 were Resident #45's pants were discolored from laundry, CNAs are to pick up the resident's linens, and the facility will order Resident #45 new pants. The Date Assigned for this grievance was 2/26/25, and Date Resolved By is 2/28/25. The grievance report Resolution was checked as Not Confirmed. 2. During a resident council meeting on 8/25/2025 at 3:06PM, multiple residents mentioned that the facility is slow acting on grievances and grievances being completed, especially in regard to laundry. Residents were experiencing missing and damaged clothing and have not heard back on a conclusion with grievances made pertaining to laundry. On 8/27/25 at 1:38 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported she cannot tell what has been done in regard to the grievances made by Resident #45. The NHA explained Resident #45's pants were not returned because they probably did not have an identification label and were not on the resident's inventory sheet. The NHA said clothing items that do not have a label, go on a No Name rack so staff can go and look for any missing items of residents, but Resident #45's missing items were not found there. The NHA expressed expectations were for Resident #45 to be reeducated on the process and policy of purchasing items and at least advising the Certified Nursing Assistant (CNA) or Nurse to label and add the items to the resident's inventory sheet. The NHA confirmed even though the grievances were marked as complete, there was no follow up or course of action describing the action taken by the Social Worker, and that grievances should only be marked as completed as soon as Resident #45's pants were purchased back and received by the facility. The NHA verified that the marked completed grievances were not followed out as notated, and there is no receipt or proof of repurchase by the facility. A review of the facility's Grievance/Concern Management Policy & Procedure, with an effective date of May 2025 revealed that rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. Social services will monitor and document resident/representative satisfaction upon completion of the investigation and the summary of findings/conclusion. The facility leadership team will review and discuss concerns and the progress of an investigation(s) and resolution(s). Concerns are tracked, trended, and reported in the monthly Quality Assessment, Assurance and Compliance Committee Meeting. Complete a concern report investigation with summary and conclusion. Social Services staff will provide information regarding compliance line information for unresolved concerns.

Based on observations, record reviews, and interviews the facility failed to complete a Level II Pre-admission Screening and Resident Review (PASRR) for one resident (#3) and failed to ensure the accuracy of a Level I PASRR for one resident (#4) out of thirty-five initial pool residents. On 8/24/25 at 12:25 p.m. Resident #3 was observed lying in bed, with eyes closed and rhythmically breathing. Review of Resident #3’s admission Record showed the resident had been admitted on [DATE]. The record included diagnoses not limited to unspecified bipolar disorder, unspecified insomnia, and unspecified depression. Review of Resident #3’s PASRR dated 7/11/25 revealed it was completed at this facility and showed the resident had diagnoses of bipolar disorder, depressive disorder, and Post-Traumatic Stress Disorder (PTSD). The screening showed the resident was exhibiting signs and symptoms (s/s) of depression as spouse recently passed. The decision-making portion of the PASRR did not reveal the resident had any disorder resulting in functional limitations, did not typically have any issues with interpersonal functioning, concentration, persistence or pace, and/or adaption to change. The screening completion showed the resident did not have a diagnosis or suspicion of serious mental illness or intellectual disability therefore a Level II PASRR evaluation was not required. Review of Resident #3’s Care Plan revealed a focus for Trauma Informed Care – PTSD diagnosis due to being a war veteran and used psychotropic medications to manage bipolar disorder and insomnia. An interview was conducted on 8/27/25 at 5:33 p.m. with the Director of Clinical Reimbursement (DCR). The DCR stated if a resident had a diagnosis of PTSD and bipolar and stayed in the facility longer than 30 days a Level II PASRR was needed. 2. A review of Resident #4‘s admission Record revealed an original admission date of 1/2/2023, and a re-admission date of 6/17/2025. The diagnoses included depression (1/5/23), insomnia (1/9/23), and anxiety (9/22/23). A review of Resident #4‘s Level I PASRR, dated 1/9/23, under Section I-Part A MI (Mental Illness) or suspected MI, indicated only depressive disorder. On 8/27/2025 at 2:36 p.m., during an interview the DCR said that updating PASRRs are the responsibility of Social Services, but the Minimum Data Set personnel do a PASRR if anything such as new diagnoses needs to be added. The DCR mentioned that she started doing this task “maybe a week ago to help out.” The DCR revealed that the PASRR process starts when the admissions packet is received. A review is done and if corrections need to be made, then they are corrected. The DCR is not sure if there is a review process for PASRRs on a regular basis and the DCR only reviews them if a change of diagnosis is made. The DCR confirmed that the PASRR for Resident #4 is missing anxiety, and mentioned that she knows some PASRRs list insomnia, but not sure if it has to be documented on the PASRR for a resident. The DCR mentioned that she is not sure why the PASRR for Resident #4 is not updated with the new diagnosis from 2023, or when Resident #4 was re-admitted to the facility. A review of the facility’s PASRR-Requirements for Completion Policy, with an effective date of August 2025 revealed that “Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program… required to be performed on all individuals prior to admission to a Nursing Home.” . “The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services.” . “The facility administration will confirm a Level I review has been completed prior to transfer to the SNF setting.” . “Determine if a serious mental illness and / or intellectual disability or a related condition exists while reviewing the PASRR form completed by the Acute Care Facility. (Trigger for Level II Completion)” . “If Serious Mental Illness or ID [intellectual disability] is indicated, determine if the resident will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30-days of Nursing Facility services. Assure that the certificate is signed and dated.” . “If the admission is a provisional admission, the Social Service Director must start a tickler file and assure the Level II is completed within the state specified time frame.” . “If the preadmission screening requires a Level II evaluation submit all required documents to CARES timely, so that a Level II can be completed within the required time frames.”

Based on observations, record reviews, and interviews the facility failed to provide nail care for two residents (#97 and #45) out of five residents sampled for activities of daily living.Findings included: 1. On 8/24/25 at 12:35 p.m. Resident #97 was observed lying in bed. The resident was very pleasant and answered questions appropriately. The observation revealed the resident’s fingernails on both hands extended approximately 1/3 to ½ inch past the fingertips and were discolored. The resident reported not wanting long fingernails and staff had not offered to cut them. Resident #97 said it had been at least one month since the fingernails had been clipped. On 8/26/25 at 12:03 p.m. Resident #97 was observed with fingernails 1/3 to ½ inch past the tips of the fingers. The fingernails were discolored with a dark substance. The resident stated staff had not offered to cut them and yes, the resident would allow them to do so. On 8/27/25 at 9:09 a.m. Resident #97’s fingernails continued to be long and discolored. Review of Resident #97s admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle wasting and atrophy not elsewhere classified multiple sites, other lack of coordination, and adult failure to thrive. Review of Resident #97s Certified Nursing Assistant (CNA) tasks showed staff are to perform nail care with personal hygiene/oral care. The task documentation showed the resident was to receive nail care as needed (prn). The documentation revealed staff had documented nail care had been provided eight out of twenty-seven days, and nail care had not been provided on the resident’s shower days of 8/5/25, 8/12/25, 8/15/25, 8/19/25, 8/22/25, and 8/26/25. The documentation showed the resident was to receive a shower on the 3:00 p.m. – 11:00 p.m. shift on Tuesdays and Fridays and showed the resident had not received a shower on Tuesday 8/5/25 and Tuesday 8/12/25, revealing the resident had three showers in 15 days. Review of Resident #97s care plan showed the resident had an ADL self-care performance deficit related to (r/t) weakness (and) activity intolerance. The interventions showed CNAs were to set up for oral care and personal hygiene and assist of one for bathing. The care plan revealed the resident had impaired cognitive function/dementia or impaired thought process related to (r/t) dementia and instructed staff to explain care before providing it, ask yes/no questions in order to determine the resident’s needs, and to request feedback to ensure understanding. The care plan did not include any focuses and/or interventions related to the resident’s behavior of refusing care. An interview was conducted on 8/27/25 at 11:27 a.m. with the Nursing Home Administrator (NHA). The NHA stated staff could clip fingernails on certain residents and diabetics would put on list for podiatry to see. The NHA reported believing podiatry could clip fingernails also, can file them down. An interview was conducted on 8/27/25 at 1:38 p.m. with the Director of Nursing (DON). The DON reported aides and nurses could cut fingernails and fingernails are cut by nurses for diabetic (resident's). 2. On 8/24/25 at 11:56 a.m., an observation of Resident #45 revealed long fingernails that had a dark brown substance caked underneath. On 8/27/25 at 1:13 p.m., an interview with Resident #45 revealed the resident preferred to be showered, and nails clipped and upkept. Resident #45 stated that the staff never mentions anything about cutting his nails, and that he would prefer them to be cut, Resident #45 also revealed that the staff has been cutting his toenails only once every two months. Resident #45 would independently cut their nails if they had the supplies to do so. Resident #45 had a scheduled shower on 8/25/25 and was still observed with long, dirty fingernails. A review of Resident #45’s admission record revealed an original admission date of 2/15/2024, and a re-admission date of 8/14/2025. A review of Resident #45’s care plan revealed ADL instruction to “Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.” A review of Resident #45’s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section GG- Functional Abilities, the resident required supervision or touching assistance for shower/bathe self-assessment and is independent for personal hygiene. A review of Resident #45’s Nail Care task, with a look back over the last 30 days, revealed that Resident #45 did not receive nail care on 7/31/25, 8/2/25, 8/4/25, 8/15/25, 8/16/25, 8/17/25, 8/18/25, 8/20/25, and 8/24/25 marked as “No Nail Care.” A review of Resident #45’s bathing log revealed a shower schedule for Monday and Thursday during the evening shift. The Administrator was requested to provide the past 60 days of shower logs for Resident #45 but was only able to find shower logs for 8/18/25-8/25/25. Review of shower sheets for 8/18/25 and 8/21/25 revealed no answer was indicated for the question, “Does the resident need his/her toenails cut?” An interview on 8/27/25 at 10:56 a.m., with Staff T, Certified Nursing Assistant (CNA) said Resident #45 does not refuse ADL and nail care often, and that refusals for ADL care are documented on the resident’s shower sheets and tasks, but the reason for refusal is written in “from time to time, but most of the time it is just documented as ‘refused.” Staff T, CNA mentioned that the nurse is made aware when refusals for ADL care are made. An interview was conducted on 8/27/25 at 5:25 p.m., with Staff Q, CNA. Staff Q, CNA said “not sure” if ADL care is provided for Resident #45 and her other residents when she is pulled to do kitchen duties. Staff Q, CNA mentioned she provides ADL care for Resident #45 when she has the time and is availability to complete the task. An interview on 8/27/25 at 4:57 p.m., the Director of Nursing (DON) revealed that ADL care should be provided to residents on the following shift and day if the resident is not available for care or refuses care and should be documented along with the reason for refusal on the resident’s shower sheet. The DON reviewed Resident #45’s fingernail photograph and confirmed the state of Resident #45’s nails are not acceptable. A review of the facility’s Care and/or Treatment Declination revealed “The form will be completed and signatures obtained on all residents who choose not to accept the recommended care and/or treatment.” … “Record exactly what the resident/resident representative gives as a reason for refusing the proposed care/treatment plan.” An interview was conducted on 8/27/25 at 6:05 p.m. with the Regional [NAME] President (RVP). The RVP stated the facility did not have an ADL policy. (Photographic evidence obtained)

Based on observations, record reviews and interviews, the facility failed to provide assistance out of the bed for one dependent resident (#127) out of four residents sampled.On 08/24/2025 at 10:00 a.m., Resident #127 was observed lying down in bed with her call light within reach. She said staff will not assist her on the toilet whenever she asked them.On 08/24/2025 at 1:00 p.m., and on 08/24/2025 at 11:00 a.m., Resident #127 was observed lying down in bed. She said she has not been able to go to activities because staff will not get her up.Review of Resident #127's admission Record revealed Resident #127 was admitted to the facility on [DATE] with diagnoses to include but not limited to muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified fracture of right femur, sequela, type 2 diabetes mellitus with unspecified complications.Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicated intact cognitive abilitiesReview of Resident #127's activity of daily living (ADL) care plan with an initiated date of 08/15/2025 revealed a focus for Resident #127 has an ADL self-care performance deficit. The care plan goals revealed will prevent decline in ADL self-performance through next review (revision date 08/20/2025). The care plan interventions for transfer revealed Resident #127 is an assist of one staff participation with transfers. Date initiated 08/15/2025, revision date 08/27/2025.On 08/25/2025 at 1:00 p.m. an interview was conducted with Staff AA. Certified Nursing Assistant, CNA. Staff AA said she has taken care of Resident #127 for a week. Staff AA said Resident #127 is a two person assist with the mechanical lift. She said she has not assisted Resident #127 out the bed. Staff AA said she only gets residents up whenever they ask her to get up.On 08/27/2025 at 10: 41a.m., an interview was conducted with the Director of Nursing (DON). The DON said every resident should be offered to get out the bed. It is not acceptable for staff to say they are not getting their residents up because the residents did not ask them to.Review of the Certified Nursing Assistant (CNA) Job Description, dated 07/1/2019, revealed Summary of position: Under the supervision and guidance of a licensed nurse Registered Nurse or License Practical Nurse (RN/ LPN), well as other work on the unit which supports the patient environment. The CNA assists staff to ensure optimal patient care and assists the healthcare team to provide and maintain a clean, safe, and attractive environment for patients. Work will include components of direct patient care, nutrition, observation, documentation, transportation of patients and supplies, hygiene and general maintenance of the residents/ patient's environment.Essential Duties and Responsibilities (To be completed without harming or injuring the resident/patient, co-worker, self, or others):Assists with lifting, turning, moving, positioning, and transporting residents/patients into and out of beds, chairs, bathtubs, wheelchairs, lefts, etc.Transfer residents/ patient safety. Some examples are, but not limited to: Bed to a wheelchair or wheelchair to bed.

Based on observations, record reviews, and interviews the facility failed to assess and obtain podiatry services for one (#114) of one resident sampled for foot care and podiatry needs. Findings included: On 8/26/25 at 12:21 p.m., Resident #114 was observed lying in bed. The resident reported wanting to keep fingernails long however needs a podiatrist to cut toenails.On 8/26/25 at 12:35 p.m. an observation was conducted with Staff K, Licensed Practical Nurse (LPN) of Resident #114s toenails on both feet. The toenails were malformed lifting up from nailbed, thickened grayish brown in color, and extending past the tip of toes.An interview was conducted on 8/26/25 at 12:38 p.m. with Staff K. The staff member placed the resident's name in the Social Service folder and stated the resident was on the list for Social Worker to put on the podiatry list. Staff K stated the aides see resident daily and the issue with Resident #114s toenails was not brought to the staff members attention.Review of Resident #114s admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to chronic respiratory failure unspecified whether with hypoxia or hypercapnia, end stage renal disease, and dependence on renal dialysis.Review of Resident #114s physician orders showed an order dated 5/19/25 to allow for Opthalmic, Auditory, Psychological, Psychiatric, Dental, Physiatry, and Podiatry services as needed. Review of Resident #114s comprehensive assessment, dated 5/25/25 revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating an intact cognition.Review of Resident #114s Certified Nursing Assistant (CNA) documentation showed the resident received nail care as needed (PRN), which did not differentiate between fingernails or toenails, as needed on 10 of twenty-seven opportunities.Review of Resident #114s care plan revealed the resident had the preference/choice of refusing recommended supplements at times. The preference/choice focus did not show the resident had refused nail care and/or podiatry care. The care plan had an Activity of Daily Living self-care performance deficit and interventions showed the resident required personal hygiene with one assist.An interview was conducted on 8/27/25 at 11:27 a.m. with the Nursing Home Administrator (NHA). The NHA stated nursing was to put in a referral for the ancillary services and did not know how often podiatry comes on a monthly basis. The NHA stated the expectation is if nursing saw an issue with a resident's feet they would notify the Social Worker of need to see the podiatrist and had heard the Social Worker ask during clinical meetings if anyone needed to see ancillary services.An interview was conducted on 8/27/25 at 1:38 p.m. with the Director of Nursing (DON). The DON stated aides and nurses would document in the Plan of Care (POC) and it would alert nursing management team to notify Social Services who is the one to put on the list to see podiatry. The podiatrist comes in monthly. The DON stated aides are supposed to let nurses know if there was an issue with toenails so nurses can assess and allow for nursing management know of an issue. The DON reported not remembering if podiatry had been at the facility the month of August.Review of Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, revealed The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Based on observations, record reviews, and interviews the facility failed to initiate care plan interventions related to the placement and functioning of an electronic wander device for one (#97) of one resident sampled and to ensure staff followed protocol when a door alarm system alerted of an issue. Findings included: On 8/24/25 at 12:35 p.m. Resident #97 was observed in a room near the end of the 100 high hallway. The resident was very pleasant and able to answer questions appropriately. On 8/24/25 at 1:55 p.m. an alarm for the exterior double doors at the end of the 100 high hall was beeping. Staff N, Certified Nursing Assistant (CNA) was observed passing ice to two residents on the hallway, then the staff member went to the end of the hallway and shut off the alarm (keypad). The staff member did not look outside of the door. On 8/25/25 at 11:34 a.m. the alarm for the exterior double doors at the end of the 100-high hall was alarming. Resident #97 was observed lying in bed. On 8/26/25 at 12:01 p.m. Staff K, Licensed Practical Nurse (LPN) was observed shutting off the door alarm to the exterior double doors at the 100 high hall without checking the door. On 8/26/25 at 12:03 p.m. Resident #97 was observed in room, wearing short non-slip socks. The resident was not wearing an elopement bracelet on either wrist and did not appear to be wearing one on either ankle. The resident stated the bracelet was to big and having small wrists. An interview was conducted on 12:09 p.m. Staff K stated Resident #97's elopement bracelet should be on the resident's left ankle as most of the time it's on the left. On 8/26/25 at 12:11 p.m. an observation was conducted with Resident #97. The resident pulled both socks to the heel and no elopement bracelet was observed on either. An interview was conducted on 8/26/25 at 12:13 p.m. with Staff L, CNA. The assigned staff member stated Resident #97 does not leave room except with therapy and does not have an elopement bracelet. The resident has a wheelchair but barely used it except with therapy. Staff L reported the resident empties catheter bag by self and takes self to the bathroom. Staff K was observed in the hallway on 8/26/25 at 12:17 p.m. and stated it looked like the resident had taken the bracelet off. The staff member reported at 12:24 p.m. to finding the transmitter in Resident #97s sheets and stated (pronoun) took it off clean. Review of Resident #97s admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to Unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety and other lack of coordination. Review of the CNA bedside tasks revealed Resident #97 was independent with bed mobility and was ambulatory with walker and wheelchair requiring supervision. The monitoring portion of the tasks did not include the monitoring for elopement. Review of Resident #97s care plan showed the resident was at risk for elopement, initiated on 8/4/25 and revised on 8/24/25. The goal showed the resident would not exit the facility without staff knowledge or appropriate supervision, initiated on 8/4/25 and on 8/24/25. The interventions included:- Apply electronic wander bracelet (check function after placed), initiated on 8/4/25 for Registered Nurse/Licensed Practical Nurse (RN/LPN), Unit Manager (UM) and Director of Nursing (DON).- Apply electronic wander bracelet due to elopement risk, initiated on 8/4/25 for RN/LPN.- Communicate to staff regarding resident elopement risk, initiated 8/4/25.- Verify the location of the electronic wander bracelet during routine care, initiated 8/4/25 for the RN, LPN, and CNA. Review of Resident #97s Treatment Administration Record (TAR) revealed the following:- Dated 8/24/25 for Electronic Wander Bracelet: check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly every night shift.- Dated 8/24/25 at 1:04 p.m. for Electronic Wander Bracelet: check placement daily every shift. The order was discontinued on 8/26/25 at 12:25 p.m. and showed the placement was not checked on the day shift of 8/25/25. The order did not reveal the location of the wander bracelet.- Dated 8/26/25 at 12:25 p.m. for Electronic Wander Bracelet: check placement to left ankle daily every shift. An interview was conducted on 8/27/25 at 1:54 p.m. with the DON. The DON stated Resident #97 had dementia and able to be mobile so was considered an elopement risk. The DON reported never seeing the resident out of bed and should do another (elopement) assessment. She reported when a door alarm sounded staff should be going to the door to ensure a resident had not gone out the door, go outside and check grounds, and do a facility sweep. Staff should be making sure nobody went out the door. Review of the policy, Elopement - Facility Practices, dated October 2021, revealed The facility team will assess the environment to identify potential risk associated with the elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/ or hazards associated with the elopement.1. Assess the security of potential internal environmental risk factors including, but not limited to the following:- elevators- exit doors- screens- stairwells- windows2. Maintain door alarms and wander control systems in proper working order.4. Review and correct deficiencies and practices as they relate to the following, including, but not limited to:- Cueing devices/ monitors- Resident/ Patient identification systems- Response to alarms- Testing of alarms7. Validate, through observation, the resident/ patient is wearing an electronic device every shift as indicated in document on the TAR.8. Validate daily that the electronic device is properly functioning and document um the TAR.

Based on record reviews and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as body weight for two (Resident #3 and #28) of three residents sampled. Review of Resident #28s admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to Muscle Wasting and Atrophy not elsewhere classified multiple sites, Iron Deficiency Anemia, Oropharyngeal Phase Dysphagia, Type 2 Diabetes Mellitus, and Depression. Review of Resident #28s weight summary showed on 4/3/25 the resident weighed 233.6# via mechanical lift, on 5/14/25 the resident weighed 224# via mechanical lift, a weight loss of 9.6#s and weight loss of 4.11%, and on 8/12/25 the resident weighed 198.2# via mechanical lift, a total weight loss of 35.4# and a total weight loss of 15.15% since admission. Review of Resident #28s Weight Change Note created on 8/18/25 by the Dietitian showed the resident triggered for significant weight loss. “Weight loss not new. Weight loss related to fluid shifts with lymphedema and diuretic treatment (Tx). No new recommendations at this time. Continue current plan of care. Will monitor and follow accordingly.” Review of Resident #28s Care Plan showed the resident is at nutritional risk related to recent hospitalization, IVFs in hospital, Advanced age, High BMI, Therapeutic diet, requires assistance with all ADL's, predicted sub-optimal oral (PO) intake, Psychotropic medications, Diuretic Tx (may affect weight/electrolytes), BLE edema, weight loss is anticipated as edema resolves, dependent on oxygen (O2), altered labs, and impaired skin integrity. The focus was initiated on 04/04/25. The goal was to maintain nutritional intake and initiated on 4/4/25. The interventions, initiated on 4/10/25, were monitor weight changes, diet as ordered, fluids as ordered, Registered Dietitian consult & follow as needed (PRN), supplements as ordered, report results to Medical Doctor (MD) and follow up as indicated, Observe/document as indicated: Meal Consumption, Amount assistance needed with meal, tolerance to diet/fluids, and Notify/Report to physician as needed. The interventions did not show any intervention was added after the resident’s significant weight loss was discovered. Review of Resident #28s Physician Order Summary Report showed an order written on 4/3/25 allowing to Delegate to dietitian the responsibility to alter, change, or modify dietary orders including oral supplements, measurement of height and weight, modification to or addition of diet restrictions/therapeutics, downgrade of diet consistency in consultation with SLP when needed, enteral feeding and water flushes. The order report showed Resident #28 was to receive a house diet of House diet, Regular texture, Regular (Thin) consistency for Diet. The order report showed Resident #28 may not have dietary liberties on special occasions. The Order Summary Report did not include the dietician’s recommendation for weekly weights. On 8/24/25 at 12:00 P.M. Resident #28 was observed laying in bed with eyes opened, and her bilateral lower extremities were red and appeared puffy. During an interview on 8/24/25 at 12:00 P.M. with Resident #28, she stated she has lost 40 pounds since she was admitted . She said, “I don’t eat the food, it’s gross.” She said when she asks for something different, the staff tell her no. She said she is not offered snacks. During an interview on 8/26/25 at 4:35 P.M with Staff D, she stated she could not answer questions because she was the Regional Dietitian. She said a new dietitian was hired and she started training today, 8/26/25. She said the Dietitian’s last day was yesterday. During an interview on 8/27/25 at 3:00 P.M. with the DON, she stated the dietitian looks at the weights and then decides the appropriate supplement. She said she doesn’t see any supplements for this resident. She said the dietitian will put the orders in for whatever supplement is needed to promote a stable weight. She said she didn’t know the resident had significant weight loss. She said the resident is on two diuretics. On 8/24/25 at 12:25 p.m. Resident #3 was observed lying in bed, with eyes closed and rhythmically breathing. On 8/26/25 at 12:26 p.m. Resident #3 reported losing weight, does not like the pureed diet and it’s the same thing every day. The resident reported having the one top denture (no bottom) and could not eat the food. Review of Resident #3s admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to Muscle wasting and atrophy not elsewhere classified multiple sites, (generalized) muscle weakness, oropharyngeal phase dysphasia, and gastro-esophageal reflux disease without esophagitis. Review of Resident #3s Weight Summary showed on 7/4/25 the resident weighed 158.8 pounds (#) via mechanical lift, on 7/10/25 (6 days later) the resident weighed 152.1# via mechanical lift (a weight loss of 6.7#s, loss of 4.22%), and on 8/8/25 the resident weighed 145.6# via mechanical lift (a weight loss of 13.2#’s), a loss of 8.31% in 32 days. The summary did not include any further weights for the resident. Review of Resident #3s Nutrition Evaluation assessment dated [DATE] showed the resident was receiving a pureed diet with nectar-thick liquids and ate 0-100% of the meals. The evaluation showed the resident was slightly overweight for height with a Body Mass Index of 24.5, was noted with a weight loss of 4.2% in 7 days and was not meeting estimated needs. The note revealed the dietician would follow up quarterly. Review of Resident #3s Nutritional Risk Evaluation Monthly dated 8/11/25 showed the resident had triggered for significant weight loss (145.6#), was receiving a pureed house diet with mildly thick liquids with no supplements/nourishments. The evaluation showed the resident’s intake was 26-75% of estimated needs and there was a greater than/equal (>=) 5% weight loss in 1 month, >= 7.5% in 3 months or >=10% in 6 months. The resident was not receiving enteral feeding and estimated 2000-2300 kilocalories per day, with the current intake did not meet the estimated needs. The documented goals and interventions showed the resident on a antidepressant which may increase appetite, recommended adding liquid nutritional supplement of 120 milliliters (mL) twice daily for an additional 510 kcal/day and 20 grams of protein/day, and weekly weights. The note showed the resident was discussed with the Interdisciplinary Team (IDT) and the dietician would monitor and follow accordingly. Review of Resident #3s Situation, Background, Appearance, and Review (SBAR), dated 8/13/25 by the Director of Nursing (DON) showed the resident’s weight loss started on 8/11/25 and it was unknown if the condition, symptom, or sign had occurred before. The weight was noted as 145.6# on 8/8 and the last weight prior was on 7/10/25 of 152.1#. The evaluation revealed no change was observed in the mental or functional status of the resident. The primary care clinician (unnamed) was notified on 8/13/25 at 12:00 p.m. with a recommendation of “supplement bolus feedings”. The nursing note did not include any further information. Review of Resident #3s Care Plan showed the resident was at nutritional risk related to recent hospitalization, advanced age, recent loss of spouse, high BMI, therapeutic & mechanically altered diet/fluids, require assistance with all Activities of Daily Living (ADLs), predicted sub-optimal oral (po) intake, dependent on supplemental oxygen (O2), psychotropics, antibiotics (abt), altered labs, impaired skin integrity, and diagnosis/history: urinary tract infection (UTI), atrophy, dysphagia, Coronary Artery Disease (CAD), hypertension (HTN), hyperlipidemia (HLD), hypothyroidism, insomnia, bipolar depression, atrial fibrillation (a-fib), and post-traumatic stress disorder (PTSD), weight – history of (h/o) weight loss. The focus was initiated on 7/4/25 and revised on 8/11/25. The goal was to maintain nutritional intake and included an intervention to monitor weight changes. The interventions did not show any intervention was added after the resident’s significant weight loss was discovered. Review of Resident #3s Physician Order Summary Report showed an order written on 7/4/25 allowing to Delegate to dietitian the responsibility to alter, change, or modify dietary orders including oral supplements, measurement of height and weight, modification 2 or addition of diet restrictions/ therapeutics, downgrade of diet consistency in consultation with SLP when needed, enteral feeding and water flushes. The orders showed the resident was to receive a house diet of Pureed PU 4 (pureed/extremely thick) texture, nectar/mildly thick (MT2) consistency. The report included an order dated 8/11/25 to start on 8/12/25 for 120 mL’s of liquid nutritional supplement to be administered orally (po) twice daily (BID). The report showed the resident was also to receive the following supplements: 22.5 milligram (mg) of the antidepressant, Mirtazapine (active as of 7/9/25), 25 microgram (mcg) of cholecalciferol (Vitamin D) for vitamin deficiency (active as of 7/4/25), and 325 mg Ferrous Sulfate for iron deficiency (active as of 7/4/25). The Order Summary Report did not include the dietician’s recommendation for weekly weights. Review of Resident #3s Speech Therapy notes showed Speech/Language Pathologists (SLP) had been working with the resident. A note on 7/15/25 showed Staff J, SLP saw the resident to encourage oral intake and assess tolerance of puree diet and direct thin liquid trials. A SLP note on 7/17/25 showed the resident had complained about puree texture but had informed the SLP of being unable to get soft bite-sized foods down. A trial was conducted with soft/mashable snack which the resident reported a preference. The SLP educated the resident on limitations to various types of food. Review of SLP notes showed the resident was seen by this therapy on 7/23, 7/25, 8/6, 8/11, 8/12, 8/15, 8/19, 8/20, 8/22, 8/25, and 8/26/25. The notes did not reveal the SLPs were aware of the resident’s weight loss. An interview was conducted on 8/27/25 at 10:03 a.m. with Staff J. The staff member reported seeing Resident #3 for dysphagia, the resident did not like the puree diet and was trialing soft/bite size solids. Staff J reported being unaware of the resident’s weight loss. Staff J stated typically would know if there was weight loss, the dietician would prescribe supplements to increase caloric values and sometimes would let the staff member know about weight loss. The staff member stated would have expected collaboration regarding where the resident was in the process, interdisciplinary collaboration is crucial. An interview was conducted on 8/26/25 at 4:35 p.m. with the Director of Nursing (DON). The DON stated the Regional Dietitian was not allowed to answer questions. During an interview on 8/27/25 at 1:47 p.m. the Director of Nursing (DON) stated psychiatry had reported Resident #3 was really depressed and started on a supplement, 120 mL’s of liquid nutritional supplement twice daily. The DON stated the expectation was a collaboration between the dietitian and speech therapy (SLP). The DON stated the facility does weekly weights on the resident, then reviewed the orders and reported not seeing an order for the weekly weights. The nursing director reported the dietitian would have put the order for weekly weights in, didn’t see weekly weights just monthly weights. The DON reported the Director of Rehab (DoR) was included in clinical meetings and she had informed the director of Resident #3s weight loss and would have expected the DoR to inform SLP of the weight loss. Review of the policy – Weight Management, effective February 2025, showed, Weights are completed on admission and readmission, then weekly for four (4) weeks, then monthly unless physician orders more frequently. Residents with weight loss of 5% in 30 days, 7.5% in three (3) months, and 10% and six (6) months require physician notification, and resident/ resident representative notification. Speech therapy (ST) and/ or occupational therapy (OT) are notified as needed. Documentation of notification(s) is documented in the progress notes. The care plan and Kardex are updated with interventions. Weight loss is reviewed in Standards of Care (SOC) with the Interdisciplinary team (IDT). The SOC, areas assessed and discussed may include, but may not be limited to pain management, psychotropic use, depression, dental or oral concerns, nausea, vomiting, diarrhea, Constipation, food dislikes and dislikes, in a deadline in the ability to feed self, chew or swallow. If a resident with weight loss chooses not to take a supplement, try other nutrition interventions such as use of fortified foods or snacks. Registered Dietitian provides recommendations directly to the Director of Nursing. DON assigns follow up to Unit Managers on the next business days. Follow up response is turned into DON with verification of completion.

Based on observations, record reviews, and interviews the facility failed to ensure the intravenous catheter dressing for one (#97) of one resident sampled for catheter dressing was changed per professional standards and per facility expectation. Findings included:On 8/24/25 at 12:40 p.m. Resident #97 was observed lying in bed. The observation showed the resident had a single lumen peripherally inserted central catheter (PICC) inserted into the right upper arm. The area under the clear inclusive dressing showed a dark dry-looking substance and a red wet-looking substance. The dressing was dated 8/19. On 8/27/25 at 9:09 a.m. Resident #97s PICC line dressing was observed, the dressing continued to be soiled and dated 8/19. Review of Resident #97s physician orders, active as of 8/27/25 at 3:24 p.m. showed orders dated 8/15/25 instructing to Change Intravenous (IV) dressing every 7 days as well as as needed (PRN) for soiling and /or dislodgement as needed and Change IV dressing every 7 days as well as PRN for soiling and/or dislodgement every evening shift every 7 day(s). Review of Resident #97s August 2025 Medication Administration Record (MAR) showed nursing staff had changed the dressing on the evening shift of 8/16 and 8/23/25. The MAR showed staff had not changed the dressing as needed for soiling and/or dislodgement. During an interview on 8/27/25 at 1:54 p.m. the Director of Nursing (DON) reported Resident #97s MAR showed the dressing was changed on 8/23 and it should not have been documented as done if it wasn't done. An observation was conducted on 8/27/25 at 2:11 p.m. the DON and the Regional Nurse Consultant (RNC) of Resident #97s PICC line dressing. The resident was pleasant and accommodating allowing for the observation. The DON confirmed the date of 8/19 on the dressing, not 8/23 and stated the dressing should be changed every 7 days and it should have been changed. The DON informed the resident she would be in to change it. Review of the policy - Infection Prevention Measures, dated 10/24, revealed the purpose was to Apply infection prevention principles to reduce the risk of infusion-related infections. The policy revealed Infection prevention measures are implemented for all infusion therapy procedures to prevent infusion and vascular access device related infections. Transparent, semi-permeable membrane (TSM) dressings are changed a minimum of every 7 days and PRN whenever the dressing integrity becomes disrupted, becomes wet, loose, or soiled or if skin integrity is compromised under the dressing.

Based on observation, record review and interviews the facility failed to post the Daily Nursing Staffing form appropriately.Findings Included: During an observation on 08/24/2025 at 9:00 a.m., the Daily Nursing Staffing form was located on the wall near the reception area. The date on the form was 08/21/2025. (Photographic Evidence Obtained)During multiple observations from 08/24/2025 thru 08/27/2025 revealed the Daily Nursing Staffing form was not posted on the 2nd floor. During an interview on 08/27/2025 at 12:30 p.m., Staffing Coordinator stated the daily nursing staffing form is only posted at the entrance. The supervisor is responsible for updating and posting the form on the weekends.During an Interview on 08/27/2025 at 2:06 p.m., the Nursing Home Administrator (NHA) stated the daily nursing staffing form is only posted up front. Nurse management or staffing is responsible for posting the form. The nursing staffing form should be posted each day. The facility did not have a policy related to this cite.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#2) of three residents dependent upon staff to feed at meal times, was provided supervision and services related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on [DATE] at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance. The facility failed to take action to prevent the resident from choking by not providing supervision during the resident's meal and not checking the resident's plan of care prior to providing the meal to the resident. At approximately 5:38 p.m., Staff A, Licensed Practical Nurse discovered Resident #2 unresponsive after being alerted by Resident #2's roommate. Resident #2 required use of the Heimlich maneuver and cardiopulmonary resuscitation (CPR) by facility staff and Emergency Medical Services (EMS) staff due to suspected choking and being found without a pulse or respirations. Resident #2 was transported to the hospital where she expired. The failure created a situation that resulted in Resident #2's death and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: A review of Resident #2's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE] and authored by Staff A, Licensed Practical Nurse (LPN), revealed under the section titled Mental Status Evaluation (compared to baseline; check all changes that you observe), Unresponsiveness, was checked. Under the section titled Functional Status Evaluation (compared to baseline; check all changes that you observe), Other (describe) was checked with a description symptom or sign of aspirated documented. The form revealed the following under Appearance: Writer was across the hall at [room number] providing medication. Writer turned to go to [Resident #2's room], [Resident #2's roommate] said to writer that, you need to look at [Resident #2]. Writer assessed resident, resident was unresponsive, writer called a code blue and grabbed the crash cart. Other nurses arrived and we began CPR, because the resident was eating dinner before going unconscious, we then began the Heimlich maneuver. The [Emergency Medical Services personnel] arrived and took over. According to the Mayo Clinic, choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person does not give the signal, look for these indications: - Inability to talk - Difficulty breathing or noisy breathing - Squeaky sounds when trying to breathe - Cough, which may either be weak or forceful - Skin, lips, and nails turning blue or dusky - Skin that is flushed, then turns pale or bluish in color - Loss of consciousness https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637#:~:text=To%20perform%20abdominal%2 0thrusts%20([MEDICATION(S)]%20maneuver)%20on%20yourself%2C%20place,do%20in%20a%20choking%20emergency. A review of Resident #2's medical record Resident #2 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness; and dysphagia, oropharyngeal phase. A review of Resident #2's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of [DATE] revealed under Section C: Decision Making Capacity (Patient) Resident #2 required a surrogate for medical decision making. The transfer form revealed under Section U: Nutrition/Hydration, Resident #2 required assistance with eating. Section U: Mental/Cognitive Status at Transfer revealed Resident #2 was alert and disoriented but could follow simple instructions. A review of Resident #2's Admission/Readmission Data Collection assessment dated [DATE] revealed under section C: Body System Review, Resident #2 had no natural teeth or dentures and was on a mechanically altered diet. The assessment revealed under section D: Mobility/ADL/ROM (Activities of Daily Living/Range of Motion), Resident #2 was dependent on staff with eating. Resident #2's care plan was updated with a Focus: (Resident #2) has an ADL Self Care Performance Deficit. Interventions included assist of one staff with eating and dependent upon staff to feed. A review of the facility policy titled Admission/Readmission Data Collection, effective [DATE] revealed the Resident's Admission/Readmission Data Collection will provide a comprehensive description of the Resident's status on admission. The assessment is designed to identify past history, current findings, and factors that may put the Resident at risk. A review of Resident #2's [DATE] Order Summary Report revealed the following orders: - Renal diet mechanical soft/soft and bite-sized texture, regular (thin) consistency. Dated [DATE]. - Full resuscitation. Dated [DATE]. - Speech Therapy Clarification resident to be seen 5 times per week for 6 weeks for focus on dysphagia management, resident/caregiver education, discharge planning with group treatment when appropriate/and do planning. Dated [DATE]. - Renal diet, regular texture, regular (thin) consistency. Dated [DATE] and discontinued on [DATE]. A review of Resident #2's care plan revealed a Focus area of the resident has an ADL self-care performance deficit. Interventions included an assist of 1 for eating and dependent upon staff to feed. Resident #2's care plan revealed a Focus are of the resident has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included to provide orientation and validation, and cue, reorient, and supervise as needed. A review of Resident #2's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment revealed under Section GG - Functional Abilities, Resident #2 required substantial/maximal assistance (helper does more than half the effort) with eating. The assessment revealed under Section K - Swallowing/Nutritional Status, Resident #2 had coughing or choking during meals or when swallowing medications and had a mechanically altered diet on admission and while a resident in the facility. An interview was conducted on [DATE] at 1:14 p.m. with Resident #6, former roommate of Resident #2. Resident #6 stated she was Resident #2's roommate during the duration of her stay at the facility and would regularly see the resident's daughter coming in to feed the resident, but never witnessed facility staff assisting the resident with her meals. Resident #6 stated on [DATE] during the dinner meal, she witnessed Resident #2 feeding herself and the resident, was eating as fast as she could get it in there. Resident #6 noticed Resident #2 had food coming out of her mouth and was no longer swallowing food, which is when she notified the nurse who was across the hallway Resident #2 needed help. Resident #6 stated the nurse entered the room to check on Resident #2 and ran down the hallway. Resident #6 stated she heard code blue followed by their room number on the overhead speaker and the entire room filled up with people. Resident #6 stated the following day she was informed by Resident #2's daughter the resident passed away. A review of Resident #6's MDS assessment with an ARD of [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15, which indicated the resident was cognitively intact. A review of the facility policy titled CPR Code Status Orders & Response, last revised in February 2023 revealed under the section titled Procedure for Initiating CPR, upon identification that a resident is unresponsive, the person making the identification will check for pulse and respirations, and immediately call for help; loudly calling Code Blue Room (#). Staff will respond to room with medical record and emergency cart. Code Status and resident will be verified by 2 identifiers such as [electronic health record] photo, armband, with another nursing care center personnel if resident is a full code CPR will be initiated. An interview was conducted on [DATE] at 3:11 p.m. with the facility's Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional [NAME] President of Operations (VPO). The NHA stated on [DATE], an allegation of neglect was reported to her by Resident #2's daughter when she came to the facility to gather Resident #2's belongings. The NHA stated she was told by Resident #2's daughter, I know she choked on her food and that's why she was sent to the emergency room , prompting them to initiate an investigation. The DON stated they conducted interviews with the staff involved during the incident and discovered staff performed CPR on Resident #2 as well as the Heimlich maneuver because there was concern the resident may have had something in their airway and there was vomit in the resident's mouth during the CPR. The NHA stated Resident #2 aspirated during the incident and was suctioned by staff. The DON stated facility developed the following timeline of events through interviews with staff: - On [DATE] around 3:00 p.m., Resident #2 was observed by facility staff in her room, with no signs of distress and at her baseline level. Resident #2's care was assigned to Staff A, LPN and Staff B, Certified Nursing Assistant (CNA). - On [DATE] around 5:15 p.m., Staff B, CNA and her hall partner Staff C, CNA passed meal trays in Resident #2's hall while Staff A, LPN performed blood glucose checks and medication administration for other residents in the hall. Resident #2 was provided a dinner tray in her room by Staff C, CNA, which was left on the bedside table in front of her after the resident stated she did not want it. After passing meal trays, Staff B, CNA, looked into Resident #2's room and saw her upright in bed and eating without difficulty. Staff B, CNA went to another resident's room to assist the resident with dining. - On [DATE] at 5:38 p.m., Staff A, LPN entered Resident #2's room to administer medications to Resident #6. Resident #6 told Staff A, LPN she needed to first check on Resident #2. Resident #2 was observed upright in the bed with her head to the side and unresponsive. At that time, Staff A, LPN ran from the room to call a Code Blue overhead and grabbed the emergency cart. Staff A, LPN verified Resident #2's code status as a Full Code and responded back to the room. Staff D, CNA responded to the resident's room and began life saving measures, including CPR, on Resident #2. Staff E, LPN, Staff F, LPN, and Staff G, LPN all responded to Resident #2's room and assisted in providing CPR. During the CPR, Resident #2 had an episode of vomiting and regained a pulse and respirations, verified by Staff E, LPN by palpation and by attaching a pulse oximeter to the resident's finger. Staff sat Resident #2 up in the bed and performed the Heimlich maneuver on the resident. No food or vomit came out of Resident #2's mouth during the performance of the Heimlich maneuver. During the event, at 5:43 p.m., a staff member called 911. - On [DATE] at approximately 5:58 p.m., Emergency Medical Services (EMS) arrived. Resident #2 became unresponsive without a pulse or respirations shortly after arrival of EMS and CPR was initiated by EMS. Per interview with Staff H, LPN, who was near the facility entrance when EMS left with Resident #2, Resident #2 had a pulse on the monitor and was intubated by EMS when she was being taken out of the facility and to the hospital. The DON stated the next day on [DATE], all information relating to the incident was collected to ensure the Code Blue process was properly executed and all CPR certifications of the involved staff were verified. The DON stated Resident #2's dinner meal was verified and the resident received the appropriate diet, but not the food she was supposed to receive per her diet slip. Resident #2 received potato salad on her dinner tray instead of rice with thick gravy. The DON addressed Resident #2's care plan revealed she required assistance of one staff member with dining, but the care plan did not indicate the resident could not feed herself. The DON stated Resident #2 was evaluated by the Speech Language Pathologist (SLP), who determined the resident was able to feed herself, but would consume food too quickly at times. The DON addressed Resident #2's care plan did not include anything related to the resident consuming food too quickly and stated none of the staff interviewed spoke about the resident consuming food too fast. The DON stated upon investigation and interview with staff, they determined Staff C, CNA was the staff member who passed the meal tray to Resident #2 and did not check the resident's plan of care prior to passing the meal tray and was not told the resident required assistance. The DON stated they could not verify if Resident #2 choked on her food during the meal due to documentation stating the resident had aspirate, which could have been from the CPR performed on the resident. The NHA stated after the facility investigation the concern, they substantiated the allegation of neglect due to Resident #2 receiving the wrong food on her meal tray and not being provided assistance with the meal per the plan of care. The DON stated the facility separated employment from Staff A, LPN, Staff B, CNA, Staff C, CNA, and Staff I, [NAME] following the incident. A review of an ambulance run report dated [DATE] revealed two EMS personnel (E2 and R1) were dispatched and responded to the facility after notification of Resident #2 being unresponsive. The run report included the following: E2 and R1 responded to a medical call. E2 was first on scene and found a 76 [year old] female in a nursing home in cardiac arrest. E2 began ACLS [Advanced Cardiac Life Support] procedures and CPR was initiated. E2 began CPR and ventilations per AHA [American Heart Association] guidelines. [Patient] was positioned in bed with [cervical] spine board to support CPR. Staff on scene state the [patient] appeared to be choking and they began the Heimlich maneuver. [Patient] became unresponsive and was laid supine as E2 walked into the room. E2 performed CPR and ventilations per AHA until R1 arrived . No pulse asystole. R1 arrived and assisted E2 in establishing ALS [Advanced Life Support] interventions. A suction was provided and utilized to removed emesis and food from the patients airway. A pulse check rhythm check was performed again after 2 minutes with no pulse, [patient] in asystole. CPR and ventilations were resumed per AHA throughout the duration of the call with a pulse check rhythm check every 2 minutes . Around 10 cycles of CPR were performed throughout the duration of the arrest. After the current cycle finished, a pulse check was performed, pulse present with sinus rhythm. ROSC [Return of Spontaneous Circulation] procedures were initiated. [Patient] was prepped for transport and transferred to the stretcher and secured. [Patient] placed into the rescue and emergency transport to [local hospital] started. [Patient] interventions were reassessed and intact. Pulse still present. A blood pressure was obtained and recorded. Pulse check performed on arrival of ER [emergency room ], pulse present . The section of the run report titled Specialty Patient - CPR revealed the following: Cardiac Arrest Etiology: Respiratory/Asphyxia Estimated time of arrest: ,d+[DATE] Minutes The run report revealed the following Incident Times: Call received: 17:41 (5:41 p.m.) En Route: 17:44 (5:44 p.m.) On scene: 17:50 (5:50 p.m.) Depart scene: 18:18 (6:16 p.m.) At destination: 18:26 (6:26 p.m.) A review of Resident #2's Emergency Department Documents dated [DATE] revealed EMS reported Resident #2 was found unresponsive in her room with vomiting and fluid all over. Upon EMS arrival, Resident #2 was pulseless and in PEA (Pulseless Electrical Activity) cardiac arrest. On arrival to the ER, initial evaluation and pulse check demonstrated recurrent cardiopulmonary arrest. Resident #2 had a significant amount of oropharyngeal and aspiration output after ET (endotracheal) tube placement. The section of the documents titled Medical Decision Making revealed Resident #2 had no signs of significant neurofunction and had prolonged oxygen deprivation due to either prolonged downtime or severe aspiration. The section of the documents titled Assessment/Plan revealed Resident #2 had diagnoses of cardiopulmonary arrest and aspiration into airway (unspecified foreign body in respiratory tract, part unspecified causing other injury, initial encounter). A telephone interview was attempted on [DATE] at 9:48 a.m. with Staff D, CNA, who performed CPR on Resident #2 when she was found unresponsive on [DATE]. Staff D, CNA did not answer the phone call and a message was left for call back. The phone call was not returned by Staff D, CNA. A telephone interview was attempted on [DATE] at 10:10 a.m. with Staff C, CNA, who provided Resident #2's dinner meal tray on [DATE]. Staff C, CNA did not answer the phone call and a message was left for call back. The phone call was not returned by Staff C, CNA. A telephone interview was attempted on [DATE] at 10:21 a.m. with Staff I, Cook, who prepared Resident #2's dinner meal tray on [DATE]. Staff I, [NAME] did not answer the phone call and a message was left for call back. The phone call was not returned by Staff I, Cook. A telephone interview was attempted on [DATE] at 10:28 a.m. with Staff J, Dietary Aide, who verified the contents of Resident #2's dinner meal tray on [DATE]. Staff J, Dietary Aide did not answer the phone call and a message was left for call back. The phone call was not returned by Staff J, Dietary Aide. A telephone interview was conducted on [DATE] at 10:45 a.m. with Staff B, CNA, who was Resident #2's assigned CNA on [DATE]. Staff B, CNA stated the dinner meal arrived on her floor around 5:15 p.m. while she was assisting another resident with a shower. Two other CNA's came to the floor to pass dinner meals to the residents, including Resident #2. Staff B, CNA stated after seeing Resident #2 was set up with her dinner meal, she went to another resident's room to assist the resident with eating. While feeding the other resident, the staff member heard a Code Blue over the facility's intercom system and ran to Resident #2's room. Staff B, CNA observed Resident #2 laid flat in the bed with food on her gown and around her mouth and other staff members began CPR on the resident. Staff B, CNA stated when she asked what happened with the resident, Staff A, LPN told her Resident #2 was choking on her food. Staff A, LPN called 911 from her cell phone and passed the phone to Staff B, CNA while she continued CPR on Resident #2. Staff B, CNA stated once EMS arrived at the facility, they continued CPR on the resident. Staff B, CNA stated Resident #2 usually fed herself at meal times and was not fed by the facility staff. Review of the facility policy titled Dining Program, effective [DATE], revealed under Policy, the nursing staff assists residents in need of assistance during mealtimes. An interview was conducted on [DATE] at 11:28 a.m. with Staff K, Speech Language Pathologist (SLP). Staff K, SLP stated when Resident #2 was admitted to the facility she was on a regular diet but did not have any teeth and did not wear dentures. Staff K, SLP verified from Resident #2's previous facility the resident received a mechanical soft diet. Staff K, SLP stated a trial was conducted, which determined a mechanical soft diet with bite size food was an appropriate diet for the resident. Staff K, SLP stated she educated Resident #2's direct care staff regarding providing set-up assistance for the resident, sitting the resident up 90 degrees in bed for meals prior to the resident eating, and monitoring the resident to ensure she was eating safely. Staff K, SLP stated she did not witness the resident choking or having difficulty swallowing during trials, but the resident would occasionally take consecutive sips of liquids before swallowing what was already in her mouth. Staff K, SLP recommended the resident have supervision during her meals due to the resident's dementia and safe swallowing reminders might not be retained be the resident. Staff K, SLP stated she wanted nursing staff present in the room during meals to ensure the resident was safe during her meals, which was the level of supervision the resident had at her previous facility. Staff K, SLP stated she would expect nursing staff to put interventions in the care plan and communicate any recommendations she provides so all other nursing staff were aware. Staff K, SLP informed Resident #2's physician of the recommendations, who signs and approves the resident's orders. A review of Resident #2's SLP Evaluation & Plan of Treatment, initiated [DATE], revealed under Plan of Treatment, treatment approaches may include treatment of swallowing dysfunction and/or oral function for feeding and evaluation of oral and pharyngeal swallow function. The Evaluation & Plan of Treatment revealed the following under Initial Assessment/Current Level of Functioning & Underlying Impairments: Patient was admitted to the facility on regular/thin liquids diet from the hospital, however, nursing downgraded and referred to Speech Therapy due to patient complaints of difficulty masticating. Per daughter, patient was previously receiving mechanical soft/thin diet at her previous facility. Patient presents for a BSE (Bedside Swallowing Evaluation) to assess current swallow function. The Evaluation & Plan of Treatment revealed under Objective Tests/Measures & Additional Analysis, Resident #2 displayed behaviors impacting safety of decreased safety awareness and poor self-monitoring skills. The section titled Recommendations revealed recommendations for close supervision of oral intake. The Evaluation & Plan of Treatment was signed by the resident's physician on [DATE]. An interview was conducted on ,d+[DATE] at 11:53 a.m. with Staff G, LPN. Staff G, LPN stated on [DATE], she was working on the first floor of the facility when she heard a Code Blue on the overhead speaker. Staff G, LPN responded to Resident #2's room, which was on a different floor, and witnessed about four people already in the resident's room assessing the resident. Staff G, LPN stated Resident #2 appeared sitting upright in bed, was unresponsive, and appeared to be losing color. She was asked by Staff E, LPN for assistance in providing the Heimlich maneuver to Resident #2, so Staff G, LPN got onto the bed and behind the resident to perform the Heimlich maneuver. Staff G, LPN stated she put her hands in front of Resident #2's upper abdominal region and performed thrusts in an upward position. After a few thrusts, Resident #2 had an episode of vomiting, which the staff member described as watery and without solids. Staff G, LPN stated they performed the Heimlich maneuver on the resident because they suspected the resident may have had something in their airway and the resident's oxygen level was dropping. Staff G, LPN stated once she became fatigued, another staff member, who she was unable to state the name of, performed the Heimlich maneuver on the resident with no results. Staff G, LPN stated EMS arrived shortly after and stated, we kind of got out of the way. Staff G, LPN stated she returned to her floor after EMS arrived. According to the Cleveland Clinic, the Heimlich maneuver is a first-aid method for choking that you can use on adults and children. Another name for the Heimlich maneuver is abdominal thrusts, because it involves thrusting into the abdominal area. It is a quick and life-saving method, but you should only use it on conscious people who can not breathe on their own. https://my.clevelandclinic.org/health/treatments/21675-heimlich-maneuver An interview was conducted on [DATE] at 12:21 p.m. with Staff A, LPN, who was Resident #2's assigned nurse on [DATE]. Staff A, LPN stated when Resident #2 was first admitted to the facility, she was on a regular diet. After speaking with Resident #2's daughter, she found out the resident was previously receiving a mechanical soft diet and changed the resident's diet order. Staff A, LPN stated on [DATE], she was passing medications and went into Resident #2's room to administer medications to Resident #6. Resident #6 informed her to check on Resident #2 because she saw the resident eating and point to her mouth as if she could not breathe. Staff A, LPN stated Resident #2 appeared unresponsive with food all over her chest. Staff A, LPN put a pulse oximeter on Resident #2's finger and did not get a pulse reading, so she ran to call a Code Blue and retrieve the emergency cart. Staff A, LPN stated when she returned to the resident's room, a CNA was already doing CPR on the resident. Staff A, LPN retrieved a bag valve mask and applied it to Resident #2 while attempting to maintain the resident's airway. Staff A, LPN stated other nursing staff responded to the room and they eventually discovered a pulse using the pulse oximeter. Once they determined the resident had a pulse, they stopped CPR and began to perform the Heimlich maneuver on Resident #2 until EMS personnel arrived at the room. Staff A, LPN stated Resident #2 had an episode of emesis during the Heimlich maneuver, which was of a watery consistency. EMS personnel checked for the resident's pulse and the resident was still unresponsive, so they laid the resident back onto the bed and began CPR. Staff A, LPN stated EMS took Resident #2 to the hospital. The staff member stated Resident #2 fed herself and no staff assisted the resident since her admission. Staff A, LPN stated she did not look at Resident #2's care plan to determine if the resident required assistance and was told in the shift report the resident did not require assistance with dining. Staff A, LPN stated you just know, because this resident was an independent eater and had never needed help before. An interview was conducted on [DATE] at 10:08 a.m. with Staff L, LPN and Clinical Reimbursement Specialist (CRS) and Staff M, Clinical Reimbursement Consultant (CRC). Staff L, LPN CRS stated resident care plans are developed using physician orders, hospital documentation, and interviews with the resident and/or the resident's family members, and would include anything needed to provide care to the resident. Staff L, LPN CRS stated everybody has access to the resident's care plan and can see the interventions in the care plans. Staff M, CRC stated staff should be following resident care plans if the care plan shows a resident was dependent on dining with an assist of one staff member. An assist of one staff member means the staff member would be physically assisting the resident with eating. Staff M, CRC stated interventions from the care plan are pulled over into the CNA charting system, which can be viewed by the CNA staff providing care to the resident. An interview was conducted on [DATE] at 12:17 p.m. with the facility's Medical Director (MD), who was Resident #2's primary care provider. The MD stated Resident #2 was initially admitted to the facility for a fractured hip and was receiving physical and occupational therapy. The resident had dementia, diabetes, mild congestive heart failure, and pulmonary hypertension, among other comorbidities. The MD stated the resident was not able to get out of the bed safely due to the hip fracture, so the resident had all of her meals in the bed and the MD, would guess she would need assistance with all of them. The MD stated he was aware the resident had a previous cerebral vascular accident (CVA), but did not think she had a problem with her swallowing because the CVA was not a recent issue. The MD stated he was not aware the resident required supervision with her meals and would think the resident was a self-feeder. The MD stated his knowledge of the event on [DATE] came from the NHA, who told him the resident was found unresponsive in bed and required CPR and use of the Heimlich maneuver before being transported to the hospital. He said he did not review any of the resident's hospital documentation but there was concern the resident could have aspirated. An interview was conducted on [DATE] at 12:35 p.m. with Resident #2's daughter and emergency contact (EC). The EC stated in 2021, Resident #2 suffered a massive stroke and required nursing home care due to the resident's inability to care for herself. After suffering a fall with hip fracture at a previous facility, she decided to place the resident at this facility. The EC stated when at the previous facility, Resident #2 was provided a mechanical soft diet and needed supervision during meals because the resident could not feel food on the left side of her mouth and would pocket food. The EC observed Resident #2's meal tray left in the resident's room on several occasions and never observed staff assisting the resident or providing supervision to the resident during meals, even after informing the facility of the resident's needs several times. The EC stated when Resident #2 would attempt to feed herself, she would get food all over her and was not aware of how much food she was putting in her mouth. The EC was at work when she received a call from the facility informing her Resident #2 was unresponsive. When the EC asked the facility staff if the resident choked, they told her she was unresponsive and they were assessing the situation. The facility called the EC back appropriately five minutes later and was informed EMS personnel were taking Resident #2 to the hospital. During the phone call, the EC asked facility staff if Resident #2 choked on her food and the facility staff responded, I believe so. The EC stated Resident #2 passed away later that night on [DATE]. The facility's immediate actions to remove the Immediate Jeopardy included: - On [DATE], Resident #2 discharged to the hospital and has not returned to the facility. - The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete on [DATE]. - The DON and NHA received directed education by the Regional Nurse Consultant on [DATE] regarding ensuring proper resident supervision and/or assistance during meals is occurring. - A total of 104 out of 104 nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was 100% completed on [DATE]. - An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held on [DATE][TRUNCATED]

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to implement care plan interventions to provide supervision and assistance during meals for one resident (#2) of three residents dependent upon staff to feed at meal times, related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on [DATE] at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance in accordance with the plan of care. The facility failed to take action to prevent the resident from choking by not providing supervision during the resident's meal and not checking the resident's plan of care prior to providing the meal to the resident. At approximately 5:38 p.m., Staff A, Licensed Practical Nurse discovered Resident #2 unresponsive after being alerted by Resident #2's roommate. Resident #2 required use of the Heimlich maneuver and cardiopulmonary resuscitation (CPR) by facility staff and Emergency Medical Services (EMS) staff due to suspected choking and being found without a pulse or respirations. Resident #2 was transported to the hospital where she expired. The failure created a situation that resulted in Resident #2's death and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: A review of Resident #2's medical record Resident #2 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness; and dysphagia, oropharyngeal phase. A review of Resident #2's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of [DATE] revealed under Section C: Decision Making Capacity (Patient) Resident #2 required a surrogate for medical decision making. The transfer form revealed under Section U: Nutrition/Hydration, Resident #2 required assistance with eating. Section U: Mental/Cognitive Status at Transfer revealed Resident #2 was alert and disoriented but could follow simple instructions. A review of Resident #2's Admission/Readmission Data Collection assessment dated [DATE] revealed under section C: Body System Review, Resident #2 had no natural teeth or dentures and was on a mechanically altered diet. The assessment revealed under section D: Mobility/ADL/ROM (Activities of Daily Living/Range of Motion), Resident #2 was dependent on staff with eating. Resident #2's care plan was updated with a Focus: (Resident #2) has an ADL Self Care Performance Deficit. Interventions included assist of one staff with eating and dependent upon staff to feed. A review of the facility policy titled Admission/Readmission Data Collection, effective [DATE] revealed the Resident's Admission/Readmission Data Collection will provide a comprehensive description of the Resident's status on admission. The assessment is designed to identify past history, current findings, and factors that may put the Resident at risk. A review of Resident #2's care plan revealed a Focus area of the resident has an ADL self-care performance deficit. Interventions included an assist of 1 for eating and dependent upon staff to feed. Resident #2's care plan revealed a Focus are of the resident has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included to provide orientation and validation, and cue, reorient, and supervise as needed. A review of Resident #2's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment revealed under Section GG - Functional Abilities, Resident #2 required substantial/maximal assistance (helper does more than half the effort) with eating. The assessment revealed under Section K - Swallowing/Nutritional Status, Resident #2 had coughing or choking during meals or when swallowing medications and had a mechanically altered diet on admission and while a resident in the facility. A review of Resident #2's [DATE] Order Summary Report revealed the following orders: - Renal diet mechanical soft/soft and bite-sized texture, regular (thin) consistency. Dated [DATE]. - Full resuscitation. Dated [DATE]. - Speech Therapy Clarification resident to be seen 5 times per week for 6 weeks for focus on dysphagia management, resident/caregiver education, discharge planning with group treatment when appropriate/and do planning. Dated [DATE]. - Renal diet, regular texture, regular (thin) consistency. Dated [DATE] and discontinued on [DATE]. A review of Resident #2's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE] and authored by Staff A, Licensed Practical Nurse (LPN), revealed under the section titled Mental Status Evaluation (compared to baseline; check all changes that you observe), Unresponsiveness, was checked. Under the section titled Functional Status Evaluation (compared to baseline; check all changes that you observe), Other (describe) was checked with a description symptom or sign of aspirated documented. The form revealed the following under Appearance: Writer was across the hall at [room number] providing medication. Writer turned to go to [Resident #2's room], [Resident #2's roommate] said to writer that, you need to look at [Resident #2]. Writer assessed resident, resident was unresponsive, writer called a code blue and grabbed the crash cart. Other nurses arrived and we began CPR, because the resident was eating dinner before going unconscious, we then began the Heimlich maneuver. The [Emergency Medical Services personnel] arrived and took over. According to the Cleveland Clinic, the Heimlich maneuver is a first-aid method for choking that you can use on adults and children. Another name for the Heimlich maneuver is abdominal thrusts, because it involves thrusting into the abdominal area. It is a quick and life-saving method, but you should only use it on conscious people who can not breathe on their own. https://my.clevelandclinic.org/health/treatments/21675-heimlich-maneuver An interview was conducted on [DATE] at 1:14 p.m. with Resident #6, former roommate of Resident #2. Resident #6 stated she was Resident #2's roommate during the duration of her stay at the facility and would regularly see the resident's daughter coming in to feed the resident, but never witnessed facility staff assisting the resident with her meals. Resident #6 stated on [DATE] during the dinner meal, she witnessed Resident #2 feeding herself and the resident, was eating as fast as she could get it in there. Resident #6 noticed Resident #2 had food coming out of her mouth and was no longer swallowing food, which is when she notified the nurse who was across the hallway Resident #2 needed help. Resident #6 stated the nurse entered the room to check on Resident #2 and ran down the hallway. Resident #6 stated she heard code blue followed by their room number on the overhead speaker and the entire room filled up with people. Resident #6 stated the following day she was informed by Resident #2's daughter the resident passed away. A review of Resident #6's MDS assessment with an ARD of [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15, which indicated the resident was cognitively intact. An interview was conducted on [DATE] at 3:11 p.m. with the facility's Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional [NAME] President of Operations (VPO). The NHA stated on [DATE], an allegation of neglect was reported to her by Resident #2's daughter when she came to the facility to gather Resident #2's belongings. The NHA stated she was told by Resident #2's daughter, I know she choked on her food and that's why she was sent to the emergency room , prompting them to initiate an investigation. The DON stated they conducted interviews with the staff involved during the incident and discovered staff performed CPR on Resident #2 as well as the Heimlich maneuver because there was concern the resident may have had something in their airway and there was vomit in the resident's mouth during the CPR. The NHA stated Resident #2 aspirated during the incident and was suctioned by staff. The DON stated facility developed the following timeline of events through interviews with staff: - On [DATE] around 3:00 p.m., Resident #2 was observed by facility staff in her room, with no signs of distress and at her baseline level. Resident #2's care was assigned to Staff A, LPN and Staff B, Certified Nursing Assistant (CNA). - On [DATE] around 5:15 p.m., Staff B, CNA and her hall partner Staff C, CNA passed meal trays in Resident #2's hall while Staff A, LPN performed blood glucose checks and medication administration for other residents in the hall. Resident #2 was provided a dinner tray in her room by Staff C, CNA, which was left on the bedside table in front of her after the resident stated she did not want it. After passing meal trays, Staff B, CNA, looked into Resident #2's room and saw her upright in bed and eating without difficulty. Staff B, CNA went to another resident's room to assist the resident with dining. - On [DATE] at 5:38 p.m., Staff A, LPN entered Resident #2's room to administer medications to Resident #6. Resident #6 told Staff A, LPN she needed to first check on Resident #2. Resident #2 was observed upright in the bed with her head to the side and unresponsive. At that time, Staff A, LPN ran from the room to call a Code Blue overhead and grabbed the emergency cart. Staff A, LPN verified Resident #2's code status as a Full Code and responded back to the room. Staff D, CNA responded to the resident's room and began life saving measures, including CPR, on Resident #2. Staff E, LPN, Staff F, LPN, and Staff G, LPN all responded to Resident #2's room and assisted in providing CPR. During the CPR, Resident #2 had an episode of vomiting and regained a pulse and respirations, verified by Staff E, LPN by palpation and by attaching a pulse oximeter to the resident's finger. Staff sat Resident #2 up in the bed and performed the Heimlich maneuver on the resident. No food or vomit came out of Resident #2's mouth during the performance of the Heimlich maneuver. During the event, at 5:43 p.m., a staff member called 911. - On [DATE] at approximately 5:58 p.m., Emergency Medical Services (EMS) arrived. Resident #2 became unresponsive without a pulse or respirations shortly after arrival of EMS and CPR was initiated by EMS. Per interview with Staff H, LPN, who was near the facility entrance when EMS left with Resident #2, Resident #2 had a pulse on the monitor and was intubated by EMS when she was being taken out of the facility and to the hospital. The DON stated the next day on [DATE], all information relating to the incident was collected to ensure the Code Blue process was properly executed and all CPR certifications of the involved staff were verified. The DON stated Resident #2's dinner meal was verified and the resident received the appropriate diet, but not the food she was supposed to receive per her diet slip. Resident #2 received potato salad on her dinner tray instead of rice with thick gravy. The DON addressed Resident #2's care plan revealed she required assistance of one staff member with dining, but the care plan did not indicate the resident could not feed herself. The DON stated Resident #2 was evaluated by the Speech Language Pathologist (SLP), who determined the resident was able to feed herself, but would consume food too quickly at times. The DON addressed Resident #2's care plan did not include anything related to the resident consuming food too quickly and stated none of the staff interviewed spoke about the resident consuming food too fast. The DON stated upon investigation and interview with staff, they determined Staff C, CNA was the staff member who passed the meal tray to Resident #2 and did not check the resident's plan of care prior to passing the meal tray and was not told the resident required assistance. The DON stated they could not verify if Resident #2 choked on her food during the meal due to documentation stating the resident had aspirate, which could have been from the CPR performed on the resident. The NHA stated after the facility investigation the concern, they substantiated the allegation of neglect due to Resident #2 receiving the wrong food on her meal tray and not being provided assistance with the meal per the plan of care. The DON stated the facility separated employment from Staff A, LPN, Staff B, CNA, Staff C, CNA, and Staff I, [NAME] following the incident. A review of an ambulance run report dated [DATE] revealed two EMS personnel (E2 and R1) were dispatched and responded to the facility after notification of Resident #2 being unresponsive. The run report included the following: The section of the run report titled Specialty Patient - CPR revealed the following: Cardiac Arrest Etiology: Respiratory/Asphyxia Estimated time of arrest: ,d+[DATE] Minutes A review of Resident #2's Emergency Department Documents dated [DATE] revealed EMS reported Resident #2 was found unresponsive in her room with vomiting and fluid all over. Upon EMS arrival, Resident #2 was pulseless and in PEA (Pulseless Electrical Activity) cardiac arrest. On arrival to the ER, initial evaluation and pulse check demonstrated recurrent cardiopulmonary arrest. Resident #2 had a significant amount of oropharyngeal and aspiration output after ET (endotracheal) tube placement. The section of the documents titled Medical Decision Making revealed Resident #2 had no signs of significant neurofunction and had prolonged oxygen deprivation due to either prolonged downtime or severe aspiration. The section of the documents titled Assessment/Plan revealed Resident #2 had diagnoses of cardiopulmonary arrest and aspiration into airway (unspecified foreign body in respiratory tract, part unspecified causing other injury, initial encounter). According to the Mayo Clinic, choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person does not give the signal, look for these indications: - Inability to talk - Difficulty breathing or noisy breathing - Squeaky sounds when trying to breathe - Cough, which may either be weak or forceful - Skin, lips, and nails turning blue or dusky - Skin that is flushed, then turns pale or bluish in color - Loss of consciousness https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637#:~:text=To%20perform%20abdominal%2 0thrusts%20([MEDICATION(S)]%20maneuver)%20on%20yourself%2C%20place, do%20in%20a%20choking%20emergency A telephone interview was conducted on [DATE] at 10:45 a.m. with Staff B, CNA, who was Resident #2's assigned CNA on [DATE]. Staff B, CNA stated the dinner meal arrived on her floor around 5:15 p.m. while she was assisting another resident with a shower. Two other CNA's came to the floor to pass dinner meals to the residents, including Resident #2. Staff B, CNA stated after seeing Resident #2 was set up with her dinner meal, she went to another resident's room to assist the resident with eating. While feeding the other resident, the staff member heard a Code Blue over the facility's intercom system and ran to Resident #2's room. Staff B, CNA observed Resident #2 laid flat in the bed with food on her gown and around her mouth and other staff members began CPR on the resident. Staff B, CNA stated when she asked what happened with the resident, Staff A, LPN told her Resident #2 was choking on her food. Staff A, LPN called 911 from her cell phone and passed the phone to Staff B, CNA while she continued CPR on Resident #2. Staff B, CNA stated once EMS arrived at the facility, they continued CPR on the resident. Staff B, CNA stated Resident #2 usually fed herself at meal times and was not fed by the facility staff. Review of the facility policy titled Dining Program, effective [DATE], revealed under Policy, the nursing staff assists residents in need of assistance during mealtimes. Review of the facility Job Description for Certified Nursing Assistants revealed under Summary of Position, the CNA Is responsible for assisting with direct residents/patients care within the scope of their practice as well as other work on the unit which supports the patient environment. The section titled Essential Duties and Responsibilities revealed direct care responsibilities include participating and receiving the nursing report upon reporting to duty, report and record observations of resident's/patient's conditions, and ensuring each resident's personal care needs are being met in accordance with the resident's/patient's wishes. An interview was conducted on [DATE] at 11:28 a.m. with Staff K, Speech Language Pathologist (SLP). Staff K, SLP stated when Resident #2 was admitted to the facility she was on a regular diet but did not have any teeth and did not wear dentures. Staff K, SLP verified from Resident #2's previous facility the resident received a mechanical soft diet. Staff K, SLP stated a trial was conducted, which determined a mechanical soft diet with bite size food was an appropriate diet for the resident. Staff K, SLP stated she educated Resident #2's direct care staff regarding providing set-up assistance for the resident, sitting the resident up 90 degrees in bed for meals prior to the resident eating, and monitoring the resident to ensure she was eating safely. Staff K, SLP stated she did not witness the resident choking or having difficulty swallowing during trials, but the resident would occasionally take consecutive sips of liquids before swallowing what was already in her mouth. Staff K, SLP recommended the resident have supervision during her meals due to the resident's dementia and safe swallowing reminders might not be retained be the resident. Staff K, SLP stated she wanted nursing staff present in the room during meals to ensure the resident was safe during her meals, which was the level of supervision the resident had at her previous facility. Staff K, SLP stated she would expect nursing staff to put interventions in the care plan and communicate any recommendations she provides so all other nursing staff were aware. Staff K, SLP informed Resident #2's physician of the recommendations, who signs and approves the resident's orders. A review of Resident #2's SLP Evaluation & Plan of Treatment, initiated [DATE], revealed under Plan of Treatment, treatment approaches may include treatment of swallowing dysfunction and/or oral function for feeding and evaluation of oral and pharyngeal swallow function. The Evaluation & Plan of Treatment revealed the following under Initial Assessment/Current Level of Functioning & Underlying Impairments: Patient was admitted to the facility on regular/thin liquids diet from the hospital, however, nursing downgraded and referred to Speech Therapy due to patient complaints of difficulty masticating. Per daughter, patient was previously receiving mechanical soft/thin diet at her previous facility. Patient presents for a BSE (Bedside Swallowing Evaluation) to assess current swallow function. The Evaluation & Plan of Treatment revealed under Objective Tests/Measures & Additional Analysis, Resident #2 displayed behaviors impacting safety of decreased safety awareness and poor self-monitoring skills. The section titled Recommendations revealed recommendations for close supervision of oral intake. The Evaluation & Plan of Treatment was signed by the resident's physician on [DATE]. An interview was conducted on ,d+[DATE] at 11:53 a.m. with Staff G, LPN. Staff G, LPN stated on [DATE], she was working on the first floor of the facility when she heard a Code Blue on the overhead speaker. Staff G, LPN responded to Resident #2's room, which was on a different floor, and witnessed about four people already in the resident's room assessing the resident. Staff G, LPN stated Resident #2 appeared sitting upright in bed, was unresponsive, and appeared to be losing color. She was asked by Staff E, LPN for assistance in providing the Heimlich maneuver to Resident #2, so Staff G, LPN got onto the bed and behind the resident to perform the Heimlich maneuver. Staff G, LPN stated she put her hands in front of Resident #2's upper abdominal region and performed thrusts in an upward position. After a few thrusts, Resident #2 had an episode of vomiting, which the staff member described as watery and without solids. Staff G, LPN stated they performed the Heimlich maneuver on the resident because they suspected the resident may have had something in their airway and the resident's oxygen level was dropping. Staff G, LPN stated once she became fatigued, another staff member, who she was unable to state the name of, performed the Heimlich maneuver on the resident with no results. Staff G, LPN stated EMS arrived shortly after and stated, we kind of got out of the way. Staff G, LPN stated she returned to her floor after EMS arrived. An interview was conducted on [DATE] at 12:21 p.m. with Staff A, LPN, who was Resident #2's assigned nurse on [DATE]. Staff A, LPN stated when Resident #2 was first admitted to the facility, she was on a regular diet. After speaking with Resident #2's daughter, she found out the resident was previously receiving a mechanical soft diet and changed the resident's diet order. Staff A, LPN stated on [DATE], she was passing medications and went into Resident #2's room to administer medications to Resident #6. Resident #6 informed her to check on Resident #2 because she saw the resident eating and point to her mouth as if she could not breathe. Staff A, LPN stated Resident #2 appeared unresponsive with food all over her chest. Staff A, LPN put a pulse oximeter on Resident #2's finger and did not get a pulse reading, so she ran to call a Code Blue and retrieve the emergency cart. Staff A, LPN stated when she returned to the resident's room, a CNA was already doing CPR on the resident. Staff A, LPN retrieved a bag valve mask and applied it to Resident #2 while attempting to maintain the resident's airway. Staff A, LPN stated other nursing staff responded to the room and they eventually discovered a pulse using the pulse oximeter. Once they determined the resident had a pulse, they stopped CPR and began to perform the Heimlich maneuver on Resident #2 until EMS personnel arrived at the room. Staff A, LPN stated Resident #2 had an episode of emesis during the Heimlich maneuver, which was of a watery consistency. EMS personnel checked for the resident's pulse and the resident was still unresponsive, so they laid the resident back onto the bed and began CPR. Staff A, LPN stated EMS took Resident #2 to the hospital. The staff member stated Resident #2 fed herself and no staff assisted the resident since her admission. Staff A, LPN stated she did not look at Resident #2's care plan to determine if the resident required assistance and was told in the shift report the resident did not require assistance with dining. Staff A, LPN stated you just know, because this resident was an independent eater and had never needed help before. A review of the facility policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, revealed under the section titled Policy, the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facticity shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. An interview was conducted on [DATE] at 10:08 a.m. with Staff L, LPN and Clinical Reimbursement Specialist (CRS) and Staff M, Clinical Reimbursement Consultant (CRC). Staff L, LPN CRS stated resident care plans are developed using physician orders, hospital documentation, and interviews with the resident and/or the resident's family members, and would include anything needed to provide care to the resident. Staff L, LPN CRS stated everybody has access to the resident's care plan and can see the interventions in the care plans. Staff M, CRC stated staff should be following resident care plans if the care plan shows a resident was dependent on dining with an assist of one staff member. An assist of one staff member means the staff member would be physically assisting the resident with eating. Staff M, CRC stated interventions from the care plan are pulled over into the CNA charting system, which can be viewed by the CNA staff providing care to the resident. An interview was conducted on [DATE] at 12:17 p.m. with the facility's Medical Director (MD), who was Resident #2's primary care provider. The MD stated Resident #2 was initially admitted to the facility for a fractured hip and was receiving physical and occupational therapy. The resident had dementia, diabetes, mild congestive heart failure, and pulmonary hypertension, among other comorbidities. The MD stated the resident was not able to get out of the bed safely due to the hip fracture, so the resident had all of her meals in the bed and the MD, would guess she would need assistance with all of them. The MD stated he was aware the resident had a previous cerebral vascular accident (CVA), but did not think she had a problem with her swallowing because the CVA was not a recent issue. The MD stated he was not aware the resident required supervision with her meals and would think the resident was a self-feeder. The MD stated his knowledge of the event on [DATE] came from the NHA, who told him the resident was found unresponsive in bed and required CPR and use of the Heimlich maneuver before being transported to the hospital. He said he did not review any of the resident's hospital documentation but there was concern the resident could have aspirated. An interview was conducted on [DATE] at 12:35 p.m. with Resident #2's daughter and emergency contact (EC). The EC stated in 2021, Resident #2 suffered a massive stroke and required nursing home care due to the resident's inability to care for herself. After suffering a fall with hip fracture at a previous facility, she decided to place the resident at this facility. The EC stated when at the previous facility, Resident #2 was provided a mechanical soft diet and needed supervision during meals because the resident could not feel food on the left side of her mouth and would pocket food. The EC observed Resident #2's meal tray left in the resident's room on several occasions and never observed staff assisting the resident or providing supervision to the resident during meals, even after informing the facility of the resident's needs several times. The EC stated when Resident #2 would attempt to feed herself, she would get food all over her and was not aware of how much food she was putting in her mouth. The EC was at work when she received a call from the facility informing her Resident #2 was unresponsive. When the EC asked the facility staff if the resident choked, they told her she was unresponsive and they were assessing the situation. The facility called the EC back appropriately five minutes later and was informed EMS personnel were taking Resident #2 to the hospital. During the phone call, the EC asked facility staff if Resident #2 choked on her food and the facility staff responded, I believe so. The EC stated Resident #2 passed away later that night on [DATE]. The facility's immediate actions to remove the Immediate Jeopardy included: - On [DATE], Resident #2 discharged to the hospital and has not returned to the facility. - An audit was completed on [DATE] of care plans for current residents, totaling 115, related to necessary dietary interventions to ensure that residents requiring assistance receive appropriate care during mealtimes as per the resident care plan and [CNA documentation system]. The audits for meal tray accuracy and appropriate level of assistance were initiated [DATE] and is currently ongoing. There are currently 50 audits at this time. The tray line audit reviewing adequate consistency and items matching meal tickets was initiated on [DATE] and is ongoing, there are currently 118 audits at this time. - The DON and NHA received directed education by the Regional Nurse Consultant on [DATE] on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/[CNA documentation system] interventions. - A total of 90 out of 90 Licensed nursing staff and Certified Nursing Assistants were provided education by the DON or designee on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/[CNA documentation system] interventions. This education was 100% completed on [DATE]. - An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held on [DATE]. Verification of the facility's removal actions was conducted by the survey team on [DATE]. Review of facility education was conducted. Staff roster provided by NHA and DON. All facility Licensed nursing staff and Certified Nursing Assistants were educated on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions, completed on [DATE]. Four additional resident records reviewed to verify care plan interventions related to assisted dining. All resident records reviewed revealed care plan interventions related to assisted dining and need for assistance. Observations were conducted [DATE] at 11:30 a.m. and on [DATE] at 5:00 p.m. of the facility's meal service process. Nursing staff were observed verifying meal tickets with the resident tray before handing the tray to CNA staff to provide to residents, who verified the meal tickets match the resident tray. Nursing staff observed holding resident meal trays with NURSING on the meal ticket, indicating the resident requires assistance with the meal. Nursing staff observed assisting residents with meals as required. Staff were observed providing direct supervision during meals held in facility dining rooms. Interviews were conducted with 37 facility nursing staff members, including 4 Registered Nurses, 8 LPNs, and 25 CNAs. The staff members were able to state that they had been trained and were knowledgeable about the subject matter regarding implementation of resident care plans and care plan/CNA documentation system interventions. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#2) of three residents dependent upon staff to feed at meal times, was provided supervision and services related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on [DATE] at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance. The facility failed to take action to prevent the resident from choking by not providing supervision during the resident's meal and not checking the resident's plan of care prior to providing the meal to the resident. At approximately 5:38 p.m., Staff A, Licensed Practical Nurse discovered Resident #2 unresponsive after being alerted by Resident #2's roommate. Resident #2 required use of the Heimlich maneuver and cardiopulmonary resuscitation (CPR) by facility staff and Emergency Medical Services (EMS) staff due to suspected choking and being found without a pulse or respirations. Resident #2 was transported to the hospital where she expired. The failure created a situation that resulted in Resident #2's death and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: A review of the facility policy titled Abuse Prevention Program, last reviewed in [DATE], revealed under the section titled Policy, the facility had designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. The policy defines neglect as failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of Resident #2's medical record Resident #2 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness; and dysphagia, oropharyngeal phase. A review of Resident #2's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of [DATE] revealed under Section C: Decision Making Capacity (Patient) Resident #2 required a surrogate for medical decision making. The transfer form revealed under Section U: Nutrition/Hydration, Resident #2 required assistance with eating. Section U: Mental/Cognitive Status at Transfer revealed Resident #2 was alert and disoriented but could follow simple instructions. A review of Resident #2's Admission/Readmission Data Collection assessment dated [DATE] revealed under section C: Body System Review, Resident #2 had no natural teeth or dentures and was on a mechanically altered diet. The assessment revealed under section D: Mobility/ADL/ROM (Activities of Daily Living/Range of Motion), Resident #2 was dependent on staff with eating. Resident #2's care plan was updated with a Focus: (Resident #2) has an ADL Self Care Performance Deficit. Interventions included assist of one staff with eating and dependent upon staff to feed. A review of the facility policy titled Admission/Readmission Data Collection, effective [DATE] revealed the Resident's Admission/Readmission Data Collection will provide a comprehensive description of the Resident's status on admission. The assessment is designed to identify past history, current findings, and factors that may put the Resident at risk. A review of Resident #2's [DATE] Order Summary Report revealed the following orders: - Renal diet mechanical soft/soft and bite-sized texture, regular (thin) consistency. Dated [DATE]. - Full resuscitation. Dated [DATE]. - Speech Therapy Clarification resident to be seen 5 times per week for 6 weeks for focus on dysphagia management, resident/caregiver education, discharge planning with group treatment when appropriate/and do planning. Dated [DATE]. - Renal diet, regular texture, regular (thin) consistency. Dated [DATE] and discontinued on [DATE]. A review of Resident #2's care plan revealed a Focus area of the resident has an ADL self-care performance deficit. Interventions included an assist of 1 for eating and dependent upon staff to feed. Resident #2's care plan revealed a Focus are of the resident has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included to provide orientation and validation, and cue, reorient, and supervise as needed. A review of Resident #2's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment revealed under Section GG - Functional Abilities, Resident #2 required substantial/maximal assistance (helper does more than half the effort) with eating. The assessment revealed under Section K - Swallowing/Nutritional Status, Resident #2 had coughing or choking during meals or when swallowing medications and had a mechanically altered diet on admission and while a resident in the facility. A review of Resident #2's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE] and authored by Staff A, Licensed Practical Nurse (LPN), revealed under the section titled Mental Status Evaluation (compared to baseline; check all changes that you observe), Unresponsiveness, was checked. Under the section titled Functional Status Evaluation (compared to baseline; check all changes that you observe), Other (describe) was checked with a description symptom or sign of aspirated documented. The form revealed the following under Appearance: Writer was across the hall at [room number] providing medication. Writer turned to go to [Resident #2's room], [Resident #2's roommate] said to writer that, you need to look at [Resident #2]. Writer assessed resident, resident was unresponsive, writer called a code blue and grabbed the crash cart. Other nurses arrived and we began CPR, because the resident was eating dinner before going unconscious, we then began the Heimlich maneuver. The [Emergency Medical Services personnel] arrived and took over. A review of an ambulance run report dated [DATE] revealed two EMS personnel (E2 and R1) were dispatched and responded to the facility after notification of Resident #2 being unresponsive. The run report included the following: E2 and R1 responded to a medical call. E2 was first on scene and found a 76 [year old] female in a nursing home in cardiac arrest. E2 began ACLS [Advanced Cardiac Life Support] procedures and CPR was initiated. E2 began CPR and ventilations per AHA [American Heart Association] guidelines. [Patient] was positioned in bed with [cervical] spine board to support CPR. Staff on scene state the [patient] appeared to be choking and they began the Heimlich maneuver. [Patient] became unresponsive and was laid supine as E2 walked into the room. E2 performed CPR and ventilations per AHA until R1 arrived . No pulse Asystole. R1 arrived and assisted E2 in establishing ALS [Advanced Life Support] interventions. A suction was provided and utilized to removed emesis and food from the patients airway. A pulse check rhythm check was performed again after 2 minutes with no pulse, [patient] in asystole. CPR and ventilations were resumed per AHA throughout the duration of the call with a pulse check rhythm check every 2 minutes . Around 10 cycles of CPR were performed throughout the duration of the arrest. After the current cycle finished, a pulse check was performed, pulse present with sinus rhythm. ROSC [Return of Spontaneous Circulation] procedures were initiated. [Patient] was prepped for transport and transferred to the stretcher and secured. [Patient] placed into the rescue and emergency transport to [local hospital] started. [Patient] interventions were reassessed and intact. Pulse still present. A blood pressure was obtained and recorded. Pulse check performed on arrival of ER [emergency room ], pulse present . The section of the run report titled Specialty Patient - CPR revealed the following: Cardiac Arrest Etiology: Respiratory/Asphyxia Estimated time of arrest: ,d+[DATE] Minutes The run report revealed the following Incident Times: Call received: 17:41 (5:41 p.m.) En Route: 17:44 (5:44 p.m.) On scene: 17:50 (5:50 p.m.) Depart scene: 18:18 (6:16 p.m.) At destination: 18:26 (6:26 p.m.) According to the Cleveland Clinic, the Heimlich maneuver is a first-aid method for choking that you can use on adults and children. Another name for the Heimlich maneuver is abdominal thrusts, because it involves thrusting into the abdominal area. It is a quick and life-saving method, but you should only use it on conscious people who can not breathe on their own. https://my.clevelandclinic.org/health/treatments/21675-heimlich-maneuver According to the Mayo Clinic, choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person does not give the signal, look for these indications: - Inability to talk - Difficulty breathing or noisy breathing - Squeaky sounds when trying to breathe - Cough, which may either be weak or forceful - Skin, lips, and nails turning blue or dusky - Skin that is flushed, then turns pale or bluish in color - Loss of consciousness https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637#:~:text=To%20perform%20abdominal%2 0thrusts%20([MEDICATION(S)]%20maneuver)%20on%20yourself%2C%20place, do%20in%20a%20choking%20emergency A review of Resident #2's Emergency Department Documents dated [DATE] revealed EMS reported Resident #2 was found unresponsive in her room with vomiting and fluid all over. Upon EMS arrival, Resident #2 was pulseless and in PEA (Pulseless Electrical Activity) cardiac arrest. On arrival to the ER, initial evaluation and pulse check demonstrated recurrent cardiopulmonary arrest. Resident #2 had a significant amount of oropharyngeal and aspiration output after ET (endotracheal) tube placement. The section of the documents titled Medical Decision Making revealed Resident #2 had no signs of significant neurofunction and had prolonged oxygen deprivation due to either prolonged downtime or severe aspiration. The section of the documents titled Assessment/Plan revealed Resident #2 had diagnoses of cardiopulmonary arrest and aspiration into airway (unspecified foreign body in respiratory tract, part unspecified causing other injury, initial encounter). An interview was conducted on [DATE] at 1:14 p.m. with Resident #6, former roommate of Resident #2. Resident #6 stated she was Resident #2's roommate during the duration of her stay at the facility and would regularly see the resident's daughter coming in to feed the resident, but never witnessed facility staff assisting the resident with her meals. Resident #6 stated on [DATE] during the dinner meal, she witnessed Resident #2 feeding herself and the resident, was eating as fast as she could get it in there. Resident #6 noticed Resident #2 had food coming out of her mouth and was no longer swallowing food, which is when she notified the nurse who was across the hallway Resident #2 needed help. Resident #6 stated the nurse entered the room to check on Resident #2 and ran down the hallway. Resident #6 stated she heard code blue followed by their room number on the overhead speaker and the entire room filled up with people. Resident #6 stated the following day she was informed by Resident #2's daughter the resident passed away. A review of Resident #6's MDS assessment with an ARD of [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15, which indicated the resident was cognitively intact. An interview was conducted on [DATE] at 3:11 p.m. with the facility's Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional [NAME] President of Operations (VPO). The NHA stated on [DATE], an allegation of neglect was reported to her by Resident #2's daughter when she came to the facility to gather Resident #2's belongings. The NHA stated she was told by Resident #2's daughter, I know she choked on her food and that's why she was sent to the emergency room , prompting them to initiate an investigation. The DON stated they conducted interviews with the staff involved during the incident and discovered staff performed CPR on Resident #2 as well as the Heimlich maneuver because there was concern the resident may have had something in their airway and there was vomit in the resident's mouth during the CPR. The NHA stated Resident #2 aspirated during the incident and was suctioned by staff. The DON stated facility developed the following timeline of events through interviews with staff: - On [DATE] around 3:00 p.m., Resident #2 was observed by facility staff in her room, with no signs of distress and at her baseline level. Resident #2's care was assigned to Staff A, LPN and Staff B, Certified Nursing Assistant (CNA). - On [DATE] around 5:15 p.m., Staff B, CNA and her hall partner Staff C, CNA passed meal trays in Resident #2's hall while Staff A, LPN performed blood glucose checks and medication administration for other residents in the hall. Resident #2 was provided a dinner tray in her room by Staff C, CNA, which was left on the bedside table in front of her after the resident stated she did not want it. After passing meal trays, Staff B, CNA, looked into Resident #2's room and saw her upright in bed and eating without difficulty. Staff B, CNA went to another resident's room to assist the resident with dining. - On [DATE] at 5:38 p.m., Staff A, LPN entered Resident #2's room to administer medications to Resident #6. Resident #6 told Staff A, LPN she needed to first check on Resident #2. Resident #2 was observed upright in the bed with her head to the side and unresponsive. At that time, Staff A, LPN ran from the room to call a Code Blue overhead and grabbed the emergency cart. Staff A, LPN verified Resident #2's code status as a Full Code and responded back to the room. Staff D, CNA responded to the resident's room and began life saving measures, including CPR, on Resident #2. Staff E, LPN, Staff F, LPN, and Staff G, LPN all responded to Resident #2's room and assisted in providing CPR. During the CPR, Resident #2 had an episode of vomiting and regained a pulse and respirations, verified by Staff E, LPN by palpation and by attaching a pulse oximeter to the resident's finger. Staff sat Resident #2 up in the bed and performed the Heimlich maneuver on the resident. No food or vomit came out of Resident #2's mouth during the performance of the Heimlich maneuver. During the event, at 5:43 p.m., a staff member called 911. - On [DATE] at approximately 5:58 p.m., Emergency Medical Services (EMS) arrived. Resident #2 became unresponsive without a pulse or respirations shortly after arrival of EMS and CPR was initiated by EMS. Per interview with Staff H, LPN, who was near the facility entrance when EMS left with Resident #2, Resident #2 had a pulse on the monitor and was intubated by EMS when she was being taken out of the facility and to the hospital. The DON stated the next day on [DATE], all information relating to the incident was collected to ensure the Code Blue process was properly executed and all CPR certifications of the involved staff were verified. The DON stated Resident #2's dinner meal was verified and the resident received the appropriate diet, but not the food she was supposed to receive per her diet slip. Resident #2 received potato salad on her dinner tray instead of rice with thick gravy. The DON addressed Resident #2's care plan revealed she required assistance of one staff member with dining, but the care plan did not indicate the resident could not feed herself. The DON stated Resident #2 was evaluated by the Speech Language Pathologist (SLP), who determined the resident was able to feed herself, but would consume food too quickly at times. The DON addressed Resident #2's care plan did not include anything related to the resident consuming food too quickly and stated none of the staff interviewed spoke about the resident consuming food too fast. The DON stated upon investigation and interview with staff, they determined Staff C, CNA was the staff member who passed the meal tray to Resident #2 and did not check the resident's plan of care prior to passing the meal tray and was not told the resident required assistance. The DON stated they could not verify if Resident #2 choked on her food during the meal due to documentation stating the resident had aspirate, which could have been from the CPR performed on the resident. The NHA stated after the facility investigation the concern, they substantiated the allegation of neglect due to Resident #2 receiving the wrong food on her meal tray and not being provided assistance with the meal per the plan of care. The DON stated the facility separated employment from Staff A, LPN, Staff B, CNA, Staff C, CNA, and Staff I, [NAME] following the incident. A telephone interview was attempted on [DATE] at 9:48 a.m. with Staff D, CNA, who performed CPR on Resident #2 when she was found unresponsive on [DATE]. Staff D, CNA did not answer the phone call and a message was left for call back. The phone call was not returned by Staff D, CNA. A telephone interview was attempted on [DATE] at 10:10 a.m. with Staff C, CNA, who provided Resident #2's dinner meal tray on [DATE]. Staff C, CNA did not answer the phone call and a message was left for call back. The phone call was not returned by Staff C, CNA. A telephone interview was attempted on [DATE] at 10:21 a.m. with Staff I, Cook, who prepared Resident #2's dinner meal tray on [DATE]. Staff I, [NAME] did not answer the phone call and a message was left for call back. The phone call was not returned by Staff I, Cook. A telephone interview was attempted on [DATE] at 10:28 a.m. with Staff J, Dietary Aide, who verified the contents of Resident #2's dinner meal tray on [DATE]. Staff J, Dietary Aide did not answer the phone call and a message was left for call back. The phone call was not returned by Staff J, Dietary Aide. A telephone interview was conducted on [DATE] at 10:45 a.m. with Staff B, CNA, who was Resident #2's assigned CNA on [DATE]. Staff B, CNA stated the dinner meal arrived on her floor around 5:15 p.m. while she was assisting another resident with a shower. Two other CNA's came to the floor to pass dinner meals to the residents, including Resident #2. Staff B, CNA stated after seeing Resident #2 was set up with her dinner meal, she went to another resident's room to assist the resident with eating. While feeding the other resident, the staff member heard a Code Blue over the facility's intercom system and ran to Resident #2's room. Staff B, CNA observed Resident #2 laid flat in the bed with food on her gown and around her mouth and other staff members began CPR on the resident. Staff B, CNA stated when she asked what happened with the resident, Staff A, LPN told her Resident #2 was choking on her food. Staff A, LPN called 911 from her cell phone and passed the phone to Staff B, CNA while she continued CPR on Resident #2. Staff B, CNA stated once EMS arrived at the facility, they continued CPR on the resident. Staff B, CNA stated Resident #2 usually fed herself at meal times and was not fed by the facility staff. Review of the facility policy titled Dining Program, effective [DATE], revealed under Policy, the nursing staff assists residents in need of assistance during mealtimes. An interview was conducted on [DATE] at 11:28 a.m. with Staff K, Speech Language Pathologist (SLP). Staff K, SLP stated when Resident #2 was admitted to the facility she was on a regular diet but did not have any teeth and did not wear dentures. Staff K, SLP verified from Resident #2's previous facility the resident received a mechanical soft diet. Staff K, SLP stated a trial was conducted, which determined a mechanical soft diet with bite size food was an appropriate diet for the resident. Staff K, SLP stated she educated Resident #2's direct care staff regarding providing set-up assistance for the resident, sitting the resident up 90 degrees in bed for meals prior to the resident eating, and monitoring the resident to ensure she was eating safely. Staff K, SLP stated she did not witness the resident choking or having difficulty swallowing during trials, but the resident would occasionally take consecutive sips of liquids before swallowing what was already in her mouth. Staff K, SLP recommended the resident have supervision during her meals due to the resident's dementia and safe swallowing reminders might not be retained be the resident. Staff K, SLP stated she wanted nursing staff present in the room during meals to ensure the resident was safe during her meals, which was the level of supervision the resident had at her previous facility. Staff K, SLP stated she would expect nursing staff to put interventions in the care plan and communicate any recommendations she provides so all other nursing staff were aware. Staff K, SLP informed Resident #2's physician of the recommendations, who signs and approves the resident's orders. An interview was conducted on ,d+[DATE] at 11:53 a.m. with Staff G, LPN. Staff G, LPN stated on [DATE], she was working on the first floor of the facility when she heard a Code Blue on the overhead speaker. Staff G, LPN responded to Resident #2's room, which was on a different floor, and witnessed about four people already in the resident's room assessing the resident. Staff G, LPN stated Resident #2 appeared sitting upright in bed, was unresponsive, and appeared to be losing color. She was asked by Staff E, LPN for assistance in providing the Heimlich maneuver to Resident #2, so Staff G, LPN got onto the bed and behind the resident to perform the Heimlich maneuver. Staff G, LPN stated she put her hands in front of Resident #2's upper abdominal region and performed thrusts in an upward position. After a few thrusts, Resident #2 had an episode of vomiting, which the staff member described as watery and without solids. Staff G, LPN stated they performed the Heimlich maneuver on the resident because they suspected the resident may have had something in their airway and the resident's oxygen level was dropping. Staff G, LPN stated once she became fatigued, another staff member, who she was unable to state the name of, performed the Heimlich maneuver on the resident with no results. Staff G, LPN stated EMS arrived shortly after and stated, we kind of got out of the way. Staff G, LPN stated she returned to her floor after EMS arrived. An interview was conducted on [DATE] at 12:21 p.m. with Staff A, LPN, who was Resident #2's assigned nurse on [DATE]. Staff A, LPN stated when Resident #2 was first admitted to the facility, she was on a regular diet. After speaking with Resident #2's daughter, she found out the resident was previously receiving a mechanical soft diet and changed the resident's diet order. Staff A, LPN stated on [DATE], she was passing medications and went into Resident #2's room to administer medications to Resident #6. Resident #6 informed her to check on Resident #2 because she saw the resident eating and point to her mouth as if she could not breathe. Staff A, LPN stated Resident #2 appeared unresponsive with food all over her chest. Staff A, LPN put a pulse oximeter on Resident #2's finger and did not get a pulse reading, so she ran to call a Code Blue and retrieve the emergency cart. Staff A, LPN stated when she returned to the resident's room, a CNA was already doing CPR on the resident. Staff A, LPN retrieved a bag valve mask and applied it to Resident #2 while attempting to maintain the resident's airway. Staff A, LPN stated other nursing staff responded to the room and they eventually discovered a pulse using the pulse oximeter. Once they determined the resident had a pulse, they stopped CPR and began to perform the Heimlich maneuver on Resident #2 until EMS personnel arrived at the room. Staff A, LPN stated Resident #2 had an episode of emesis during the Heimlich maneuver, which was of a watery consistency. EMS personnel checked for the resident's pulse and the resident was still unresponsive, so they laid the resident back onto the bed and began CPR. Staff A, LPN stated EMS took Resident #2 to the hospital. The staff member stated Resident #2 fed herself and no staff assisted the resident since her admission. Staff A, LPN stated she did not look at Resident #2's care plan to determine if the resident required assistance and was told in the shift report the resident did not require assistance with dining. Staff A, LPN stated you just know, because this resident was an independent eater and had never needed help before. An interview was conducted on [DATE] at 10:08 a.m. with Staff L, LPN and Clinical Reimbursement Specialist (CRS) and Staff M, Clinical Reimbursement Consultant (CRC). Staff L, LPN CRS stated resident care plans are developed using physician orders, hospital documentation, and interviews with the resident and/or the resident's family members, and would include anything needed to provide care to the resident. Staff L, LPN CRS stated everybody has access to the resident's care plan and can see the interventions in the care plans. Staff M, CRC stated staff should be following resident care plans if the care plan shows a resident was dependent on dining with an assist of one staff member. An assist of one staff member means the staff member would be physically assisting the resident with eating. Staff M, CRC stated interventions from the care plan are pulled over into the CNA charting system, which can be viewed by the CNA staff providing care to the resident. An interview was conducted on [DATE] at 12:17 p.m. with the facility's Medical Director (MD), who was Resident #2's primary care provider. The MD stated Resident #2 was initially admitted to the facility for a fractured hip and was receiving physical and occupational therapy. The resident had dementia, diabetes, mild congestive heart failure, and pulmonary hypertension, among other comorbidities. The MD stated the resident was not able to get out of the bed safely due to the hip fracture, so the resident had all of her meals in the bed and the MD, would guess she would need assistance with all of them. The MD stated he was aware the resident had a previous cerebral vascular accident (CVA), but did not think she had a problem with her swallowing because the CVA was not a recent issue. The MD stated he was not aware the resident required supervision with her meals and would think the resident was a self-feeder. The MD stated his knowledge of the event on [DATE] came from the NHA, who told him the resident was found unresponsive in bed and required CPR and use of the Heimlich maneuver before being transported to the hospital. He said he did not review any of the resident's hospital documentation but there was concern the resident could have aspirated. An interview was conducted on [DATE] at 12:35 p.m. with Resident #2's daughter and emergency contact (EC). The EC stated in 2021, Resident #2 suffered a massive stroke and required nursing home care due to the resident's inability to care for herself. After suffering a fall with hip fracture at a previous facility, she decided to place the resident at this facility. The EC stated when at the previous facility, Resident #2 was provided a mechanical soft diet and needed supervision during meals because the resident could not feel food on the left side of her mouth and would pocket food. The EC observed Resident #2's meal tray left in the resident's room on several occasions and never observed staff assisting the resident or providing supervision to the resident during meals, even after informing the facility of the resident's needs several times. The EC stated when Resident #2 would attempt to feed herself, she would get food all over her and was not aware of how much food she was putting in her mouth. The EC was at work when she received a call from the facility informing her Resident #2 was unresponsive. When the EC asked the facility staff if the resident choked, they told her she was unresponsive and they were assessing the situation. The facility called the EC back appropriately five minutes later and was informed EMS personnel were taking Resident #2 to the hospital. During the phone call, the EC asked facility staff if Resident #2 choked on her food and the facility staff responded, I believe so. The EC stated Resident #2 passed away later that night on [DATE]. The facility's immediate actions to remove the Immediate Jeopardy included: - On [DATE], Resident #2 discharged to the hospital and has not returned to the facility. - The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete on [DATE]. - The DON and NHA received directed education by the Regional Nurse Consultant on [DATE] regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. - A total of 109 out of 109 facility staff were provided education by the DON or designee regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. Education was provided to 28 out of 28 contracted staff members regarding abuse, neglect, and misappropriation. A total of 104 out of 104 nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was 100% completed on [DATE]. - An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held on [DATE]. Verification of the facility's removal actions was conducted by the survey team on [DATE]. Review of facility education was conducted. Staff roster provided by NHA and DON. All facility staff were educated related to abuse, neglect, exploitation, and misappropriation, completed on [DATE]. All nursing, therapy staff, and department heads were educated related to tray ticket indication of need for dining assistance/dependent diners/staff role during meal times and the all hands dining process, completed on [DATE]. Observations were conducted [DATE] at 11:30 a.m. and on [DATE] at 5:00 p.m. of the facility's meal service process. Nursing staff were observed verifying meal tickets with the resident tray before handing the tray to CNA staff to provide to residents, who verified the meal tickets match the resident tray. Nursing st[TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases. The facility failed to 1) ensure staff donned personal protective equipment and performed hand hygiene prior to entering and exiting an isolation area for 1 of 1 isolation areas. 2) The facility failed to follow the Center for Disease Control Prevention (CDC) guidelines to contact their local health department when a resident presented with signs and symptoms of COVID-19 and did not follow their facility policy for monitoring and detection, triage and isolation of potentially infectious residents that could have prevented unnecessary exposure among their residents, and healthcare personnel for the facility for 2 of 2 reviewed, 3) Failed to clean shared areas and shared items on 1 of 2 floors. 4) The facility failed to use an approved cleaner for shared equipment on 2 of 2 floors, 5) Failed to ensure staff entering and exiting resident rooms performed hand hygiene on 1 of 2 floors and 6) Failed to ensure that medical equipment used for suctioning, which comes into contact with mucus membranes, was stored correctly, and that a sterile tracheotomy kit, which is used to clean around the airway, was unopened in the resident's room for 1 (#21) out of 4 tracheotomy residents. 7) The facility did not ensure that foam cups, used for resident consumption of fluids, were stored correctly underneath an ice chest on 2 of 2 hydration carts. These failures in infection control practices contributed to 49 vulnerable residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #23, #27, #29, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61), testing positive for the COVID19 virus and one (#1) confirmed death out of 49 positive sampled residents and contributed to 17 staff members testing positive for COVID19 out of 122 staff members tested . Findings included: 1) An observation on [DATE] at 10:35 a.m., Staff S, Certified Nurse's Aide (CNA), was observed entering the building and walking up the hall towards a plastic barrier. Staff C, without washing or sanitizing her hands, walked up to and unzipped the plastic isolation barrier, entered, zipped the barrier closed and began donning personal protective equipment (PPE), gown, gloves and a N95 mask and walked into an isolation room. A second observation was conducted at 10:53 a.m., Staff S, CNA was inside the isolation area at the opposite end of the hall than the zippered plastic barrier with a bag of dirty linen in her hand. Staff S did not have on gloves or a gown. Staff S, CNA, used her un-gloved right hand to push open the emergency exit door at the end of the hallway, walked out, placed the soiled linen in a gray plastic bin, then walked back into the isolation area and closed the door. An interview was conducted on ,[DATE] at 10:53 a.m., Staff S, CNA said, When I came in this morning, I came in the side door that staff are supposed to come in and checked in. Then I walked down here and unzipped the plastic barrier, Yes for isolation. Yes, then I put on my PPE. If I have to leave or go to lunch, I have to go out of the door down there, (pointing to the emergency exit door at the end of the hall). No, there is not any PPE set up outside that exit door. I remove my gloves and gown after leaving the room. An interview was conducted on [DATE] at 11:03 a.m., the ADON (Assistant Director of Nursing) said, They should put on their PPE before going into the isolation area. I need to re-think how to do that when they exit the isolation hall by going out of the emergency door on the end of the hall. No, there is not any PPE set up out there. 2) A review of facility deaths from [DATE] through [DATE] revealed Resident #35 had expired in the facility on [DATE] at 19:45(7:45 pm). Resident #35 was admitted to the facility on [DATE] with relevant medical history for [MEDICAL CONDITIONS] and Diabetes. A review of the facility documentation for Resident and Staff Change of Condition log reflected documentation on [DATE] for Resident #35 with signs and symptoms of Temp, SOB(shortness of breath), Low O2 sats(Oxygen Saturation of the blood, normal ,[DATE]%). Tests: Flu for A and B (-) Negative, chest x-ray and CBC (complete blood count) normal. Details: Resident is being followed closely by the ARNP (Advanced Registered Nurse Practitioner). A review of the nurses note on [DATE] at 21:47 (9:47 pm) (4 hours after presenting with symptoms of elevated temperature, respirations and oxygen desaturated to 77% on room air). Resident had stat (immediate) labs and stat chest x-ray. Chest x-ray Negative. [MEDICATION NAME] 1 gram x 3 days. Negative for flu [MEDICATION NAME] 1 and 2. Resident (O2) sats at 93%, bp (blood pressure),[DATE], pulse 98 at this time. The nurses note dated [DATE] at 16:59 (4:59 pm) documented, Resident had stat labs and stat chest x-ray. Chest x-ray Negative. [MEDICATION NAME] 1 gram x 3 days. Negative for flu [MEDICATION NAME] 1 and 2. Resident sats at 93% bp ,[DATE], pulse 98 at this time. Review of a change in condition, SBAR(situation, background, assessment, recommendations) note dated [DATE] at 16:59(4:59 pm) revealed: Pulse: 148, [DATE] 17:01 Pulse Type: Irregular - new onset, Respirations 24 - [DATE] 17:03, Temp: T 102.5 - [DATE] 17:02 Route: Oral, Pulse Oximetry(O2 Saturation): O2 77% - [DATE] 17:03 Method: Room Air Code Status: DNR Nursing observations, evaluation, and recommendations are: (O2) Sats at 77%, p-148, temp 102.5, crackles (sound heard in the lungs caused by excess fluid) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: ARNP B. New Testing Orders: X-ray. Review of a change in condition, SBAR note dated [DATE] at 8:46 am: Temp: T 97.0 - [DATE] 14:31 Route: Axilla Pulse Oximetry: O2 93.0 % - [DATE] 13:15 Method: Oxygen via Nasal Cannula. Primary Care Provider responded with the following feedback: Recommendations: [MEDICATION NAME] solution for pain, [MEDICATION NAME] for increased oral secretions, continued comfort measures. [MEDICATION NAME] 1 gm IM x 7 days for pneumonia. A review of the resident Change in Condition assessment dated [DATE] documented under Respiratory Status Evaluation boxes checked on the form were: Shortness of breath, abnormal lung sounds, symptoms of a common cold. Describe shortness of breath: Abrupt onset of SOB with pain, fever, or respiratory distress. Describe respiratory signs and symptoms: congestion, sob (shortness of breath), increased temp. A review of the vital signs documented in the medical record revealed: [DATE] at 17:01 Pulse 148 bpm (beats per minute) documented: Irregular-new onset [DATE] at 17:02 Temperature documented at 102.5 F [DATE] at 17:03 Respirations of 24 [DATE] at 17:03 Oxygen saturation at 77% room air [DATE] at 17:45 Pulse 150 bpm Regular [DATE] at 18:02 Pulse 154 bpm Regular [DATE] at 03:14 Oxygen saturation at 88% oxygen via nasal cannula [DATE] at 13:15 Pulse 112 bpm Regular [DATE] at 13:50 Pulse 99 bpm Regular [DATE] at 17:17 Pulse 68 bpm Regular [DATE] at 18:48 Pulse 0 bpm Irregular-new onset. A review of the facility infection control line item revealed no documentation for Resident #35. A review of the physician orders and treatments revealed there were no orders or telephone orders for isolation for Resident #35. A review of the care plan for resident #35 revealed nothing in place for monitoring, isolation or potential for infection. A review of the Medication Administration Record [REDACTED]. An interview was conducted on [DATE] at 3:58 p.m., the Director of Nursing (DON), said, I don't remember Resident #35. The DON reviewed the information in the medical record for Resident #35 and said, Wow. I never heard anything about Resident #35. He definitely could have been COVID19 with those symptoms. That was in the beginning of all of this. No, I do not see that we notified the DOH (Department of Health). An interview was conducted on [DATE] at 4:00 p.m., the Assistant Director of Nursing (ADON), said, As you can see, we notified his physician. If the physician did not order testing or feel he should have been tested then we did not. We followed physician orders. A return call was received on [DATE] at 12:14 p.m., the interested family member said, I was there that day at the facility when he died . I tried to feed him and he would not eat. I heard him make a noise so I went and got the nurse and she told me you probably just heard him take his last breath. I don't know if he had [MEDICAL CONDITION]. They told me they did not test him. A review of the CMS (Centers for Medicare & Medicaid Services), Guidelines for [DATE], Ref: QSO-,[DATE]-NH, revealed .Guidance for Limiting the Transmission of COVID-19 for Nursing Homes: Additional guidance: 2. Implement active screening of residents and staff for fever and respiratory symptoms. Nursing homes with residents suspected of having COVID-19 infection should contact their local health department. Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms or fatality. A review of the medical record showed Resident #3 was admitted to the facility on [DATE]. On admission Resident #3 was not placed in a private room or put on isolation precautions for 14 days or placed in a step-down unit designed to isolate new residents for a length of time to make sure they do not develop symptoms of COVID19 and infect a current resident. A review of the facility infection control line item revealed documentation for Resident #3 with an onset of symptoms on [DATE] with documentation of fever. The medical record revealed Resident #3 developed respiratory symptoms on [DATE] and was tested . The resident was positive for COVID19. The medical record revealed on [DATE] at 17:07 (5:07 pm) a change in condition, SBAR assessment showing: Situation: The Change in Condition reported Evaluation are/were: Fever Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Nursing observations, evaluation, and recommendations are: Resident noted with a fever. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: COVID19 swab B. New Testing Orders: COVID19 swab. A review of the physician orders and treatments revealed there were no orders or telephone orders for isolation after [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at 4:30 p.m., with the DON who said, We had the report from the hospital showing that she was tested on [DATE] and she was negative. Since she had already been tested and was negative, why would we have placed her in isolation when she got here? An interview was conducted on [DATE] at 3:41 p.m., the ADON said, No, we have not isolated any new admissions (on a step-down unit) or residents returning from the hospital. At the time, it is just enhanced monitoring of their vital signs. This is what we were told to do. An interview was conducted on [DATE] at 4:04 p.m., the DON said, No, we have not isolated any new admissions or residents returning from the hospital. It was just enhanced monitoring of their vital signs. This is what we were told from our corporate office. I will have to check who the directive was from. Yes, it was for enhanced monitoring for anybody coming in like new admissions or re-admissions. An interview was conducted on [DATE] at 3:45 p.m., The ADON when asked if she was aware of the CDC guidelines said, I do not know. I am drowning right now. I don't know. An interview was conducted on [DATE] at 10:50 a.m., the Medical Director said, We should follow the CDC guidelines and my expectations are that if the facility receives a resident from the hospital, they should place them in a private room if possible. They must follow the CDC guidelines. I do recommend we follow the CDC guidelines with the step-down recommendation when a resident is transferred to the facility. An interview was conducted on [DATE] at 1:19 p.m., Admissions Coordinator said, I complete a pre-admission screening. All of it is done by phone and electronic process. I call the patient or the family and introduce myself, tell them about our facility. I tell them I have a video about the facility and can send it to them if they like. Most of them want to look at the video. I ask them a series of questions like where they have been the last month. Admissions Coordinator said, I tell the potential residents or families that we have a step-down area. An interview was conducted by phone with the ADON on [DATE] at 9:48 am who said that the current census was 56. All residents had been tested which began on Thursday [DATE] and was completed that same evening. The facility received the results on [DATE] at approximately 10:00 pm, 29 of 85 residents tested were positive for COVID-19. She said that on [DATE] they transferred 30 residents with (+) results, 10 to one hospital, 19 to another hospital (One resident was already at the hospital). Our plan is we are shifting all residents that were in with roommates that the roommate had tested positive, they will be moving to our COVID Unit (1 WEST) this morning, a total of 16 residents. We are in the process of expanding the unit this morning. We have informed families via phone. She said that the DON notified the Medical Director during a telephone conference call at 9:00 a.m. today. A visit to the facility was conducted on [DATE] at approximately 11:30 am. At 2:10 p.m. the COVID Unit (1 West) was observed and found to be empty. The ADON was interviewed and said I am not sure why we have not started moving residents down to the isolation area. I am not sure where the breakdown in communication was. An interview was conducted on [DATE] at 2:20 p.m., with the Director of Housekeeping and Laundry who said, No one has told me yet to clean that area.(1 West) We have to wait at least ,[DATE] hours before we go into clean and then another 2 hours before anyone can be moved down into those rooms. On [DATE] at 2:31 p.m., observed the DON, ADON and the Director of Housekeeping and Laundry come out of an office and the DON said, We will get the residents moved today. I know I said this morning that we were in the process of moving residents to the isolation area. We will all have to help her get it clean down there. She is the only one here. It was observed that only one housekeeping employee was in the facility, the director. An observation was conducted on [DATE] at 3:31 p.m., the Director of Housekeeping and Laundry with PPE on, was cleaning a room on the isolation hall. The next day on [DATE] at 1:08 p.m., the DON said We have the area set up now. We moved the last resident over there to PUI (Persons Under Investigation for COVID) unit on 1 West, at 11:00 p.m., last night. A review of the CMS (Centers for Medicare & Medicaid Services), Guidelines for [DATE], Ref: Ref: QSO-,[DATE]-Pertinent for Nursing Homes: . We remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and to whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). CDC recommends that nursing homes notify their health department about residents with severe respiratory infection, or a cluster of respiratory illness (e.g., > or = 3 residents or HCP with new-onset respiratory symptoms within 72 hours). Local and state reporting guidelines or requirements may vary. Monitor the CDC website for information and resources to help prevent the introduction and spread of COVID-19 in nursing homes . A review of the Facility policy titled COVID-19 Guidance provided by the Director of Nursing (DON), on [DATE] (without an effective date or implementation date noted). Documentation revealed: Standard: In order to reduce the risk of infectious disease exposure in the facility the following guidance will be a utilized. This guidance is being utilized in conjunction with the visitors and visitation directive policy. Communication/education: Provide Resident Council education about COVID-19 and measures the facility is taking to identify risks and reduce risk of transmissions. Provide all staff education including contractors about COVID-19 and measures the facility is taking, including signs and symptoms to report: Sick and employees should stay home. If you're experiencing the following symptoms, you should contact your health care practitioner: cough, fever, sore throat, runny nose, and/or shortness of breath. Notify the infection prevention nurse or nursing supervisor if you develop respiratory symptoms while at work. These include; cough, fever, sore throat, runny nose, and/or shortness of breath. Practice proper Handwashing hygiene. All employees should clean their hands before and after interactions with residents and their environment with an alcohol-based hand sanitizer that contains at least 60 to 95% alcohol or wash their hands with soap and water for at least 20 seconds. Soap and water should be use preferentially if hands are visibly dirty. Cover your mouth and nose with a tissue and coughing or sneezing. Perform routine environmental cleaning. Routinely clean all frequently touch surfaces in the workplace, such as workstations, countertops, and door knobs. Use the cleaning agents that are usually used in these areas and follow the directions on the label. No special cleaning is necessary for COVID-19. Screeners to be educated on their role and how to complete the COVID-19 screening and report findings. Screening: Will be conducted for all employees, contractors, vendors, and visitors. Monitoring: After initial screening, employees and healthcare contractors that have received the education will only be screened again upon return from vacation, and prior to return to work after sick leave. Visitors will be screened every visit. A review of the facility process titled Enhanced Monitoring: Admissions/readmissions, with no effective date or revision date. The process was provided by the Director of Nursing (DON), on [DATE] at 5:00 p.m. Documented in hand writing at the top of the page, Templates and computer implemented on [DATE]. The process documented the following Order template: enhanced monitoring: Re-admissions to include vital signs and notifications every shift time 14 days then daily. Description: Enhanced monitoring: risk for COVID-19 infections every shift for 14 days then daily to include vital signs, oxygen saturations and notifications of abnormal findings. Details: every (Q) shift eight hours for enhanced monitoring infection prevention for 14 days guidance: notify practitioner if resident exhibits a temperature greater than 100 or a cute drop in oxygen saturation. Schedule: every shift (8 hour range) for 14 days then switches over to daily and open for the user to choose which shift to monitor on, Q shift (eight hour range) supplementary documentation: blood pressure, temperature, pulse, respirations, 02. Order set: enhanced monitoring: suspected: Order template: enhanced monitoring: suspected/confirm to include vital signs and notifications every four hours for 14 days then daily Description: enhanced monitoring: suspected a confirmed COVID-19 infection every four hours for 14 days then daily to include vital signs, oxygen saturation and notification of abnormal findings. Schedule: every four hours for 14 days then switches over to daily and open for the user to choose which shift to monitor on Every four hours supplementary documentation: blood pressure, temperature, pulse, respirations, O2 Daily supplementary documentation: temperature, O2. The process provided by the DON reflected several available templates within their electronic medical record system for clinicians to choose from for documentation purposes. 3 & 4) On [DATE] the survey team entered the facility and walked to the reception desk at 10:30 a.m. Staff V, Registered Nurse (RN), and Staff W, Receptionist assisted with screening to include checking the visitors' temperatures with a temporal thermometer (The directions for use of a temporal thermometer include: Slide the thermometer in a reasonably straight line across the forehead, midway between the eyebrows and the upper hairline. Do not slide down the side of the face. Midway on the forehead area, the temporal artery is less than 2 millimeters below the skin surface. Exergen.com) Neither Staff V nor W were wearing gloves. Staff V was observed cleaning the temporal thermometer with a bacterial wipe manufactured for cleaning hands not medical equipment. An interview was conducted on [DATE] at 10:49 a.m., Staff V, Wearing gloves like that goes against everything we were taught. Why would we wear them if we are not coming in contact with the person, we are screening? I guess you're right. We could accidentally touch their forehead or other areas when checking their temperatures. Upon arrival to the facility, on [DATE] at 12:34 p.m., the DON was present and initiated the health assessment and temperature. The screening items included a temporal thermometer and a large container of hand wipes (bacterial wipes manufactured for cleaning hands not medical equipment), sitting on a bed side table that had been rolled out of the facility placed out at the front entrance. The DON was not wearing gloves after each temperature check and the thermometer was not cleaned. On [DATE] at 9:30 a.m., the surveyors entered the facility and walked up to the reception desk. The ADON conducted temperature screening, and was observed cleaning the temporal thermometer with a bacterial wipe manufactured for cleaning hands not medical equipment. On [DATE], [DATE] and [DATE] observed large containers of bacterial hand wipes on the nurse's station on the first and the second floor and on 1 medication cart on the 2nd floor. An interview was conducted on [DATE] at 4:00 p.m., a corporate representative looked at the bottle of the hand wipes and said, No, this should not be used to clean medical equipment. It is not the right thing to use. The hand wipes used were Sani-Hands Instant Hand Sanitizing Wipes, A non-alcohol based Hands Antibacterial Wipes, a hand wipe that is perfect for foodservice settings, retail operations, offices, and locations where access to soap and running water is limited. An interview was conducted on [DATE] at 10:58 a.m., the Director of Nursing (DON) confirmed that staff entered the facility through the door close to the breakroom. We have two points of entry. We have all visitors come through the front entrance. Staff enter through the door close to the breakroom (pointing to the door), and they come to this table to be screened, and if no one is here they ring the bell and a staff member will come out and screen them. Well, we hope all staff come through and do what they are supposed to do. An interview was conducted on [DATE] at 2;05 p.m., with the ADON and DON who said, Yes, that is where the employees enter the building. They are screened there; you saw the table in the hallway outside of the employee break room. As far as only having one point of entry, the Department of Health never made that recommendation. The ADON spoke up and said, Can you give me a copy of the CDC guide lines? On [DATE] at 2:57 p.m., Staff X, Educator confirmed that all staff should have their temperatures taken twice per shift and is unable to provide evidence to that effect. Staff X, Educator was unable to provide proof that the agency staff's temperature was taken 2 x a day are required. The only documented proof provided was screening of staff at the beginning of their shifts, with temperature taken. An observation was conducted on the second floor at 11:28 a.m., a computer tablet was observed uncovered propped up between the rail on the wall and the wall touching the inside of the wall rails on the outside of room [ROOM NUMBER] that was covered with a yellow substance. An observation was conducted on [DATE] at 11:31 a.m., on the 2nd floor air conditioner air handler vents with large clumps of gray debris hanging out of the vent towards the floor from the vent cover. An observation was conducted on [DATE] at 1:34 p.m., a fitted sheet was observed on the top of a clean covered linen cart. An interview was conducted on [DATE] at 1:34 p.m., Staff U, Registered Nurse (RN), reached up on the top of the clean linen cart and pulled the fitted sheet off of the top of the cart and said, No, that should not be up there. An observation was conducted on [DATE] at 11:33 p.m., observed a treatment cart on the 2nd floor without a trash bag in the bin on the cart for trash and inside the bin were pairs of dirty gloves that had been disposed of in the bin. An interview was conducted on [DATE] at 11:35 p.m., Staff U, RN said, No, those used gloves should not have been put in there without a bag in there. We are trying to send out 4 more residents. Yes, all of them are COVID19 positive. A tour of the laundry area was conducted on [DATE] at 12:12 p.m., Staff T, Laundry Aide said, Yes, this area is where we keep all of the clean linen. The top of the table is where we fold laundry. On the bottom shelf are bedspreads. Yes, they are clean. Observed a long silver metal table with a top shelf and another shelf underneath, with bedspreads and bed covers stored underneath the metal table that were not covered. Observed on the 2nd shelf, with the clean bedspreads and covers was a green and orange camouflaged lunch bag. Next to the lunch bag was a pair of used clear plastic gloves. Once the staff lunch bag was removed from the bottom shelf, resting on top of clean bedspreads observed several pairs of used gloves, Kleenex, condiment containers and lids. The shelve and wall behind was full of gray fuzzy debris. An interview was conducted on [DATE] at 12:14 p.m., the Director of Housekeeping and Laundry said, That lunch bag should not be there. The metal table was moved out away from the wall and the Director of Housekeeping and Laundry said, Oh wow. I did not know all of that was there. No, I will get it cleaned immediately. An observation was conducted on [DATE] at 1:08 p.m., Staff T, Laundry Aide was observed coming out of the laundry room door (door in hallway that leads to the area where clean linen is kept), with a bag of trash. An interview was conducted with Staff T, Laundry Aide on [DATE] at 1:08 p.m., as she was walking in the hall with the bag of trash and she said, Sorry, Yes, I should have gloves on. An interview was conducted on [DATE] at 1:30 p.m., the Maintenance Director said, Yes, the air conditioner vents should have been dusted. At 1:53 p.m., the Maintenance Director said, They are cleaned now. Based on tours of the facility on [DATE] and [DATE] there were no observations of housekeeping staff in the building either day. An interview was conducted on [DATE] at 1:40 p.m., during the tour with the DOH the Director of Housekeeping and Laundry stated that she was here. An observation was conducted on [DATE] at 12:45 p.m., Staff Y, nurse was observed on the 2nd floor going from room to room without washing her hands or using hand sanitizer before or after entering the resident rooms. An interview with Staff Y said, Ok, I will do that. An interview was conducted on [DATE] at 1:18 p.m., the ADON stated, Yes, I expect staff to perform hand hygiene whenever they enter or leave a resident room. 6) During a tour of the facility on [DATE] at 11 am, two pieces of equipment were seen on the floor of Resident #21's room. Upon walking closer to the room, the equipment could be identified as suction machines. (Photographic evidence obtained.) The resident could be seen from the hallway, and without entering the room, the resident was noted to have a [MEDICAL CONDITION] (a surgically created hole through the front of the neck and into the windpipe to provide an airway for breathing). While writing down the resident's information, the sink inside the room could be visualized. On top of a stack of brown cardboard boxes, which were on the counter next to the sink, was a plastic white container with the paper lid partially peeled off. Staff R, Registered Nurse (RN), was walking down the hallway at that time and was asked if the suction machines were supposed to be on the floor. She said that they should not be there. She said that they are broken, so she will bag them and take them where they need to go. She confirmed that the resident did have a working suction machine in the room. Staff R was also asked if the white plastic container on the boxes near the sink was an open [MEDICAL CONDITION] kit. She confirmed that it was, and that nothing had been taken out of it. When asked if that should be there, or if it should be open and, on the sink, she said that it should not be there, and she isn't sure why someone would open it, and then leave it there. She said that she will throw it away, because she could not guarantee that it was still sterile. Resident #21 was initially admitted to the facility on [DATE] with the most recent re-Admission being [DATE] for a [DIAGNOSES REDACTED]. The resident was care planned to have a [MEDICAL CONDITION] due to impaired breathing mechanics. In an annual MDS dated [DATE], the resident was assessed to have a brief interview for mental status (BIMS) of 15, indicating the resident had no cognition deficits, and to have a tracheotomy. Resident #21 has had multiple prescriptions for upper respiratory infections in the past year, with the most recent being [MEDICATION NAME] Tablet ([MEDICATION NAME]), Give 500 mg by mouth one time a day for URI for 10 Days beginning [DATE] and ending on [DATE], and [MEDICATION NAME] Solution Reconstituted ([MEDICATION NAME] Sodium) Inject 1 gram intramuscularly one time a day for URI (Upper respiratory infection) on [DATE]. The one previous to that was [MEDICATION NAME] Solution Reconstituted (Ertapenem Sodium), Use 1 gram intravenously one time a day for URI for 7 Days starting [DATE] and ending [DATE]. The resident also had an order to [MEDICAL CONDITION] needed dated [DATE]. On [DATE] at 1:40 p.m., the ADON (assistant director of nursing) said that the suction machines should not have been left on the floor, that they should be bagged and taken care of immediately. She also said that the [MEDICAL CONDITION] kit should have just been thrown away. There was no reason for it to be open in the room. At 4:09 p.m., in an interview the DON (director of nursing) said that he does not know of any policy that addresses the open [MEDICAL CONDITION] kit in the residents room, but he said the kit should have been thrown away, and it is his expectation that they be used when they are taken into the room. In a policy and procedure titled Equipment-cleaning/disinfecting dated as effective [DATE], under the topic Critical Items it reveals Instruments or objects that are introduced directly into the bloodstream or into other normally sterile areas of the body. The facility utilized disposable items. Examples include .[MEDICAL CONDITION]. Under Semi-critical Items it reads Items that come in contact with intact mucus membranes.require high-level disinfections. 7) During a tour of the facility on (TRUNCATED)

Based on observation, interview, and QAA (Quality Assessment and Assurance) review, it was determined that the facility failed to demonstrate an effective system to implement plans of action to correct identified quality deficiencies following the survey of 10/31/12 as well as follow up surveys of 12/19/12 and 1/11/13 and which resulted in an increase in the scope and severity of findings to Immediate Jeopardy during the survey ending 1/24/13. During the survey of 1/24/13 the facility failed to protect the well-being of residents and staff during facility renovations and physical plant upgrading for two of two floors of resident living areas including: community and in- room bathroom floor tiling, sanding of walls and baseboards in hallways, and the displacement of resident ' s beds, nightstands, and personal items into hallways. The failure of a plan to anticipate and protect the residents from the stressors of construction dust and debris, noise, and the displacement of necessary everyday items, such as a functional toilet in room [ROOM NUMBER]/130, can place medically fragile residents in a state of unnecessary physical and emotional stress for an undetermined amount of time specifically for 10 of 117 residents #1, #2, #3, #4, #5, #7, #8, #9, #10, and #11. The lack of an effective Quality Assurance plan, which placed these vulnerable residents at continued risk, resulted in a determination of Immediate Jeopardy on 01/23/13 at severity and scope of L. The Immediate Jeopardy was removed on 01/24/13 at 6:00 p.m. and the scope and severity was reduced to F. Findings include: 1. On 01/24/13 at 4:00 p.m. an interview with the interim NHA (Nursing Home Administrator) was conducted regarding the functionality of the QAA committee. He stated he began the role of NHA at this facility on 01/03/13 and a QAA meeting had been scheduled for 01/23/13, but was cancelled due to the complaint investigation by AHCA. He stated the last QAA meeting was conducted on 12/26/12 with the prior NHA presiding. He provided the sign in sheet for the meeting, dated 12/26/12, and stated each department reported issues. He stated that this was an end -of- the- year meeting and policy and procedures would have been reviewed also. It was his understanding that the prior NHA would have reviewed the last AHCA 2567 deficiencies. He stated he did not know if the pending plans for renovation were discussed. He was unaware of any preparatory measures to begin prior to the work force coming on the property to begin the renovations. The NHA stated he did not recall any discussion with the Medical Director, or any of the other physicians, about protecting the residents that were respiratory compromised from the airborne byproducts of sanding, dirt and debris, and inhalants of paint and floor tile adhesive. 2. A review of the outstanding AHCA 2567 deficiencies revealed: On 10/31/12 a complaint survey identified deficiencies related to housekeeping and maintenance, F 253, (D). A revisit on 12/19/12, and an additional complaint, revealed deficiencies were, again, identified at F 253, (E). The original physical plant deficiency was uncorrected. These surveys occurred during the time of the prior NHA and were what the current NHA presumed to have been discussed during the QAA meeting of 12/26/12. During the week of 1/9 to 1/11/13 the annual QIS Health and Life Safety survey was conducted, in addition to the second revisit for F253, a revisit to a second physical plant deficiency, and a new complaint. The facility remained in continued noncompliance and was again cited at F 253, Housekeeping and Maintenance, at scope and severity of E. This citation was related to holes in the wall, peeling paint, fall hazards, stains and dust throughout the facility. One of the findings of stains and drywall damage, per the current NHA and a consultant, were attributed to a roof leak. On 01/10/13 the Life Safety survey was conducted with findings of four K tag deficiencies; K 0018 (D), related to corridor fire doors; K 0025 (D) related to smoke penetration of ceiling tiles; K 0070 (D) related to a space heater and; K 0075 (D) related to electrical safety. The facility remained in continued noncompliance under the new NHA, an interim appointed by the management corporation. 3. It was unknown by this NHA when the decision was made to enlist multiple workers and contractors and to begin a more extensive renovation, rather than correcting the current deficiencies and proceeding with the defined stages outlined by the prior NHA in the facility newsletter. Corporate management staff was present throughout this two day investigation. The NHA further stated during the interview on 01/24/13 that he met with the Resident Council on 1/14/13 and discussed the upcoming renovations. He stated that on 01/14/13 work began on one of two shower rooms on the second floor. He did not state to the surveyor if residents were specifically informed of how the renovations would affect them. That shower room remained closed as of this date, 1/24/13. He stated first floor renovations began either 1/16 or 1/17/13. The NHA provided the surveyor a copy of a facility newsletter given to residents and family members, dated January 2013. A small article on the front page was written by the prior NHA. The article stated generally that the facility was beginning long awaited renovations. It stated that the " next phase of renovations, that we have been discussing for quite some time, will be starting this month with an entire exterior facelift, including a new roof. Then, the next phase will begin again on the interior. " The article did not specify a beginning or end date. It did not state residents would be inconvenienced or exposed to construction hazards during the process. This article clearly implied two separate stages of renovations would be done. 4. During the facility tour on 01/23/13 between 9:40 a.m. and approximately 11:00 a.m., it was determined that the facility was in the process of a remodeling project for the interior and the exterior of the building. Photographs were taken during this time. Observations during this period included the following: a. 100 West hallway: An observation of the 100 West hallway revealed a fire extinguisher on the floor; heavy dust on the floor and handrail in the hallway; open residential door to room [ROOM NUMBER], and painter ' s tape with brown paper on the residential door frame that was attached to the resident ' s doorways. The brown paper was approximately 12 inches in width and was attached to several of the door frames in the 100 hallway, impairing the resident visually when entering and exiting the room and impeding safe movement. Uncovered drywall and wall patching was observed in progress. b. 100 West hallway: An observation of construction dust on the handrails, a worker ' s tool on the hand rail, a spray bottle on the hallway floor; uncovered drywall; wall patching was in progress and the floor had 3-4 inches of construction dust present along the wall. At the time of the observation, three workers were scraping the wall in the area, and they stepped out of the way of the camera picture. Residential doors were open during these observations. c. 100 West hallway: On the 100 West hallway, an uncovered medication cart was positioned touching the handrail in the hallway; a layer of drywall dust was covering the top of the handrail and debris was present along the board attaching the handrail to the wall. Above the handrail the wall had indications that it had recently been sanded and was unpainted. Sitting on the medication cart was a container/pitcher of fluid which appeared to be water, as well as cups and containers of nutritional supplement. Construction dust and debris were observed on the floor along the wall of the hallway. Residents were observed moving about throughout the hallway moving in close proximity to the construction dust and debris. d. 100 East hallway, facing the South residential end: The 100 East hallway was observed to have painter paper taped to the flooring. Unpainted drywall with patching of drywall was in progress throughout the hallway where residents were residing, as well as drywall dust on the floor. Doors were open to resident rooms and the hallway was used by staff and residents while observed in the stated condition. e. 100 East hallway, facing North towards the fire exit: An unsecured fire extinguisher was observed sitting directly on the floor in the resident hallway, which had been moved as a result of the renovations. Large sections of paper were taped to the floor throughout the hallway and uncovered drywall with patching was observed in progress. Visible dust was observed in the hand rail area and on the floor along the wall. Reviewing the area between the handrail and the wall, revealed the presence of construction debris that was of a depth of approximately one half to three quarters of an inch thick, rendering the hand rails undesirable to use for the residents residing in this hallway. f. The bathroom between room [ROOM NUMBER] and 130, the new tile placement. A commode had been brought into the bathroom between the initial observation and the time of the picture. g. This picture was taken in the area where one would get off the elevator on the 2nd floor: Located in the hallway, across from the elevator on the 2nd floor, were metal rod braces, which extended from the floor to ceiling. Yellow caution tape was secured to each rod extending down the hallway from the elevator area to the nurse ' s station. The yellow caution tape traversed the hallway and extended through the area of the smoke/fire compartment doors. The placement of the partitioned off area with the caution tape potentially impeded the functioning and the purpose of the fire doors which was to contain smoke if a fire were to occur. A resident bed was also observed in the 200 South hallway with two medication carts positioned at the end of the hall. h. Approximately one third of the way down the 200 South hall, looking back towards the elevator area, an observation found uncovered drywall and metal poles with yellow tape traversing through the smoke barrier doors. The area was a high traffic area used by staff and residents to move about the unit and was located across from the elevator. The metal bars created an obstacle and a safety hazard for ambulating residents and self-propelling residents in wheel chairs. i. 200 East hall: Two beds, a bedside commode, a night stand, a resident chair, and facility renovation equipment were observed positioned on the left side of the hallway on the 200 East hallway. Sitting on the floor on the right side of the hallway was a piece of maintenance equipment. The equipment extended through the door way of a resident ' s room and, approximately, one foot into the hallway. Fresh paint and dust was present on the floor. A wet paint sign hung from the door frame of a resident ' s room indicating the frame had recently been painted. Several of the wet paint signs attached to resident ' s doors were observed throughout the facility. The drinking fountain in the hallway was inaccessible due to the bedside commode in front of it. The rooms were occupied by mobile residents at the time of the observations. j. 200 East hall: A resident was observed sitting in a chair in the 200 East hall coming out of their room. A resident chair and an unoccupied wheelchair were near the end of the hall. The walls in the hallway where the resident was sitting were observed to have painting in progress and a tool on the handrail. At the floor and wall juncture, a visible line of construction debris was present. k. At 11:20 a.m. on 1/23/13 Resident #10 was observed self -propelling his wheelchair down the South hallway towards this area. While standing in the door frame of room [ROOM NUMBER], looking into the hall, several large items were observed [DIAGNOSES REDACTED] the hallway near room [ROOM NUMBER], partially blocking the entrance to the room. The items included: a housekeeping cart, linen cart, uncovered medication cart, night stand, and a bed. A wet paint sign was observed taped on the wall above the handrail in the same area. Resident #10 had to stop because the articles [DIAGNOSES REDACTED] the hallway prevented him from moving forward to his room, which was located in this vicinity. The area was not wide enough for his wheelchair to fit through, and a maintenance man had to move some of the furniture for him to access his room. A review of Resident #10 ' s clinical chart [DIAGNOSES REDACTED]. l. In front of room [ROOM NUMBER] looking at the 200 South hall, two beds, a nightstand, medication cart, and wheel chair were noted. During the observation of the 200 hall near room [ROOM NUMBER] it was also observed that both sides of the hallway, 200 South and 200 East, contained furniture items that prevented easy access of maneuvering the hallway. Both of the resident ' s beds, that were sitting in the hallway, had an electrical cord extending out from under the bed into the walking path. m. While looking toward South West hall leading to the residential common area, a wheel chair was observed sitting next to an unplugged and hanging cord for a bug light. Debris was on the floor and in the hand rail juncture. Wall patching and uncovered drywall was present in the hallway. n. In the 100 South hall, outside of the Main Dining Room, directly across from the dining room doors, the doors to the dining room were open. A small recessed area was observed to have heavy dust on the floor, approximately up to 4-5 feet away from the wall and the floor juncture. The dust was approximately one quarter to one half inch thick. Two dust covered receptacle plates were on the floor, and an uncovered drywall was observed. Residents were present in the Main Dining Room and the hallway at the time of the picture. o. In the 100 South hall, outside of Main Dining Room area, heavy dust was present on the floor, approximately eight inches in width along the wall and floor juncture. As you looked down the hall, it had uncovered dry wall. The door was open to the Main Dining Room, and visible layered construction dust was present in the hallway in front of the Dining Room door, where the reception desk was located. Residents were observed to be in the Main Dining Room at this time, approximately 11:30 a.m., eating their lunch. p. 100 South hall: The floor and wall juncture was observed with approximately two to three inches of construction debris layered on the floor. This area was directly outside of a second set of Main Dining Room doors that were open at the time of observation. q. An observation was conducted from the West side of the single story portion of the facility. Men and roofing materials were present on the roof. Construction materials were present in the parking lot. The facility was in the process of having its roof replaced. r. In the 100 South hall an observation in the area across from the Main Dining Room found an " X " had been drawn in the dust and debris on the floor, which portrayed the depth of the debris. Continued observations of 01/23/13 at approximately 1:00 -3:00 p.m. found the following conditions (Photographs were also taken during this time): s. In 100 West hallway, the word " Sand " was written above room [ROOM NUMBER]. This word " sand " was written sporadically throughout the hall way, on the walls. t. An observation was conducted in the kitchen revealed a plastic barrier that separated the food prep area from what was reported to be the dishwashing area. The plastic barrier had visible construction dust and debris leaking into the area of the kitchen that was being utilized to prepare the residents food. The plastic barrier was approximately 15 feet in width and approximately 6-8 feet of the bottom portion was not sealed to the floor of the kitchen which allowed for the debris to come across the barrier. u. On 01/23/13 at approximately 3:00 p.m., an additional observation of the kitchen found the thin plastic sheet traversing the kitchen. The top of the plastic was not sealed and the bottom was not sealed in areas. While reviewing the thin, unsecured, plastic barrier in the middle of the kitchen, an interview was conducted on 01/23/13 at approximately 3:00 p.m., with the Director of Physical Plant, (N), who confirmed that renovations were taking place on the other side of the plastic and at night after the kitchen had closed, the workers were removing and replacing the kitchen floor tile. He further stated that the workers would remove the plastic from one end or the other and the plastic would stay unsecure during the working session and they would reseal the plastic in the morning. The observations conducted on 01/23/13 at approximately 3:00 p.m. revealed a thin plastic barrier, which was approximately 15 feet in length by 8 feet high. The plastic was taped to the sides of the kitchen walls and a portion of the floor area; an area of approximately five feet in length on the floor, towards the middle of the plastic, was not sealed to the floor. Visible white debris and dust were present along this area, extending approximately 8 inches onto the kitchen floor, in the portion of the kitchen where food was being prepared for the residents. The top of the plastic barrier was not taped or sealed allowing air and airborne particles to get through. If the plastic was intended to prevent construction dust and debris from coming across the sheath of plastic, the lack of the sheath being sealed at the edges was preventing it from performing that function, as evidenced by the amount of debris and dust on the food prep area side. v. During an observation conducted on 01/23/13 at approximately 1:00 p.m. of the second floor South hall in front of nurse ' s station, a rod with caution tape tied to it was located in the hallway, blocking off an area in the hallway. Two resident beds in the hallway had been moved out of the resident rooms for room renovation. The residents had not been relocated to another room during this process. Their belongings/possessions had been moved into the hallway during this time. The residents were unable to lie down in their rooms, during the period of their room renovation. Bathrooms were also being renovated and residents had to use community commodes. w. An observation at approximately 2:00 p.m. was conducted of the 200 East hall. Viewing the hall from the north end and looking at the South end, the amount of furniture in the residential hallway revealed two of three residential beds, one of which was positioned length wise across the hall, two resident sitting chairs, three night stands/dressers and miscellaneous equipment. Also, observed was a thermostat that was hanging from the wall with the wire exposed. The hallway walls had the look of being freshly painted. x. An observation at approximately 1:30 p.m. on 1/23/13 of the ceiling vent, located on the 100 hall west, the end of the corridor near the exterior exit, found the air filter, inside the vent, had a visible thick layer of dust with the appearance of a " cake like " quality, i.e. very heavy. The air filter was visibly bowing up into the duct, indicating that the air filter was not passing the air as intended. 5. On 1/23/13, at approximately 10:00 a.m., the DON presented the surveyors with a hand written list titled " O2 and Nebs [MEDICAL CONDITION]' s " . Record review of this list showed thirty one of 117 residents were identified as residents utilizing oxygen solely or with the use of a nebulizer and seven residents ' utilized nebulizers for a total of 31 residents with compromised respiratory systems. Two of the 31 residents also had tracheostomies. 6. Resident interviews, observations and record reviews conducted on 01/23/13 revealed the following: a. An interview was conducted on 01/23/13 at 9:50 a.m. with Resident #1. She stated that " The dust bothers me, it comes and goes, I fan to get air. " Resident #1 was observed in her bed, in her room off the 100 East hall, fanning herself. Resident #1 further stated in the interview that she could not get up or out of her bed without assistance. Resident #1 ' s door was open to the hallway. A review of Resident #1 ' s Physician order [REDACTED]. b. An observation was conducted at approximately 10:00 a.m. during which Resident #8 was observed to be sitting in a wheelchair, positioned between the two beds in the room: The resident ' s eyes were closed and she had a lap belt over the front of her torso and the TV was on. Located just inside the door to the resident ' s room was a three tier push cart with tools present. Also observed was a maintenance person, M, on his knees under the sink area of the room, banging and removing tile from the floor. He was interviewed at this time, and he stated that he was replacing the tile under the sink, due to its broken condition. (It was noted that the work was taking place while the resident was in the room and dozing in her wheelchair). A review of Resident #8 ' s Record of Admission sheet documented [DIAGNOSES REDACTED]. c. An interview was conducted with Resident #2 at 2:45 p.m. on 01/23/2013. The resident was lying in bed wearing nasal tubing supplying oxygen. He stated that yesterday he felt sick around lunch time and vomited. He stated that he told the nurse about being sick and could not hold anything down, but did not take any medication for the symptoms. He stated that he became sick due to the smell of the chemical, that stuff they use to put down the tile smelled. He said that they had been working in his bathroom with the door open for the past two days, while he was present in his room lying in bed. He said that he uses oxygen whenever he is in bed. He said that he has [MEDICAL CONDITION] and Asthma. Silver duct tape was observed on the door frame, covering approximately 75% of the door and frame junctures. Resident #2 ' s bed was observed to be approximately four feet from the bathroom door in his room. The bathroom was observed to have new tile flooring, the commode had been removed and an uncovered pipe with debris was present. Resident #2 was in a room located off the 100 West hall. A review of Resident #2 ' s clinical record [DIAGNOSES REDACTED]. d. An interview was conducted at approximately 10:15 a.m. with Staff member A, a Certified Nursing Assistant. She was observed to have a mask on her face. She stated " dust affects my sinuses. " She was present in room [ROOM NUMBER] at the time of interview. e. An interview was conducted on 01/23/13 at 10:20 a.m. with Resident #3. She stated: " I have a hard time breathing. " " Not having a hard time breathing right now. " It was observed that the resident was an elderly person, lying in bed, able to communicate, with oxygen tubing via nasal cannula. The machine was observed to deliver between 2 and 2.5 liters of oxygen per minute. The resident stated: " I wear the oxygen all the time. Resident #3 stated that she had received " Nebulizer treatments for the last couple of days, they have been doing it quite often; every 4-5 hours. " Resident #3 was located off of 200 East hall. A review of Resident #3 ' s clinical record of a Physician Order, dated 12/28/12, documented [DIAGNOSES REDACTED]. f. An interview was conducted on 01/23/13 at 3:18 p.m. with Resident #7 and a family member. Resident #7 resided on the 200 East hall. The family member stated that Resident #7 had not been breathing well the last couple of days and that, in the past week, he had not been acting the same. Resident #7 stated that his breathing had been more difficult the past few days and that he had been using his oxygen more often than usual. Subsequently, the resident ' s family member was observed to proceed to the nurses ' station and asked the nurse to order a chest x-ray for Resident #7. A record review was completed for Resident #7. The [DIAGNOSES REDACTED].O.P.D.) and Pneumonia. A review of the Quarterly/P.R.N. Data Collection, dated 01/6/2013, documented: Respiratory: [MEDICAL CONDITION]/C.O.P.D. g. A random interview was conducted on 01/23/2013 at 10:40 a.m. with Resident #4 ' s family member who stated, " You should have been here yesterday. They were sanding the dry wall, there was dust everywhere. " h. An interview was conducted on 01/23/2013 at 2:55 p.m. with Resident #9, who resided in the 200 hall. She said that she keeps her oxygen on 24 hours a day. She stated the smell of the construction makes her feel like coughing. A review of Resident #9 ' s clinical chart revealed a [DIAGNOSES REDACTED].????????????? [MEDICAL CONDITIONS], and Acute [MEDICAL CONDITION] were documented on the [DIAGNOSES REDACTED]. i. On 01/24/13 at around 10:15 a.m. an observation of resident #5 was conducted. The resident was lying in bed with oxygen infusing into a [MEDICAL CONDITION]. She was coughing with a small amount of yellow mucus observed on the [MEDICAL CONDITION] dressing. She stated she did not feel well today. At 2:19 p.m. the physician ordered a stat (urgent) chest x-ray. At 3:45 p.m. on 1/24/13 resident #5 was observed again. The DON was at the bedside also. The DON stated her oxygen saturation was 95%. Her x-ray from earlier in the day was negative, but he would ask the physician to see her today. An interview with the nurse caring for the resident was conducted and she stated she placed a wet towel under the door to prevent dust from coming into the room of this resident. The DON then explained that " most of the dust was on the first floor. " 7. Staff interviews conducted on 01/23/13 revealed the following: a. In an interview, conducted on 01/23/13 at approximately 3:15 p.m. with Licensed Practical Nurse (LPN), (B), she was asked if Resident #3 had complained about the dust. She stated: " The resident did not complain about the dust; her family member complained about the dust; this happened yesterday-afternoonish. She was walking in the hallway and made the comment about the dust. " b. The interview continued with LPN, (B). She further stated that in her area, 200 West hall, she had two residents that have really bad respiratory problems, Residents #3 and Resident #11. She stated that she had told the Certified Nursing Assistants to enter the resident ' s room through the adjoining room bathroom to limit opening the door to the hall due to the amount of dust. LPN B stated that she put wet towels along the bottom of these two residents ' doors to limit the dust for them. LPN B stated they just started painting today, and the paint smell is strong. LPN B agreed that the poor air quality could affect her residents with respiratory illnesses. A review of a list provided by the facility on 01/24/13 documented that Resident #11 utilized a [MEDICAL CONDITION] machine which is used during sleep for sleep apnea. c. During an interview, conducted on 01/23/13 at approximately 1:00 p.m., the Administrator confirmed that the building was currently having renovation in progress and that paperwork, regarding the renovations, had not been completed or submitted to the Agency for approval prior to commencing with the renovation projects. d. An interview was conducted with the Administrator on 01/24/2013 at 2:27 p.m. He said that he had just started working at the facility the first of the year. He stated that he was in charge of the construction project. To the best of his recollection the project started on January 14th. He said that there was no deadline for completion. He said that they were trying to make a big impact in the shortest amount of time without disrupting the residents. He said that they did not call the planning department about the construction project. He was asked about a policy regarding the construction project. He said he does have a book with the renovations and scope to be done and a revised ICRA. He said it details what ' s going to be done and by whom. The Administrator said that minor work was done by submitting work orders. He had never been involved with major work before. e. On 01/24/13 at 2:18 p.m. the DON was interviewed. He stated there were two different groups of workers on the inside of the building. The second floor workers were contractors and the first floor workers were from sister facilities from the management company. The DON stated " It could have been contained better " (referring to the dust and debris generated from the construction), but he did not think people were in jeopardy. He agreed that yesterday, 01/23/13, it was " dusty and dirty. " He thought it was too much at once but he was monitoring the residents. f. During an interview, conducted on 01/24/13 at approximately 10:10 a.m., with the Facility Maintenance Supervisor, (M), he was asked the question: Do you believe the residents health or safety was an issue while renovation was going on? Employee M stated the only issue he was concerned about was the drywall dust from sanding the walls. He further stated that the floors would become slippery at times. 8. On 01/24/13, an interview was conducted at 4:00 p.m. with the NHA was conducted regarding the role of the QAA committee in guiding the reconstructions. During that interview, the NHA stated the administrative staff had produced a document on 01/23/13 to address the survey concerns. He read from this document the following items to be implemented immediately: ? Stopped all construction. ? Informed contractor that until further notice not doing renovations, only day to day maintenance. ? An air quality company was called 1/23/13. No results of the testing at the time of this interview. ? Called all families and responsible parties to inform them of renovation and monitoring of residents. ? All physicians were notifed. ? A nurse, RN, was called in, 1/23/13, to evaluate all residents for change of condition. None found. ? A housekeeping company brought in a crew. They were assigned clean up/sweep/mop/ scrub and wipe down the walls in all areas. They came overnight. ? Three resident bathrooms were taken out of service and residents were given bedside commodes. ? Fire extinguishers were secured. ? Impediments on hand rails and smoke barrier doors were removed. ? Beds were removed for hallways. ? The barrier in the kitchen had been repaired and is no longer compromised. ? Plans have been submitted to ICRA processing, Plan and Construction office in Tallahassee. NHA stated he spoke with them also. On 01/24/13 at approximately at 6:00 p.m. the following was verified: ? As of 5:55 p.m. the painting, bathroom floor repairs and removal of wall paper and replacement of tile in common shower room and installation of the new roof has been stopped. ? Immediately upon notification by the surveyors that the Immediate Jeopardy was identified, measures were put in place to remove the potential harm. ? Housekeeping Services Group was notified that all resident care areas need to be cleaned and made free of any dust or dust particles. ? The resident bathrooms that were taken out of service will remain out of service until the tile can safely be grouted. ? The residents sharing those bathrooms have bedside commodes to ensure we are address their toileting needs. ? Fire Extinguishers were secured to their appropriate receptacles. ? All smoke barrier doors are fully functional ? The impediment of the handrails on the second floor was removed to allow residents easy access. ? All beds were removed from the hallways to ensure hallway accessibility for all residents. ? The clinical team will assess all residents with respiratory [DIAGNOSES REDACTED]. ? An air quality specialist had been hired to ensure that the air quality meets professional standards. ? The barrier surrounding the dish machine had

Based on observation, record review and interview, the facility failed to ensure that housekeeping and maintenance services were carried out in a safe and orderly manner and with regard for the well-being of all residents, failed to protect the well-being of residents during facility wide renovations and physical plant upgrading for 2 of 2 floors of residential living areas including community bathrooms and in- room bathroom floor tiling, sanding of walls and baseboards in hallways, and the displacement of resident ' s beds, nightstands, and personal items into hallways. The failure of a plan to anticipate and protect the residents from the stressors of construction dust and debris, noise, and the displacement of necessary everyday items, such as a functional toilet in room 128/130, can place medically fragile residents in a state of unnecessary physical and emotional stress for an undetermined amount of time. All facility residents were determined to be at risk for injuries from environmental hazards and respiratory complications related to the following, specifically 10 of 117 residents #1, 2, 3, 4, 5, 7, 8, 9, 10 and 11. The facility failed to implement appropriate critical barriers i.e. sheetrock, plywood, and plastic to seal renovation project areas from all inhabited residential areas and living spaces for an elderly and vulnerable population. This resulted in residents verbalizing symptoms of coughing, nausea, effects from chemical smells, and trouble breathing due to the construction dust in the air. The facility failed to implement renovation project debris containment and cleanup to limit hazards for residents, as evidenced by observations of uncontained movement of debris; presence of multiple areas of accumulation of construction dust; unclean surface areas; improper isolation of construction areas within the kitchen; and a lack of sensitivity for resident personal space and working in rooms while residents were present. The facility failed to maintain clear, accessible hallways throughout the facility and an unimpeded means of egress, as evidenced by the presence of beds, nightstands, bedside commode, in combination with a medication cart, linen cart, and housekeeping cart in the hallways, which restricted the free movement of the residents in the hallway. Also, the presence of metal rods, that extended from floor to ceiling, with yellow cautionary tape traversing thru the smoke barrier doors, which could inhibit the function of these doors. The facility failed to comprehensively implement the Management Plan for Safety, which stated that the policy was to provide an environment as safe as possible for all residents, staff and visitors while providing residents with quality care and a homelike environment. By failing to provide a safe and orderly environment and by failing to implement proactive measures to protect residents from construction hazards, the facility placed all of the residents (117) at risk for an unsafe environment that was not orderly, was unsafe for ambulating, had poor air quality, and infringed upon the rights of the residents to have a safe environment to live in. These findings resulted in determination of Immediate Jeopardy on 01/23/13. The finding of Immediate Jeopardy was found to be removed on 01/24/13 at 6:00 p.m. and the severity and scope was reduced to an F. Findings include: 1. On 1/23/13, at approximately 10:00 a.m., the DON presented the surveyors with a hand written list titled " O2 and Nebs and Trach ' s " . Record review of this list showed thirty one of 117 residents were identified as residents utilizing oxygen solely or with the use of a nebulizer and seven residents ' utilized nebulizers for a total of 31 residents with compromised respiratory systems. Two of the 31 residents also had tracheostomies. 2. Resident interviews, observations and record reviews conducted on 01/23/13 revealed the following: a. An interview was conducted on 01/23/13 at 9:50 a.m. with Resident #1. She stated that " The dust bothers me, it comes and goes, I fan to get air. " Resident #1 was observed in her bed, in her room off the 100 East hall, fanning herself. Resident #1 further stated in the interview that she could not get up or out of her bed without assistance. Resident #1 ' s door was open to the hallway. A review of Resident #1 ' s Physician order [REDACTED]. b. An observation was conducted at approximately 10:00 a.m. during which Resident #8 was observed to be sitting in a wheelchair, positioned between the two beds in the room: The resident ' s eyes were closed and she had a lap belt over the front of her torso and the TV was on. Located just inside the door to the resident ' s room was a three tier push cart with tools present. Also observed was a maintenance person, M, on his knees under the sink area of the room, banging and removing tile from the floor. He was interviewed at this time, and he stated that he was replacing the tile under the sink, due to its broken condition. (It was noted that the work was taking place while the resident was in the room and dozing in her wheelchair). A review of Resident #8 ' s Record of Admission sheet documented [DIAGNOSES REDACTED]. c. An interview was conducted with Resident #2 at 2:45 p.m. on 01/23/2013. The resident was lying in bed wearing nasal tubing supplying oxygen. He stated that yesterday he felt sick around lunch time and vomited. He stated that he told the nurse about being sick and could not hold anything down, but did not take any medication for the symptoms. He stated that he became sick due to the smell of the chemical, that stuff they use to put down the tile smelled. He said that they had been working in his bathroom with the door open for the past two days, while he was present in his room lying in bed. He said that he uses oxygen whenever he is in bed. He said that he has Emphysema and Asthma. Silver duct tape was observed on the door frame, covering approximately 75% of the door and frame junctures. Resident #2 ' s bed was observed to be approximately four feet from the bathroom door in his room. The bathroom was observed to have new tile flooring, the commode had been removed and an uncovered pipe with debris was present. Resident #2 was in a room located off the 100 West hall. A review of Resident #2 ' s clinical record [DIAGNOSES REDACTED]. d. An interview was conducted at approximately 10:15 a.m. with Staff member A, a Certified Nursing Assistant. She was observed to have a mask on her face. She stated " dust affects my sinuses. " She was present in Room 130 at the time of interview. e. An interview was conducted on 01/23/13 at 10:20 a.m. with Resident #3. She stated: " I have a hard time breathing. " " Not having a hard time breathing right now. " It was observed that the resident was an elderly person, lying in bed, able to communicate, with oxygen tubing via nasal cannula. The machine was observed to deliver between 2 and 2.5 liters of oxygen per minute. The resident stated: " I wear the oxygen all the time. Resident #3 stated that she had received " Nebulizer treatments for the last couple of days, they have been doing it quite often; every 4-5 hours. " Resident #3 was located off of 200 East hall. A review of Resident #3 ' s clinical record of a Physician Order, dated 12/28/12, documented [DIAGNOSES REDACTED]. f. An interview was conducted on 01/23/13 at 3:18 p.m. with Resident #7 and a family member. Resident #7 resided on the 200 East hall. The family member stated that Resident #7 had not been breathing well the last couple of days and that, in the past week, he had not been acting the same. Resident #7 stated that his breathing had been more difficult the past few days and that he had been using his oxygen more often than usual. Subsequently, the resident ' s family member was observed to proceed to the nurses ' station and asked the nurse to order a chest x-ray for Resident #7. A record review was completed for Resident #7. The [DIAGNOSES REDACTED].O.P.D.) and Pneumonia. A review of the Quarterly/P.R.N. Data Collection, dated 01/6/2013, documented: Respiratory: Emphysema/C.O.P.D. g. A random interview was conducted on 01/23/2013 at 10:40 a.m. with Resident #4 ' s family member who stated, " You should have been here yesterday. They were sanding the dry wall, there was dust everywhere. " h. An interview was conducted on 01/23/2013 at 2:55 p.m. with Resident #9, who resided in the 200 hall. She said that she keeps her oxygen on 24 hours a day. She stated the smell of the construction makes her feel like coughing. A review of Resident #9 ' s clinical chart revealed a [DIAGNOSES REDACTED].????????????? Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Failure were documented on the [DIAGNOSES REDACTED]. i. On 01/24/13 at around 10:15 a.m. an observation of resident #5 was conducted. The resident was lying in bed with oxygen infusing into a tracheostomy. She was coughing with a small amount of yellow mucus observed on the tracheostomy dressing. She stated she did not feel well today. At 2:19 p.m. the physician ordered a stat (urgent) chest x-ray. At 3:45 p.m. on 1/24/13 resident #5 was observed again. The DON was at the bedside also. The DON stated her oxygen saturation was 95%. Her x-ray from earlier in the day was negative, but he would ask the physician to see her today. An interview with the nurse caring for the resident was conducted and she stated she placed a wet towel under the door to prevent dust from coming into the room of this resident. The DON then explained that " most of the dust was on the first floor. " 3. During the facility tour on 01/23/13 between 9:40 a.m. and approximately 11:00 a.m., it was determined that the facility was in the process of a remodeling project for the interior and exterior of the building. Photographs were taken during this time. Observations during this period included the following: a. 100 West hallway: An observation of the 100 West hallway revealed a fire extinguisher on the floor; heavy dust on the floor and handrail in the hallway; open residential door to room 108, and painter ' s tape with brown paper on the residential door frame that was attached to the resident ' s doorways. The brown paper was approximately 12 inches in width and was attached to several of the door frames in the 100 hallway, impairing the resident visually when entering and exiting the room and impeding safe movement. Uncovered drywall and wall patching was observed in progress. b. 100 West hallway: An observation of construction dust on the handrails, a worker ' s tool on the hand rail, a spray bottle on the hallway floor; uncovered drywall; wall patching was in progress and the floor had 3-4 inches of construction dust present along the wall. At the time of the observation, three workers were scraping the wall in the area, and they stepped out of the way of the camera picture. Residential doors were open during these observations. c. 100 West hallway: On the 100 West hallway, an uncovered medication cart was positioned touching the handrail in the hallway; a layer of drywall dust was covering the top of the handrail and debris was present along the board attaching the handrail to the wall. Above the handrail the wall had indications that it had recently been sanded and was unpainted. Sitting on the medication cart was a container/pitcher of fluid which appeared to be water, as well as cups and containers of nutritional supplement. Construction dust and debris were observed on the floor along the wall of the hallway. Residents were observed moving about throughout the hallway moving in close proximity to the construction dust and debris. d. 100 East hallway, facing the South residential end: The 100 East hallway was observed to have painter paper taped to the flooring. Unpainted drywall with patching of drywall was in progress throughout the hallway where residents were residing, as well as drywall dust on the floor. Doors were open to resident rooms and the hallway was used by staff and residents while observed in the stated condition. e. 100 East hallway, facing North towards the fire exit: An unsecured fire extinguisher was observed sitting directly on the floor in the resident hallway, which had been moved as a result of the renovations. Large sections of paper were taped to the floor throughout the hallway and uncovered drywall with patching was observed in progress. Visible dust was observed in the hand rail area and on the floor along the wall. Reviewing the area between the handrail and the wall, revealed the presence of construction debris that was of a depth of approximately one half to three quarters of an inch thick, rendering the hand rails undesirable to use for the residents residing in this hallway. f. The bathroom between room 128 and 130, the new tile placement. A commode had been brought into the bathroom but was not functional. g. While getting off the elevator on the 2nd floor the following was observed: Located in the hallway, across from the elevator on the 2nd floor, were metal rod braces, which extended from the floor to ceiling. Yellow caution tape was secured to each rod extending down the hallway from the elevator area to the nurse ' s station. The yellow caution tape traversed the hallway and extended through the area of the smoke/fire compartment doors. The placement of the partitioned off area with the caution tape potentially impeded the functioning and the purpose of the fire doors which was to contain smoke if a fire were to occur. A resident bed was also observed in the 200 South hallway with two medication carts positioned at the end of the hall. h. Approximately one third of the way down the 200 South hall, looking back towards the elevator area, an observation found uncovered drywall and metal poles with yellow tape traversing through the smoke barrier doors. The area was a high traffic area used by staff and residents to move about the unit and was located across from the elevator. The metal bars created an obstacle and a safety hazard for ambulating residents and self-propelling residents in wheel chairs. i. 200 East hall: Two beds, a bedside commode, a night stand, a resident chair, and facility renovation equipment were observed positioned on the left side of the hallway on the 200 East hallway. Sitting on the floor on the right side of the hallway was a piece of maintenance equipment. The equipment extended through the door way of a resident ' s room and, approximately, one foot into the hallway. Fresh paint and dust was present on the floor. A wet paint sign hung from the door frame of a resident ' s room indicating the frame had recently been painted. Several of the wet paint signs attached to resident ' s doors were observed throughout the facility. The drinking fountain in the hallway was inaccessible due to the bedside commode in front of it. The rooms were occupied by mobile residents at the time of the observations. j. 200 East hall: A resident was observed sitting in a chair in the 200 East hall coming out of their room. A resident chair and an unoccupied wheelchair were near the end of the hall. The walls in the hallway where the resident was sitting were observed to have painting in progress and a tool on the handrail. At the floor and wall juncture, a visible line of construction debris was present. k. At 11:20 a.m. on 1/23/13 Resident #10 was observed self -propelling his wheelchair down the South hallway towards this area. While standing in the door frame of room 217, looking into the hall, several large items were observed [DIAGNOSES REDACTED] the hallway near room 217, partially blocking the entrance to the room. The items included: a housekeeping cart, linen cart, uncovered medication cart, night stand, and a bed. A wet paint sign was observed taped on the wall above the handrail in the same area. Resident #10 had to stop because the articles [DIAGNOSES REDACTED] the hallway prevented him from moving forward to his room, which was located in this vicinity. The area was not wide enough for his wheelchair to fit through, and a maintenance man had to move some of the furniture for him to access his room. A review of Resident #10 ' s clinical chart [DIAGNOSES REDACTED]. l. In front of Room 217 looking at the 200 South hall, two beds, a nightstand, medication cart, and wheel chair were noted. During the observation of the 200 hall near room 217 it was also observed that both sides of the hallway, 200 South and 200 East, contained furniture items that prevented easy access of maneuvering the hallway. Both of the resident ' s beds, that were sitting in the hallway, had an electrical cord extending out from under the bed into the walking path. m. While looking toward South West hall leading to the residential common area, a wheel chair was observed sitting next to an unplugged and hanging cord for a bug light. Debris was on the floor and in the hand rail juncture. Wall patching and uncovered drywall was present in the hallway. n. In the 100 South hall, outside of the Main Dining Room, directly across from the dining room doors, the doors to the dining room were open. A small recessed area was observed to have heavy dust on the floor, approximately up to 4-5 feet away from the wall and the floor juncture. The dust was approximately one quarter to one half inch thick. Two dust covered receptacle plates were on the floor, and an uncovered drywall was observed. Residents were present in the Main Dining Room and the hallway at the time of the picture. o. In the 100 South hall, outside of Main Dining Room area, heavy dust was present on the floor, approximately eight inches in width along the wall and floor juncture. As you looked down the hall, it had uncovered dry wall. The door was open to the Main Dining Room, and visible layered construction dust was present in the hallway in front of the Dining Room door, where the reception desk was located. Residents were observed to be in the Main Dining Room at this time, approximately 11:30 a.m., eating their lunch. p. 100 South hall: The floor and wall juncture was observed with approximately two to three inches of construction debris layered on the floor. This area was directly outside of a second set of Main Dining Room doors that were open at the time of observation. q. An observation was conducted from the West side of the single story portion of the facility. Men and roofing materials were present on the roof. Construction materials were present in the parking lot. The facility was in the process of having its roof replaced. r. In the 100 South hall an observation in the area across from the Main Dining Room found an " X " had been drawn in the dust and debris on the floor, which portrayed the depth of the debris. Continued observations of 01/23/13 at approximately 1:00 -3:00 p.m. found the following conditions: s. In 100 West hallway, the word " Sand " was written above room 106. This word " sand " was written sporadically throughout the hall way, on the walls. t. During an observation conducted on 01/23/13 at approximately 1:00 p.m. of the second floor South hall in front of nurse ' s station, a rod with caution tape tied to it was located in the hallway, blocking off an area in the hallway. Two resident beds in the hallway had been moved out of the resident rooms for room renovation. The residents had not been relocated to another room during this process. Their belongings/possessions had been moved into the hallway during this time. The residents were unable to lie down in their rooms, during the period of their room renovation. Bathrooms were also being renovated and residents had to use community commodes. u. An observation at approximately 2:00 p.m. was conducted of the 200 East hall. Viewing the hall from the north end and looking at the South end, the amount of furniture in the residential hallway revealed two of three residential beds, one of which was positioned length wise across the hall, two resident sitting chairs, three night stands/dressers and miscellaneous equipment. Also, observed was a thermostat that was hanging from the wall with the wire exposed. The hallway walls had the look of being freshly painted. v. An observation at approximately 1:30 p.m. on 1/23/13 of the ceiling vent, located on the 100 hall west, the end of the corridor near the exterior exit, found the air filter, inside the vent, had a visible thick layer of dust with the appearance of a " cake like " quality, i.e. very heavy. The air filter was visibly bowing up into the duct, indicating that the air filter was not passing the air as intended. 4. Additional Staff interviews conducted on 01/23/13 revealed the following: a. In an interview, conducted on 01/23/13 at approximately 3:15 p.m. with Licensed Practical Nurse (LPN), (B), she was asked if Resident #3 had complained about the dust. She stated: " The resident did not complain about the dust; her family member complained about the dust; this happened yesterday-afternoonish. She was walking in the hallway and made the comment about the dust. " b. The interview continued with LPN, (B). She further stated that in her area, 200 West hall, she had two residents that have really bad respiratory problems, Residents #3 and Resident #11. She stated that she had told the Certified Nursing Assistants to enter the resident ' s room through the adjoining room bathroom to limit opening the door to the hall due to the amount of dust. LPN B stated that she put wet towels along the bottom of these two residents ' doors to limit the dust for them. LPN B stated they just started painting today, and the paint smell is strong. LPN B agreed that the poor air quality could affect her residents with respiratory illnesses. A review of a list provided by the facility on 01/24/13 documented that Resident #11 utilized a CPAP machine which is used during sleep for sleep apnea. c. During an interview, conducted on 01/23/13 at approximately 1:00 p.m., the Administrator confirmed that the building was currently having renovation in progress and that paperwork, regarding the renovations, had not been completed or submitted to the Agency for approval prior to commencing with the renovation projects. d. An interview was conducted with the Administrator on 01/24/2013 at 2:27 p.m. He said that he had just started working at the facility the first of the year. He stated that he was in charge of the construction project. To the best of his recollection the project started on January 14th. He said that there was no deadline for completion. He said that they were trying to make a big impact in the shortest amount of time without disrupting the residents. He said that they did not call the planning department about the construction project. He was asked about a policy regarding the construction project. He said he does have a book with the renovations and scope to be done and a revised ICRA. He said it details what ' s going to be done and by whom. The Administrator said that minor work was done by submitting work orders. He had never been involved with major work before. e. On 01/24/13 at 2:18 p.m. the DON was interviewed. He stated there were two different groups of workers on the inside of the building. The second floor workers were contractors and the first floor workers were from sister facilities from the management company. The DON stated " It could have been contained better " (referring to the dust and debris generated from the construction), but he did not think people were in jeopardy. He agreed that yesterday, 01/23/13, it was " dusty and dirty. " He thought it was too much at once but he was monitoring the residents. f. An interview was conducted on 01/24/13 at 2:18 p.m. with the Director of Nursing he stated, " I don ' t believe people were in jeopardy. It could have been contained better. My opinion is that we just wanted to get it fixed and it was too much at one time. I agree yesterday it was dusty and dirt. " g. During an interview, conducted on 01/24/13 at approximately 10:10 a.m., with the Facility Maintenance Supervisor, (M), he was asked the question: Do you believe the residents health or safety was an issue while renovation was going on? Employee M stated the only issue he was concerned about was the drywall dust from sanding the walls. He further stated that the floors would become slippery at times. 5. Policy and Procedure review: A review of the facility ' s Management Plan for Safety, dated 11/01/97, manual page # 7A.1, documented the policy to be: " It is the policy of this facility to provide an environment as safe as possible for all residents, staff and visitors while providing residents with quality care and homelike environment. Procedures: No safety program is 100% effective, but risks within the facility can be significantly reduced with planning and organization. An effective safety program depends on preparation and organization to protect both people and the physical structure. The program contains the following: A continuous Quality Improvement (CQI) process that identifies known or potential hazards or risks in the physical environment, equipment, or activities of daily living. A preventative maintenance program that allows the facility to catch potential problems before they endanger the environment. An active safety committee. Through this committee, the facility safety is emphasized on a daily basis. A training program that makes safety a priority. New employees participate in an orientation program that provides necessary safety information such as fire plans, incident hazard reporting systems, smoking policies and general safety policies. " 6. A record review of Florida Administrative Code, 59A-4.133, Plans Submission and Review and Construction Standards, states the following: "(1) When construction is contemplated for new buildings or for additions, conversions, renovations, or alterations to existing buildings, the plans and specifications for the contemplated construction shall be prepared by Florida-registered architects and engineers.(2) All contemplated additions, conversions, renovations, or alterations shall be submitted for approval or exemption from the plans review process. " 7. Guidelines for Health Care industry : A review of www.eheinc.com/infectioncontrol.htm <http://www.eheinc.com/infectioncontrol.htm>, documented: In April of 2001, the American Institute of Architects (AIA) issued directives in the Guidelines for Design and Construction of Hospitals and Health Care Facilities which formalized the Pre-construction Risk Assessment (PCRA) and Infection Control Risk Assessment (ICRA) process. Later that same year, the Joint Commission adopted the AIA guidelines as part of their regulations and established an enforcement date of January 2002. Since that time, healthcare facilities have been required to use the AIA guidelines and to provide documentation of compliance. A process for HealthCare facilities to follow as a compliance standard: A review of section 5.1 Planning and Design from Guidelines for Design & Construction of Hospitals and Health Care Facilities, excerpted-ICRA Standards 2001 (AIA Guidelines) stated the following: Planning for health care facilities shall include , in addition to space and operational needs, provisions for infection control and protection of patients during any renovations or new construction. Continual health care facility upgrade through renovation and new construction involving existing facilities can create conditions that can be hazardous to patients. During the programing phase of a construction project, the owner shall provide an Infection Control Risk Assessment (ICRA). An ICRA is a determination of the potential risk of transmission of various agents in the facility. This continuous process is an enssential component of a facility functional or master program to provide a safe environment of care. The ICRA shall be conducted by a panel with expertise in infection control, risk management, facility design, construction, ventilation, safety and epidemiology. The panel shall provide updated documentation of the risk assessment throughout out the planning, design, and construction. A review of an ICRA Matrix of Precautions for Construction & Renovations stated: Step One was to use a table to identify the Type of Construction Project Activity (Type A-D). Type C stated: Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies includes, but is not limited to: Sanding of walls for painting or wall covering; removal of floorcoverings, ceiling tiles and casework; new wall construction; minor duct work or electrical work above ceilings; major cabling activities; any activity which cannot be completed within a single work shift. Step Two was stated to be the use of a table to identify the Patient Risk Groups that will be affected. Low Risk=Office Areas. Medium Risk, High Risk and Highest Risk followed. It could be determined by elemination, that at minimum, the Long Term Facility could be classified as a Medium Risk or potentially higher. Step Three was to match the patient risk group with planned Construction project to find the Class of Precautions, I, II, III, or IV, or level of infection control activities required. Reviewing the table, a Type C construction with a Patient Risk Group of Medium would require at minimum a Class III Precaution level. A review of the ICRA Description of required Infection Control Precautions, Class III, documented a sample of the following precautions: 1.Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system. 2.Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) befor construction begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. 8. A demonstration of the lack of process implemented by the facility Administration to follow established guidelines for a Healthcare facility by not formalizing a plan to protect the residents from CLASS III type renovations hazards as defined on the ICRA Matrix is captured in the following: An interview was conducted on 01/24/13 at approximately 2:00 p.m. with the Regional Vice President of Operations, RVP. The RVP stated that: " I oversee the operations of the facility; I have been overseeing the building for 3 years in March. " For the grant monies for renovation, my bosses solicited the grant, because it is a non for profit facility. We received the grant in 11/17/2012. That is when we started lining up all the contractors. We, the former Administrator and I, started to go through the building and make the arrangements to start the remodeling project. The date for the remodeling was to be after the holiday. The contractors were actually here during the QIS survey/ that started on 01/07/13. We sent them away because we did not want to start the process during the survey. We did not formulate a written plan for the remodeling and we did not submit it to any agency. She stated: " I am familiar with the IRCA, (at this point, the RVP started to call the remodeling project " a puff and powder " project, not remodeling) and saw no need to submit any paperwork to the Agency due to the type of work that was being done. She stated: Painting the hallways; taking up flooring and putting tile down; (I was not present if they were sanding); Roofing; were not something that ne

Based on observation, record review, resident interviews, staff interview, family interview, and management interviews the facility failed to provide a safe environment, to protect the well-being of all residents. The facility undertook in renovations to the physical plant which included activities such as sanding of walls for painting; painting; removal of floor tile; replacement of floor tile; all of which created conditions that could be hazardous to residents by creating a high level of dust and chemical odors. The failure to implement proactive measures for the safety of the residents, and failure to protect the residents from the hazardous conditions created by the ongoing renovation, placed all of its residents, staff, and the public at risk for serious harm from the hazardous conditions created by the remodeling project as evidenced by the following, specifically 10 of 117 residents #1, #2, #3, #4, #5, #7, #8, #9, #10, and #11. The facility failed to implement renovation barriers to separate remodeling areas from residential living areas which interviewed residents reported physical symptoms that included: trouble with breathing, coughing; and the feeling of nausea. The facility failed to implement appropriate isolation barrier in the kitchen area to protect food products, food preparation surfaces, and residential meals from coming in contact with construction debris. The facility failed to utilize or complete the process, ICRA (Infection Control Risk Assessment), designed to recognize hazardous conditions for patients during any phase of renovation. (ICRA Standards 2001; AIA Guidelines) These findings resulted in the identification of Immediate Jeopardy on 11/23/13. The finding of Immediate Jeopardy was found to be removed on 01/24/2013 at 6:00 p.m. and the scope and severity was reduced to an F. Findings include: 1. A tour of the facility was conducted on 01/23/2013 and observations were made from approximately 9:40 a.m. through approximately 11:00 a.m., where it was revealed that the facility was in the process of interior and exterior renovations. Photographs were taken during this time. a. The 1st floor consisted of 3 residential hallways, the 100 West, 100 South, and 100 East, respectively. All of the hallways on the 1st floor were observed to have remodeling efforts in progress, uncovered drywall, patching in the drywall, implications of drywall sanding, and spot painting. The following observations were made during this tour: An observation in the 100 West hallway revealed a fire extinguisher on the floor, heavy dust on the floor and handrails in the hallway, open residential doors, with large sections of brown paper taped onto door frames at the entrance to the resident rooms. The brown paper was approximately 12 inches in width and was attached to the door frames impairing the resident visually while entering and exiting the room and impeding safe movement. Uncovered drywall and wall patching was observed in progress throughout the unit. A worker ' s tool was observed sitting unattended on a hallway handrail and a spray bottle was sitting on the hallway floor. b. Also observed on the 100 West hallway was an uncovered medication cart which was positioned touching the handrail in the hallway that had a layer of drywall dust covering the top of the handrail. The handrails present in the hallways had very heavy dust and construction filaments present on over 50 % of the top of the rails, rendering them unsafe, unsanitary, and undesirable for use of the residents. c. Sitting on the medication cart was a container/pitcher of clear fluid which appeared to be water, as well as cups and containers of nutritional supplement. Above the handrail the wall had indications that it had recently been sanded and was unpainted. Construction dust and debris were observed on the floor along the wall of the hallway. Residents were observed moving about the hallway and in close proximity to the construction dust and debris. The word " sand " was present on the drywall at sporadic intervals along the hall wall. These drywall areas were perceived to be in the process of being sanded. d. Drywall dust was observed on the floor of the 100 West hall, approximately 2 feet from Room 108, extending approximately 1 foot from the wall. Residents were present in their rooms and in the hallway. Doors were open to resident rooms and the hallway was being used by staff and residents while observed in the stated condition. The majority of the bedroom doors were observed open throughout the facility during the ongoing renovation. e. A fire extinguisher was observed sitting directly on the floor in the 100 West resident hallway approximately 2 feet from Room 108 and approximately 1 foot from the wall creating a trip hazard. Residents were present in their rooms and in the hallway during this time. Visible dust was observed in the hand rail area and on the floor along the wall. f. An observation conducted on 01/23/13 at approximately 1:00 p.m., of the 1st floor West and East wing, revealed the hallways had ceiling vents that were located at the end of the hallway near the exit. When reviewing these vents it was noted that the entire air filter was covered with a visible, heavy, white colored dust like product; the appearance was a " caked over " look and the air filter was visibly bowing towards the interior of the duct, thus indicating that the air flow was compromised. Large sections of paper were taped to the floor throughout the East hallway and unpainted drywall and patching of drywall was in progress throughout the hallway where residents were residing. It was noted that the 1st floor had residential activity going on. Residents were in the hall ambulating and in wheelchairs. Staff were also present, both nursing staff and maintenance, at this time. g. An observation was conducted on 01/23/2013 in a room off 100 West hall, at approximately 10:00 a.m. Resident #8 was observed to be seated in a wheelchair, positioned between the two beds in the room. The resident ' s eyes were closed, she had a lap belt over the front of her torso, and the television was on. Located just inside the door to this residential room, was a three tier push cart with tools present. Also observed was maintenance person (M), who was observed to be on his knees under the sink area of the room, banging and removing tile from the floor. He was interviewed at this time and he stated that he was replacing the tile under the sink, due to its broken condition. It was noted that the work was taking place while the resident was in the room and napping in her wheelchair. A record review was completed for Resident # 8 where the [DIAGNOSES REDACTED]. h. Located in the hallway across from the elevator on the 2nd floor was the presence of metal rod braces, observed on 01/23/2013 at approximately 11:10 a.m., that extended from floor to ceiling. Yellow caution tape was secured to each rod extending down the hallway from the elevator area to the nurse ' s station. The yellow caution tape traversed the hallway and extended through the area of the smoke/fire compartment doors. The placement of the partitioned off area with the caution tape potentially impeded the functioning and the purpose of the fire doors. The area was a high traffic area used by staff and residents to move about the unit and was located across from the elevator. Two beds, a bedside commode, and resident equipment were observed positioned on the left side of the hallway on the 200 East hallway. Sitting on the floor on the right side of the hallway was a piece of maintenance equipment. The equipment extended through the door way of a resident ' s room and approximately one foot into the hallway. Fresh paint and dust were present on the floor. A wet paint sign hung from the door frame of a resident ' s room indicating the frame had recently been painted. Several of the wet paint signs attached to resident ' s doors were observed throughout the facility. The rooms were occupied by mobile residents at the time of the observations. A resident was observed sitting in a chair in the 200 East hall on 01/23/2013 at approximately 11:20 a.m. The walls in the hallway where the resident was sitting were observed to have painting in progress and a tool on the handrail. i. Several large items were observed, on 01/23/2013 at approximately 11:20 a.m., [DIAGNOSES REDACTED] the hallway on the 200 hall near room 217 partially blocking the entrance to the room. Items included: a housekeeping cart, linen cart, uncovered medication cart, night stand, and a bed. A wet paint sign was observed taped on the wall above the handrail in the same area. During a random observation Resident #10 was observed self- propelling in his wheelchair down the South hallway towards this area. He had to stop because the articles [DIAGNOSES REDACTED] the hallway preventing him from moving forward to his room which was located in this vicinity. The area was not wide enough for his wheelchair to fit through. A maintenance man then moved some of the furniture for him to access his room. A record review was completed for Resident # 10 where the [DIAGNOSES REDACTED]. j. During an observation, on 01/23/2013 at approximately 11:30 a.m. of the 200 hall near room 217 it was noted that both sides of the hallway contained items positioned in a way that prevented easy access for maneuvering the hallway. One of the resident ' s beds, that was sitting in the hallway, had an electrical cord extending out from under the bed into the path of walking. On the south west hall, leading to the residential common area, a wheel chair was observed sitting next to an unplugged and hanging cord for a bug light. Debris was on the floor and in the hand rail juncture. Wall patching and uncovered drywall was present in the hallway. Continued observations of 01/23/13 at approximately 1:00 -4:30 p.m. found the following conditions (Photographs were also taken during this time): k. An observation was conducted on 01/23/13 at 2:41 p.m. of a maintenance person, (K), in room 126 carrying uncovered tile debris out of the resident ' s bathroom. He confirmed that he was retiling the bathroom. A resident was observed lying on her bed at this time in room 126. l. Located outside of the Main Dining Room on the first floor was a small recessed area which was observed to have heavy dust on the floor and uncovered drywall. Miscellaneous materials were present on the floor in the area. The doors to the dining room were open at the time of the observation and the room was being used by residents who were dining. m. An observation was conducted on 01/23/13 at approximately 4:30 p.m. of the kitchen area. The observation was conducted with the Director of Physical Plant. The interior of the kitchen was observed to have a thin plastic barrier in place, approximately in the middle of the kitchen beyond the food prep area, that extended from floor to ceiling and from wall to wall for the purpose of quarantining the back area of the kitchen where construction was occurring. An interview was conducted at this time with the Director of Physical Plant Consultant (N) and he confirmed that renovations were taking place on the other side of the plastic, at night after the kitchen had closed. The workers were then removing and replacing the kitchen floor tile. He further stated that the workers would remove the plastic from one end or the other, the plastic would stay unsecure during the working session, and they would then reseal the plastic in the morning. The observations of the thin plastic barrier, which was approximately 15 feet in length by 8 feet high, revealed that the plastic was taped to the sides of the kitchen walls and a portion of the floor area; an area of approximately 5 feet in length on the floor towards the middle of the plastic was not sealed to the floor. Visible white debris and dust were present along this area extending approximately eight inches on the kitchen floor, in the portion of the kitchen where food was being prepared for the residents. The top of the plastic barrier was not taped or sealed allowing for airborne particles to get through. 2. On 1/23/13, at approximately 10:00 a.m., the DON presented the surveyors with a hand written list titled " O2 and Nebs [MEDICAL CONDITION]' s " . Record review of this list showed thirty one of 117 residents were identified as residents utilizing oxygen solely or with the use of a nebulizer and seven residents ' utilized nebulizers for a total of 31 residents with compromised respiratory systems. Two of the 31 residents also had tracheostomies. 3. Random interviews were conducted with residents, family members, and staff regarding the renovation project that was in progress. An interview was conducted on 01/23/2013 at 9:50 a.m. with Resident #1 who stated, " The dust bothers me, it comes and goes. I fan to get air. " The resident was observed in her bed fanning herself. A record review was completed for Resident # 1 where the [DIAGNOSES REDACTED]. 4. An interview was conducted at approximately 10:10 a.m. on 01/23/2013 with Resident #2 who stated that his bathroom door had been open and that the stuff they used to put down the tile smelled. The resident stated that yesterday he could not hold anything down. A 2nd interview was conducted with resident #2 at 2:45 p.m. on 01/23/2013. The resident was lying in bed wearing nasal tubing supplying oxygen. He stated that yesterday he felt sick around lunch time and vomited. He stated that he told the nurse about being sick, but did not take any medication for the symptoms. He stated that he became sick due to the smell of the chemical that they used in the bathroom construction. He said that they had been working in his bathroom for the past two days while he was present in his room. Tape was observed around the bathroom door sealing the cracks on this day. He said that he uses oxygen whenever he is in bed. He said that he has [MEDICAL CONDITION] and Asthma. Silver tape was observed on the door frame, covering approximately 75% of the door and frame junctures. Resident #2 ' s bed was observed to be approximately four feet from the bathroom door in his room. The bathroom was observed to have new tile flooring, the commode had been removed, and an uncovered pipe with debris was present. A record review was completed for Resident # 2 where the [DIAGNOSES REDACTED]. 5. An observation and interview was conducted with resident #2 again on 1/24/13 at 12:31 p.m. He was lying in bed wearing a nasal tube supplying oxygen. He said that nursing staff knew about his episode of vomiting two days previous. Regarding the smell from the bathroom and the vomiting he said: " That did it. I don ' t know what they put on it " , referring to the chemical used on the bathroom floor. He said he normally gets out of bed and was just up a few days ago, but lately he hadn ' t felt well so he hadn ' t been out of the bed. 6. A random interview was conducted on 01/23/2013 at 10:40 a.m. with Resident #4 ' s family member who stated, " You should have been here yesterday. They were sanding the dry wall, there was dust everywhere. " 7. An interview was conducted on 01/23/2013 at 10:20 a.m. with Resident #3 who stated, " I have hard time breathing. " Her room was located on the 2nd floor. An interview conducted on 01/23/13 at approximately 3:15 p.m. with Licensed Practical Nurse (LPN), (B), she was asked if Resident #3 had complained about the dust. She stated: " The resident did not complain about the dust; her family member complained about the dust; this happened yesterday-afternoonish; She was walking in the hallway and made the comment about the dust. " A record review was completed for Resident #3 where the [DIAGNOSES REDACTED].????????????? Pneumonia, Dyspnea, Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION] were documented on the Physician order [REDACTED]. 8. An interview was conducted on 01/23/2013 at 3:18 p.m. with Resident #7, who resided on the 2nd floor, and a family member. The family member stated that Resident #7 had not been breathing well the last couple of days and that in the past week he had not been acting the same. Resident #7 stated that his breathing had been more difficult the past few days and that he had been using his oxygen more often than usual. Subsequently, the resident ' s family member was observed to proceed to the nurses ' station and ask the nurse to order a chest x-ray for Resident #7. A record review was done for Resident #7, the [DIAGNOSES REDACTED].O.P.D.), Pneumonia, and [MEDICAL CONDITION]. A review of the Quarterly/P.R.N. Data Collection dated 01/6/2013 documented: Respiratory: [MEDICAL CONDITION]/C.O.P.D. 9. A random interview was conducted on 01/23/2013 at 2:55 p.m. with Resident #9, who resided in the 200 hall. She said that she keeps her oxygen on 24 hours a day. She stated the smell of the construction makes her feel like coughing. A record review was completed for Resident # 9 where the [DIAGNOSES REDACTED]. 10. On 01/24/2013 at 1:55 a.m. an interview was conducted with Maintenance person (L). He said he works for the corporation and does hands on work maintenance. He stated that the Administrator oversees the construction project. He said that the classification of the construction would be minor modifications. He said that construction started on Monday January 14th. He said he took part in the sanding being done in the hallway, which included wet and dry sanding. Some of workers wore masks, but he did not. He stated that while sanding occurs some of the drywall falls to the floor, and then it is vacuumed up. 11. An interview was conducted at approximately 10:15 a.m. with Certified Nursing Assistant (A) who was observed in a resident ' s room wearing a mask on her face. She stated, " Dust affects my sinuses. " 12. During an interview conducted on 01/23/2013 at approximately 1:00 p.m., the Administrator confirmed that the building was currently having renovations in progress and that paperwork regarding the renovations had not been completed or submitted to the Agency for approval prior to commencing with the renovation projects. 13. An interview was conducted on 01/23/2013 at approximately 3:30p.m. with L.P.N, (B). She stated that in her area, 200 west hall, she had two residents that have really bad respiratory problems, Resident #3 and Resident #11. She stated that she had told the Certified Nursing Assistants to enter the resident ' s room through the adjoining room bathroom to limit opening the door to the hall due to the amount of dust. LPN B stated that she put wet towels along the bottom of these two residents ' doors to limit the dust for them. LPN B stated they just started painting today, and the paint smell is strong. LPN B agreed that the poor air quality could affect her residents with respiratory illnesses. A review of a list provided by the facility on 01/24/13 documented that Resident #11 utilized a [MEDICAL CONDITION] machine which is used for sleep apnea. 14. Another interview was conducted with the Administrator on 01/24/2013 at 2:27 p.m. He said that he had just started working at the facility the first of the year. He stated that he was in charge of the construction project. To the best of his recollection the project started on January 14th. He said that there was no deadline for completion. He said that they were trying to make a big impact in the shortest amount of time without disrupting the residents. He said that they did not call the planning department about the construction project. He was asked about a policy regarding the construction project. He said he did have a book with the renovations and scope to be done and a revised ICRA (Infection Control Risk Assessment). He said it detailed what ' s going to be done and by whom. The Administrator said that minor work was done by submitting work orders. Major work he has never been involved with before. The Administer further stated that the residents are out of their rooms when work was being done, even when work was being done in the bathrooms. He confirmed that on the 2nd floor he saw blue tape either over the smoke detectors or strobe. He also saw a hairnet over a smoke detector and he removed it. The Administrator was asked if there was a potential risk for safety, he confirmed that " yes " stating, " Stuff in hallway that could have impeded safety. " 15. On 01/24/13 at around 10:15 a.m. an observation of resident #5 was conducted. The resident was lying in bed with oxygen infusing into a [MEDICAL CONDITION]. She was coughing with a small amount of yellow mucus observed on the [MEDICAL CONDITION] dressing. She stated she did not feel well today. At 2:19 p.m. the physician ordered a stat (urgent) chest x-ray. At 3:45 p.m. on 1/24/13 resident #5 was observed again. The DON was at the bedside also. The DON stated her oxygen saturation was 95%. Her x-ray from earlier in the day was negative, but he would ask the physician to see her today. An interview with the nurse caring for the resident was conducted and she stated she placed a wet towel under the door to prevent dust from coming into the room of this resident. The DON then explained that " most of the dust was on the first floor. " 16. A record review of Florida Administrative Code, 59A-4.133, Plans Submission and Review and Construction Standards, states the following: (1) When construction is contemplated for new buildings or for additions, conversions, renovations, or alterations to existing buildings, the plans and specifications for the contemplated construction shall be prepared by Florida-registered architects and engineers. (2) All contemplated additions, conversions, renovations, or alterations shall be submitted for approval or exemption from the plans review process. 17. Record review of a Purchase Requisition order, 0, signed and dated 11/21/12, documented a description of work to be completed and coordinated by a vendor, sample descriptions of work as follows for " Facility Renovations " : Page 1 Remove the existing hydra-therapy tubs and convert area to new roll-in showers. Remove all existing tile and drywall at walls from finished floor to ceiling. Repair studs if necessary and replace drywall with cement board from finished floor to ceiling at shower area and moisture board on all other wall area. Provide and install new wall tile from finished floor to ceiling. Skim to a smooth coat and paint ceiling. Upgrade lighting; Includes all associated electrical Remove all existing floor tile throughout shower rooms. Provide and install new shower valves and ADA shower fixtures. Includes Associated plumbing Remove existing toilets and replace with new ADA toilets Remove reset sinks. Replace existing with new ADA faucets page2: Scope of work includes: the demo of wardrobes and convert into closets, the removal and replacement of resident rooms counter tops/sinks, cove base, mirrors, drywall repairs, skim texture and paint (including resident room restrooms) and new can light over resident room sinks. It was noted that the purchase order documented a cost of $161,960.00 dollars. 18. A review of www.eheinc.com/infectioncontrol.htm <http://www.eheinc.com/infectioncontrol.htm>, documented: In April of 2001, the American Institute of Architects (AIA) issued directives in the Guidelines for Design and Construction of Hospitals and Health Care Facilities which formalized the Pre-construction Risk Assessment (PCRA) and Infection Control Risk Assessment (ICRA) process. Later that same year, the Joint Commission adopted the AIA guidelines as part of their regulations and established an enforcement date of January 2002. Since that time, healthcare facilities have been required to use the AIA guidelines and to provide documentation of compliance. 19. A review of section 5.1 Planning and Design from Guidelines for Design & Construction of Hospitals and Health Care Facilities, excerpted-ICRA Standards 2001 (AIA Guidelines) stated the following: Planning for health care facilities shall include, in addition to space and operational needs, provisions for infection control and protection of patients during any renovations or new construction. Continual health care facility upgrade through renovation and new construction involving existing facilities can create conditions that can be hazardous to patients. During the programing phase of a construction project, the owner shall provide an Infection Control Risk Assessment (ICRA). An ICRA is a determination of the potential risk of transmission of various agents in the facility. This continuous process is an enssential component of a facility functional or master program to provide a safe environment of care. The ICRA shall be conducted by a panel with expertise in infection control, risk management, facility design, construction, ventilation, safety and epidemiology. The panel shall provide updated documentation of the risk assessment throughout out the planning, design, and construction. 20. A review of an ICRA Matrix of Precautions for Construction & Renovations stated: Step One was to use a table to identify the Type of Construction Project Activity (Type A-D). Type C stated: Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies includes, but is not limited to: Sanding of walls for painting or wall covering; removal of floorcoverings, ceiling tiles and casework; new wall construction; minor duct work or electrical work above ceilings; major cabling activities; any activity which cannot be completed within a single work shift. Step Two was stated to be the use of a table to identify the Patient Risk Groups that will be affected. Low Risk=Office Areas. Medium Risk, High Risk and Highest Risk followed. It could be determined by elemination, that at minimum, the Long Term Facility could be classified as a Medium Risk or potentially higher. Step Three was to match the patient risk group with planned Construction project to find the Class of Precautions, I, II, III, or IV, or level of Infection Control activities required. Reviewing the table, a Type C construction with a Patient Risk Group of Medium would require at minimum a Class III Precaution level. A review of the ICRA Description of required Infection Control Precautions, Class III, documented a sample of the following precautions: 1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. 21. A record review of an environmental assessment of the facility completed by a company at the request of the facility, dated 01/24/13, Report # 6249- , provided to the survey office on 01/25/13, documented the following on page 5: The results revealed markedly elevated dust levels in four of the eleven representative zones evaluated, Nurses Station 1, Hall 2 East by rooms 219 and 227 and Hall West by Room 204. Construction dust (black and opaque particles, and fibers) and/or skin cell fragments were principal constituents of the dust detected. Because of its nature, construction dust is corrosive and hygroscopic and therefore considered an irritant of the skin eyes and mucous membranes. Dust particles whose overall diameter ranges from 0.3 to 5.0 microns are recognized as respirable-size particles. Respirable size particles are generated by a broad variety of processes and activities and there are increasingly more studies liking associations between the concentrations of particles of respirable size and health effects. In this case, the respirable-size particle concentrations detected in ten of the eleven zones assessed were greater than the recommended guidelines. 22. On 01/24/13, an interview was conducted at 4:00 p.m. with the NHA was conducted regarding the role of the QAA committee in guiding the reconstructions. During that interview, the NHA stated the administrative staff had produced a document on 01/23/13 to address the survey concerns. He read from this document the following items to be implemented immediately: ? Stopped all construction. ? Informed contractor that until further notice not doing renovations, only day to day maintenance. ? An air quality company was called 1/23/13. No results of the testing at the time of this interview. ? Called all families and responsible parties to inform them of renovation and monitoring of residents. ? All physicians were notifed. ? A nurse, RN, was called in, 1/23/13, to evaluate all residents for change of condition. None found. ? A housekeeping company brought in a crew. They were assigned clean up/sweep/mop/ scrub and wipe down the walls in all areas. They came overnight. ? Three resident bathrooms were taken out of service and residents were given bedside commodes. ? Fire extinguishers were secured. ? Impediments on hand rails and smoke barrier doors were removed. ? Beds were removed for hallways. ? The barrier in the kitchen had been repaired and is no longer compromised. ? Plans have been submitted to ICRA processing, Plan and Construction office in Tallahassee. NHA stated he spoke with them also. On 01/24/13 at approximately at 6:00 p.m. the following was verified: ? As of 5:55 p.m. the painting, bathroom floor repairs and removal of wall paper and replacement of tile in common shower room and installation of the new roof has been stopped. ? Immediately upon notification by the surveyors that the Immediate Jeopardy was identified, measures were put in place to remove the potential harm. ? Housekeeping Services Group was notified that all resident care areas need to be cleaned and made free of any dust or dust particles. ? The resident bathrooms that were taken out of service will remain out of service until the tile can safely be grouted. ? The residents sharing those bathrooms have bedside commodes to ensure we are address their toileting needs. ? Fire Extinguishers were secured to their appropriate receptacles. ? All smoke barrier doors are fully functional ? The impediment of the handrails on the second floor was removed to allow residents easy access. ? All beds were removed from the hallways to ensure hallway accessibility for all residents. ? The clinical team will assess all residents with respiratory [DIAGNOSES REDACTED]. ? An air quality specialist had been hired to ensure that the air quality meets professional standards. ? The barrier surrounding the dish machine had been repaired. The finding of Immediate Jeopardy was found to be removed on 01/24/2013 at 6:00 p.m. and the scope and severity was reduced to a F.

Based on observations, interviews, and job description reviews the facility administration, including the Nursing Home Administrator (NHA) failed to provide the leadership and accountability necessary to implement renovation plans and provide administrative oversight to the anticipated, complex, facility wide renovations of the building. It was determined that the facility failed to demonstrate an effective administrative oversight to implement plans of action to correct identified quality deficiencies following the survey of 10/31/12, as well as follow up surveys of 12/19/12 and 1/11/13 and which resulted in an increase in the scope and severity of findings to Immediate Jeopardy during the survey ending 1/24/13. During the survey of 1/24/13 the facility failed to protect the well-being of residents during facility renovations and physical plant upgrading for two of two floors of resident living areas and the entire facility roof. Without the proper planning containment, and oversight, residents were unnecessarily exposed to construction materials such as floor tile adhesive odors; construction noise; dust and debris in the air and on surfaces; displaced resident items including beds, nightstands, and overbed trays; and obstructed hallways preventing access to resident rooms. Failure to provide a concrete plan, with beginning and end dates of the expected construction, denied the residents the choice of family or resident intervention such as short leave of absences or day trips out of the building to minimize the physical and emotional stressors of the renovations on the 117 medically fragile residents residing in the facility. The byproducts of sanding, and other construction airborne debris, posed a serious hazard to chronically ill residents with preexisting respiratory conditions specifically for 10 of 117 residents #1, #2, #3, #4, #5, #7, #8, #9, #10, and #11. These findings resulted in a determination of Immediate Jeopardy on 01/23/13 at level L. The Immediate Jeopardy was removed on 01/24/13 at 6:00 p.m. and the scope and severity was reduced to F. Findings include: 1. Review of the job description for the Nursing Home Administrator (NHA) revealed that he was hired August 19, 2011 as a Nursing Home Administrator for a consulting service contracted by the management company that the facility hired. He reported to the Regional Vice President, who was on site at the facility during this investigation. ESSENTIAL DUTIES of the NHA included: -Ensure that the most current resident care policies, personnel policies and other operational policies and procedures ...are available and followed. -Ensures that all facility personnel, residents, visitors, etc. follow established safety regulations to include fire protection/prevention, accident prevention, sanitation/infection control, etc. -Monitors and ensures compliance with all state and federal regulations including OSHA and other related programs. SUPERVISORY RESPONSIBILITES: Supervises staff whether directly or indirectly. ABILITIES: " The ability to tell when something is wrong or is likely to go wrong. It does not invlove solving the problem, only recognizing there is a problem. " 2. On 01/24/13 at approximately 2:00 p.m. the Regional Vice Present of Operations was interviewed. She stated: " I oversee the operations of the facility. I have been overseeing the building for three years in March. " She stated that the facility is a nonprofit and her bosses secured a grant for the renovations. She recalled they received the grant on 11/17/12, and the corporation started to line up contractors at that time. She stated that she and the former NHA started to go throughout the building and make arrangements to begin the project. She stated the plan was to start the process of renovation after the holidays. She recalled that contractors were in the building on 01/07/13 however, the annual survey began on that day and " we sent them away because we did not want to start the process during the survey. " She stated that a written plan was not formulated and nothing was submitted to any agency for approval. She stated she was familiar with ICRA, but referred to the remodel as a " puff and powder " project, and not a remodeling or renovation. She stated: " We did not formulate a written plan for the remodeling and we did not submit it to any agency. " She felt that was due to the type of work being done, such as painting the hallways, taking up flooring, and putting tile down. She stated she was not present during the wall sanding and that replacement of the roof did not need to go through the Office of Planning and Construction. The RVP confirmed that no barriers were used during the renovation of resident living areas. She stated there was no written plan to protect residents from the disruption, noise, smells, dust and debris related to the work in progress. She further stated that " It would be a team decision in regards to recognizing the need to submit an ICRA " , the instructional matrix for protecting medically fragile residents. 3. During an interview conducted on 01/23/13 at approximately 1:00 p.m., the Administrator confirmed that the building was currently undergoing major renovation in progress and that paperwork, regarding the renovations had not been competed or submitted to the State of Florida Agency for approval, prior to commencing with the renovation projects. 4. An interview was conducted with the NHA on 1/24/13 at 2:27 p.m., during the complaint survey, to discuss the facility wide renovations taking place. He said that he had just started working at the facility the first of the year, 2013. He said he worked for a consulting service, as a traveling Administrator. He was not paid by the facility, but by the contracted consulting company. He said that his contract is for six months and his title was Interim Traveling Administrator. He stated that he was in charge of the construction project. To the best of his recollection the project started on January 14th , 2013. He said that there was no deadline for completion. He said that they were trying to make a big impact in the shortest amount of time, without disrupting the residents. He said that they did not call the Office of Plans and Construction for the Agency for Health Care Administration about the construction project. He was asked about a policy regarding the construction project. He stated he did have a book with the renovations and scope to be done and a revised ICRA (Infection Control Risk Assessment Matrix for Precautions for Construction and Renovation tool). He said it details what is going to be done and by whom. The Administrator said that minor work was done by submitting work orders within the facility. He stated he had never been involved with major work before. Regarding the fire alarm system, he did not know if the fire alarm system was down for more than 4 hrs. He said he was not aware of the system being taken " off line " , whereby it signaled the second party contractor, but, not the local fire department. He stated they follow the rule of keeping the furniture to one side of the hall and doing no more than two rooms at a time. He said that the residents were out of their rooms when work was being done, including when work was being done in the bathrooms. On the 2nd floor, he recalled that he saw blue tape either over the smoke detectors or strobe. He also saw a hairnet over a smoke detector and he removed it. He agreed to a sensitivity test being done. He stated he did not hear any negative comments from residents or family regarding the construction. He said he did not have any concerns about resident safety. He was asked if there was a potential risk for safety and he responded " yes " , that the " Stuff in hallway that could have impeded safety. " He said that the resident ' s health was not compromised. He said that the current plan, after today ' s survey, was to keep the census at no more than 118, then seal off an unoccupied room, complete the room in the entirety, then move the resident back in. He said that the chain of command was the Administrator, then staff N whose title was Director of Physical Plant Management Consultant (hired by the corporation) and then, staff L the Physical Plant Consultant, also hired by the corporation to cover multiple facilities. 5. On 1/24/13 at 1:55 p.m. an interview was conducted with the Physical Plant Consultant, staff L. He stated he worked for a consulting service company, hired by the management company, and carried out " hands on " work maintenance. He stated that the Administrator was responsible to oversee the construction project. He said that the classification of the construction would be minor modifications. He said his immediate supervisor, when in a facility, was the Administrator. He said that construction started on Monday January 14th 2013. He had been here since the survey of January 10, 2013 working on correcting the deficiencies. He said that Staff N had also been here most of the duration since the January 14th. He said he took part in the sanding of the walls in the hallway, which included wet and dry sanding during the time period since January 14th. Subcontractors, hired by the management company were completing the second floor work. He was working on the first floor, with a crew of employees from sister facilities. The subcontractors assigned to the second floor jobs, started the same Monday as he did, January 14th. He stated he had no concerns with resident safety, however he said there was a mishap that happened when one of the Hepavac Vacuums, used to clean up the sanding dust, accidentally released dust into the air on the first floor. He did not state the date of the incident. No other concerns were brought to his attention. He said that some of workers wore masks, but he did not. He stated that, while sanding occurs, some of the drywall particles fall to the floor, and then they are vacuumed up. He did not address the care of the particles lingering in the air. He did not notice the fire alarm being deactivated. He said that they did do an ICRA (Infection Control Risk Assessment) at the facility and had pre-construction meetings with the NHA and others at an unknown time and date. He said that he, the Administrator, infection control coordinator, the Director of Physical Plant Management Consultant participated in doing the ICRA form. He stated resident safety played a part in the plan, and it ' s based on each project. He was asked about the policy regarding the construction. He said he ' d have to consult the NHA on the policy for the construction. As far as roof replacement and various work on the 1st floor, he didn ' t have any concerns for resident safety, even though some of the workers on the crew were wearing masks. He was asked, regarding the fire alarm, who would be the one responsible for making sure it worked. He said that there was a pass code that had to be given to the alarm company to have it turned off. The Maintenance Director from the facility would be the one to do that, Staff M. Staff L said he doesn ' t have the passwords for the 17 facilities he works as Physical Plant Consultant. The surveyor verified that the ICRA form was never sent to the Office of Plans and Construction. When asked about the deadline for completion of the renovation, he said he didn ' t remember. An inquiry by the surveyor on 01/24/13, to the office of Plans and Construction for the State Agency, revealed that no renovation plan was submitted for the current renovation in progress at the facility. 6. Observations conducted on 01/23/13 at 9:40 a.m. through approximately 11:00 a.m. during a tour of the facility, photographs were taken during this time. The observations revealed that interior and exterior renovations were in progress as evidenced by: a.) Observations conducted of the 1st floor, which consisted of three residential hallways, the 100 West, 100 South and 100 East respectively. All of the hallways on the 1st floor had remodeling efforts in progress, uncovered drywall, patching in the drywall, and spot painting. An observation in the 100 West hallway revealed an unsecured fire extinguisher resting on the floor, heavy dust on the floor and handrails in the hallway, open residential doors, and large sections of brown paper taped onto door frames at the entrance to the resident rooms. The brown paper was approximately 12 inches in width and was attached to the door frames impairing the resident visually while entering and exiting the room and impeding safe movement. The handrails, present in the hallways, had very heavy dust and construction filaments present over 50 % of the top of the rails. Floor areas had heavy dust in areas of four to eight inches or more in width, along the walls and approximately one eight to one quarter of an inch thick. b.) Observations conducted on the 2nd floor, the 200 room numbers, consisted of three residential hallways, the 200 West, 200 South and 200 East, respectively. All of the hallways on the 2nd floor had remodeling efforts in progress, uncovered drywall, patching in the drywall, freshly painted areas, floor to ceiling brace like metal rods with yellow cautionary tape were present outside of the elevator exit. One of two community bathrooms was under construction. It was noted that the renovation work that was taking place during the tour was being conducted with no presence of barriers to isolate the renovations projects from the residents residing in the rooms that connected to the hallways. Residents were observed to be walking, self-propelling their wheel chairs, resting in their bedrooms with doors open or being assisted by staff members around the construction debris and displaced items. c.) An observation was conducted on 01/23/13 at approximately 4:30 p.m. of the kitchen area. The observation was conducted with the Director of the Physical Plant, DPP. The interior of the kitchen was observed to have a thin plastic barrier in place approximately in the middle of the kitchen, beyond the food prep area. An interview was conducted at this time with the DPP and he confirmed that renovations were taking place on the other side of the plastic, at night after the kitchen had closed; the workers were removing and replacing the kitchen floor tile. He further stated that the workers would remove the plastic from one end or the other, the plastic would stay unsecure during the working session and they would reseal the plastic in the morning. The observations of the thin plastic barrier, which was approximately 15 feet in length by 8 feet high, revealed that the plastic was taped to the sides of the kitchen walls and a portion of the floor area. An area of approximately 5 feet in length on the floor towards the middle of the plastic was not sealed to the floor and visible white debris and dust was present along this area, extending approximately 8 inches on the kitchen floor in the portion of the kitchen where food was being prepared for the residents. The top of the plastic barrier was not taped or sealed allowing for air to get thru. The surveyor observation revealed concerns of construction dust and debris contaminating the kitchen floor and possibly becoming airborne contaminating food and food surface areas. 7. On 1/23/13, at approximately 10:00 a.m., the DON presented the surveyors with a hand written list titled " O2 and Nebs [MEDICAL CONDITION]' s " . Record review of this list showed thirty one of 117 residents were identified as residents utilizing oxygen solely or with the use of a nebulizer and seven residents ' utilized nebulizers for a total of 31 residents with compromised respiratory systems. Two of the 31 residents also had tracheostomies. 8. Observations and interviews, conducted 1/23/13 through 1/24/13, related to residents were as follows: a.) An interview was conducted on 01/23/13 at 9:50 a.m. with Resident #1. She stated that " The dust bothers me, it comes and goes, " I fan to get air. " Resident #1 was observed in her bed, in her room off the 100 East hall, fanning herself. Resident #1 further stated in the interview that she could not get up or out of her bed without assistance. Resident #1 ' s door was open to the hallway. A review of Resident #1 ' s Physician order [REDACTED]. b.) An observation was conducted at approximately 10:00 a.m. Resident #8 was observed to be sitting in a wheelchair, positioned between the two beds in the room; the resident ' s eyes were closed; she had a lap belt over the front of her torso; and the TV was on. Located just inside the door to the residential room was a three tier push cart with tools present. Also observed was a maintenance person, M, on his knees under the sink area of the room, banging and removing tile from the floor. He was interviewed at this time, and he stated that he was replacing the tile under the sink, due to its broken condition. (It was noted that the work was taking place while the resident was in the room and dozing in her wheelchair). A review of Resident #8 ' s Record of Admission sheet documented [DIAGNOSES REDACTED]. c.) An interview was conducted with Resident #2 at 2:45 p.m. on 01/23/2013. The resident was lying in bed wearing nasal tubing supplying oxygen. He stated that yesterday he felt sick around lunch time and vomited. He stated that he told the nurse about being sick and could not hold anything down, but did not take any medication for the symptoms. He stated that he became sick due to the smell of the chemical, that stuff they use to put down the tile smelled. He said that they had been working in his bathroom with the door open for the past two days, while he was present in his room lying in bed. He said that he uses oxygen whenever he is in bed. He said that he has [MEDICAL CONDITION] and Asthma. Silver duct tape was observed on the door frame, covering approximately 75% of the door and frame junctures. Resident #2 ' s bed was observed to be approximately four feet from the bathroom door in his room. The bathroom was observed to have new tile flooring, the commode had been removed and an uncovered pipe with debris was present. Resident #2 was in a room located off the 100 West hall. A review of Resident #2 ' s clinical record [DIAGNOSES REDACTED]. d.) An interview was conducted at approximately 10:15 a.m. with Staff member A, a Certified Nursing Assistant. She was observed to have a mask on her face. She stated " dust affects my sinuses. " She was present in room [ROOM NUMBER] at the time of interview. e.) An interview was conducted on 01/23/13 at 10:20 a.m. with Resident #3. She stated: " I have a hard time breathing. " " Not having a hard time breathing right now. " It was observed that the resident was an elderly person, lying in bed, able to communicate, with oxygen tubing via nasal cannula. The machine was observed to deliver between 2 and 2.5 liters of oxygen per minute. The resident stated: " I wear the oxygen all the time. Resident #3 stated that she had received " Nebulizer treatments for the last couple of days, they have been doing it quite often; every 4-5 hours. " Resident #3 was located off of 200 East hall. A review of Resident #3 ' s clinical record, a Physician order [REDACTED]. f.) A random interview was conducted on 01/23/2013 at 10:40 a.m. with Resident #4 ' s family member who stated, " You should have been here yesterday. They were sanding the dry wall, there was dust everywhere. " g.) On 01/24/13 at around 10:15 a.m. an observation of resident #5 was conducted. The resident was lying in bed with oxygen infusing into a [MEDICAL CONDITION]. She was coughing with a small amount of yellow mucus observed on the [MEDICAL CONDITION] dressing. She stated she did not feel well today. At 2:19 p.m. the physician ordered a stat (urgent) chest x-ray. At 3:45 p.m. on 1/24/13 resident #5 was observed again. The DON was at the bedside also. The DON stated her oxygen saturation was 95%. Her x-ray from earlier in the day was negative, but he would ask the physician to see her today. An interview with the nurse caring for the resident was conducted and she stated she placed a wet towel under the door to prevent dust from coming into the room of this resident. The DON then explained that " most of the dust was on the first floor. " h.) An interview was conducted on 01/23/13 at 3:18 p.m. with Resident #7 and a family member. Resident #7 resided on the 200 East hall. The family member stated that Resident #7 had not been breathing well the last couple of days and that in the past week he had not been acting the same. Resident #7 stated that his breathing had been more difficult the past few days and that he had been using his oxygen more often than usual. Subsequently, the resident ' s family member was observed to proceed to the nurses ' station and ask the nurse to order a chest x-ray for Resident #7. A record review was done for Resident #7, the [DIAGNOSES REDACTED].O.P.D.) and Pneumonia. A review of the Quarterly/P.R.N. Data Collection dated 01/6/2013 documented: Respiratory: [MEDICAL CONDITION]/C.O.P.D. i.) An interview conducted on 01/23/13 at approximately 3:15 p.m. with Licensed Practical Nurse (LPN), (B), she was asked if Resident #3 had complained about the dust. She stated: " The resident did not complain about the dust; her family member complained about the dust; this happened yesterday-afternoonish. She was walking in the hallway and made the comment about the dust. " j.) The interview continued with LPN, (B). She further stated that in her area, 200 West hall, she had two residents that have really bad respiratory problems, Resident #3 and Resident #11. She stated that she had told the Certified Nursing Assistants to enter the resident ' s room through the adjoining room bathroom to limit opening the door to the hall due to the amount of dust. LPN B stated that she put wet towels along the bottom of these two residents ' doors to limit the dust for them. LPN B stated they just started painting today, and the paint smell is strong. LPN B agreed that the poor air quality could affect her residents with respiratory illnesses. A review of Resident #3 ' s clinical record, a Physician order [REDACTED]. A review of a list provided by the facility on 01/24/13 documented that Resident #11 utilized a [MEDICAL CONDITION] machine which is used during sleep for sleep apnea. k.) An observation was conducted at approximately 10:00 a.m. Resident #8 was observed to be sitting in a wheelchair, positioned between the two beds in the room; the resident ' s eyes were closed; she had a lap belt over the front of her torso; and the TV was on. Located just inside the door to the residential room was a three tier push cart with tools present. Also observed was a maintenance person, M, on his knees under the sink area of the room, banging and removing tile from the floor. He was interviewed at this time, and he stated that he was replacing the tile under the sink, due to its broken condition. (It was noted that the work was taking place while the resident was in the room and dozing in her wheelchair). A review of Resident #8 ' s Record of Admission sheet documented [DIAGNOSES REDACTED]. l.) A random interview was conducted on 01/23/2013 at 2:55 p.m. with Resident #9, who resided in the 200 hall. She said that she keeps her oxygen on 24 hours a day. She stated the smell of the construction makes her feel like coughing. A record review was completed for Resident # 9 where the [DIAGNOSES REDACTED].????????????? [MEDICAL CONDITIONS], and Acute [MEDICAL CONDITION] were documented on the [DIAGNOSES REDACTED]. m.) Several large items were observed, on 01/23/2013 at approximately 11:20 a.m., [DIAGNOSES REDACTED] the hallway on the 200 hall near room [ROOM NUMBER] partially blocking the entrance to the room. Items included: a housekeeping cart, linen cart, uncovered medication cart, night stand, and a bed. A wet paint sign was observed taped on the wall above the handrail in the same area. During a random observation Resident #10 was observed self- propelling in his wheelchair down the South hallway towards this area. He had to stop because the articles [DIAGNOSES REDACTED] the hallway preventing him from moving forward to his room which was located in this vicinity. The area was not wide enough for his wheelchair to fit through. A maintenance man then moved some of the furniture for him to access his room. A record review was completed for Resident # 10 where the [DIAGNOSES REDACTED]. 9. On 01/24/13 an interview was conducted at 4:00 p.m. with the NHA was conducted. During that interview the NHA stated the administrative staff had produced a document, dated 01/23/13, to address the survey concerns. The NHA read from this document the following items to be implemented immediately: ? Stopped all construction ? Informed contractor that until further notice not doing renovations, only day to day maintenance. ? An air quality company was called 1/23/13. No results of the testing at the time of this interview. ? Called all families and responsible parties to inform them of renovation and monitoring of residents. ? All physicians were notifed. ? A nurse, RN, was called in, 1/23/13, to evaluate all residents for change of condition. None found. ? A housekeeping company brought in a crew. They were assigned clean up/sweep/mop/ scrub and wipe down the walls in all areas. They came overnight. ? Three resident bathrooms were taken out of service and residents were given bedside commods. ? Fire extinguishers were secured. ? Impediments on hand rails and smoke barrier doors were removed. ? Beds were removed for hallways. ? The barrier in the kitchen had been repaired and is no longer compromised. ? Plans have been submitted to ICRA processing, Plan and Construction office in Tallahassee. NHA stated he spoke with them also. On 01/24/13 at 6:00 p.m. the survey team was notified that the facility was ceasing the renovation project and the following was verified: ? As of 5.55 p.m. the painting, bathroom floor repairs and removal of wall paper and replacement of tile in common shower room and installation of the new roof has been stopped. ? Immediately upon notification by the surveyors that the Immediate Jeopardy was identified, measures were put in place to remove the potential harm. ? Housekeeping Services Group was notified that all resident care areas need to be cleaned and made free of any dust or dust particles. ? The resident bathrooms that were taken out of service will remain out of service until the tile can safely be grouted. ? The residents sharing those bathrooms have bedside commodes to ensure we are address their toileting needs. ? Fire Extinguishers were secured to their appropriate receptacles. ? All smoke barrier doors are fully functional. ? The impediment of the handrails on the second floor was removed to allow residents easy access. ? All beds were removed from the hallways to ensure hallway accessibility for all residents. ? The clinical team will assess all residents with respiratory [DIAGNOSES REDACTED]. As of 6 p.m., no residents were identified to have any ill effects from the work being done. ? An air quality specialist has been hired to ensure that the air quality meets professional standards. ? The barrier surrounding the dish machine has been repaired. ? Ongoing compliance with this plan submitted to AHCA on 01/23/13 will continue. After verification that the steps in the plan stated above were in place and all construction and renovation had ceased the finding of Immediate Jeopardy was found to be removed on 01/24/13 at 6:00 p.m. and the scope and severity was reduced to a F.

Based on clinical record review, policy and procedure review for code status orders and response, job description reviews, and interviews with facility staff, it was determined that administration failed to provide resource management to meet the needs for one (#8) of 54 residents identified as full code, according to the resident code status audit tool of [DATE]. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. This related to not implementing policies and procedures for advanced directives and failure to administer CPR and ensuring that staff maintained current training in C.P.R. to carry out this function to ensure that the highest degree of attention and care was provided to residents. Failure to ensure that staff would properly implement training on emergency policies and procedures led to neglect of one resident when staff did not perform CPR and call for Emergency Medical Services (EMS/911). These actions resulted in findings of immediate jeopardy, which were removed on [DATE] at 2:00 p.m. and the severity and scope was reduced to a D. Findings included: 1. Review of the POS [REDACTED] I. Summary of Position: Responsible for the financial, administrative and personnel management of the facility. Maintains appropriate guidelines and regulations to assure the highest degree of attention and care is provided to residents at all times. Follows all company policies and procedures. II. Position Responsibilities: A. Essential Functions 1. Supervisory Responsibilities b. Directs the work of employees 2. Plans, develops, organizes, implements, and directs the facility ' s programs and activities. Manage the overall day-to-day functions ... 4. Ensures that each resident ' s right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced. 5. Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations and guidelines are available and followed. 25. Resident Rights a. Knows Resident Rights. Helps the residents exercise and/or protect their rights 2. Review of resident #8 ' s clinical record revealed a Record of Admission Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. Review of the Advance Directives Policy and Record for resident #8 revealed the following relevant information: It is the facility ' s policy to recognize and implement the resident ' s rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. 1. Decisions Concerning Medical Care and Valid Advance Directives. Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. 2. Invalid Advance Directives or No Advance Directive. If the resident has an invalid Advance Directive or no Advance Directive and the resident or the representative wishes to refuse, withhold, or withdraw life-sustaining medical treatment, such decision shall be made consistent with state law and in conjunction with the facility staff, management staff and the attending physician. Continued review of this document revealed it was initialed by a staff member and dated ,[DATE] indicating advanced directives has been discussed with the resident/representative and no written Advance Directives were in effect at that time. A review of the CPR (Cardiopulmonary Resuscitation) Consent form contained in resident #8 ' s clinical record revealed the box was checked to indicate " I do not wish to make a choice at this time. " The form was signed by the resident ' s spouse and dated [DATE]. Review of the admission physician order [REDACTED]. Continued review of the clinical record revealed the following nurses note entries were made by a registered nurse (RN) on [DATE]: 3:00 a.m. Resident alert and responsive with confusion. Resident with shortness of breath. Oxygen cannula in use but resident had turned the flow liter to zero. Oxygen turned to 2 liters via nasal cannula with pulse ox of 92% with nebulizer treatment. Will continue to monitor for shortness of breath or oxygen turned down again. Will continue to monitor. 7:30 a.m. Checked on resident and resident had no heart beat and no respirations. Confirmed in chart that resident was DNR (do not resuscitate) and doctor notified and daughter called with information on change in mother ' s status and that she had passed. Daughter to call resident ' s husband ... Family arrived and spent time with resident and husband chose a funeral home. The funeral home was notified and picked up the body at 6:00 a.m .... Review of the physician telephone orders revealed an order was written on [DATE] at 4:45 a.m. May release body to funeral home. Review of the resident ' s vital signs last recorded on the vital signs individual resident flow sheet dated [DATE] on the 11:00 p.m. - 7:00 a.m. shift revealed a temperature of 97.6, a pulse of 66, respirations of 12, and blood pressure of ,[DATE]. These vital signs were initialed by the same RN who documented the nurses notes of [DATE] and found the resident deceased . 3.Interview with the facility ' s Director of Nursing (DON) on [DATE] at approximately 8:35 a.m. revealed they had a long term RN that found resident #8 on [DATE] at about 4:30 a.m. with no pulse or respirations. The RN looked at the wrong paperwork in the chart and thought the resident had a do not resuscitate order (DNR) when in fact, she was a full code. The DON first became aware of the situation on [DATE] at about 7:30 a.m. when he reviewed the resident ' s medical record. Once the DON reviewed the chart, he called the RN on the telephone and asked her what paperwork she looked at because he wasn ' t seeing anything to indicate the resident was a DNR. The DON stated it is the procedure at this facility to check the physician's order [REDACTED]. Resident #8 ' s CPR consent form stated does not wish to make a decision at this time. The DON stated he did not know what the RN was thinking at the time she made the decision that the resident was a DNR. As a result of this incident, the RN was immediately suspended and then later terminated. A call was placed to the resident ' s physician/medical director, Abuse hotline, and the resident ' s spouse to report the incident. In addition, the facility filed a day one report to the Agency for Health Care Administration (AHCA) and began re-in servicing staff on the policy and procedure for Full Code and DNR. A chart audit was also completed for all current residents to make sure the information contained on advanced directives/code status was correct, in the proper section of the charts, and had the supporting documentation. In addition, a performance improvement plan was initiated to help prevent a similar occurrence. 4. Telephone interview with the resident ' s daughter on [DATE] at 11:35 a.m. revealed the news of her mother ' s death was a complete shock even though she was aware her mother had some underlying medical issues. The daughter stated apparently mom went into [MEDICAL CONDITION], there was no attempt to resuscitate her, and we had never signed a DNR. The daughter stated part of me is " really, really angry " and I don ' t know what to do from here. The daughter remembered the nurse calling her around 4 30 a.m. - 4:40 a.m. on [DATE]. The nurse said mom ' s status changed. She was having trouble breathing and the nurse had given her a breathing treatment and put oxygen on, but when they went back to check on her she had expired. The daughter stated they knew she was in distress and they did not call an ambulance or do anything. The daughter recalled arriving at the facility around 5:00 a.m. - 5:15 a.m. The daughter stated her mother was still warm but she assumed her brain had already died . The daughter stated the facility did not inform her that CPR had not been done. Prior to finding out this information, the plan had been to cremate her mother; however, they were now planning to perform an autopsy. The daughter stated the one nurse who was on duty that night was the only one she had trouble with. She stated " I knew if my mom was going to die it would be under that women ' s care. " 5. A review was made of the facility ' s policy and procedure, "Code Status Orders & Response," effective [DATE] and Revised [DATE]. This policy states the physician's order [REDACTED]. each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. " The procedures portion of this policy includes the following relevant information: 1. The Physician &/or Social Services/Clinical Team will discuss the resident/patient or authorized responsible party wishes regarding code Status as it relates the current clinical condition. This discussion will include an explanation of DNR and/or Full Code. 2. Obtain a written order signed by the Physician indicating the chosen code status. 3. Response a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, and pulse c. The respondent to the call for help will immediately overhead page a " code blue " and indicate the room number or the location of the resident and deliver the medical record and emergency cart and automated external defibrillator (AED) if applicable to the location of the code blue. d. If heartbeat, respirations, and pulse cannot be identified, promptly verify code status- Respondent verifies Code Status by review of the resident ' s medical record. e. If Code Status is " DNR " - DO NOT initiate CPR (Notify Physician, Supervisor, and Family) f. If Code Status includes CPR and respondent is CPR certified, BEGIN Cardio [MEDICAL CONDITION] Resuscitation *If respondent is not CPR certified, STAY with the resident - Continue to summon assistance *The first CPR certified responder will initiate CPR g. If code status is not designated, the resident is a FULL CODE & CPR will be initiated. h. A scribe will be designated to record activity related the the Code blue using the " Code Blue worksheet " provided on the Emergency Cart i. The Certified respondent will continue CPR until: Relieved by EMS, relieved by another CPR certified respondent, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. *EMS(911) *Physician *Family/Legal Representative 4. Document actions in the medical record using the " Code Blue " worksheet as a reference. 5. Review DNR orders monthly & with change in condition and renew by Physician ' s signature on monthly orders. 6.Telephone interview with the RN involved in the incident on [DATE] at 12:41 p.m. revealed she had checked on resident #8 at about 4:30 a.m. She found resident #8 had no pulse or respirations. She called out to the resident ' s certified nursing assistant, C.N.A., to stay with the resident so she could check the resident ' s chart. She reviewed the chart and looked at the wrong form. The form she looked at said CPR, DNR or I do not choose to make a decision at this time. She misread the form and saw it said DNR and had a check right below it. She did not realize at the time that the check mark indicated the resident/responsible party did not wish to make a decision at that time. The RN then went back to the room and told the C.N.A. to go ahead and prepare the body. She then returned to the nurses ' station and called the resident ' s daughter and physician. She told the resident ' s daughter she had checked on the resident around 3:30 a.m. and she was resting quietly, not having any problems. But at 4:30 a.m., she was gone. The RN said resident #8 had a little shortness of breath in the beginning of the shift and she administered a nebulizer treatment. The resident ' s pulse oximetry improved from 88 to 92. The RN said the resident felt better and wanted to get back in bed whereas prior to this she had wanted to sit up in the wheelchair. The RN put the resident to bed in an almost sitting position and then made sure she and the C.N.A. checked on her frequently. According to the RN, the C.N.A. had checked on the resident around 2:00 a.m. or 2:30 a.m. and she was resting quietly. The RN then checked on the resident around 3:30 a.m. -3:45 a.m. and again, she was resting quietly. The resident ' s daughter asked if they (meaning her and the resident ' s spouse) could come see the patient and the RN said yes. The RN then asked another C.N.A. to assist the resident ' s C.N.A. with preparing the body so they would be completely finished before the family arrived. The RN stated she had also called the resident ' s doctor and told him resident #8 had died . She had no pulse or respirations. The RN stated she was sure she told the doctor that the resident was a DNR. She recalled the physician commented back to her " okay. " The doctor gave orders to release the body. Continued interview with the RN revealed she had received training in [DATE] on the facility ' s new CPR/DNR policy. Prior to [DATE] they had color coded bracelets to tell a resident ' s DNR status. In addition, outside of the resident ' s room, they had stickers to identify the residents ' code status. The facility ' s new policy was to check the chart. She did go to the chart on the day of the incident but looked at the wrong paper. She did not look at the resident ' s physician's order [REDACTED]. She did not even realize she had looked at the wrong form and that the resident was a full code until the DON called her the morning of the incident. This was the first code she had since the system had changed. She made a mistake. 7.Telephone interview with the resident ' s physician/facility medical director on [DATE] at 1:12 p.m. revealed he did not remember the resident very well, and he was not the on-call doctor on [DATE], the day resident #8 had expired. This physician did however state he had completed the death certificate with a [DIAGNOSES REDACTED]. He had been notified by the facility, after the incident occurred that the resident was not a DNR. Normally, the facility staff would begin CPR until 911 arrives on a resident who was a full code; however, in this case they made an error when reading the chart. 8.Telephone interview on [DATE] at 2:41 p.m. with the physician who was on call on [DATE] revealed he had been informed on [DATE] that resident #8 had expired. His response to the nurse that morning was to release the body to the funeral home the family had chosen and send the drugs back to the pharmacy. He could not recall if the nurse told him the resident ' s code status. 9. Review of the personnel file for the RN involved in the incident involving resident #8 on [DATE] revealed a Position Description for RN Supervisor, dated and signed by the RN on [DATE]. This job description revealed the following relevant information: I. Summary of position: Under the supervision of DON, a RN Supervisor assumes responsibility and accountability for a group of residents for a shift of duty. Nursing care is provided through assessment, implementations, and evaluation of the plan of care. The RN adheres to the standards of care for the area, manages the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by nursing assistants and helpers. Follows all company policies and procedures. Performs duties as defined by the State Nurse Practice Act. A. Essential Functions 7. Provides the following nursing functions: a. Responsible for resident/patient care during his/her respective shift. b. Provides required patient assessments and interventions e. Takes and records blood pressure and vital signs. l. Prepares and administers medications and performs treatments as ordered by the physician. m. Provides resident/patient care as needed. n. Charts nurses notes in an informative and descriptive manner that reflects the care provided as well as the resident ' s response to the care. o. Documents all pertinent data as required by Medicare, Medicaid and the company ' s standards and policies. q. Informs physician of resident/patient change of condition 14. Complies with laws and regulations applicable to position and acts in accordance with the company ' s Corporate Compliance Program. 20. Safety a. Knows and follows facility rules. 21. Resident Rights a. Knows Resident Rights. Help the residents/patients exercise and/or protect their rights. III. Knowledge, skills, and abilities: E. Must have current CPR 10. Subsequent interview with the DON on [DATE] at 10:32 a.m. revealed the facility ' s investigation of the incident revealed not all nurses in the facility are CPR certified. The DON stated there was always at least one CPR certified nurse or C.N.A. present on each shift at all times. The facility conducted an audit of the personnel files with a focus on the nurses for documentation of CPR certification as a result of the [DATE] incident. The DON stated we are lacking on this. The RN who found resident #8 on [DATE] did not have current CPR certification. 11. Review of the CPR certification audit for nurses on [DATE] at 2:05 p.m. with the DON revealed only 3 of 28 regularly scheduled nurses were found to have documentation of current CPR certification in their employee files. As a result of this information, all nurses were contacted on [DATE] to bring in their current CPR certification card or to come in to the facility and take an on-line CPR certification course if their certification had expired. 12. Interview and record review of in-service records and CPR certifications with the DON and regional vice president of the corporation on [DATE] at approximately 1:30 p.m. revealed the facility has 28 regularly scheduled nurses. Twenty-seven of the nurses were re-in serviced on the policy and procedure for Code Status Orders & Response between [DATE] and [DATE]. The final nurse was re-in serviced on [DATE]. At the time of the incident the facility only had 3 out of 28 regularly scheduled nurses CPR certification on file. On [DATE], fifteen additional nurses brought their current CPR certification cards in for their files. Eight nurses completed an on-line CPR certification course on [DATE], and the remaining 2 regularly scheduled nurses completed the on-line course on [DATE] with the last one being completed at 2:00 p.m. Random interviews were conducted with 10 nurses on [DATE] to determine if they would act appropriately in the event a resident was found unresponsive without pulse or respirations. All 10 answered questions appropriately in accordance with the facility ' s policy and procedure. The facility also initiated a performance improvement plan for the continued in-servicing and education of staff to include code blue drills, continued audits of resident ' s advanced directives, and a system for monitoring the CPR certification of licensed nurses. On [DATE] at approximately 1:45 p.m., the facility had a " code blue " during this complaint investigation. Observation of the staff ' s response to this code alert and a review of this resident ' s clinical record revealed the facility acted swiftly and in accordance with their policy and procedure. On [DATE] at approximately 11:45 a.m., the facility started a new performance improvement plan to make it easier for staff to identify a resident who is a DNR. Prior to this [DATE] plan nurses were to check the physician's order [REDACTED]. Review of the [DATE] performance improvement plan indicated staff will be re-educated to check the Advanced Directive Tab for a yellow DNR form. Because the code status information is still contained under the physician order [REDACTED].

Based on interview with facility staff and a family member, and review of the resident ' s medical record, facility policy, and an employee disciplinary action report, it was determined that the facility failed to ensure that needed services for resuscitation were initiated for one (#8) of 54 residents identified as full code, according to the resident code status audit tool of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation (CPR) when the resident was found with no heartbeat and no respirations. The facility did not implement their policy and procedure, Code Status Orders & Response effective [DATE] and Revised [DATE], as staff did not begin the administration of CPR and did not call 911 for medical aide. The facility did not honor the expressed wishes of the resident and her family. Failure of the facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy which was removed on [DATE] at 2:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. Interview with the facility ' s Director of Nursing (DON) on [DATE] at approximately 8:35 a.m. revealed they had a long term registered nurse (RN) that found resident #8 on [DATE] at about 4:30 a.m. with no pulse or respirations. The RN looked at the wrong paperwork in the chart and thought the resident had a do not resuscitate order (DNR) when in fact, she was a full code. The DON first became aware of the situation on [DATE] at about 7:30 a.m. when he reviewed the resident ' s medical record, as he does on all residents who pass away or discharge from the facility. Once the DON reviewed the chart, he called the RN on the telephone and asked her what paperwork she looked at because he wasn ' t seeing anything to indicate the resident was a DNR. The DON stated it is the procedure at this facility to check the physician's order [REDACTED]. This form was completed at the time of admission. Resident #8 ' s CPR consent form stated does not wish to make a decision at this time. The DON stated he did not know what the RN was thinking at the time she made the decision that the resident was a DNR. As a result of this incident, the RN was immediately suspended and then later terminated. A call was placed to the resident ' s physician/medical director, Abuse hotline, and the resident ' s spouse to report the incident. In addition, the facility filed a day one report to the Agency for Health Care Administration (AHCA). The facility began re-in servicing staff on the day of the incident and continued in-services throughout the weekend on the policy and procedure for Full Code and DNR. A chart audit was also completed for all current residents to make sure the information contained on advanced directives/code status was correct, in the proper section of the charts, and had the supporting documentation. In addition, a performance improvement plan was initiated to help prevent a similar occurrence. 2. Telephone interview with the RN involved in the incident on [DATE] at 12:41 p.m. revealed she had been in the room across from resident #8 changing a dressing around 4:30 a.m. After she came out of that room she went to check on resident #8. She found resident #8 had no pulse or respirations. She called out to the resident ' s certified nursing assistant, C.N.A., to stay with the resident so she could check the resident ' s chart. She reviewed the chart and looked at the wrong form. The form she looked at says CPR, DNR or I do not choose to make a decision at this time. She misread the form and saw it said DNR and had a check right below it. She did not realize at the time that the check mark indicated the resident/responsible party did not wish to make a decision at that time, she read the form as a DNR. The RN then went back to the room and told the C.N.A. to go ahead and prepare the body. She then returned to the nurses ' station and called the resident ' s daughter and physician. She told the resident ' s daughter she had checked on the resident around 3:30 a.m. and she was resting quietly, not having any problems. But at 4:30 a.m., she was gone. The RN said resident #8 had a little shortness of breath in the beginning of the shift and she administered a nebulizer treatment. The resident ' s pulse oximetry improved from 88 to 92. The RN said the resident felt better and wanted to get back in bed whereas prior to this she had wanted to sit up in the wheelchair. The RN put the resident to bed in an almost sitting position and then made sure she and the C.N.A. checked on her frequently. According to the RN, the C.N.A. had checked on the resident around 2:00 a.m. or 2:30 a.m. and she was resting quietly. The RN then checked on the resident around 3:30 a.m. -3:45 a.m. and again, she was resting quietly. The resident ' s daughter asked if they (meaning her and the resident ' s spouse) could come see the patient and the RN said yes. The RN then asked another C.N.A. to assist the resident ' s C.N.A. with preparing the body so they would be completely finished before the family arrived. The RN stated she had also called the resident ' s doctor and told him resident #8 had died . She had no pulse or respirations. The RN stated she was sure she told the doctor that the resident was a DNR. She recalled the physician commented back to her " okay. " The doctor gave orders to release the body. Continued interview with the RN revealed she had received training in [DATE] on the facility ' s new CPR/DNR policy. Prior to [DATE] they had color coded bracelets to tell a resident ' s DNR status. In addition, outside of the resident ' s room, they had stickers. The new policy was to check the chart. She did go to the chart on the day of the incident but looked at the wrong paper. She did not look at the resident ' s physician's order [REDACTED]. She did not even realize she had looked at the wrong form and that the resident was a full code until the DON called her the morning of the incident. This was the first code she had since the system had changed. She made a mistake. 3. Telephone interview with the resident ' s physician/facility medical director on [DATE] at 1:12 p.m. revealed he did not remember the resident very well. He could not recall the nurse calling him on [DATE] and stated he is one of six doctors ' on-call once a week. He then checked the on-call schedule for [DATE] and informed the surveyor a different doctor had been on-call that day. This physician/medical director stated he did complete the death certificate with a [DIAGNOSES REDACTED]. He had been notified by the facility after the fact that the resident was not a DNR. Normally, the facility staff would begin CPR until 911 arrives, however, in this case they made an error when reading the chart. 4. Telephone interview on [DATE] at 2:41 p.m. with the physician who was on call on [DATE] revealed he had been informed on [DATE] that resident #8 had expired. His response to the nurse that morning was to release the body to the funeral home the family had chosen and send the drugs back to the pharmacy. He could not recall if the nurse told him the resident ' s code status. 5. Telephone interview with the resident ' s daughter on [DATE] at 11:35 a.m. revealed the news of her mother ' s death was a complete shock even though she was aware her mother had some underlying medical issues. The daughter stated apparently mom went into [MEDICAL CONDITION], there was no attempt to resuscitate her, and we had never signed a DNR. The daughter stated part of me is " really, really angry " and I don ' t know what to do from here. The daughter remembered the nurse calling her around 4 30 a.m. - 4:40 a.m. on [DATE]. She said mom ' s status changed; she was having trouble breathing and she had given her a breathing treatment and put oxygen on but when they went back to check on her, she had expired. The daughter stated they knew she was in distress and they did not call an ambulance or do anything. The daughter recalled arriving at the facility around 5:00 a.m. - 5:15 a.m. and found her mother was still warm but assumed her brain had already died . The daughter stated the facility did not inform her that CPR had not been done. Prior to finding out this information, the plan had been to cremate her mother; however, they were now planning to perform an autopsy. The daughter stated the one nurse who was on duty that night was the only one she had trouble with. She stated " I knew if my mom was going to die it would be under that women ' s care. " 6. Review of the resident ' s clinical record revealed a Record of Admission Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. A review of the CPR (Cardiopulmonary Resuscitation) Consent revealed the box which was checked stated " I do not wish to make a choice at this time. " The form was signed by the resident ' s spouse and dated [DATE]. Review of the admission physician order [REDACTED]. Review of the October POS also revealed a code status of full resuscitate. Continued review of the clinical record revealed the following nurses note entries on [DATE]: 3:00 a.m. Resident alert and responsive with confusion. Resident with shortness of breath. Oxygen cannula in use but resident had turned the flow liter to zero. Oxygen turned to 2 liters via nasal cannula with pulse ox of 92% with nebulizer treatment. Will continue to monitor for shortness of breath or oxygen turned down again. Will continue to monitor. 7:30 a.m. Checked on resident and resident had no heart beat and no respirations. Confirmed in chart that resident was DNR and doctor notified and daughter called with information on change in mother ' s status and that she had passed. Daughter to call resident ' s husband ... Family arrived and spent time with resident and husband chose a funeral home. The funeral home was notified and picked up the body at 6:00 a.m. Golden colored ring removed and placed in bag with eyeglasses which daughter picked up at 7:15 a.m. along with personal belongings. Dentures sent with resident in her mouth. Family thanked everyone for the care her mother had received while in facility. Review of the physician telephone orders revealed an order was written on [DATE] at 4:45 a.m. May release body to funeral home. Review of the resident ' s vital signs last recorded on the vital signs individual resident flow sheet dated [DATE] on the 11:00 p.m. - 7:00 a.m. shift revealed a temperature of 97.6, a pulse of 66, respirations of 12, and blood pressure of ,[DATE]. These vital signs were initialed by the RN involved in the incident involving resident #8 on [DATE]. 7. A review was made of the facility ' s policy and procedure, " Code Status Orders & Response " effective [DATE] and Revised [DATE]. This policy states the physician's order [REDACTED]. each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. " The procedures portion of this policy includes the following relevant information: 1. The Physician &/or Social Services/Clinical Team will discuss the resident/patient or authorized responsible party wishes regarding code Status as it relates the current clinical condition. This discussion will include an explanation of DNR and/or Full Code. 2. Obtain a written order signed by the Physician indicating the chosen code status. 3. Response a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, and pulse c. The respondent to the call for help will immediately overhead page a " code blue " and indicate the room number or the location of the resident and deliver the medical record and emergency cart and automated external defibrillator (AED) if applicable to the location of the code blue. d. If heartbeat, respirations, and pulse cannot be identified, promptly verify code status- Respondent verifies Code Status by review of the resident ' s medical record. e. If Code Status is " DNR " - DO NOT initiate CPR (Notify Physician, Supervisor, and Family) f. If Code Status includes CPR and respondent is CPR certified, BEGIN Cardio [MEDICAL CONDITION] Resuscitation *If respondent is not CPR certified, STAY with the resident - Continue to summon assistance *The first CPR certified responder will initiate CPR g. If code status is not designated, the resident is a FULL CODE & CPR will be initiated. h. A scribe will be designated to record activity related the the Code blue using the " Code Blue worksheet " provided on the Emergency Cart i. The Certified respondent will continue CPR until: Relieved by EMS, relieved by another CPR certified respondent, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. *EMS(911) *Physician *Family/Legal Representative 4. Document actions in the medical record using the " Code Blue " worksheet as a reference. 5. Review DNR orders monthly & with change in condition and renew by Physician ' s signature on monthly orders. 8. .Subsequent interview with the DON on [DATE] at 10:32 a.m. revealed not all nurses in the facility are CPR certified. The DON stated there was always at least one CPR certified nurse or C.N.A. present on each shift. The facility conducted an audit of the personnel files for documentation of CPR certification as a result of the [DATE] incident. The DON stated we are lacking on this. The RN who found resident #8 on [DATE] did not have current CPR certification. 9. Review of the CPR certification audit for nurses on [DATE] at 2:05 p.m. with the DON revealed only 3 of 28 regularly scheduled nurses were found to have documentation of current CPR certification in their employee files. As a result of this information, all nurses have been contacted to bring in their current CPR certification card or to come in to the facility and take an on-line CPR certification course if their certification had expired. 10. Review of an undated Licensed Practical Nurse (LPN) and an undated Registered Nurse (RN) job description revealed both stated, " Must have a current CPR certification. " In addition, review of the personnel file for the RN involved in the incident involving resident #8 on [DATE] revealed a Position Description for RN Supervisor, dated and signed by the RN on [DATE]. This job description revealed the following relevant information: I. Summary of position: Under the supervision of DON, a RN Supervisor assumes responsibility and accountability for a group of residents for a shift of duty. Nursing care is provided through assessment, implementations, and evaluation of the plan of care. The RN adheres to the standards of care for the area, manages the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by nursing assistants and helpers. Follows all company policies and procedures. Performs duties as defined by the State Nurse Practice Act. A. Essential Functions 7. Provides the following nursing functions: a. Responsible for resident/patient care during his/her respective shift. b. Provides required patient assessments and interventions e. Takes and records blood pressure and vital signs. l. Prepares and administers medications and performs treatments as ordered by the physician. m. Provides resident/patient care as needed. n. Charts nurses notes in an informative and descriptive manner that reflects the care provided as well as the resident ' s response to the care. o. Documents all pertinent data as required by Medicare, Medicaid and the company ' s standards and policies. q. Informs physician of resident/patient change of condition 14. Complies with laws and regulations applicable to position and acts in accordance with the company ' s Corporate Compliance Program. 20. Safety a. Knows and follows facility rules. 21. Resident Rights a. Knows Resident Rights. Help the residents/patients exercise and/or protect their rights. III. Knowledge, skills, and abilities: E. Must have current CPR 11. Interview and record review of in-service records and CPR certifications with the DON and regional vice president of the corporation on [DATE] at approximately 1:30 p.m. revealed the facility has 28 regularly scheduled nurses. Twenty-seven of the nurses were re-in serviced on the policy and procedure for Code Status Orders & Response between [DATE] and [DATE]. The final nurse was re-in serviced on [DATE]. At the time of the incident the facility only had 3 out of 28 regularly scheduled nurses CPR certification on file. On [DATE], fifteen additional nurses brought their current CPR certification cards in for their files. Eight nurses completed an on-line CPR certification course on [DATE], and the remaining 2 regularly scheduled nurses completed the on-line course on [DATE] with the last one being completed at 2:00 p.m. Random interviews were conducted with 10 nurses on [DATE] to determine if they would act appropriately in the event a resident was found unresponsive without pulse or respirations. All 10 answered questions appropriately in accordance with the facility ' s policy and procedure. The facility also initiated a performance improvement plan for the continued in-servicing and education of staff to include code blue drills, continued audits of resident ' s advanced directives, and a system for monitoring the CPR certification of licensed nurses. On [DATE] at approximately 1:45 p.m., the facility had a " code blue " during this complaint investigation. Observation of the staff ' s response to this code alert and a review of this resident ' s clinical record revealed the facility acted swiftly and in accordance with their policy and procedure. On [DATE] at approximately 11:45 a.m., the facility started a new performance improvement plan to make it easier for staff to identify a resident who is a DNR. Prior to this [DATE] plan nurses were to check the physician's order [REDACTED]. Review of the [DATE] performance improvement plan indicated staff will be re-educated to check the Advanced Directive Tab for a yellow DNR form. Because the code status information is still contained under the physician order [REDACTED].

Based on interview with facility staff and a family member, and review of the resident ' s medical record and facility policy, it was determined that the facility failed to protect the rights for one (#8) of 54 residents with a Full Code status, according to the resident code status audit tool of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation when the resident was found unresponsive, with no respirations and heartbeat. The facility staff did not begin the administration of CPR and did not call 911 for medical aide in accordance with their policy and procedure (Code Status Orders & Response effective [DATE] and Revised [DATE]). The facility did not honor the advanced directives expressed by the resident and her spouse. Failure of the facility staff to correctly implement advance directives resulted in findings of immediate jeopardy which was removed on [DATE] at 2:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of resident #8 ' s clinical record revealed a Record of Admission Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. Review of the Advance Directives Policy and Record for resident #8 revealed the following relevant information: It is the facility ' s policy to recognize and implement the resident ' s rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. 1. Decisions Concerning Medical Care and Valid Advance Directives. Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. 2. Invalid Advance Directives or No Advance Directive. If the resident has an invalid Advance Directive or no Advance Directive and the resident or the representative wishes to refuse, withhold, or withdraw life-sustaining medical treatment, such decision shall be made consistent with state law and in conjunction with the facility staff, management staff and the attending physician. Continued review of this document revealed it was initialed by a staff member and dated ,[DATE] indicating advanced directives has been discussed with the resident/representative and no written Advance Directives are in effect at this time. A review of the CPR (Cardiopulmonary Resuscitation) Consent form contained in resident #8 ' s clinical record revealed the box was checked to indicate " I do not wish to make a choice at this time. " The form was signed by the resident ' s spouse and dated [DATE]. Review of the admission physician order [REDACTED]. Continued review of the clinical record revealed the following nurses note entries were made by a registered nurse (RN) on [DATE]: 3:00 a.m. Resident alert and responsive with confusion. Resident with shortness of breath. Oxygen cannula in use but resident had turned the flow liter to zero. Oxygen turned to 2 liters via nasal cannula with pulse ox of 92% with nebulizer treatment. Will continue to monitor for shortness of breath or oxygen turned down again. Will continue to monitor. 7:30 a.m. Checked on resident and resident had no heart beat and no respirations. Confirmed in chart that resident was DNR (do not resuscitate) and doctor notified and daughter called with information on change in mother ' s status and that she had passed. Daughter to call resident ' s husband ... Family arrived and spent time with resident and husband chose a funeral home. The funeral home was notified and picked up the body at 6:00 a.m. Golden colored ring removed and placed in bag with eyeglasses which daughter picked up at 7:15 a.m. along with personal belongings. Dentures sent with resident in her mouth. Family thanked everyone for the care her mother had received while in facility. Review of the physician telephone orders revealed an order was written on [DATE] at 4:45 a.m. May release body to funeral home. Review of the resident ' s vital signs last recorded on the vital signs individual resident flow sheet dated [DATE] on the 11:00 p.m. - 7:00 a.m. shift revealed a temperature of 97.6, a pulse of 66, respirations of 12, and blood pressure of ,[DATE]. These vital signs were initialed by the same RN who documented the nurses notes of [DATE]. 2. Telephone interview with the resident ' s daughter on [DATE] at 11:35 a.m. revealed the news of her mother ' s death was a complete shock even though she was aware her mother had some underlying medical issues. The daughter stated apparently mom went into [MEDICAL CONDITION], there was no attempt to resuscitate her, and we had never signed a DNR. The daughter stated part of me is " really, really angry " and I don ' t know what to do from here. The daughter remembered the nurse calling her around 4 30 a.m. - 4:40 a.m. on [DATE]. She said mom ' s status changed; she was having trouble breathing and she had given her a breathing treatment and put oxygen on but when they went back to check on her, she had expired. The daughter stated they knew she was in distress and they did not call an ambulance or do anything. The daughter recalled arriving at the facility around 5:00 a.m. - 5:15 a.m. and found her mother was still warm but assumed her brain had already died . The daughter stated the facility did not inform her that CPR had not been done. Prior to finding out this information, the plan had been to cremate her mother; however, they were now planning to perform an autopsy. The daughter stated the one nurse who was on duty that night was the only one she had trouble with. She stated " I knew if my mom was going to die it would be under that women ' s care. " 3. Interview with the facility ' s Director of Nursing (DON) on [DATE] at approximately 8:35 a.m. revealed they had a long term registered nurse (RN) that found resident #8 on [DATE] at about 4:30 a.m. with no pulse or respirations. The RN looked at the wrong paperwork in the chart and thought the resident had a do not resuscitate order (DNR) when in fact, she was a full code. The DON first became aware of the situation on [DATE] at about 7:30 a.m. when he reviewed the resident ' s medical record. Once the DON reviewed the chart, he called the RN on the telephone and asked her what paperwork she looked at because he wasn ' t seeing anything to indicate the resident was a DNR. The DON stated it is the procedure at this facility to check the physician's order [REDACTED]. This form was completed at the time of admission. Resident #8 ' s CPR consent form stated does not wish to make a decision at this time. The DON stated he did not know what the RN was thinking at the time she made the decision that the resident was a DNR. As a result of this incident, the RN was immediately suspended and then later terminated. The facility notified the appropriate parties of the incident and filed the necessary reports. Re-in servicing of licensed nurses on the policy and procedure for DNR/Full code was initiated, a chart audit was completed, and a performance improvement plan was initiated to help prevent further re-occurrence. 4. A review was made of the facility ' s policy and procedure, " Code Status Orders & Response " effective [DATE] and Revised [DATE]. This policy states the physician's order [REDACTED]. each resident will have the elected code status documented in their medical record within the physician's order [REDACTED]. " The procedures portion of this policy included the following relevant information: 1. The Physician &/or Social Services/Clinical Team will discuss the resident/patient or authorized responsible party wishes regarding code Status as it relates the current clinical condition. This discussion will include an explanation of DNR and/or Full Code. 2. Obtain a written order signed by the Physician indicating the chosen code status. 3. Response a. Upon finding a resident/patient unresponsive, call for help. b. Evaluate for heartbeat, respirations, and pulse c. The respondent to the call for help will immediately overhead page a " code blue " and indicate the room number or the location of the resident and deliver the medical record and emergency cart and automated external defibrillator (AED) if applicable to the location of the code blue. d. If heartbeat, respirations, and pulse cannot be identified, promptly verify code status- Respondent verifies Code Status by review of the resident ' s medical record. e. If Code Status is " DNR " - DO NOT initiate CPR (Notify Physician, Supervisor, and Family) f. If Code Status includes CPR and respondent is CPR certified, BEGIN Cardio [MEDICAL CONDITION] Resuscitation *If respondent is not CPR certified, STAY with the resident - Continue to summon assistance *The first CPR certified responder will initiate CPR g. If code status is not designated, the resident is a FULL CODE & CPR will be initiated. h. A scribe will be designated to record activity related the the Code blue using the " Code Blue worksheet " provided on the Emergency Cart i. The Certified respondent will continue CPR until: Relieved by EMS, relieved by another CPR certified respondent, &/or Physician orders [REDACTED]. j. A staff member will be designated to notify the following person(s) upon initiation of CPR. *EMS(911) *Physician *Family/Legal Representative 4. Document actions in the medical record using the " Code Blue " worksheet as a reference. 5. Review DNR orders monthly & with change in condition and renew by Physician ' s signature on monthly orders. 5. Telephone interview with the RN involved in the incident on [DATE] at 12:41 p.m. revealed she checked on resident #8 around 4:30 a.m. on [DATE]. At that time, she found resident #8 had no pulse or respirations. She called out to the resident ' s certified nursing assistant, C.N.A., to stay with the resident so she could check the resident ' s chart. She reviewed the chart and looked at the wrong form. The form she looked at says CPR, DNR or I do not choose to make a decision at this time. She misread the form as a DNR and did not realize at the time that it had been marked to indicate the resident/responsible party did not wish to make a decision at that time on CPR. The RN returned to resident #8 after reviewing the record and told the C.N.A. to prepare the body. The RN then returned to the nurses ' station and called the resident ' s daughter and physician. The RN recalled telling the daughter she had checked on the resident around 3:30 a.m. and she was resting quietly, not having any problems. But at 4:30 a.m., she was gone. The RN said resident #8 had a little shortness of breath in the beginning of the shift and she administered a nebulizer treatment to the resident. The resident ' s pulse oximetry improved from 88 to 92. The RN said the resident felt better and wanted to get back in bed whereas prior to this she wanted to sit in the wheelchair. The RN put the resident to bed in an almost sitting position and then made sure she and the C.N.A. checked on her frequently. According to the RN, the C.N.A. had checked on the resident around 2:00 a.m. or 2:30 a.m. and she was resting quietly. The RN then checked on the resident around 3:30 a.m. -3:45 a.m. and again, she was resting quietly. The resident ' s daughter asked if they (meaning her and the resident ' s spouse) could come see the patient and the RN said yes. The RN then asked another C.N.A. to assist with preparing the body so they would be completely finished before the family arrived. The RN stated she had also called the resident ' s doctor and told him resident #8 had died . She recalled telling the physician the resident had no pulse or respirations. The RN stated she was sure she told the doctor that the resident was a DNR. She remembered the physician commented back to her " okay " and orders were given to release the body. Continued interview with the RN revealed she had received training in [DATE] on the facility ' s new CPR/DNR policy. Prior to [DATE] they had color coded bracelets to tell a resident ' s DNR status. In addition, outside of the resident ' s room, they had stickers. The new policy was to check the chart. She did go to the chart on the day of the incident but looked at the wrong paper. She did not look at the resident ' s physician's order [REDACTED]. She did not even realize she had looked at the wrong form and that the resident was a full code until the DON called her the morning of the incident. This was the first code she had since the system had changed. She made a mistake. 6. Telephone interview with the resident ' s physician/facility medical director on [DATE] at 1:12 p.m. revealed he did not remember the resident very well. This physician was not the on-call doctor the morning of [DATE] when resident #8 expired, however, he did remember completing the death certificate with a [DIAGNOSES REDACTED]. He had been notified by the facility that resident #8 was not a DNR and had made an error on [DATE] when reading the chart. Normally on a full code, the facility staff would begin CPR until 911 arrives. 7. Telephone interview on [DATE] at 2:41 p.m. with the physician who was on call on [DATE] revealed he had been informed that resident #8 had expired. His response to the nurse that morning was to release the body to the funeral home the family had chosen and send the drugs back to the pharmacy. He could not recall if the nurse told him the resident ' s code status. 8. Interview and record review of in-service records and CPR certifications with the DON and regional vice president of the corporation on [DATE] at approximately 1:30 p.m. revealed the facility has 28 regularly scheduled nurses. Twenty-seven of the nurses were re-in serviced on the policy and procedure for Code Status Orders & Response between [DATE] and [DATE]. The final nurse was re-in serviced on [DATE]. At the time of the incident the facility only had 3 out of 28 regularly scheduled nurses CPR certification on file. On [DATE], fifteen additional nurses brought their current CPR certification cards in for their files. Eight nurses completed an on-line CPR certification course on [DATE], and the remaining 2 regularly scheduled nurses completed the on-line course on [DATE] with the last one being completed at 2:00 p.m. Random interviews were conducted with 10 nurses on [DATE] to determine if they would act appropriately in the event a resident was found unresponsive without pulse or respirations. All 10 answered questions appropriately in accordance with the facility ' s policy and procedure. The facility also initiated a performance improvement plan for the continued in-servicing and education of staff to include code blue drills, continued audits of resident ' s advanced directives, and a system for monitoring the CPR certification of licensed nurses. On [DATE] at approximately 1:45 p.m., the facility had a " code blue " during this complaint investigation. Observation of the staff ' s response to this code alert and a review of this resident ' s clinical record revealed the facility acted swiftly and in accordance with their policy and procedure. On [DATE] at approximately 11:45 a.m., the facility started a new performance improvement plan to make it easier for staff to identify a resident who is a DNR. Prior to this [DATE] plan nurses were to check the physician's order [REDACTED]. Review of the [DATE] performance improvement plan indicated staff will be re-educated to check the Advanced Directive Tab for a yellow DNR form. Because the code status information is still contained under the physician order [REDACTED].