Every finding on record at Coquina Center

Based on observations, interviews and record review, the facility failed to ensure that three (Residents #1, #8 and #20) of three residents reviewed for dignity were able to exercise their right to dignity. Staff referred to Residents #1 and #8 as feeders, and were observed standing over Residents #1, #8 and #20 while assisting them with their meals. The findings include:1.On 2/23/26 at 12:10 PM, Certified Nursing Assistant (CNA) I was observed in Resident #1's room assisting her with her lunch meal. Resident #1 was lying in bed while CNA I stood over her feeding her food from her lunch tray. This observation lasted five minutes. During an interview with CNA I at the time of the observation, she was asked if Resident #1 normally required assistance with her meal. CNA I stated the resident was a feeder but that she did not usually feed the residents and was not sure if the resident normally required assistance.On 2/25/26 at 12:00 PM, CNA F was observed in Resident #1's room assisting her with her lunch meal. Resident #1 was lying in bed while CNA F stood over her feeding her food from her lunch tray. This observation lasted 5 minutes. During an interview with CNA F at the time of the observation, she was asked if she received training related to assisting residents with their meals. She stated she received annual training in this area. She further stated she stood when feeding a resident in their room at bedside, and she sat when feeding residents in the dining room.A review of Resident #1's medical record revealed a quarterly Minimum Data Set (MDS) assessment conducted on 12/26/25 with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. The resident's medical diagnoses included dementia and anorexia. 2.On 2/24/26 at 10:05 AM during an interview with Licensed Practical Nurse (LPN) H, she stated she had removed Resident #8's breakfast tray from her room. She was asked if the resident had eaten any of her breakfast. She replied, yes, the CNA told her the resident ate a few bites of her breakfast and drank some juice. She was asked if the resident required assistance with eating her meals. She replied, Yes, she is an assisted feeder.A record review for Resident #8 revealed a quarterly MDS assessment dated [DATE] with a BIMS score of 5 out of 15 possible points, indicating severe cognitive impairment. The resident's diagnoses included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). 3. On 2/24/26 at 1:15 PM, CNA G was observed in Resident #20's room assisting her with her lunch meal. Resident #20 was lying in bed while CNA G stood over her feeding her food from her lunch tray. This observation lasted seven minutes.

Based on record review and interviews, the facility failed to review the accuracy and completion of the Preadmission Screening and Resident Review (PASRR) forms for two (Residents #70 and #44) of two residents reviewed for PASRR completion. Failure to ensure the accuracy/completion of the residents' PASRRs placed the residents at risk for not receiving needed services.The findings include:1.A review of Resident #70's medical record revealed an admission date of 7/29/24 with diagnoses including brief psychotic disorder, major depressive disorder (MDD) - recurrent, insomnia, and signs/symptoms involving cognitive functions and awareness. An active physician's order dated 1/7/25 revealed Escitalopram Oxalate (antidepressant) Tablet 10 mg (milligrams) - Give 1 tablet by mouth one time a day related to major depressive disorder.A review of the active care plan (revised 11/12/25) revealed that the resident was at risk and/or had actual impaired cognitive function/impaired thought processes related to a diagnosis of brief psychotic disorder, unspecified signs and symptoms involving cognitive function and awareness, and a Brief Interview for Mental Status (BIMS) score of 00 out of 15 possible points, indicating severe cognitive impairment.A review of a psychiatric progress note dated 2/20/26 revealed that the reason for referral/chief complaint was follow up for mood, anxiety, adjustment and psychotic symptoms. The resident's psychiatric history was noted as MDD, dementia, mood disorder, psychosis and insomnia.A review of the resident's PASRR Level I, dated 7/23/24 section 1, revealed that the PASRR screening decision making was not completed. 2.A review if Resident #44's medical record revealed an admission date of 3/13/25 and diagnoses including encephalopathy, mental disorder, delusional disorders, dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, brief psychotic disorder, anxiety disorder, major depressive disorder - recurrent, moderate adjustment disorder with mixed anxiety and depressed mood.A review of the active care plan (revised 7/3/25), revealed that the resident had a history of exhibiting the following behaviors: History of non-compliance with smoking policy, non-compliance with medical care, refuses medications, history of calling 911, verbally aggressive/yelling out at staff. Hoarding cups. The care plan further noted that the resident was at risk and/or had actual impaired cognitive function/impaired thought processes related to acute encephalopathy, dementia, altered mental status (AMS), confusion, delusions, cerebral ischemia, parenchymal volume loss, memory and cognitive deficits, unspecified psychiatric disorder, adjustment disorder with mixed anxiety and depressed mood. A review of the resident's PASRR Level 1, dated 2/18/26 - Section 1, revealed that the PASRR screening decision making was not completed.Section II: Other indications for PASRR screen decision making.Question #2. Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis?Interpersonal functioning: The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been dismissed from employment. This was answered Yes.Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption was noted as not a provisional Admission. Therefore, Level II PASRR should have been completed.In an interview with the Minimum Data Set (MDS) Coordinator on 2/25/26 at 2:34 PM, she stated the Social Services Director (SSD) and she reviewed PASRRs for new admissions during the clinical meetings. If any discrepancy was noted, the Admissions Department requested a new PASRR from the discharging facility or they completed a new PASRR at the facility. The MDS Coordinator stated current residents were reviewed quarterly for any new diagnoses to ensure that a new PASRR was not required. When she was asked to review Residents #70 and #44' PASRRs, she confirmed that the PASRRs were incomplete. She stated she would check the medical record for any additional copies. She said, I'm sure we reviewed them. During a follow-up interview with the MDS Coordinator on 2/26/26 at 1:25 PM, she confirmed that the PASRRs for Residents #70 and #44 were incomplete and there were no additional PASRRs found in medical records. She added that she was conducting a whole house audit of all residents' PASRRs for accuracy.

Based on interviews and record review, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one (Resident #128) of two residents reviewed for transfer/discharge. The findings include: A record review for Resident #128 revealed that the resident had been emergently transferred on 1/8/26. A nursing note dated 1/9/26 at 7:30 AM revealed: Upon coming onto my shift at 11pm, I received in report from the 3-11 nurse that (Resident #128's physician) had come to the facility and initiated customer to being (emergently transferred) related to aggressive behaviors toward staff. Police officer was already on site and EVAC (emergency medical transportation) arrived at approx 11:10 in which I helped assist the medics transfer resident onto the stretcher. Per police officer, customer was being transferred to (local) hospital.During an interview with the Director of Nursing (DON) on 2/25/26 at 12:58 PM, she was asked if Resident #128 had been transferred or discharged on 1/8/26. She stated the police (emergently transferred) her, not the facility. She was asked if the resident was in the facility and under the care of the facility when she was emergently transferred. She replied, Yes, I will get you the documentation we have to review. I was told because the police emergently transferred the resident, it doesn't fall under the facility. The DON returned 20 minutes later and stated, I called (local police) but they said they don't have a record of an (emergent transfer). I called (Resident #128's physician) and he said he completed the paperwork and handed it to the (local police). She was transferred by (emergency medical transport), not by police. She was status-post fracture, and the police transport would not have been appropriate.During an interview with the Administrator on 2/25/26 at 1:30 PM, she was asked if the local Ombudsman's office was notified of Resident #128's transfer on 1/8/26 along with the reason for the transfer. The Administrator replied, Yes, we have the faxed report to show they were notified on 2/10/26. A discharge report, which included Resident #128's discharge on [DATE], was reviewed. The report showed the resident was transferred to a local acute care hospital. The report did not show the reason for the transfer. The Administrator was asked if she had any information verifying that the local Ombudsman's office was notified of the reason for Resident #128's transfer/discharge. She provided a copy of a Nursing Home Transfer and Discharge Notice for Resident #128, dated 1/8/26. This report revealed:Reason for Discharge or Transfer:Your needs cannot be met in this facility.Brief explanation to support this action: [NAME] Act [The discharge form identified the brief explanation as [NAME] Act, indicating an involuntary emergency psychiatric evaluation for safety concerns.] The Administrator was asked if this report was sent to the Ombudsman's office. She replied, No. She was asked if she could confirm whether the reason for discharge was sent to the Ombudsman's office. She replied, No, the reason for transfer was not sent. On 2/26/26 at 9:30 AM during an interview with the Ombudsman, she was asked if her office was made aware of Resident #128's transfer on 1/8/26. She replied Yes, we have their monthly transfer/discharge report for January, and I see Resident #128 was transferred to (local hospital) on January 8th. She was asked if the facility reported to her office that this resident was sent out as an involuntary emergency psychiatric evaluation. She replied, No, we were not aware of that. I have explained several times both in person and on the phone to that facility's Administrator and Social Worker that whatever notice they send to the resident and/or family, they need to send to us, too, and they should be letting us know if any resident is sent out for an involuntary emergency psychiatric evaluation. During a follow-up interview with the Administrator on 2/26/26 at 9:50 AM, she was asked if she could confirm who was notified that Resident #128 was sent out for an involuntary emergency psychiatric evaluation on 1/8/26. She stated (resident's physician) was notified by the Unit Manager. She was asked if she could confirm whether the Ombudsman's office was notified not just of the transfer to an acute care facility, but of the reason for the resident's transfer. She replied, I believe they were sent the transfer/discharge notice which stated that on it. I'll need to confirm with Social Services. She returned a few minutes later and stated the transfer form was not sent to the Ombudsman's office. We send a monthly discharge report. We didn't notify the Ombudsman's office that the transfer was due to an involuntary emergency psychiatric evaluation. On 2/26/26 at 10:27 AM during an interview with Resident #128's physician, he was asked if he recalled sending Resident #128 out for an involuntary emergency psychiatric evaluation. He replied, Yes, that did happen. It was in January of this year. It was at night. I recall the facility calling and I could hear her screaming in the background. The facility had called me to say she was out of control, hitting staff, throwing things, yelling. I could hear her in the background. I came into the facility and asked her why she was acting this way. She just kept screaming and yelling and trying to throw things. Basically, she wasn't getting what she wanted. I decided to send her for an involuntary emergency psychiatric evaluation for her safety and the staff and other residents' safety. I filled out the paperwork and told staff to stay with her until she was transferred. I wasn't there when she was actually transferred. A review of the facility's policy titled Transfers and Discharges (effective 5/2020, revised 2/2024), revealed: Standard: The facility will develop and implement an effective discharge process that focuses on the residents' discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Procedure: 4. A copy of the transfer notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on observation, interviews and record review, the facility failed to check gastric residual volume (GRV) for one (Resident #52) of three residents reviewed for enteral nutrition. Failure to check for gastric residual volume can result in accidental inhalation of food/liquid into the airway and lungs instead of the esophagus, which can lead to choking, lung infections and/or breathing difficulty.The findings include:A review of Resident #52's medical record revealed an admission date of 12/2/25 with diagnoses including quadriplegia (paralysis resulting in partial or total loss of function in all four limbs and the torso), protein-calorie malnutrition, gastrostomy (feeding tube) status, metabolic encephalopathy (brain dysfunction causing symptoms like confusion, delirium, tremors and/or seizures), expressive language disorder (difficulty expressing thoughts, ideas and feelings despite having normal comprehension).A review of the resident's active physician's orders revealed: Enteral Tube: Flush tube with 60 ml (milliliters) of water every 1 hour while feeding in progress. Total 1026 ml - ordered 2/25/26 Jevity 1.5 (enteral nutrition formula designed for tube feeding) at the rate of 75 ml per hour for 18 hours a day until the total volume (1350mL) is infused; 60 ml water auto flush every 1 hour while feeding in progress; Start feeding at 4:00 pm - ordered 2/25/26 NPO (Nothing by mouth) diet, NPO texture, NPO consistency - ordered 12/2/25 Enteral Tube: Check residual every shift. If greater than 60 ml, hold feeding for one hour. If residual remains greater than 60 ml, continue to hold feeding and notify physician. A review of the resident's active care plan (revised 1/13/26), revealed that the resident was at risk for Alteration in Nutrition/Hydration related NPO, g-tube (feeding tube) status, and risk for malnutrition. The care plan further noted that the resident required tube feeding related to multiple strokes. Interventions included following physician's orders regarding the nutrition orders and flushes. Check for tube placement and gastric contents/residual volume and record. Notify MD (physician) as indicated. A review of the Nutritional Note dated 2/25/26 revealed that the resident was tolerating her enteral nutrition and g-tube feedings. Recommendations included increasing formulary as follows: Jevity 1.5 via pump at 75 ml/hour (milliliters per hour) x 18 hours. 60 ml water every 1 hour while feeding in progress (1026 mL H2O); start pump at 4 pm and finish (pump off) at 10 am or when 1350 ml formulary is infused. On 2/25/26 at 3:56 pm, Licensed Practical Nurse (LPN) E was observed administering nutrition via a g-tube (feeding tube) to the resident. The nurse donned a gown and gloves after performing hand hygiene. She hung a bottle of Jevity 1.5, ran the tubing through the pump and primed the tube. She flushed the resident's g-tube with 60 ml of water and connected the tube with the enteral nutrition to the resident's g-tube. LPN E turned on the pump which was preset to 75 ml/hour. She did not review the physician's orders first. She doffed her gown and gloves and performed hand hygiene. When she was asked about checking for gastric residual, she said, Oh, I forgot; you got me on that one. She stated she should have checked the residual prior to connecting the feeding. On 2/26/26 at 12:25 pm during an interview, the Director of Nursing (DON) stated LPN E notified her of the enteral feeding concern that occurred with Resident #52. The DON confirmed that nursing staff should review the physician's orders prior to administering medication or enteral nutrition to ensure that they were administered appropriately as ordered.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, by repeatedly failing to ensure that one (Resident #1) of one resident who was reviewed for urinary catheter care, had a urinary catheter bag that was kept off the floor. Failure to ensure a urinary catheter bag remains off the floor can result in a catheter-associated urinary tract infection.The findings include: On 2/23/2026 at 12:10 PM, Resident #1 was observed lying in bed. Her urinary catheter bag was observed on the door side of her bed and was observed to be resting on the floor. (Photographic evidence obtained) On 2/24/2026 at 9:58 AM, Resident #1 was observed lying in her bed. Her urinary catheter bag was observed on the door side of her bed and was observed to be resting on the floor. (Photographic evidence obtained) On 2/24/2026 at 12:40 PM, Resident #1 was observed lying in her bed. Her urinary catheter bag was observed on the door side of her bed and was observed to be resting on the floor. On 2/26/2026 at 5:20 AM during an interview with Certified Nursing Assistant (CNA) J, she confirmed that she was caring for Resident #1. She confirmed that she provided urinary catheter care for the resident. When she was asked what that care involved, she stated, I make sure there are no kinks in the tubing, I empty the bag and I let the nurse know how much was in the bag. She was asked about the positioning of the urinary catheter bag. She stated, I make sure the tubing is straight. She was asked if the urinary drainage bag should be resting on the floor. She replied, No, it can't touch the floor. On 2/26/2026 at 5:30 AM, Resident #1 was observed lying in her bed. Her urinary catheter bag was observed on the door side of her bed and was observed to be resting on the floor. (Photographic evidence obtained) On 2/26/2026 at 5:35 AM, during an interview with CNA J, she was asked to observe Resident #1's urinary catheter bag. During the observation, she was asked to confirm whether or not the urinary catheter bag was resting on the floor. She stated, Yes, I see it's on the floor. Sometimes when the beds are in low position like her's is, the bags will touch the floor. A review for Resident #1's medical record revealed diagnoses including encounter for fitting and adjusting or urinary device. A review of the resident's active physician's orders revealed an order dated 12/30/25: Indwelling Urinary Catheter: Encourage and assist resident to use/apply catheter tube securing device as tolerated, may change, replace, and change position as needed. A review of the person-centered care plan revealed a Focus Area indicating that Resident #1 was At Risk for Urinary Tract Infection related to incontinence, indwelling urinary catheter. Resident has a risk for injury/infection related to presence of catheter. Goal: Resident will remain free from signs/symptoms of urinary tract infection through the next review date. Interventions: Position catheter bag and tubing so that it promotes dignity and drainage. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. A review of the facility's policy titled Catheter Care – Quality of Care (effective 10/2020, revised 1/2024) revealed: Standard: The facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. Procedure: 3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is kept at an appropriate level to promote urine flow, and dignity is maintained.

Based on observations, interviews, record review, and a review of the facility's policy and procedure, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to administer scheduled medications within the required timeframes per the ordered times and the facility's policy, allowing for administration one hour before to one hour after the scheduled time for two (Residents #4 and #1) of eight sampled residents. Failure to administer medications timely could result in changes to therapeutic drug levels, ineffective pain management, development of antibiotic resistance, unregulated blood pressures, unregulated blood sugar levels and more. The findings include: On 6/13/23 at 10:31 a.m., Licensed Practical Nurse (LPN) A was observed during morning medication administration. She was preparing medication for Resident #4. An observation of the resident's electronic Medication Administration Record (MAR), revealed that the text color was red. When LPN A was asked what the red type indicated, she replied, The MAR is set up to show red if the medication is an hour past the administration time. When she was asked if there was a process for obtaining help when medication administration was running late, she replied that she was not sure. On 6/13/23 at 10:47 AM, an interview was conducted with LPN B, who was in the process of dispensing medications for Resident #1. The electronic MAR text was red. When she was asked what the significance of the red text was, she replied, It means we are outside the one-hour window. With thirty residents and not knowing them, it's impossible to get all the meds out on time. When she was asked if anyone was available to help ensure the medications were administered timely, she replied that she did not know. She stated she did a quick review of the residents' medications to determine which medications/residents were a priority. She administered those medications and then finished medication administration for the rest of her assigned residents. On 6/13/23 at 12:25 PM, an interview was conducted with Registered Nurse (RN) C, former Director of Nursing (DON) for this facility, now at a sister facility, but brought in to assist with this survey. RN C confirmed that the medication administration window was one hour before to one hour after the scheduled administration time. If the medication was not administered within this window of time, the resident's physician was to be notified to change the dispensing time if not contraindicated. When he was asked if there was a protocol for nurses to ask for help with medication administration when they were falling behind, he replied that they should be letting someone know so we can try to find them help. When he was asked how often medications were not given at the scheduled time, he replied that he was not sure. On 6/13/23 at 12:50 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When she was ssked if agency staff were oriented about who or how to ask for assistance with medication administration, she replied, They should be asking for help. I'm more likely to use an agency nurse who asks for help than one who does not and gets behind. When she was asked if she was aware of how often medications were administered late, she replied no. A review of the Medication Administration Audit Report for Residents #1 and #3 from June 3-13, 2023, revealed that Resident #1 received his medications beyond the one-hour past scheduled administration time for 106 of 239 opportunities (44% of the time during that period). Resident #3 received his medications beyond the one-hour past scheduled administration time for 23 of 136 opportunities (17% of the time during that period). A review of the facility's current Performance Improvement Projects (PIPs) revealed that the facility had not identified late medication administration issues. A review of the facility's policy for Administering Medications (revised April 2020) revealed on page. 1, Item #4 - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. Item #6 -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on resident representative and staff interviews, and review of resident records, the facility failed to ensure that it provided an effective discharge planning process that evaluated and identified changes requiring modification and updates as needed for 1 (Resident #1) of 3 residents reviewed for discharge. The findings include: A telephone interview was conducted with the daughter of Resident #1 on 9/26/22 at 10:30 am. She stated that Resident #1 was discharged from the facility and dropped at home by the facility's private transportation vehicle. The staff left a wheelchair despite being told Resident #1's wife could no longer take care of him at home. The family member added that the facility did not conduct a home assessment prior to discharge. That same day, Resident #1 was admitted to an acute care facility after falling and was found to have aspiration pneumonia. Resident #1 was recovering at another facility at the time of the call. Record review for Resident #1 revealed he was admitted to the facility on [DATE] and discharged [DATE]. He was [AGE] years old. Resident #1's spouse was his emergency contact and representative. He also had another family member listed as a second representative. Review of the 5-day minimum data set (MDS) assessment for Resident #1 with an assessment reference date of 8/14/22, revealed a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. He required extensive assistance with bed mobility and transfers, and limited assistance walking. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section Q0400, Discharge Plan, asked if active discharge planning was occurring. The answer was Not assessed, no information. Review of the care plan for Resident #1, dated 8/24/22 revealed he was admitted as short-term placement, with a goal to have discharge planning initiated. Interventions included discuss discharge plan with resident/responsible party, establish teaching needs and involve family in teaching. A second discharge care plan dated 8/24/22 noted Resident #1 was admitted for short term placement secondary to decline in previous levels of function and noted medical conditions. The goal was Resident #1 would like to complete therapy, get stronger and go home. Interventions included medications and treatments as ordered and physical, occupational and speech therapy as ordered. (Photographic evidence was obtained) Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes found on 9/1/22 (Thursday) revealed Resident #1's family member left a voice message to move forward with home health arrangements and plans for Resident #1 to discharge Wednesday (9/7/22). A nursing progress note dated 9/12/22, reported the Social Services Director (SSD) left a voicemail for Resident #1's family member to make her aware of options for [Resident #1]. There was no further explanation as to what those options were. The SSD noted that Friday, 9/9/22, this family member mentioned Resident #1's representative was no longer able to provide the care Resident #1 needed at home. The previous discharge plan was home with home care or hospice. The SSD noted she was awaiting a reply from the family member on how to proceed. (Photographic evidence was obtained) No other progress notes were found in the record related to Resident #1's discharge. There was no further communication with Resident #1's representative related to his pending discharge home documented. Further record review contained a Nursing Home Transfer Discharge Notice for Resident #1. The reason for the discharge was Resident #1's needs could no longer be met in the facility, and his health had improved sufficiently that services were no longer needed. The date the notice was given, and the effective date were both left blank. Resident #1's representative and the SSD signed the document on 9/14/22, the day of discharge. (Photographic evidence was obtained) A Discharge Summary dated 9/14/22 included a recapitulation of Resident #1's stay in the facility. It indicated Resident #1 was discharging to his family home and that Resident 1 was ambulatory with assistance. An interview with the Rehab Director (RD) and review of Resident #1's therapy progress notes were conducted on 9/27/22 at 2:30 pm. She explained Resident #1 started physical therapy on 8/12/22. On initial assessment, Resident #1 required moderate assistance with bed mobility and transfers and could ambulate 15 feet using a walker with minimal assistance. On 8/18/22, Resident #1 required minimal assist with transfers and was ambulating 20 feet with minimal assistance. By 8/25/22, Resident #1 was ambulating 25 feet with minimal assistance; however, by 9/9/22 he required moderate assistance with transfers and was not ambulating at all (0 feet). A second progress note on 9/9/22 said Resident #1 was able to ambulate only 4 feet and that his maximum (rehab) potential had been met. He would discharge home with hospice services. When asked what contributed to the resident's sudden and significant decline in ambulation skills, the RD said she did not know. She reviewed the therapy notes, which revealed no indication of illness or other contributing factor for the loss of skills. The RD did recall noticing a decline toward the end of therapy and recommended hospice, as Resident #1 had been on hospice at home prior to admission. She departed the room to call the Physical Therapist (PT) to see if there were additional details. She returned at 2:53 pm to report the PT had noticed a decline during Resident #1's last week of therapy and set a therapy discharge date of [DATE]. Family appealed the discharge decision, but insurance upheld it, so Resident #1 lost his appeal and discharged . An interview was conducted with the Social Services Director (SSD) on 9/27/22 at 2:58 pm. She said when Resident #1 was first admitted , his family member mentioned he would go home with hospice services. Therapy had a meeting regarding his rehabilitation status and on 9/9/22, the SSD issued a Notice of Medicare Non-Coverage (NOMNC- notice to the resident that insurance will no longer pay for therapy). The SSD said she left the family member a message to discuss options with her regarding Resident #1's discharge, since this family member had mentioned Resident #1's representative might not be able to care for him at home. The SSD was asked if the call was ever returned, as there were no further notes indicating discharge plans had been communicated. The SSD said she left a voicemail listing all the options and that the family member did call back; however, she did not document the conversation. The facility provided Resident #1's transportation home, and the SSD accompanied him on the van. She had the resident's representative sign the discharge papers then. Typically, the facility doesn't provide discharge transportation but the Administrator at the time set that up. He was the one who communicated with the family as to what time Resident #1 was coming home. The former Administrator was adamant, like, Let's get him home! so she followed his lead. Resident #1's representative seemed happy that he was home, but then said, I don't know . he has really changed. That same evening the SSD received a call from the home health company representative. He reported Resident #1 had a nasty fall within one hour of returning home and was sent to the hospital. The SSD explained that the last therapy notes she saw said Resident #1 could walk 15 feet. It was pointed out to her that the 15 feet status was from his admission assessment on 8/12/22. There had been several assessments since. She was told of the Rehab Director's and therapy progress notes reflecting a significant decline in ambulation before his discharge. The SSD said to her knowledge, that information had not been communicated to her in the daily meeting. She insisted she had not heard from therapy that Resident #1 was not walking and said there must have been some miscommunication. Had she known Resident 1 was not able to ambulate, she would have not made the discharge, especially if the resident's representative could not help him due to his decline. She would have also called adult protective services. The SSD concluded by saying, sadly, some of the communication and follow-up could have been better. If there is ever a concern, she needs to be notified of that. The SSD confirmed Resident #1's discharged was likely unsafe, as she was blindsided with the information that he was not able to be safe at home.

Based on observations, interviews, and record reviews, the facilty failed to provide treatment and care in accordance with professional standards of practice for one (Resident #48) of 39 residents sampled. Resident #48 received no flushes to her Peripherally Inserted Central Catheter (PICC) line. The findings include: A review of Resident #48's medical record revealed she was admitted on [DATE] with a readmission on 3/1/22. The resident was transferred to a hospital on 5/18/22 to have a PICC line removed. The PICC line was present on the 3/1/22 readmission. Resident #48 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/16/22 observation of Resident #48 at 1:59 PM, revealed a left [MEDICATION(S)] central line (SCL) with a transparent dressing covering the insertion site. The date on the dressing was illegible. On 5/17/22 at 3:48 PM, the left SCL had a transparent dressing covering the insertion site. The site was clean, dry, and intact. The insertion site was dark pink, and the dressing was dated 5/17/22. A review of the Admission Minimum Data Set (MDS) assessment, dated 3/5/22, revealed under Section O - Special Treatments, Procedures, and Programs - Item H: Intravenous (IV) medications yes. A review of the resident's active Care Plan, revealed a focus area for the administration of IV antibiotics for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: IV dressing, observe dressing every shift change and record observations; labs as ordered; monitor signs and symptoms of infection at the site - drainage, inflammation, swelling, redness, warmth; monitor signs and symptoms of leaking at the IV site, [CONDITION(S)] at the insertion site; monitor site for signs and symptoms of swelling, redness, pain, and increased temperature. A review of the resident's orders revealed: 3/1/22, [MEDICATION(S)] Solution 1 gram, IV every 8 hours related to severe [CONDITION(S)] until 3/14/22. The March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/1/22 [MEDICATION(S)] solution 1 gram IV every 18 hours related to severe [CONDITION(S)] until 3/14/22. 3/7/22 [MEDICATION(S)] solution 750 milligrams in 150 ml (milliliter) normal saline every 12 hours related to severe [CONDITION(S)] until 3/14/22. 3/1/22 Change IV dressing weekly and as needed when soiled. No orders for normal saline flushes or documentation of flushes were found in the resident's medical record. A review of assessments and progress notes revealed: On 3/1/22 at 2:52 PM, Patient transferred into facility via stretcher at 1405 (2:05 PM). Patient alert. Non-verbal. Skin warm and dry. Tunneled PICC line to left upper chest. One 3/1/22 Admission/Readmission Nursing packet-Sec. IV Infection Risk Evaluation, Item 2a. Appliances - tunneled PICC left chest. Sec. XIV Baseline Care Plans, Item 7 - Special treatments/procedures, subsection d. IV medication was not marked in the affirmative. 3/4/22 Summary of Skilled Services - Currently on IV antibiotics for [CONDITION(S)]. On 5/18/22 at 10:05 AM, an interview was conducted with the Interim Director of Nursing (IDON). When asked how long a PICC line could be in place, she stated she was not aware of a time line, but if it was prophylactic, it could be in place for months. When asked whether the line needed to be flushed, she replied, If the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/18/22 at 3:15 PM, an interview was conducted with Registered Nurse (RN)/Unit Manager F. When asked how PICC lines were to be cared for at the facility, she stated the dressing was changed at least weekly and the line was flushed before and after medication administration. When asked if a PICC line that was not in use still needed to be flushed, she stated, Yes, otherwise it will clot off. On 5/19/22 at 10:40 AM, an interview was conducted with the Medical Director. He stated he had been made aware that Resident #48 needed to go to the hospital to have a PICC line removed. When asked how these types of lines were handled, he stated, When a resident comes in, the nurses are to inform the physician of the line. Then the physician will reach out the hospital to find out why the line is in place and determine a potential removal date.' When asked if this type of line should be flushed when not in use, he stated, Absolutely, they must be flushed to prevent the lines from clotting off. A review of the facility's policy on Peripherally Inserted Central Catheters (PICCs) with a revision date of 5/18/2020, stated on page 3, item #13, PICC lines are to be flushed with 3 milliliters (ml) of normal saline every 12 hours when not in use or as ordered by the provider. Item #14, PICC lines are to be flushed with 3 ml of normal saline before and after the administration of Intravenous (IV) medication solutions.

Based on record reviews and interviews, the facility failed to 1) Maintain a hospice plan of care and documentation of care in the resident record, 2) Designate a member of the facility's interdisciplinary team to coordinate care, and 3) Coordinate Hospice care for one (Resident #111) of five residents reviewed for hospice services/coordination of care, from a total sample of 39 residents. The findings include: A review of Resident #111's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an active Do Not Rescusitate order. A review of the Quarterly MDS assessment, dated 3/24/22, revealed she was receiving Hospice services. A review of Resident #111's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/22/22, a Hospice consult was ordered. On 2/1/22, Hospice Medicaid began. A 5/17/22 review of the active Care Plan, revealed a focus area for End Stage of Life (initiated on 10/1/20). The resident was not documented as receiving Hospice services; palliative care was in place. No update had been made to the care plan at the initiation of Hospice services on 2/1/22. A review of the Quarterly MDS assessment, dated 3/24/22, revealed the resident was receiving Hospice services. On 5/18/22 at 11:00 AM, five Hospice charts were reviewed. Four of the five charts had documentation from the Hospice provider with fax dates of 5/17/22. Resident #111 did not have any documents from the Hospice provider in her chart on this date. On 5/18/22 at 11:20 AM, assistance was requested with obtaining Hospice notes for Resident #111. The Administrator stated the Hospice provider had not been sending their notes to the facility. She stated she would reach out to the provider to have the notes sent to the facility. When asked if that meant staff had no opportunity for coordination of care, she replied yes. On 5/18/22 at 11:30 AM, an interview was conducted with Health Information Coordinator (HIC) C. She was asked who followed up with the Hospice provider to ensure records were being sent to the facility. She stated, No one really, but we will now do follow up to make sure the facility receives the notes. On 5/18/22 at 1:20 PM, an interview was conducted with the IDON. She stated the facility became aware of the documentation issue with the Hospice provider after having been prompted by the survey team. She further stated the facility initiated a facility assessment to identify issues to be addressed. When aked who the Hospice coordinator was, the IDON stated she thought it was the Social Worker. Then she stated she was mistaken, it was MDS Coordinator A. On 5/18/22 at 4:45 PM, an interview was conducted with RN/MDS Coordinator A. When asked if she was the designated Hospice coordinator, she stated, I guess I have a new title. When asked how the Hospice care plans were incorporated into the facility care plans, she stated the Hospice provider sent the care plans to the facility and they were given to the MDS coordinator to incorporate into the care plan. Then they were given to the HIC who either scanned them into the electronic medical record or put the hard copies in the residents' charts.

Based on observations, interviews, and record reviews, the facility failed to 1) Ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, and 2) Ensure residents received appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence for one (Resident #107) of 39 residents sampled. The findings include: On 5/16/2022 at 1:00 p.m., Resident #107 was observed with a left hand contracture. During an interview with the resident at this time he stated he denied having a splint for his left hand, but stated he thought he needed one and had mentioned this to the staff without success. A medical record review revealed that Resident #107 was admitted into the facility on [DATE]. His last readmission was on 9/14/2021. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The last three Minimum Data Set (MDS) assessments were reviewed. Per the Admission assessment dated [DATE], the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. He required supervision with eating and extensive assistance with all other Activities of Daily Living (ADLs). He was noted with limited range of motion to the upper and lower extremity on one side. Per the Quarterly assessment dated [DATE], the BIMS score for Resident #107 was again 15. The resident was noted with limited range of motion to the upper and lower extremity on one side. Per the last Quarterly assessment dated [DATE], the BIMS score for Resident #107 was incomplete and not based on an interview with the resident. He was noted with limited range of motion to the upper and lower extremity on one side. The most recent Care Plan with a review date of 3/24/2022, failed to address the left hand contracture. There were no focus areas, goals or interventions listed. A review of a quarterly Rehab Referral/Screening performed on 3/31/2022, revealed the resident was screened by a therapist. There were no recommendations during this review. A review of a quarterly Rehab Referral/Screening performed on 12/20/2021, revealed the resident was screened by a therapist. The recommendations during the screening were documented as: Mobility including transfers and ambulation; recent change - patiently currently on hospice services; resident is appropriate for physical therapy evaluation, sliding board transfers. There were no additional screenings/recommendations found to address the resident's request for a splint or splinting needs related to the resident's left hand contracture. During an interview on 5/18/2022 at 1:50 p.m. with the Rehab Director, she stated all residents in the facility were screened by rehab quarterly. Resident #107 had been on caseload twice per his request. Once for a scooter assessment and then for physical therapy to work on transfers. She stated during the survey she had gone to see the resident regarding his desire for a splint and concluded that he could definitely benefit from having one. When asked why the resident was never assessed for a splint prior to the survey she stated: I'm not sure how it was missed. I can't explain. I will do the evaluation and reach out to Hospice. During an interview on 518/2022 at 1:55 p.m. with the Director of Nursing (DON), she advised that all residents were assessed by nursing upon admission. She stated if a resident had a contracture, it would be the responsibility of the nursing department to refer the resident to therapy for an evaluation. During an interview on 5/18/2022 at 4:45 p.m. MDS Coordinator A, she stated the initial assessments were done upon admission. The facility scheduled the quarterly and annual assessments monthly. She stated the care plan review was opened and setup at the same time an assessment was scheduled. No one audited or reviewed the assessments for accuracy. The person completing the section is signing off that it's accurate. She stated the nursing assessment flowed into the MDS. When asked, MDS Coordinator A stated she was familiar with Resident #107. A record review was conducted with her. Upon review of the MDS assessments dated 9/21/2021, 12/22/2021 and 3/24/2022, she acknowledged that the BIMS score was not assessed appropriately on the 3/24/2022 MDS. She stated if a resident was accurately assessed for contractures/limited range of motion in the MDS, that concern would have been added to the resident's care plan.

Based on observations, record reviews, interviews, and facility policy and procedure review, the facility failed to ensure the prompt resolution of a family complaint/grievance related to care and services for one (Resident #1) of five residents sampled for complaints and grievances. The findings include: A review of the clinical record for Resident #1 revealed an original admitted [DATE], with re-entry dates from acute care hospital on 3/21/22 and 3/28/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was on hemodialysis and required extensive assistance for activity of daily living (ADL's). A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. A review of the resident's care plan revealed an ADL self-performance deficit with risk for actual pain related to s/p left great toe amputation, at risk for falls, (impaired cognition and amputation) and at risk for decreased activity. Resident #1's niece was noted as his contact for care concerns. A review of the facility's complaint/grievance log from 1/1/22 to 4/8/22, revealed one grievance dated 3/17/22 related to Resident #1. Further review of the grievance dated 3/17/22 revealed Resident #1's niece contacted the facility and stated that he had stepped on metal in the shower and caused injury to his foot. On 4/8/22 at 11:42 AM, an interview was conducted with Employee B, Registered Nurse (RN) (Interim Director of Nursing/DON). She confirmed that Resident #1's niece filed a grievance on 3/17/22. Employee B, RN/DON explained that both she and Nursing Home Administrator (NHA) were aware that Resident #1's niece had reported that he stepped on metal. Employee B, RN/DON confirmed, they looked into the concern, and identified that the nurse who responded was Employee A, Licensed Practical Nurse (LPN). An interview with Employee A, LPN was requested but she was unavailable due to personal emergency. On 4/8/22 at 1:08 PM, an interview was conducted with Employee C, RN Clinical Reimbursement Coordinator (RN CRC) concerning Resident #1's nieces' complaint on 3/17/22. After reviewing Resident #1's complaint and grievance log, she acknowledged that on 3/17/22 the niece told the facility that Resident #1 may have stepped on metal in the shower and caused injury to his foot. Further record review revealed the facility did not resolve Resident #1's nieces' grievance on 3/17/22 related to possible injury to left foot and no incident report was completed. An interview was conducted with Nurse Practitioner (NP) A, ARNP on 4/8/22 at 1:48 PM. He confirmed that Resident #1's niece told him about the wound on the bottom of Resident #1's foot. He explained that he did not file any incident or report the concern of any injury. A telephone interview was conducted with the niece of Resident #1 on 4/8/22 at 5:12 PM. She confirmed the facility failed to properly handle her grievance and didn't follow up on the injury to Resident #1 left foot identified on or about late February 2022. She stated, the Agency nurse who cared for Resident #1 on the evening of the incident was supposed to file an incident report, but the agency nurse did not. A progress notes for Resident #1, dated 3/10/22 at 8:57 PM documented by Employee C, Registered Nurse read, Spoke with Nurse Practitioner B, Advanced Registered Nurse Practitioner (APRN) as family concerned with patient stepping on metal approximately two weeks ago causing a wound to the sole of foot and did not receive any [CONDITION(S)] vaccine. A review of the facility's policy titled Grievances revised on 9/30/20 read, Purpose: To give Customers/Agents or concerned parties the right to express a grievance without fear of consequences or reprisal in any form and allow Service Location's Team Member to become aware of alleged or existing difficulty or complications so corrective action may be taken. Under Process: 7.2 read, Whenever possible, Team Members should make prompt efforts to resolve the grievance. The center will follow up with concerned parties in a reasonable time frame and all attempts will be made to resolve promptly within 7 business days. (Copy obtained).

Based on record review, interviews, and facility policy and procedure review, the facility failed to investigate an unwitnessed event involving a foot injury in the shower, reported by a family member for 1 (Resident #1) of 5 residents sampled for accidents. The findings include: A review of the clinical record for Resident #1 revealed an original admitted [DATE], with re-entry dates from acute care hospital on 3/21/22 and 3/28/22. His diagnoses included non-pressure ulcers, [CONDITION(S)], and type II diabetes. Resident #1 is on hemodialysis and requires extensive assistance for activity of daily living (ADL's). A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. A review of the resident's care plan revealed an ADL self-performance deficit, risk for actual pain related to s/p left great toe amputation, at risk for falls, (impaired cognition and amputation) at risk for decreased activity. Resident #1's niece was noted as his contact for care concerns. A review of the facility's Incidents by Incident Type log from 1/1/22 to 4/8/22, revealed two incidents for Resident #1. The first incident recorded on 3/10/22 was listed as Medication Occurrence Incidents and the second on 3/21/22 was listed as Other Incidents. (Copy obtained) There was no documented incident report related to Resident #1's foot injury in the shower and no investigation was conducted. On 4/8/22 at 11:42 AM, an interview was conducted with Employee B, Registered Nurse (RN) (Interim Director of Nursing/DON). She confirmed that Resident #1's niece filed a grievance on 3/17/22. Employee B, RN/DON explained that both she and Nursing Home Administrator (NHA) were aware that Resident #1's niece had reported that he stepped on metal. Employee B, RN/DON confirmed, they looked into the concern, and identified that the nurse who responded was Employee A, Licensed Practical Nurse (LPN). An interview with Employee A, LPN was requested but she was unavailable due to personal emergency. On 4/8/22 at 1:08 PM, the two incidents regarding Resident #1' were reviewed with Employee C, RN Clinical Reimbursement Coordinator (RN CRC). The first incident created on 3/10/2022 at 3:00 PM, was related to facility nurse not administering a [CONDITION(S)] shot as physician ordered (related to a left foot wound); and the second incident documented on 3/21/2022 at 10:00 AM, was related to resident going to an acute care hospital emergency department for evaluation and treatment due to an infection of the left second toe. After reviewing Resident #1's complaint and grievance log, Employee C, RN CRC acknowledged that on 3/17/22 the niece told the facility that Resident #1 may have stepped on metal in the shower and caused injury to his foot. An interview was conducted with Nurse Practitioner (NP) A, ARNP on 4/8/22 at 1:48 PM. He confirmed that Resident #1's niece told him about the wound on the bottom of Resident #1's foot. He explained that he did not file any incident or report the concern of any injury. He stated, he did not know the date he was told of the wound, but it was a few weeks ago, and said he would need his note. (Copy of wound note was obtained) During an interview with the NHA on 4/8/22 at 2:33 PM, the missing incident report for Resident #1 was reviewed. The NHA confirmed that when the incident involving Resident #1 injury to his foot first occurred, someone was supposed to enter an incident report. A telephone interview was conducted with the niece of Resident #1 on 4/8/22 at 5:12 PM. She confirmed the facility failed to properly document and investigate the injury to Resident #1 left foot identified on or about late February 2022. She was unable to provide specific dates or information except that it was reported to Nurse Practitioner A, Advanced Registered Nurse Practitioner (ARNP), a few weeks back. She stated, the Agency nurse who cared for Resident #1 on the evening of the incident was supposed to file an incident report, but the agency nurse did not. A review of the progress notes dated 3/10/22 at 8:57 PM documented for Resident #1 and entered by Employee C, RN, read: Spoke with Nurse Practitioner B, Advanced Registered Nurse Practitioner (APRN) as family concerned with patient stepping on metal approximately two weeks ago causing a wound to the sole of foot and did not receive any [CONDITION(S)] vaccine. A review of the History and Physical for Resident #1 documented by Nurse Practitioner A, ARNP dated 3/9/22 at 8:32 PM indicated Resident #1 assessment: 1. Pain in left leg. 2. Unspecified Open Wound-Left Foot-initial encounter. Plan: 1. Pain in left leg-I will order ultrasound venous Doppler to rule out a [CONDITION(S)]. We will follow up to review results at the next visit and make changes appropriately. 2. Unspecified Open Wound-Left Foot-Initial encounter. I have ordered [MEDICATION(S)] 100 mg by mouth twice daily for 7 days and a 2 view X-ray of the left foot. We will follow up at the next visit to evaluate for effectiveness. (Copy obtained) A review of the physician's order for Resident #1 indicated the following new wound care order was initiated on 2/24/2022 to 3/18/2022: Cleanse left 3rd toe with wound cleanser and apply hydrogel. A review of the facility's policy Accidents and Incidents-Investigating and Reporting revised on 7/17 read: was Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident. d. Where the accident or incident took place; e. Name of witnesses & other information including when physician notified, family notified and corrective action taken. (Copy obtained)

Based on record review, interviews and facility policy and procedure review, the facility failed to provide the necessary care, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing, by failing to provide pre-medication for pain prior to wound care for one (Resident #3) of two residents reviewed for wound care. The findings include: A review of Resident #3's medical record revealed she was admitted on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Resident Matix form revealed Resident #3 had a stage IV pressure ulcer that was checked off as Worsened Pressure Ulcer. (Copy obtained) A review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen tablet 325 mg give 2 tablets by mouth every 6 hours prn for fever. Wound vac (posterior right thigh) continuous pressure therapy at 125 mmHg: Change foam dressing every Monday, Wednesday, and Friday on day shift and as needed to maintain function for wound care with start date of 2/11/22. (Copy obtained) On 2/17/22 at 9:45 AM, an interview was conducted with Resident #3, who was alert and oriented. She stated that on Monday (2/14/22) a wound vac change was performed by staff, but they did not provide her any pain medication. Resident #3 stated, I had to suffer through the wound vac change. Resident #3 explained that it was painful and when she asked the nurse for pain medication, the nurse indicated that it was too busy, and she had to get the dressing change completed. A review of Resident #3's February 2021 treatment administration record (TAR) revealed [MEDICATION(S)] Tablet 10-325 milligrams ([MEDICATION(S)]-acetaminophen) was documented as administered on 2/14/22 at 7:42 PM and noted as E for effective with a pain score at 5 of 10. There was no documented use of Acetaminophen tablet 325 mg from 2/01 to 2/16/22. There was no documented use of [MEDICATION(S)] Tablet 10-325 mg prior to Resident #3's wound dressing change on 2/14/22 and there was no documentation that the wound vac continuous pressure therapy @ 125 mmhg was not performed on 2/14/22. (Copy obtained) On 2/17/22 at 11:01 AM, an interview was conducted with Employee B, RN Unit Manager. After reviewing the February TAR for Resident #3, she confirmed that the wound care dressing she performed on 2/14/22 was not documented on the TAR. Employee B explained, she performed the dressing change to Resident #3 on Monday at approximately 4:30 PM and there was a lot going on. She acknowledged, Resident #3 had pain medication available ([MEDICATION(S)] tablet 10-325 mg) and confirmed that the only documented dose of [MEDICATION(S)] tablet 10-325 mg administered on 2/14/22 was at 7:42 PM. On 2/17/22 at 11:22 AM, a second interview was conducted with Employee B. She explained that Resident #3 received a scheduled [MEDICATION(S)] medication at 6 AM, 2 PM and 10 PM, but no prn medication was administered on 2/14/22 related to Resident #3's wound dressing change. Employee B insisted, she informed the direct care nurse (Employee C) on 2/14/22 to administer pain medication to Resident #3, so she could complete the wound vac dressing change. On 2/17/22 at 4:11 PM, an interview was conducted with the Director of Nursing (DON). She stated that Employee B told her that on 2/14/22, she asked the direct care nurse (Employee C) to provide pain medication to Resident #3 prior to wound care. After researching the pain medication interventions ordered for Resident #3, the DON confirmed that it appeared that Employee C did not provide any pain medication to Resident #3 prior to Employee B performing the wound care on 2/14/22. A review of the facility's policy and procedure titled, Wound Care revealed: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have an as needed order for pain medication to be administered prior to wound care. (Copy obtained)

Based on record review and interviews, the facility failed to ensure it provided prompt notification to the resident's representative following a fall for one (Resident #1) of three residents reviewed for falls. Failure to notify the resident's representative as soon as possible after the fall, prevented the representative from exercising their right to have the Resident sent to the hospital for evaluation. The findings include: A medical record review for Resident #1 revealed she was admitted to the facility from the hospital on 9/16/21. Prior to hospitalization , the resident had a fall that resulted in a traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, traumatic subarachnoid hemorrhage, [CONDITION(S)], and fracture of the occiput. Her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged from the facility on 9/24/21. During a telephone interview with Resident #1's daughter on 10/13/21 at 6:52 PM, she stated that her mom had a fall on 9/24/21, and it took the facility almost 12 hours to notify her and her sister about the fall. She called the facility and the nurse practitioner to talk about her mom's care, and she was not satisfied with the outcome. She stated, the facility eventually sent her mom to the hospital. She expressed multiple times during the interview that her mother had a bad head injury, and she would have insisted that her mom immediately go to the hospital after the fall for an evaluation. A nursing note dated 9/24/21 at 4:33 AM related to Resident #1 and entered by Employee A, RN read, Heard a loud noise and an umph. Found patient lying on her back in the doorway of room [ROOM NUMBER]. Her feet were in the hall and her head against the bottom of the closet. Patient was awake, alert but looked stunned. Patient was unable to answer inquiries about what happened. Patient complains of pain to right scalp 3 inches above her right ear. A 1-inch hematoma was noted. Skin intact, no bruising noted. Staples to laceration to left posterior scalp intact with no bruising, [CONDITION(S)], or bleeding. No injuries found on examination. Call to PA to inform of incident. No new orders received. A telephone interview was conducted with Employee C, Physician Extender on 10/14/21 at 12:44 PM. He stated that based on what he was told on 9/24/21 at approximately 4:00 AM, he was not sure about Resident #1's fall status. He was told the resident did not have any real changes in her baseline. When he arrived later in the day, he thought the resident should be sent out for increased lethargy. He confirmed the nursing staff called him and that they should have also let the family know when the incident happened. He spoke with the resident's family member (daughter he believed), and they were very upset about the incident and expressed the need to transfer the resident to another facility. An interview was conducted with Employee B, Reimbursement Specialist/Licensed Practical Nurse (LPN) on 10/14/21 at 1:08 PM. She was asked to review a note dated 9/24/21 at 14:54 hours (2:54 PM) which read: ARNP (Advanced Registered Nurse Practitioner) in to see resident .call placed to family for update to send to ER (Emergency Department). Informed of fall, family was upset regarding notice of fall. After reviewing the note, she confirmed she wrote it and that the family member she contacted was upset because she was just finding out about the fall which occurred several hours earlier. An interview was conducted with the Director of Nursing (DON) on 10/14/21 at 2:37 PM. She confirmed that she spoke with Resident #1's daughter. She understood why the daughter was upset and confirmed that she/the emergency contact should have been notified earlier. The DON also confirmed that the late notification denied the family member a right to request further evaluation for Resident #1 based on her previous head injury. A review of the facility's policy on Fall Management with revision date on 9/20/18 revealed the following: A fall without injury is still a fall; Unless there is evidence suggesting otherwise when a customer is found on the floor, a fall is considered to have occurred. The indicated process post incident included at line 3, if a customer is observed on the floor and/or blue mat and sustained injury, the first team member at the scene should assess, at section (3.5) Assigned nurse should notify the Legal Representative where indicated. At line 4 it was documented if the customer is not injured, the assigned nurse should notify the Legal Representative where indicated.

Based on observation, interviews and record review, the facility failed to ensure accurately documented Foley catheter care for one (Resident #3) out of five residents sampled for Foley catheter care. This failure could result in the resident acquiring an infection, urethral erosion, or obstruction. The findings include: A review of Resident #3's Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . every night shift every 30 day(s). An observation of Resident #3 on 10/14/21 at 9:06 AM, revealed a Foley Catheter draining. Resident #3 stated a nurse came into her room late yesterday (10/13/21) and was going to change her Foley, but she didn't do it. She stated, she was trying to tell the staff about her fistula that was near her urethra so they could insert the new catheter easily without going into the fistula. Resident #3 repeated, The nurse did not change my Foley. The care plan for Resident #3 revealed a focus that required a Foley catheter secondary to urethra fistula with intervention to Change Catcher or bag as necessary. A review of the Treatment Administration Record (TAR) for Resident #3 revealed that on 10/13/21, Employee A, Registered Nurse (RN) initialed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An attempt to contact Employee A, RN was made on 10/14/21 at 12:39 PM to discuss the documented Foley change; however, Employee A, RN was unable to be reached at that time. During an interview with the Director of Nursing (DON) on 10/14/21 at 1:43 PM, she reviewed the (TAR) for Resident #3. After reviewing the TAR, she confirmed that Employee A, RN documented the resident's catheter was changed on 10/13/21 and confirmed that Resident #3's catheter was not changed as documented on the TAR.

Based on record review and staff interview, the facility failed to provide urinary catheter changes as ordered for one (Resident #46) of one resident sampled for the use of a urinary catheter, from a total sample of 26 residents. The findings include: A record review for Resident #46 revealed an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented with forgetfulness. A review of the initial nursing assessment, dated 3/6/20, found that she had a urinary catheter in place due to neuromuscular bladder dysfunction. She used a leg bag for urine collection during the day and a bedside drainage bag at night. The admission orders [REDACTED]. Irrigate with 30 ml (milliliters) saline as needed for leaking or blockage, change tubing and drainage bag monthly and as needed. Check catheter every shift for pain and signs of infection, and clean catheter with soap and water every shift. A review of the Treatment Administration Records (TARs) from admission (March 2020) to the present (October 2020), found that the order to change the catheter had never been entered onto the TARs. A review of the physician's orders [REDACTED]. An interview was conducted with the Unit Manager on 10/22/20 at 11:40 a.m. She was asked how often the Foley catheter was changed for Resident #46. She replied that the order instructed the nursing staff to change the catheter monthly and as needed. She was asked where catheter changes were documented, and she said they should be documented on the TARs. She was asked to review the treatment records and indicate where the catheter changes were documented. After a review of the TARs, she confirmed that the order had not been recorded on the TARs. When asked for the date the order for catheter changes was first obtained, she replied on admission, 3/6/20. She was asked why the order was never transcribed to the TAR, and she said she did not know but it should have been. She was asked how the nurses would know that Resident #46 required a catheter change monthly if it was not documented on the TAR. She replied that it was in the physician's orders [REDACTED]. She was asked how the facility ensured that all new orders were implemented and entered onto the medication records and treatment sheets. She stated all new orders are reviewed every morning at the morning meeting with Unit Manager and Director of Nursing (DON). She was asked how she would know when the catheter had last been changed, and she said she would have to check the progress notes. When she was asked when the catheter was last changed, she replied it was changed on 10/9/20, prior to obtaining a urine sample for culture and sensitivity. It was also changed on 9/18 and 8/18/20. There were no catheter changes documented prior to August. She was asked what size catheter was ordered, and she she said 16 French, however the order did not specify the balloon size. She stated she was not aware until today that there was no balloon size specified, and she called to clarify the balloon size today (10/22/20) and updated the orders. During an interview with the DON on 10/21/20 at 2:35 p.m., she was asked where the nurses documented Foley catheter changes. She stated the documentation was in the nursing progress notes and the TARs. When she was asked to review the TAR's for June 2020 through October 2020 to see when the catheter was changed and documented, she confirmed that the order was not on the TAR for nursing to document the catheter change had been performed. She was asked to locate the documentation in the nursing progress notes. She reviewed the record and provided a copy of the nursing progress notes for catheter changes on 10/9, 9/18, and 8/18/20. When asked if there was documentation of catheter changes for April through July, she said she would review record. During an interview with DON on 10/22/20 at 9:25 a.m., she was asked if she had been able to locate the catheter documentation for April through July. She said the only documentation she could find for that period of time was a nursing note dated 5/20/20. The note indicated Resident #46 complained of pain from the catheter. The catheter was removed and re-inserted. On 10/9/20, Resident #46 complained of a burning sensation. The physician was notified and a urine culture was ordered. Prior to the results being obtained, the resident was ordered [MEDICATION NAME] 100 mg (milligrams) twice a day on 10/10/20. On 10/12/20, the medication was discontinued and she was started [MEDICATION NAME] mg daily for seven days for urinary tract infection. On 10/13/20,[MEDICATION NAME] discontinued and [MEDICATION NAME] 500 mg twice daily was prescribed. A review of the care plan regarding use of a urinary catheter included instructions to change the urinary catheter every month and as needed for leaking.

Based on interview and record review, the facility failed to administer physician-ordered medication according to parameters set for a hypotensive medication for one (Resident #56) of five residents whose medications were reviewed, from a total of 26 residents in the sample. The findings include: A record review for Resident #56 found her most recent admission to the facility was on 6/1/2020 with [DIAGNOSES REDACTED]. A review of the October 2020 physician's orders [REDACTED]. Give for a Systolic blood pressure of less than 110 and/or a Diastolic blood pressure of less than 70. A review of the October 2020 Medication Administration Record [REDACTED]. During the same shift on 10/11/2020 Resident #56's BP was 114/72, on 10/13/2020 it was 116/78, on 10/16/2020 it was 117/76, on 10/17/2020 it was 135/86 and on 10/18/2020 it was 113/71. Further review of the MAR for October 2020 found the [MEDICATION NAME] HCL 5 mg was administered during the 7:00 AM -3:00 PM shift on 10/4/2020, 10/11/2020, 10/13/2020, 10/16/2020, 10/17/2020 , 10/18/2020 . A review of Resident #56's BP during the 3:00 PM to 11:00 PM shift found that on 10/9/2020, the resident's BP was 130/77, on 10/11/2020 it was 114/72, on 10/16/2020 it was 122/72, and on 10/19/2020 it was 120/84. Further review of the MAR for this shift revealed the [MEDICATION NAME] HCI 5 mg was administered during the 3:00 PM to 11:00 PM shift on 10/9/2020, 10/11/2020, 10/16/2020, and 10/19/2020. A review of Resident #56's BP during the 11:00 PM to 7:00 AM shift found on 10/4/2020 the resident's BP was 124/70, on 10/12/2020 it was 146/81, and on 10/19/2020 it was141/72. Further review of the MAR for this shift revealed the [MEDICATION NAME] HCI 5 mg was administered during the 11:00 PM to 7:00 AM shift on 10/4/2020, 10/12/2020, and 10/19/2020. On 10/20/2020 at 2:44 PM the Director of Nursing (DON) was asked to review the administration of Resident #56's [MEDICATION NAME] and the parameters. During an interview with the DON on 10/21/2020 at 11:49 AM, the DON stated she had reviewed the parameters for the [MEDICATION NAME]. She stated she did see the medication was given outside the parameters and the nurses misinterpreted the orders.

Based on observations, interviews and record reviews, the facility failed to provide care and services which met professional standards for two (Residents #2 and #3) of four sampled residents. Resident #2 was in regards to skin concern and treatment, and Resident #3 was in regards to monitor for bleeding. The findings include: 1. On 7/22/19 at 9:31 AM during the initial tour, Resident #3 was noted to have a trail of red-like substance leading from beside her bed into the her restroom. Photographic evidence was obtained. Employee C/Certified Nursing Aide (CNA) entered the room during observation of the floor. She stated, Oh, I will go get the nurse for that blood. She then left the room and Employee A/Licensed Practical Nurse (LPN) entered the room. Employee A stated she had no idea where the blood had come from, but she had an open wound on her foot, so that must be it. She then bent down and removed Resident #3's slipper, yellow skid proof sock (no blood noted to either) and the dressing off of her left foot. The dressing was noted to have moderate amount of dry drainage noted; there was no blood noted. Employee A then stated, Hmm, I don't know where it came from then. She then asked the resident to place her foot down on her slipper while she goes and gets the dressing to put back on. She then exited the room, and went down the hall. Upon entering the bathroom observed more blood, and a washcloth was noted to be lying in the corner with a red substance on that as well. Resident #3 stated that it was not from her. Resident #3 stated she had been in the bathroom this morning to use it, but she did not use a washcloth or anything. Random Resident in Bed B spoke up and stated, It is not mine either, I did not use it. Employee A/LPN then returned to the room with a tinfoil wrap containing dressing supplies, and a bottle of wound cleanser. Employee A then put on her gloves and sprayed the wound cleanser on 3-4 4 x 4's gauze pieces and wiped the residents wound, going back and forth. She then leaned over and discarded those into the trash can. She then picked up 3-4 more pieces of gauze and sprayed them with wound cleanser and cleaned the wound, once again rubbing back and forth. She then tossed those 4 x 4's into the trash can. She then picked up the piece of calcium alginate and applied it to her wound; it fell off and landed on the floor. Employee A then asked the resident to put her foot back down on the slipper while she got a new piece. She then removed her gloves and placed them in the trash can and exited the room. Employee A returned with another piece of tin foil with a new dressing inside. She removed a sharpie from her pocket and dated the dressing. She then applied her gloves and picked up Resident #3's left foot. She then applied the new dressing to her foot, failing to re-clean the wound. Employee A was asked where the blood had come from, and she stated, I have no idea, and looked at the residents arms. Employee A was asked if Resident #3 was on any blood thinners and she stated, I don't know, I would have to look. On 7/22/19 at 9:47 AM an interview was conducted with Employee B, Certified Nursing Assistant (CNA), and she stated she had been in there to provide care this morning, but she did not notice the blood until after interview and being asked about the blood. She was then asked about the wash cloth in the bathroom, and she confirmed she had not used it on either resident in that room this morning, and had no idea where it had come from. On 7/22/19 at 12:36 PM a second interview was conducted with Employee A/Licensed Practical Nurse (LPN) about where the blood may have come from, and she stated, I don't know. I did a complete skin assessment, and did not see anything. She was then asked about the resident being on the blood thinner, and she stated, I don't know, as she looked into the electronic medical record (EMR) and determined Resident #3 was on Eliquis. Employee A then returned to work activity. On 7/22/19 at 1:06 PM an interview was conducted with the Director of Nursing (DON), she was asked if any concerns had been brought to her attention, and she stated, Yes, the nurse about the dressing change. So I started in-serving them. The DON stated Employee A/LPN had broken infection control. She was made aware of no barrier, no handwashing, and confirmed she had broken infection control. The DON was asked about the blood on the floor, and she stated, Yes, but I thought it was just one drop of blood. She reviewed the photographic evidence and stated, I did not realize it was that much blood. That does make a difference. She then was asked if it would be her expectation for the nurses to know who is on a blood thinner, and she stated, Yes, they should know. The DON stated, But, (surveyor's name) you can tell that she is a new nurse. The DON confirmed the expectation of staff to be competent, and facility's responsibility to ensure staff competency, and she stated, Yes, it is. She stated she will go down and find out about the blood, because with Resident #3 being on Eliquis she was concerned about where it was coming from. On 7/22/19 at 1:51 PM an interview was conducted with the DON and she was asked about Resident #3 and she stated that she spoke with the nurse regarding being more alert about what she is giving the residents for medication. She stated she spoke to Employee B/CNA as well and she denied seeing any blood when she was in there this morning providing care. She said Employee A/LPN stated she did not see any blood. She was then asked if they had notified the doctor and she stated she had not asked the nurse, but she would go find out. On 7/22/19 at 2:12 PM the DON returned and stated the nurse had called the doctor and left a message for him to call back. She stated she asked the second nurse on the floor to do a skin check as well. She stated no one had determined where the blood had come from, and it might be possible she had a nose bleed. She stated they are closely monitoring Resident #3 for signs and symptoms of bleeding until the doctor calls back. She was asked if the nurse had called the doctor prior to her telling her too, and she stated, No, she had not. A record review was conducted for Resident #3 and revealed an order for [REDACTED]. Documentation determined it had been administered by Employee A, LPN at 8:30 AM. A review was conducted of Resident #3's care plan and there was an intervention for her anticoagulant therapy, to monitor for signs and symptoms of bleeding. There was no documentation this was completed. 2. On 7/21/19 at 11:17 AM, Resident #2 was observed in the hallway heading toward the dining room. Employee C/Certified Nursing Assistant (CNA), identified the resident. Resident #2 was observed with an unlabeled and undated brown adhesive dressing to his left temple. Employee C was asked about the bandage and stated, I don't know what it is from. He never has any bandages. She lifted up one end of the bandage while in the hallway across from conference room door, and stated, See? It looks like a little pimple or something. She put the bandage back in place and walked away. A record review for Resident #2 revealed he did not have an order for [REDACTED].>On 7/22/19 at 1:31 PM, an interview was conducted with Employee D/Licensed Practical Nurse (LPN), regarding Resident #2. She stated she was told in change of shift report Resident #2 had a pimple or something on his left temple. She was asked about the dressing and whether an order was required even if it was just a Band-Aid. She replied, Yes, absolutely we would need an order. She confirmed there would be no way to determine when and who applied the Band-Aid. She stated, I knew about the pimple, but I did not know about the Band-Aid. She was asked if she administered medication to Resident #2 and/or had seen him today, and she stated, Yes, I have.

Based on observations, interviews and review of policy and procedures, the facility failed to maintain infection control standards when performing wound care for one (Resident #3) of four sampled residents. The findings included: On 7/22/19 at 9:31 AM during the initial tour, Resident #3 was noted to have a trail of red-like substance leading from beside her bed into the her restroom. Photographic evidence was obtained. Employee C/Certified Nursing Aide (CNA) entered the room during the observation of the floor. She stated, Oh, I will go get the nurse for that blood. She then left the room and Employee A/Licensed Practical Nurse (LPN) entered the room. She stated she had no idea where the blood had come from, but she had an open wound on her foot, so that must be it. Employee A bent down and removed her slipper, yellow skid proof sock (no blood noted to either) and the dressing off of her left foot. The dressing was noted to have moderate amount of dry drainage; there was no blood noted. Employee A stated Hmm, I don't know where it came from then. She asked the resident to place her foot down on her slipper while she went and got the dressing to put back on. She exited the room, and went down the hall. Upon entering the bathroom observed more blood, and a washcloth was lying in the corner with a red substance on the washcloth. Resident #3 stated it was not from her. Resident #3 stated she had been in the bathroom this morning to use it, but she did not use a washcloth or anything. Random Resident in Bed B spoke up and stated, It is not mine either, I did not use it. Employee A/LPN returned to the room with a tinfoil wrap containing dressing supplies, and a bottle of wound cleanser. She put on her gloves and sprayed the wound cleanser on 3-4 4 x 4's gauze pieces and wiped the residents wound, going back and forth. She leaned over and discarded those into the trash can. Employee A picked up 3-4 more pieces of gauze and sprayed them with wound cleanser and cleaned the wound, rubbing back and forth. She tossed those 4 x 4's into the trash can. She picked up the piece of calcium alginate and applied it to Resident #3's wound; it fell off and landed on the floor. Employee A asked the resident to put her foot back down on the slipper while she got a new piece. She removed her gloves and placed them in the trash can and exited the room. She returned with another piece of tin foil with a new dressing inside. Employee A removed a sharpie from her pocket and dated the dressing. She applied her gloves and picked up Resident #3's left foot. She applied the new dressing to her foot, failing to clean the wound. On 7/22/19 at 9:43 AM an interview was conducted with Employee A/LPN regarding infection control concerns with the dressing, and she stated, No, maybe when I dropped the dressing on the floor. She was asked about not changing her gloves after cleansing the wound and applying the new dressing. She stated, Yes, I should have changed my gloves. Employee A was asked about putting the wound back down on her slipper, and then applying the dressing and not cleaning the wound, and she stated, Oh, okay. On 7/22/19 at 1:06 PM an interview was conducted with DON. She was asked if any concerns had been brought to her attention, and she stated Yes, the nurse about the dressing change. So I started in-serving them. She (Employee A) stated that she had broken infection control. She was made aware of no barrier, no handwashing, and confirmed Employee A had broken infection control. A review was completed of the facilities policy and procedure for dressing change: Dressing Techniques Clean Dressing Purpose: To assure dressing changes are performed in an environment to prevent contamination. Process 1. Prior to beginning of treatment: 1.1. Verify the physician order 1.2 Gather equipment 1.2.1. Clean barrier 1.2.2. Wound Cleanser 1.2.3. Gauze pads/cotton - tipped applicator if indicated. 1.2.4. Three (3) pair of clean gloves 1.2.5. Tape 1.2.6. Ordered dressing/medication/cream 1.2.7. One to two (1-2) small red plastic garbage bags 1.2.8. Skin protectant (if indicated) 2. Each area must be treated separately. 3. In the event that personal contamination is anticipated, all appropriate personal protective equipment must be worn. 4. If a break in the clean technique occurs at any point, stop the procedure, remove your gloves, wash your hands, re-glove and/or re-gown, and continue the procedure. 10. Ensure Privacy 11. Position the area to be treated while maintaining privacy. 12. Perform hand hygiene 13. Open dressings to be used without touching the dressing/gauze. Keep the dressing/gauze within the open packet and place directly on top of the barrier. Open as many as necessary to perform the treatment. Note: If the cleaning solution is open prior to this procedure, waste 5-10 cc into the waste basket before pouring it onto the field. If using spray wound cleanser, spray small amount in waste basket prior to using. 15. Apply the ordered treatment to the open wound. DO not touch the dressing in any way.

Based on observations, resident and facility record reviews and staff interviews, the facility failed to implement the comprehensive care plan for one (Resident #55) of one residents reviewed for falls, out of a total sample of 44 residents. The findings include: An observation of Resident #55 was made on 12/04/18 at 1:41 PM. The resident was in bed. There were no floor mats in place on either side of the bed. On 12/04/18 at 2:16 PM, Resident #55 was still in bed with no floor mats in place. Resident #55 was interviewed in the room on 12/05/18 at 2:46 PM. The resident was lying in bed with no floor mats at bedside. An interview was conducted with Employee C, Certified Nursing Assistant (CNA), on 12/06/18 at 8:52 AM. She reported Resident #55 came up to the front of the unit to make monitoring easier. The resident had some confusion. Resident #55 could stand with assistance and used to try to get up and walk. The resident was considered a fall risk initially, so staff lowered the bed when the resident was in it. No fall mats or personal alarms were in use for this resident. Employee C knew what interventions to implement for Resident #55, because they were listed in the CNA electronic charting program. An observation of Resident #55 on 12/06/18 at 1:16 PM found him in bed. The resident appeared to be sleeping as his eyes were closed and he was under the covers. There were no floor mats on either side of the bed. Employee D, Registered Nurse (RN), was interviewed on 12/06/18 at 2:37 PM. She stated Resident #55 presented with confusion, and was a fall risk. The resident had attempted to get out of the wheelchair several times. Resident #55 could stand up, but had no balance. He also liked to sit on the floor and slide himself from the wheelchair onto the floor. Fall precautions in use included hipsters (padded hip protectors worn under pants), a half lap tray, anti-rollback device on wheelchair, and a pommel cushion (a cushion that is placed in the wheelchair and keeps the resident in the proper position). Employee D stated Resident #55 could still stand and get up and over the pommel cushion. She further stated Resident #55 was to have floor mats in use as a fall precaution intervention. Resident #55 was observed on 12/06/18 at 3:02 PM in bed, under the covers. The over-bed table was positioned across his chest. The resident had his eyes closed, and did not respond to the knock on the door. There were no floor mats on either side of the bed. A final observation of Resident #55 on 12/07/18 at 9:02 AM found him in bed under the covers. There were no floor mats in place. A clinical record review revealed Resident #55 was admitted to the facility on [DATE], and readmitted on [DATE] after falling forward out of a wheelchair, hitting his head, and transferring to the hospital. A Modification of Admission Minimum Data Set (MDS) assessment with an assessment reference date of 9/7/18 revealed a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 points, indicating severely impaired cognitive skills. The resident required extensive assistance of one staff member with activities of daily living. Balance during transitions and walking was not steady. Resident #55 was only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning and facing the opposite direction, moving on and off the toilet, and when completing surface to surface transfers. The resident used a wheelchair as a mobility aid. [DIAGNOSES REDACTED]. Resident #55 had a fall in the last month prior to the assessment or entry/reentry, and two falls with injury since admission or the last assessment. Resident #55 was care planned on 12/8/18 for behavioral tendencies as evidenced by placing himself on the floor at times. The goal was for easy redirection and no resulting injuries. The resident was care planned for impaired mobility and a history of L1 (lumbar) fracture, and care planned as at risk for falls related to impaired cognition, recent falls, and impaired balance, placing himself on the floor and dementia. The goal was to minimize the risk of falls through the next review date. Interventions included: Offer to get customer up in wheelchair when wakes; anti-rollback device to wheelchair; non-slip well-fitting footwear; places self on floor; do not leave unattended in day room; frequent checks; hipsters while out of bed; pommel cushion; 1/2 lap tray; right arm bolster; do not leave in bathroom; personal items in reach when in bed. On 11/29/18, a revision was made with instructions to initiate floor mats. A second revision on 11/30/18 instructed that floor mats were to be utilized. A review of electronic nursing progress notes for Resident #55 revealed documented falls on the following dates: 9/1/18 at 1:05 am, observed lying on the floor. 9/2/18 at 6:45 pm, tried to get up and slid on floor. Was lying in fetal position on the right side. 9/3/18 at 12:00 pm, observed sitting on floor on bottom, between the beds, holding self up in a sitting position with a chair. 9/4/18 at 6:00 am, found on floor in the day room on the right side next to wheelchair. 9/4/18 at 1:00 pm, complained of right hip pain and hitting head on bed after falling in the room. 9/6/18 at 7:15 pm, observed on floor. 9/8/18 at 2:20 am, found on floor beside bed, stated sat there on purpose, did not fall. 9/8/18 at 7:15 am, customer fell forward out of wheelchair at the nurses station while attempting to ambulate without assistance. Sustained a knot to the right side of the head, and small open area to right forearm. 9/8/18 at 8:45 am, found on floor right outside dining room, complaints of left hip pain, hipsters for when in wheelchair and X-rays were ordered. 9/10/18 at 12:15 am, resident was observed sitting on the floor in the day room doorway, on the buttocks in front of wheelchair. 9/10/18 5:00 pm found on floor unable to state what happened. 9/10/18 at 8:50 pm, witnessed fall with complaints of right R hip pain, no obvious injury. At 9:30 pm, transferred to the hospital following the 8:50 pm fall when fell out of wheelchair face-forward hitting the head, and complained of right hip pain. 9/11/18 at 5:30 am, fell from wheelchair in the day room, was sitting on buttocks. Resident stood, tripped on foot rest, and fell sustaining a skin tear to the left forearm. 9/13/18 at 7:00 am, fell in the room. 9/19/18 at 630 pm, fall at nursing station. Attempted to get up from wheelchair unassisted, fell on to floor landing on back. 9/19/18 at 6:30 pm, attempted to get up unassisted and fell on to floor, landing on the back. 9/23/18 at 1:35 am, resident launched self out of the wheelchair in the day room, CNA was sitting inches away. 10/2/18 at 6:20 am, found on floor in the room. 10/3/18 at 2:30 pm, was sitting in wheelchair at the nursing station and threw self onto the floor. 10/3/18 at 11:50 pm, was found on the floor in the room. 10/5/18 at 10:30 pm, observed on floor laying on the left hip. 10/9/18, found sitting next to the bed, stating wanted to walk. 10/15/18 at 5:42 am, observed sitting on buttocks next to the bed. 10/15/18 at 10:00 pm, observed to stand from wheelchair then sit on the floor. 10/16/18 at 7:15 pm, found sitting on floor. 10/21/18 at 5:30 am, observed lying on floor beside bed. 10/25/18 at 9:00 pm, found on floor lying on left side in front of nursing counter. 10/26/18 at 10:07 am, found on the floor in day room. 10/29/18 at 5:45 pm, observed on floor. 10/30/18 at 9:27 am, observed on floor in bathroom, hands on floor in front of him. 11/3/18 at 6:00 pm, found sitting on floor with food in hand. 11/4/18 at 12:00 am, observed sitting on buttocks beside the bed. 11/17/18 at 6:45 pm, observed sitting on floor on buttocks in front of the wheelchair at the nurse's station. 11/28/18 at 5:15 am, was found sitting on the floor beside the bed. Intervention is to initiate floor mats. Further review of the clinical records revealed that CNA tasks included documentation fields for the use of protective devices (floor mats, low bed, hip savers, helmet, geri- sleeves, geri- legs, padded side rails, etc.). There was no documentation that fall mats had been utilized for Resident #55 in the last 14 days, between (MONTH) 25, (YEAR) and (MONTH) 6, (YEAR). The only interventions marked as implemented included a low bed (daily), hip savers (6 days, (MONTH) 26, 27, and 28 and (MONTH) 3, 4, and 5) and non-skid socks on one day, (MONTH) 30, (YEAR). An interview was conducted with Employee D, Registered Nurse, on 12/07/18 at 10:45 AM. She reviewed the record and confirmed the plan of care for Resident #55 instructed to use floor mats. She confirmed the mats should be in place when the resident was in bed. Employee D reviewed the CNA tasks and kardex (an electronic medical communication system used by nursing staff), and confirmed the instructions for floor mats were in place. She confirmed the floor mats had not been documented as utilized since the care plan was revised. Employee D accompanied this surveyor to the resident's room. The resident was still in bed, but no mats were present. She confirmed the mats were not in place, stating they should be per the plan of care. A review of the facility's policy and procedure titled Fall Management revised 9/20/18 revealed: Process: 1. Upon admission/readmission licensed team member should evaluate customer fall risk potential . 1.2 If customer is determined to be at risk for falls, the licensed nurse should: 1.2.1 Within 24 hours, develop a care plan, taking into consideration the customer's individual needs. 1.2.2 Implement fall management interventions as appropriate/indicated.

Based on staff interviews, clinical record reviews, and a review of facility records, the facility failed to provide care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care for 1 of 3 sampled residents who expired in the facility (Resident #1), by neglecting to initiate Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1, neglected the honor the resident's wishes for a "Full Code" status, and failed to call 911 per their own policy and procedure for CPR. Certified Nursing Assistant (CNA) A had discovered Resident #1 unresponsive in her room on [DATE]. Licensed Practical Nurse (LPN) A responded to the call of CNA A, and arrived at Resident #1 ' s room to find her unresponsive. The Registered Nurse (RN) on duty, was observed going into Resident #1 ' s room and pronounced her deceased . The RN then contacted Resident #1 ' s physician and told him that the resident had passed. The RN reported to LPN A that Resident #1 ' s physician had ordered to withhold CPR, however, based on record review and interview with the physician, he reported that withholding CPR was never discussed and there was no telephone order produced for the withholding. 911 was never contacted for Resident #1 on [DATE]. The facility ' s failure to follow Resident #1 ' s advanced directives and the facility ' s policies and procedures for documentation of resuscitation status and policy for cardiopulmonary resuscitation resulted in past noncompliance immediate jeopardy occurring on [DATE] for Resident #1 not receiving CPR when found unresponsive. Resident #1 expired at the facility on [DATE]. The facility became aware of the incident on [DATE] and immediately began implementing staff training and developing a plan of action, including interviews with involved staff, notified all required parties, reviewed all residents' advance directives for accuracy of code status, audited all resident arm bands for red dot when appropriate, in-serviced 97 of 102 staff on facility policy for initiating CPR and calling 911 when no red dot is present on arm band (remaining staff to be in-serviced before working again, random mock codes conducted with nursing and aides, daily monitoring of presence of arm bands and accuracy of code status per physician order [REDACTED]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. Cross reference to F282 (S/S J), F281 (S/S J), F155 (S/S J). The findings include: A closed record review conducted for Resident #1 found she was admitted to the facility [DATE], with readmission on [DATE]. She was [AGE] years old, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) [DATE] assessed Resident #1 with shortness of breath (SOB) upon exertion and while lying flat. She received oxygen therapy. Resident #1 had no condition or chronic disease listed in her medical chart that might result in a life expectancy of less than 6 months. Resident #1 was care planned on [DATE], with revision [DATE], for established advanced directives: Chooses to be full code (desired Cardiopulmonary Resuscitation). She had a living will and a Directed Power Of Attorney for health care and financial decisions. Care plan approaches included: Initiate CPR per protocol. Resident #1 had physician's order [REDACTED]. A Re-admission History and Physical exam completed by Resident #1's Physician on [DATE] noted she had a status of "Full Code ". Review of electronic progress notes found that on [DATE] at 9:00 pm, Resident #1 was found un-responsive, with no pulse, blood pressure, or respirations. Resident #1 was pronounced (deceased ) on [DATE] at 9:05 pm by a facility Registered Nurse (RN), and her physician was notified. The entry indicated that family members were happy that Resident #1 "went peacefully", and that 911 was not called. A telephone interview was attempted with the RN involved in Resident #1's care on [DATE] at 9:20 am. She declined an interview. A telephone interview was conducted with Licensed Practical Nurse (LPN) A on [DATE] at 9:25 am. LPN A confirmed she was the nurse assigned to Resident #1 on the night of [DATE]. She recalled being called to room [ROOM NUMBER] by Certified Nursing Assistant (CNA) A, who had found Resident #1 unresponsive. Resident #1 was blue around her lips, with her eyes rolled back in her head. LPN A reported that she knew immediately Resident #1 was deceased , as she had no pulse. As she left the resident's room to obtain her stethoscope, the on duty RN entered Resident #1's room and pronounced her (deceased ). The RN phoned Resident #1's physician, and informed him the resident had expired. LPN A then reviewed Resident #1's clinical record and discovered she was a "Full Code" resuscitation status. She reported that she had told the RN they needed to call 911 and "code" Resident #1, but the RN insisted the physician said "No CPR". LPN A did not recall if Resident #1's identification bracelet was in place at the time of the event. LPN A explained a Physician's telephone order to withhold CPR for a resident who was "Full Code" must be witnessed by at least two facility staff members. Further review of Resident #1's Physician's Interim and Telephone Orders found no directive to withhold CPR for Resident #1 when found unresponsive on [DATE]. A telephone interview was conducted with CNA A on [DATE] at 9:55 am. She stated she was assigned to Resident #1 on the evening of [DATE]. She reported that Resident #1 had been sick, and complained of chest pain that night. She reported that she called LPN A to the resident's room after finding Resident #1 with her head down and gray. CNA A reported that the RN arrived, phoned Resident #1's physician, returned to Resident #1's room and stated the physician instructed her not to initiate CPR. CNA A did not recall if Resident #1's identification wrist band was on at the time of the incident, but she knew Resident #1 was a "Full Code" status. CNA A explained that in the event a resident is found unresponsive, she was to call a nurse, who would announce "code green" three times over the facility's paging system. She explained that if the resident's identification bracelet was marked with a red dot, the resident had a DNR order and stated that this would also be indicated in the front of the resident's record. A telephone interview was conducted with CNA B on [DATE] at 10:05 am. She recalled on the evening of [DATE], when CNA A stated Resident #1 had passed away. CNA B went to Resident #1's room, and asked if she should retrieve Resident #1's chart to see if she had a DNR. LPN A told her "no", that it was too late. CNA B reported that the RN pronounced Resident #1 deceased . A Telephone interview was conducted with Resident #1's physician on [DATE] at 10:12 am. He recalled the night of [DATE] when someone from the facility (he did not recall whom) called him to report that Resident #1 had expired. The reporting nurse explained Resident #1 was last accompanied an hour prior to being found, and was not warm when discovered. He stated the caller never asked him about CPR for Resident #1, and they did not discuss the code status of this resident. He said he "probably assumed Resident #1 had a DNR". He reported that he would have instructed the facility to start CPR if he had been told she was a "Full code" status, and stated the facility should have called paramedics and attempted CPR prior to contacting him. The facility's Social Services policy on Advanced Directives dated [DATE] stated its intent was to provide customers the opportunity to make their health care decisions known, and to ensure their advanced directives for end-of-life decisions were communicated and executed appropriately by the facility. Section 2 states the customer/legal representative's advance directive decision(s) will be: 2.1 Documented on the Communication Board of PCC (Point Click Care, the facility's electronic record system). 2.3 Reviewed at all scheduled and special requested care plan conference. 2.4 Reviewed upon the 5, 14, 30, 60 day, quarterly, significant change and annual MDS's as indicated... As appropriate, and DNR status should be additionally identified with a red dot on the customer's arm band and on the spine of the medical record. The Nursing Policy and Procedure for Documentation of Resuscitation Status ([DATE]) stated the policy was developed to assure that customer's wishes are followed in the event of cardiac or respiratory arrest. The process listed on the policy and procedure included the following: 1. Each customer resuscitation status is clearly indicated on the clinical record and armband. 2. Customer requesting DNR should be identified with a RED dot on the armband and on the spine of the medical record. 3. CPR will be initiated anytime a customer's armband or spine of the medical record doesn't have a RED dot 4. Two nurses may accept a physician's verbal DNR order for up to 24 hours in the event a Customer exhibits a sudden decline in condition (where death seems to be imminent). 5. Physician should communicate with the legal representative prior to giving verbal DNR order. The Nursing Policy and Procedure for Cardiopulmonary Resuscitation ([DATE]) instructs: 3. Upon discovery of a Customer in cardiopulmonary arrest.... staff will immediately: 3.1 Determine the presence of DNR status by looking for the RED dot on the identification bracelet. 3.2 Direct another staff member to elicit necessary help by announcing "CODE GREEN" over the paging system; and 3.3 Prepare the Customer for CPR. 4. If RED dot is present: 4.1 Staff should not initiate CPR... 5. Upon discovery of a Customer in cardiopulmonary arrest and in the absence of a RED dot on the arm bracelet: 5.1 Initiate CPR using universal precautions and appropriate disposable mouthpieces: 5.2 Call 911 and notify the Physician; 5.3 CPR may not be stopped until relieved by EMS (Emergency Medical Responders) personnel, a verbal order from the Physician is given, or other state specific requirements are met. A review of the facility's AHCA Nursing Home Reporting form filed on [DATE] recapped the incident involving Resident #1's death on [DATE]. It noted the facility's failure to honor advanced directives for Resident #1, and identified LPN A, the RN, CNA A and CNA B as being directly involved on the night of the occurrence. The summary was consistent with the telephone interviews obtained from LPN A, and CNAs A and B. The Director of Nursing notified the Administrator and Risk Manager that advanced directives were not honored for Resident #1 on the evening of [DATE]. The physician denied instructing the facility not to perform CPR on Resident #1. The report's Analysis and Corrective Action concluded that CPR was not initiated per (Resident #1's) advanced directives, and outlined the following corrective actions taken: 1. Physician and family were aware customer expired and CPR was not initiated. 2. Advanced Directives/Code Status for customers on all units were reviewed for accuracy of code status, in accordance with the customer's and legal representative ' s wishes. Customer's arm bands were checked for presence.... If code status per customer's and representative's wishes and per physician order [REDACTED]. 3. 97 of 102 nursing staff were in-serviced on the center's policy as it relates to CPR and the initiation of CPR when there is no red dot present (no DNRO in place) and no arm band, and the calling of 911 Emergency Medical Services for medical assistance. The remaining nursing staff will receive in-service prior to starting on the assigned units on their next scheduled shift. Center licensed nurses and CNAs to participate in random mock codes to exhibit/reflect understanding and proficiency in identifying customer code status and ability to initiate code process per policy and guidelines. 4. DON (Director of Nursing)/Designee and Social Services Director/designee to monitor daily presence of arm bands and identification/accuracy of code status per physician's orders [REDACTED]. Findings reported to quality assurance monthly. A review of the facility's Corrective Action Plan revealed multiple staff trainings had been conducted between [DATE] and [DATE] on CPR and the DNR red dot system. The records also included completed daily monitoring checklists of resident arm bands and clinical records for the presence of the red dot, physician's orders [REDACTED]. In addition, mock code drills had been conducted and documented. The corrective actions identified by the facility were confirmed to be in place at the time of survey.

Based on staff interviews, clinical record reviews, and a review of facility records, the facility failed to safeguard the rights of 1 of 3 sampled residents who expired in the facility (Resident #1) by neglecting to initiate Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1 and failed to call 911 per the facility's policy and procedure for CPR. Certified Nursing Assistant (CNA) A had discovered Resident #1 unresponsive in her room on [DATE]. Licensed Practical Nurse (LPN) A responded to the call of CNA A, and arrived at Resident #1's room to find her unresponsive. The Registered Nurse (RN) on duty, was observed going into Resident #1's room and pronounced her deceased . The RN then contacted Resident #1's physician and told him that the resident had passed. The RN reported to LPN A that Resident #1's physician had ordered to withhold CPR, however, based on record review and interview with the physician, he reported that withholding CPR was never discussed and there was no telephone order produced for the withholding. 911 was never contacted for Resident #1 on [DATE]. The facility's failure to follow Resident #1's advanced directives and the facility's policies and procedures for documentation of resuscitation status and policy for cardiopulmonary resuscitation resulted in past noncompliance immediate jeopardy occurring on [DATE] for Resident #1 due to not receiving CPR when found unresponsive. Resident #1 expired at the facility on [DATE]. The facility became aware of the incident on [DATE] and immediately began implementing staff training and developing a plan of action, including interviews with involved staff, notified all required parties, reviewed all residents' advance directives for accuracy of code status, audited all resident arm bands for red dot when appropriate, in-serviced 97 of 102 staff on facility policy for initiating CPR and calling 911 when no red dot is present on arm band (remaining staff to be in-serviced before working again, random mock codes conducted with nursing and aides, daily monitoring of presence of arm bands and accuracy of code status per physician order [REDACTED]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F282 (S/S J), F281 (S/S J). The findings include: A closed record review conducted for Resident #1 found she was admitted to the facility [DATE], with readmission on [DATE]. She was [AGE] years old, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) [DATE] assessed Resident #1 with shortness of breath (SOB) upon exertion and while lying flat. She received oxygen therapy. Resident #1 had no condition or chronic disease listed in her medical chart that might result in a life expectancy of less than 6 months. Resident #1 was care planned on [DATE], with revision [DATE], for established advanced directives: Chooses to be full code (desired cardiopulmonary resuscitation, CPR). She had a living will and a Directed Power Of Attorney for health care and financial decisions. Care plan approaches included: Initiate CPR per protocol. Resident #1 had physician's order [REDACTED]. A Re-admission History and Physical exam completed by Resident #1's Physician on [DATE] noted she had a status of "Full Code ". Review of electronic progress notes found that on [DATE] at 9:00 pm, Resident #1 was found un-responsive, with no pulse, blood pressure, or respirations. Resident #1 was pronounced (deceased ) on [DATE] at 9:05 pm by a facility Registered Nurse (RN), and her physician was notified. The entry indicated that family members were happy that Resident #1 "went peacefully", and that 911 was not called. A telephone interview was attempted with the RN involved in Resident #1's care on [DATE] at 9:20 am. She declined an interview. A telephone interview was conducted with Licensed Practical Nurse (LPN) A on [DATE] at 9:25 am. LPN A confirmed she was the nurse assigned to Resident #1 on the night of [DATE]. She recalled being called to room [ROOM NUMBER] by Certified Nursing Assistant (CNA) A, who had found Resident #1 unresponsive. Resident #1 was blue around her lips, with her eyes rolled back in her head. LPN A reported that she knew immediately Resident #1 was deceased , as she had no pulse. As she left the resident's room to obtain her stethoscope, the on duty RN entered Resident #1's room and pronounced her (deceased ). The RN phoned Resident #1's physician, and informed him the resident had expired. LPN A then reviewed Resident #1's clinical record and discovered she was a "Full Code" resuscitation status. She reported that she had told the RN they needed to call 911 and "code" Resident #1, but the RN insisted the physician said "No CPR". LPN A did not recall if Resident #1's identification bracelet was in place at the time of the event. LPN A explained a Physician's telephone order to withhold CPR for a resident who was "Full Code" must be witnessed by at least two facility staff members. Further review of Resident #1's Physician's Interim and Telephone Orders found no directive to withhold CPR for Resident #1 when found unresponsive on [DATE]. A telephone interview was conducted with CNA A on [DATE] at 9:55 am. She stated she was assigned to Resident #1 on the evening of [DATE]. She reported that Resident #1 had been sick, and complained of chest pain that night. She reported that she called LPN A to the resident's room after finding Resident #1 with her head down and gray. CNA A reported that the RN arrived, phoned Resident #1's physician, returned to Resident #1's room and stated the physician instructed her not to initiate CPR. CNA A did not recall if Resident #1's identification wrist band was on at the time of the incident, but she knew Resident #1 was a "Full Code" status. CNA A explained that in the event a resident is found unresponsive, she was to call a nurse, who would announce "code green" three times over the facility's paging system. She explained that if the resident's identification bracelet was marked with a red dot, the resident had a DNR order and stated that this would also be indicated in the front of the resident's record. A telephone interview was conducted with CNA B on [DATE] at 10:05 am. She recalled on the evening of [DATE], when CNA A stated Resident #1 had passed away. CNA B went to Resident #1's room, and asked if she should retrieve Resident #1's chart to see if she had a DNR. LPN A told her "no", that it was too late. CNA B reported that the RN pronounced Resident #1 deceased . A Telephone interview was conducted with Resident #1's physician on [DATE] at 10:12 am. He recalled the night of [DATE] when someone from the facility (he did not recall whom) called him to report that Resident #1 had expired. The reporting nurse explained Resident #1 was last accompanied an hour prior to being found, and was not warm when discovered. He stated the caller never asked him about CPR for Resident #1, and they did not discuss the code status of this resident. He said he "probably assumed Resident #1 had a DNR". He reported that he would have instructed the facility to start CPR if he had been told she was a "Full code" status, and stated the facility should have called paramedics and attempted CPR prior to contacting him. The facility's Social Services policy on Advanced Directives dated [DATE] stated its intent was to provide customers the opportunity to make their health care decisions known, and to ensure their advanced directives for end-of-life decisions were communicated and executed appropriately by the facility. Section 2 states the customer/legal representative's advance directive decision(s) will be: 2.1 Documented on the Communication Board of PCC (Point Click Care, the facility's electronic record system). 2.3 Reviewed at all scheduled and special requested care plan conference. 2.4 Reviewed upon the 5, 14, 30, 60 day, quarterly, significant change and annual MDS's as indicated... As appropriate, and DNR status should be additionally identified with a red dot on the customer's arm band and on the spine of the medical record. The Nursing Policy and Procedure for Documentation of Resuscitation Status ([DATE]) stated the policy was developed to assure that customer's wishes are followed in the event of cardiac or respiratory arrest. The process listed on the policy and procedure included the following: 1. Each customer resuscitation status is clearly indicated on the clinical record and armband. 2. Customer requesting DNR should be identified with a RED dot on the armband and on the spine of the medical record. 3. CPR will be initiated anytime a customer's armband or spine of the medical record doesn't have a RED dot 4. Two nurses may accept a physician's verbal DNR order for up to 24 hours in the event a Customer exhibits a sudden decline in condition (where death seems to be imminent). 5. Physician should communicate with the legal representative prior to giving verbal DNR order. The Nursing Policy and Procedure for Cardiopulmonary Resuscitation ([DATE]) instructs: 3. Upon discovery of a Customer in cardiopulmonary arrest.... staff will immediately: 3.1 Determine the presence of DNR status by looking for the RED dot on the identification bracelet. 3.2 Direct another staff member to elicit necessary help by announcing "CODE GREEN" over the paging system; and 3.3 Prepare the Customer for CPR. 4. If RED dot is present: 4.1 Staff should not initiate CPR... 5. Upon discovery of a Customer in cardiopulmonary arrest and in the absence of a RED dot on the arm bracelet: 5.1 Initiate CPR using universal precautions and appropriate disposable mouthpieces (which is not current CPR practice): 5.2 Call 911 and notify the Physician; 5.3 CPR may not be stopped until relieved by EMS (Emergency Medical Responders) personnel, a verbal order from the Physician is given, or other state specific requirements are met. A review of the facility's AHCA Nursing Home Reporting form filed on [DATE] recapped the incident involving Resident #1's death on [DATE]. It noted the facility's failure to honor advanced directives for Resident #1, and identified LPN A, the RN, CNA A and CNA B as being directly involved on the night of the occurrence. The summary was consistent with the telephone interviews obtained from LPN A, and CNAs A and B. The Director of Nursing notified the Administrator and Risk Manager that advanced directives were not honored for Resident #1 on the evening of [DATE]. The physician denied instructing the facility not to perform CPR on Resident #1. The report's Analysis and Corrective Action concluded that CPR was not initiated per (Resident #1's) advanced directives, and outlined the following corrective actions taken: 1. Physician and family were aware customer expired and CPR was not initiated. 2. Advanced Directives/Code Status for customers on all units were reviewed for accuracy of code status, in accordance with the customer's and legal representative ' s wishes. Customer's arm bands were checked for presence.... If code status per customer's and representative's wishes and per physician order [REDACTED]. 3. 97 of 102 nursing staff were in-serviced on the center's policy as it relates to CPR and the initiation of CPR when there is no red dot present (no DNRO in place) and no arm band, and the calling of 911 Emergency Medical Services for medical assistance. The remaining nursing staff will receive in-service prior to starting on the assigned units on their next scheduled shift. Center licensed nurses and CNAs to participate in random mock codes to exhibit/reflect understanding and proficiency in identifying customer code status and ability to initiate code process per policy and guidelines. 4. DON (Director of Nursing)/Designee and Social Services Director/designee to monitor daily presence of arm bands and identification/accuracy of code status per physician's orders [REDACTED]. Findings reported to quality assurance monthly. A review of the facility's Corrective Action Plan revealed multiple staff trainings had been conducted between [DATE] and [DATE] on CPR and the DNR red dot system. The records also included completed daily monitoring checklists of resident arm bands and clinical records for the presence of the red dot, physician's orders [REDACTED]. In addition, mock code drills had been conducted and documented. The corrective actions identified by the facility were confirmed to be in place at the time of survey. .

Based on staff interviews, clinical record reviews, and a review of facility records, the facility failed to ensure services were provided by qualified persons in accordance with the written plan of care for 1 of 3 sampled residents who expired in the facility (Resident #1). The facility neglected to initiate Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1 and failed to call 911 per the facility's policy and procedure for CPR. Certified Nursing Assistant (CNA) A had discovered Resident #1 unresponsive in her room on [DATE]. Licensed Practical Nurse (LPN) A responded to the call of CNA A, and arrived at Resident #1 ' s room to find her unresponsive. The Registered Nurse (RN) on duty, was observed going into Resident #1 ' s room and pronounced her deceased . The RN then contacted Resident #1 ' s physician and told him that the resident had passed. The RN reported to LPN A that Resident #1 ' s physician had ordered to withhold CPR, however, based on record review and interview with the physician, he reported that withholding CPR was never discussed and there was no telephone order produced for the withholding. 911 was never contacted for Resident #1 on [DATE]. The facility ' s failure to follow Resident #1 ' s advanced directives and the facility ' s policies and procedures for documentation of resuscitation status and policy for cardiopulmonary resuscitation resulted in past noncompliance immediate jeopardy occurring on [DATE] for Resident #1 not receiving CPR when found unresponsive. Resident #1 expired at the facility on [DATE]. The facility became aware of the incident on [DATE] and immediately began implementing staff training and developing a plan of action, including interviews with involved staff, notified all required parties, reviewed all residents' advance directives for accuracy of code status, audited all resident arm bands for red dot when appropriate, in-serviced 97 of 102 staff on facility policy for initiating CPR and calling 911 when no red dot is present on arm band (remaining staff to be in-serviced before working again, random mock codes conducted with nursing and aides, daily monitoring of presence of arm bands and accuracy of code status per physician order [REDACTED]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F155 (S/S J), F281 (S/S J). The findings include: A closed record review conducted for Resident #1 found she was admitted to the facility [DATE], with readmission on [DATE]. She was [AGE] years old, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) [DATE] assessed Resident #1 with shortness of breath (SOB) upon exertion and while lying flat. She received oxygen therapy. Resident #1 had no condition or chronic disease listed in her medical chart that might result in a life expectancy of less than 6 months. Resident #1 was care planned on [DATE], with revision [DATE], for established advanced directives: Chooses to be full code (desired Cardiopulmonary Resuscitation, CPR). She had a living will and a Directed Power Of Attorney for health care and financial decisions. Care plan approaches included: Initiate CPR per protocol. Resident #1 had physician's order [REDACTED]. A Re-admission History and Physical exam completed by Resident #1's Physician on [DATE] noted she had a status of "Full Code ". Review of electronic progress notes found that on [DATE] at 9:00 pm, Resident #1 was found un-responsive, with no pulse, blood pressure, or respirations. Resident #1 was pronounced (deceased ) on [DATE] at 9:05 pm by a facility Registered Nurse (RN), and her physician was notified. The entry indicated that family members were happy that Resident #1 "went peacefully", and that 911 was not called. A telephone interview was attempted with the RN involved in Resident #1's care on [DATE] at 9:20 am. She declined an interview. A telephone interview was conducted with Licensed Practical Nurse (LPN) A on [DATE] at 9:25 am. LPN A confirmed she was the nurse assigned to Resident #1 on the night of [DATE]. She recalled being called to room [ROOM NUMBER] by Certified Nursing Assistant (CNA) A, who had found Resident #1 unresponsive. Resident #1 was blue around her lips, with her eyes rolled back in her head. LPN A reported that she knew immediately Resident #1 was deceased , as she had no pulse. As she left the resident's room to obtain her stethoscope, the on duty RN entered Resident #1's room and pronounced her (deceased ). The RN phoned Resident #1's physician, and informed him the resident had expired. LPN A then reviewed Resident #1's clinical record and discovered she was a "Full Code" resuscitation status. She reported that she had told the RN they needed to call 911 and "code" Resident #1, but the RN insisted the physician said "No CPR". LPN A did not recall if Resident #1's identification bracelet was in place at the time of the event. LPN A explained a Physician's telephone order to withhold CPR for a resident who was "Full Code" must be witnessed by at least two facility staff members. Further review of Resident #1's Physician's Interim and Telephone Orders found no directive to withhold CPR for Resident #1 when found unresponsive on [DATE]. A telephone interview was conducted with CNA A on [DATE] at 9:55 am. She stated she was assigned to Resident #1 on the evening of [DATE]. She reported that Resident #1 had been sick, and complained of chest pain that night. She reported that she called LPN A to the resident's room after finding Resident #1 with her head down and gray. CNA A reported that the RN arrived, phoned Resident #1's physician, returned to Resident #1's room and stated the physician instructed her not to initiate CPR. CNA A did not recall if Resident #1's identification wrist band was on at the time of the incident, but she knew Resident #1 was a "Full Code" status. CNA A explained that in the event a resident is found unresponsive, she was to call a nurse, who would announce "code green" three times over the facility's paging system. She explained that if the resident's identification bracelet was marked with a red dot, the resident had a DNR order and stated that this would also be indicated in the front of the resident's record. A telephone interview was conducted with CNA B on [DATE] at 10:05 am. She recalled on the evening of [DATE], when CNA A stated Resident #1 had passed away. CNA B went to Resident #1's room, and asked if she should retrieve Resident #1's chart to see if she had a DNR. LPN A told her "no", that it was too late. CNA B reported that the RN pronounced Resident #1 deceased . A Telephone interview was conducted with Resident #1's physician on [DATE] at 10:12 am. He recalled the night of [DATE] when someone from the facility (he did not recall whom) called him to report that Resident #1 had expired. The reporting nurse explained Resident #1 was last accompanied an hour prior to being found, and was not warm when discovered. He stated the caller never asked him about CPR for Resident #1, and they did not discuss the code status of this resident. He said he "probably assumed Resident #1 had a DNR". He reported that he would have instructed the facility to start CPR if he had been told she was a "Full code" status, and stated the facility should have called paramedics and attempted CPR prior to contacting him. The facility's Social Services policy on Advanced Directives dated [DATE] stated its intent was to provide customers the opportunity to make their health care decisions known, and to ensure their advanced directives for end-of-life decisions were communicated and executed appropriately by the facility. Section 2 states the customer/legal representative's advance directive decision(s) will be: 2.1 Documented on the Communication Board of PCC (Point Click Care, the facility's electronic record system). 2.3 Reviewed at all scheduled and special requested care plan conference. 2.4 Reviewed upon the 5, 14, 30, 60 day, quarterly, significant change and annual MDS's as indicated... As appropriate, and DNR status should be additionally identified with a red dot on the customer's arm band and on the spine of the medical record. The Nursing Policy and Procedure for Documentation of Resuscitation Status ([DATE]) stated the policy was developed to assure that customer's wishes are followed in the event of cardiac or respiratory arrest. The process listed on the policy and procedure included the following: 1. Each customer resuscitation status is clearly indicated on the clinical record and armband. 2. Customer requesting DNR should be identified with a RED dot on the armband and on the spine of the medical record. 3. CPR will be initiated anytime a customer's armband or spine of the medical record doesn't have a RED dot 4. Two nurses may accept a physician's verbal DNR order for up to 24 hours in the event a Customer exhibits a sudden decline in condition (where death seems to be imminent). 5. Physician should communicate with the legal representative prior to giving verbal DNR order. The Nursing Policy and Procedure for Cardiopulmonary Resuscitation ([DATE]) instructs: 3. Upon discovery of a Customer in cardiopulmonary arrest.... staff will immediately: 3.1 Determine the presence of DNR status by looking for the RED dot on the identification bracelet. 3.2 Direct another staff member to elicit necessary help by announcing "CODE GREEN" over the paging system; and 3.3 Prepare the Customer for CPR. 4. If RED dot is present: 4.1 Staff should not initiate CPR... 5. Upon discovery of a Customer in cardiopulmonary arrest and in the absence of a RED dot on the arm bracelet: 5.1 Initiate CPR using universal precautions and appropriate disposable mouthpieces: 5.2 Call 911 and notify the Physician; 5.3 CPR may not be stopped until relieved by EMS (Emergency Medical Responders) personnel, a verbal order from the Physician is given, or other state specific requirements are met. A review of the facility's AHCA Nursing Home Reporting form filed on [DATE] recapped the incident involving Resident #1's death on [DATE]. It noted the facility's failure to honor advanced directives for Resident #1, and identified LPN A, the RN, CNA A and CNA B as being directly involved on the night of the occurrence. The summary was consistent with the telephone interviews obtained from LPN A, and CNAs A and B. The Director of Nursing notified the Administrator and Risk Manager that advanced directives were not honored for Resident #1 on the evening of [DATE]. The physician denied instructing the facility not to perform CPR on Resident #1. The report's Analysis and Corrective Action concluded that CPR was not initiated per (Resident #1's) advanced directives, and outlined the following corrective actions taken: 1. Physician and family were aware customer expired and CPR was not initiated. 2. Advanced Directives/Code Status for customers on all units were reviewed for accuracy of code status, in accordance with the customer's and legal representative ' s wishes. Customer's arm bands were checked for presence.... If code status per customer's and representative's wishes and per physician order [REDACTED]. 3. 97 of 102 nursing staff were in-serviced on the center's policy as it relates to CPR and the initiation of CPR when there is no red dot present (no DNRO in place) and no arm band, and the calling of 911 Emergency Medical Services for medical assistance. The remaining nursing staff will receive in-service prior to starting on the assigned units on their next scheduled shift. Center licensed nurses and CNAs to participate in random mock codes to exhibit/reflect understanding and proficiency in identifying customer code status and ability to initiate code process per policy and guidelines. 4. DON (Director of Nursing)/Designee and Social Services Director/designee to monitor daily presence of arm bands and identification/accuracy of code status per physician's orders [REDACTED]. Findings reported to quality assurance monthly. A review of the facility's Corrective Action Plan revealed multiple staff trainings had been conducted between [DATE] and [DATE] on CPR and the DNR red dot system. The records also included completed daily monitoring checklists of resident arm bands and clinical records for the presence of the red dot, physician's orders [REDACTED]. In addition, mock code drills had been conducted and documented. The corrective actions identified by the facility were confirmed to be in place at the time of survey. .

Based on staff interviews, clinical record reviews, and a review of facility records, the facility failed to provide services that met professional standards of quality for 1 of 3 sampled residents who expired in the facility (Resident #1) by neglecting to initiate Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1, neglected the honor the resident's wishes for a "Full Code" status, and failed to call 911 per their own policy and procedure for CPR. Certified Nursing Assistant (CNA) A had discovered Resident #1 unresponsive in her room on [DATE]. Licensed Practical Nurse (LPN) A responded to the call of CNA A, and arrived at Resident #1 ' s room to find her unresponsive. The Registered Nurse (RN) on duty, was observed going into Resident #1 ' s room and pronounced her deceased . The RN then contacted Resident #1 ' s physician and told him that the resident had passed. The RN reported to LPN A that Resident #1 ' s physician had ordered to withhold CPR, however, based on record review and interview with the physician, he reported that withholding CPR was never discussed and there was no telephone order produced for the withholding. 911 was never contacted for Resident #1 on [DATE]. The facility ' s failure to follow Resident #1 ' s advanced directives and the facility ' s policies and procedures for documentation of resuscitation status and policy for cardiopulmonary resuscitation resulted in past noncompliance immediate jeopardy occurring on [DATE] for Resident #1 not receiving CPR when found unresponsive. Resident #1 expired at the facility on [DATE]. The facility became aware of the incident on [DATE] and immediately began implementing staff training and developing a plan of action, including interviews with involved staff, notified all required parties, reviewed all residents' advance directives for accuracy of code status, audited all resident arm bands for red dot when appropriate, in-serviced 97 of 102 staff on facility policy for initiating CPR and calling 911 when no red dot is present on arm band (remaining staff to be in-serviced before working again, random mock codes conducted with nursing and aides, daily monitoring of presence of arm bands and accuracy of code status per physician order [REDACTED]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F282 (S/S J), and F155 (S/S J). The findings include: A closed record review conducted for Resident #1 found she was admitted to the facility [DATE], with readmission on [DATE]. She was [AGE] years old, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) [DATE] assessed Resident #1 with shortness of breath (SOB) upon exertion and while lying flat. She received oxygen therapy. Resident #1 had no condition or chronic disease listed in her medical chart that might result in a life expectancy of less than 6 months. Resident #1 was care planned on [DATE], with revision [DATE], for established advanced directives: Chooses to be full code (desired Cardiopulmonary Resuscitation). She had a living will and a Directed Power Of Attorney for health care and financial decisions. Care plan approaches included: Initiate CPR per protocol. Resident #1 had physician's order [REDACTED]. A Re-admission History and Physical exam completed by Resident #1's Physician on [DATE] noted she had a status of "Full Code ". Review of electronic progress notes found that on [DATE] at 9:00 pm, Resident #1 was found un-responsive, with no pulse, blood pressure, or respirations. Resident #1 was pronounced (deceased ) on [DATE] at 9:05 pm by a facility Registered Nurse (RN), and her physician was notified. The entry indicated that family members were happy that Resident #1 "went peacefully", and that 911 was not called. A telephone interview was attempted with the RN involved in Resident #1's care on [DATE] at 9:20 am. She declined an interview. A telephone interview was conducted with Licensed Practical Nurse (LPN) A on [DATE] at 9:25 am. LPN A confirmed she was the nurse assigned to Resident #1 on the night of [DATE]. She recalled being called to room [ROOM NUMBER] by Certified Nursing Assistant (CNA) A, who had found Resident #1 unresponsive. Resident #1 was blue around her lips, with her eyes rolled back in her head. LPN A reported that she knew immediately Resident #1 was deceased , as she had no pulse. As she left the resident's room to obtain her stethoscope, the on duty RN entered Resident #1's room and pronounced her (deceased ). The RN phoned Resident #1's physician, and informed him the resident had expired. LPN A then reviewed Resident #1's clinical record and discovered she was a "Full Code" resuscitation status. She reported that she had told the RN they needed to call 911 and "code" Resident #1, but the RN insisted the physician said "No CPR". LPN A did not recall if Resident #1's identification bracelet was in place at the time of the event. LPN A explained a Physician's telephone order to withhold CPR for a resident who was "Full Code" must be witnessed by at least two facility staff members. Further review of Resident #1's Physician's Interim and Telephone Orders found no directive to withhold CPR for Resident #1 when found unresponsive on [DATE]. A telephone interview was conducted with CNA A on [DATE] at 9:55 am. She stated she was assigned to Resident #1 on the evening of [DATE]. She reported that Resident #1 had been sick, and complained of chest pain that night. She reported that she called LPN A to the resident's room after finding Resident #1 with her head down and gray. CNA A reported that the RN arrived, phoned Resident #1's physician, returned to Resident #1's room and stated the physician instructed her not to initiate CPR. CNA A did not recall if Resident #1's identification wrist band was on at the time of the incident, but she knew Resident #1 was a "Full Code" status. CNA A explained that in the event a resident is found unresponsive, she was to call a nurse, who would announce "code green" three times over the facility's paging system. She explained that if the resident's identification bracelet was marked with a red dot, the resident had a DNR order and stated that this would also be indicated in the front of the resident's record. A telephone interview was conducted with CNA B on [DATE] at 10:05 am. She recalled on the evening of [DATE], when CNA A stated Resident #1 had passed away. CNA B went to Resident #1's room, and asked if she should retrieve Resident #1's chart to see if she had a DNR. LPN A told her "no", that it was too late. CNA B reported that the RN pronounced Resident #1 deceased . A Telephone interview was conducted with Resident #1's physician on [DATE] at 10:12 am. He recalled the night of [DATE] when someone from the facility (he did not recall whom) called him to report that Resident #1 had expired. The reporting nurse explained Resident #1 was last accompanied an hour prior to being found, and was not warm when discovered. He stated the caller never asked him about CPR for Resident #1, and they did not discuss the code status of this resident. He said he "probably assumed Resident #1 had a DNR". He reported that he would have instructed the facility to start CPR if he had been told she was a "Full code" status, and stated the facility should have called paramedics and attempted CPR prior to contacting him. The facility's Social Services policy on Advanced Directives dated [DATE] stated its intent was to provide customers the opportunity to make their health care decisions known, and to ensure their advanced directives for end-of-life decisions were communicated and executed appropriately by the facility. Section 2 states the customer/legal representative's advance directive decision(s) will be: 2.1 Documented on the Communication Board of PCC (Point Click Care, the facility's electronic record system). 2.3 Reviewed at all scheduled and special requested care plan conference. 2.4 Reviewed upon the 5, 14, 30, 60 day, quarterly, significant change and annual MDS's as indicated... As appropriate, and DNR status should be additionally identified with a red dot on the customer's arm band and on the spine of the medical record. The Nursing Policy and Procedure for Documentation of Resuscitation Status ([DATE]) stated the policy was developed to assure that customer's wishes are followed in the event of cardiac or respiratory arrest. The process listed on the policy and procedure included the following: 1. Each customer resuscitation status is clearly indicated on the clinical record and armband. 2. Customer requesting DNR should be identified with a RED dot on the armband and on the spine of the medical record. 3. CPR will be initiated anytime a customer's armband or spine of the medical record doesn't have a RED dot 4. Two nurses may accept a physician's verbal DNR order for up to 24 hours in the event a Customer exhibits a sudden decline in condition (where death seems to be imminent). 5. Physician should communicate with the legal representative prior to giving verbal DNR order. The Nursing Policy and Procedure for Cardiopulmonary Resuscitation ([DATE]) instructs: 3. Upon discovery of a Customer in cardiopulmonary arrest.... staff will immediately: 3.1 Determine the presence of DNR status by looking for the RED dot on the identification bracelet. 3.2 Direct another staff member to elicit necessary help by announcing "CODE GREEN" over the paging system; and 3.3 Prepare the Customer for CPR. 4. If RED dot is present: 4.1 Staff should not initiate CPR... 5. Upon discovery of a Customer in cardiopulmonary arrest and in the absence of a RED dot on the arm bracelet: 5.1 Initiate CPR using universal precautions and appropriate disposable mouthpieces: 5.2 Call 911 and notify the Physician; 5.3 CPR may not be stopped until relieved by EMS (Emergency Medical Responders) personnel, a verbal order from the Physician is given, or other state specific requirements are met. A review of the facility's AHCA Nursing Home Reporting form filed on [DATE] recapped the incident involving Resident #1's death on [DATE]. It noted the facility's failure to honor advanced directives for Resident #1, and identified LPN A, the RN, CNA A and CNA B as being directly involved on the night of the occurrence. The summary was consistent with the telephone interviews obtained from LPN A, and CNAs A and B. The Director of Nursing notified the Administrator and Risk Manager that advanced directives were not honored for Resident #1 on the evening of [DATE]. The physician denied instructing the facility not to perform CPR on Resident #1. The report's Analysis and Corrective Action concluded that CPR was not initiated per (Resident #1's) advanced directives, and outlined the following corrective actions taken: 1. Physician and family were aware customer expired and CPR was not initiated. 2. Advanced Directives/Code Status for customers on all units were reviewed for accuracy of code status, in accordance with the customer's and legal representative ' s wishes. Customer's arm bands were checked for presence.... If code status per customer's and representative's wishes and per physician order [REDACTED]. 3. 97 of 102 nursing staff were in-serviced on the center's policy as it relates to CPR and the initiation of CPR when there is no red dot present (no DNRO in place) and no arm band, and the calling of 911 Emergency Medical Services for medical assistance. The remaining nursing staff will receive in-service prior to starting on the assigned units on their next scheduled shift. Center licensed nurses and CNAs to participate in random mock codes to exhibit/reflect understanding and proficiency in identifying customer code status and ability to initiate code process per policy and guidelines. 4. DON (Director of Nursing)/Designee and Social Services Director/designee to monitor daily presence of arm bands and identification/accuracy of code status per physician's orders [REDACTED]. Findings reported to quality assurance monthly. A review of the facility's Corrective Action Plan revealed multiple staff trainings had been conducted between [DATE] and [DATE] on CPR and the DNR red dot system. The records also included completed daily monitoring checklists of resident arm bands and clinical records for the presence of the red dot, physician's orders [REDACTED]. In addition, mock code drills had been conducted and documented. The corrective actions identified by the facility were confirmed to be in place at the time of survey. .