Every finding on record at Dade City Health and Rehabilitation Center

Based on interviews and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a residents' end-of-life wishes for Do Not Resuscitate (DNR) was honored for one (#3) of three residents sampled.On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. The facility's failure to honor Resident #'s DNR status deprived her of a dignified death and likely resulted in severe pain and organ damage. Additionally, Resident #3 could not express her reaction to this event. Applying the reasonable person concept, Resident #3 would likely experience serious psychosocial harm by being resuscitated against her wishes. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F578 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma.A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse.A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment.A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 3:08 p.m. Staff H, CNA said on [DATE] she found Resident# 3's DNRO form in the Code Status Binders. Upon entering Resident #3's room, Staff B, RN was crawling off [Resident #3's] bed. Staff H, CNA stated [Staff B, RN] did not check if the resident had DNR orders.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said her employment at the facility began mid-September of 2025. During orientation education and training was provided primarily through computer modules. Staff B, RN said during orientation, the facility did not provide education or training related to Code Blue procedures or DNR procedures. She was not trained how to locate a resident's code status in the computer. She did not know about the code blue binder until after Resident #3 was found not breathing and without a pulse on [DATE].During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the Code Status Binders before initiating CPR. The DON confirmed Resident #3's wishes for DNR was not honored.A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.Definitions:Code Status: Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident heart stop beating and/or should the resident stop breathing.Do Not Resuscitate (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally, if their heart stops beating and/or they stop breathing.Admission/ readmission: Code Status verified upon admission with resident/representative by admitting nurse.-Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD.)DNR: Admitting nurse must review with resident/resident representative with a witness present (preferably another nurse of social services).-Admitting nurse obtains order from physician (MD) [physician].-Initiates yellow DNR form.-Yellow DNR form will be signed by the resident/resident representative and the two nurses who obtained the order from physician (MD).-Order entered [Electronic Health Record] verbal physician order is recognized as the resident's code status.-Yellow DNR form will be copied and social services notified of the new DNR.-Yellow DNR form will be expedited to the physician for final signature.OR-Resident arrives to the facility with yellow DNR form in place either from hospital /community.-Admitting nurse must confirm with the resident/resident representative choice for DNR.-Nurse obtain orders from the physician.-Order entered into [EHR].-Yellow DNR form is scanned into the [EHR] by a designated facility representative .-Yellow DNR form is placed in the Code Status Binders at all nurses' stations .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Section-Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive. The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional Interdisciplinary team (IDT) members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On 11/17-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] observed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education regarding two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE]. On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes.

Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#3) out of three residents sampled.On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. The facility's failure to honor Resident #3's DNR status deprived her of a dignified death and likely resulted in severe pain and organ damage. Additionally, Resident #3 could not express her reaction to this event. Applying the reasonable person concept, Resident #3 would likely experience serious psychosocial harm by being resuscitated against her wishes. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F600 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma.A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse.A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment.A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 12:30 p.m. Staff F, CNA stated upon entering Resident #3's room she [Resident #3] was passed out. Staff F, CNA said, Staff B, RN was on top of [Resident #3] giving two chest pumps, she got off quick. Staff B, RN directed me to call 911 and I hurried up to call. Staff F stated later Staff A, LPN told her CNAs are not allowed to call 911.During an interview on [DATE] at 11:36 a.m. Staff D, CNA, assigned to care for Resident #3 on [DATE], stated upon picking up Resident #3's dinner tray Resident #3 was not responding. Staff D, CNA called Staff B, RN to the resident's room. Staff D, CNA stated Staff B, RN provided one or two chest compressions before stopping. Staff D stated Staff B, RN appeared to be having difficulty breathing and Staff B said she was having an asthma attack.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 1:25 p.m., Staff B, RN stated she began employment at the facility mid-[DATE]. She stated during orientation the facility provided general orientation through an online platform. Staff B, RN said the facility did not provide education or training related to CPR or DNR procedures, instruction on how to locate a resident's code status in the computer system, or the location and contents of the CPR binder. She stated after Resident #3 expired, she learned the DNRO forms were in the CPR Blue binders.During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the CPR Blue book before initiating CPR. The DON confirmed Resident #3's wishes for DNR were not honored.During an interview on [DATE] at 12:40 p.m. Resident #3's APRN said on [DATE] was notified through a Health Insurance Portability and Accountability Act (HIPAA) compliant messaging line chest compressions were performed on Resident #3. The APRN said, If a resident is a DNR do what the family wishes.During an interview on [DATE] at 12:47 p.m. Resident #3's physician said the expectation for residents with DNR status, is no interventions should be performed if the resident is pulseless; no resuscitative measures no heroics are to be started.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR).Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order; andc. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Section - Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive.A review of the facility policy titled Abuse, Neglect and Exploitation, revised [DATE], showed the following:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation andCompliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On 11/17-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] observed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes.

Based on review of the facility policy, interviews and record review, the facility failed to ensure the residents' wishes were honored related to Do Not Resuscitate (DNR) orders for one (#3) of three residents sampled.On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F678 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma.A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse.A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment.A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.A review of Resident #3's care plan meeting minutes, dated [DATE] showed: Advance Directive: DNR.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 11:36 a.m. Staff D, CNA, assigned to care for Resident #3 on [DATE], stated upon picking up Resident #3's dinner tray Resident #3 was not responding. Staff D, CNA called Staff B, RN to the resident's room. Staff D, CNA stated Staff B, RN provided one or two chest compressions before stopping. Staff D stated Staff B, RN appeared to be having difficulty breathing and Staff B said she was having an asthma attack.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 12:30 p.m. Staff F, CNA said when she entered Resident #3's room the she [Resident #3] was passed out. Staff F, CNA said, she saw Staff B, RN on top of [Resident #3] giving two chest pumps, she got off quick. Staff B, RN directed me to call 911 and I hurried up to call. Later Staff A, LPN told me CNAs are not allowed to 911.During a telephone interview on [DATE] at 3:05 p.m. Staff G, CNA said on [DATE] when Staff E, LPN said Resident #3 was a DNR, I started hollering, she [Resident #3] is a DNR.During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the code status binder before initiating CPR. The DON confirmed Resident #3's wishes for DNR was not honored. The DON said since [DATE] the facility has implemented additional education and training to prevent recurrence. Interventions include instructing staff to Stop, Think, Perform prior to initiating emergency interventions, conducting Code Blue drills, completing one-to-one Code Blue competency validations, and administering post-tests to assess staff understanding. Education was provided to all staff members and included the following topics: abuse, neglect, and exploitation; resident rights; Code Blue procedures; two-nurse verification of code status; adherence to the resident's care plan and physician orders; and timely physician notification. The facility will continue to monitor staff compliance through ongoing audits and competency evaluations.During an interview on [DATE] at 4:16 p.m. with the NHA, Regional Nurse Consultant (RNC), and the Regional Director of Operations (RDO). The NHA said on [DATE] Resident #3's code status was not checked before compressions were performed.During an interview on [DATE] at 12:40 p.m. Resident #3's APRN said on [DATE] was notified through a Health Insurance Portability and Accountability Act (HIPAA) compliant messaging line chest compressions were performed on Resident #3. The APRN said, If a resident is a DNR do what the family wishes.During an interview on [DATE] at 12:47 p.m. Resident #3's physician said the expectation for residents with DNR status, is no interventions should be performed if the resident is pulseless; no resuscitative measures no heroics are to be started.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR).Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order; andc. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Section - Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive.A review of the facility policy titled Abuse, Neglect and Exploitation, revised [DATE], showed the following:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation andCompliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect .A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.Definitions:Code Status: Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident heart stop beating and/or should the resident stop breathing.Do Not Resuscitate (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally, if their heart stops beating and/or they stop breathing.Admission/ readmission: Code Status verified upon admission with resident/representative by admitting nurse.-Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD.)DNR: Admitting nurse must review with resident/resident representative with a witness present (preferably another nurse of social services).-Admitting nurse obtains order from physician (MD).-Initiates yellow DNR form.-Yellow DNR form will be signed by the resident/resident representative and the two nurses who obtained the order from physician (MD).-Order entered [Electronic Health Record] verbal physician order is recognized as the resident's code status.-Yellow DNR form will be copied and social services notified of the new DNR.-Yellow DNR form will be expedited to the physician for final signature.OR-Resident arrives to the facility with yellow DNR form in place either from hospital /community.-Admitting nurse must confirm with the resident/resident representative choice for DNR.-Nurse obtain orders from the physician.-Order entered into [EHR].-Yellow DNR form is scanned into the [EHR] by a designated facility representative .-Yellow DNR form is placed in the Code Status Binders at all nurses' stations .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On [DATE]-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] reviewed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes.

Based on record review, interviews, and policy review, the facility failed to ensure nursing staff were competent in identifying and honoring cardiopulmonary resuscitation wishes for one (#3) of three residents sampled On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F726 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma. A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse. A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment. A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 1:25 p.m., Staff B, RN stated she began employment at the facility mid-[DATE]. She stated during orientation the facility provided general orientation through an online platform. Staff B, RN said the facility did not provide education or training related to CPR or DNR procedures, instruction on how to locate a resident's code status in the computer system, or the location and contents of the CPR binder. She stated after Resident #3 expired, she learned the DNRO forms were in the Code Status Binders.During an interview on [DATE] at 4:16 p.m. with the Nursing Home Administrator (NHA) the Regional Nurse Consultant (RNC), and the Regional Director of Operations (RDO). The NHA said Resident #3 was a DNR and she was told compressions were performed. The NHA read Staff A, LPN's witness statement. Staff A, LPN wrote [on [DATE]] Resident #3 was assessed with Staff E, LPN and they verified no heartbeat and death was pronounced at 6:38 p.m. messaged the ARNP . informing her of resident's passing around 1900 [7:00 p.m.]. The NHA said on [DATE] Resident #3's code status was not verified before chest compressions were performed. Staff did not follow the procedure to overhead page there was a code blue emergency. Licensed nurses are expected to notify EMS and a CNA notified EMS. The RNC said since incident all staff members have participated in code blue drill and licensed nurses have completed the code blue checklist. The RNC said the facility has provided additional education to CNAs regarding their role during a code blue emergency.During an interview on [DATE] at 1:46 p.m. Staff C, Licensed Practical Nurse, (LPN) Unit Manger UM) said new employee orientation consist of education/training using a collaboration platform and licensed nurses receive a minimum of three days orientation in the nursing unit. Staff C, LPN, UM said code blue checklist and mock Code Blue drills were implemented after the [DATE] event.During an interview on [DATE] at 4:00 p.m. the RNC said the Code Blue Response Worksheet is used as a training tool during drills.Review of facility Job Description, Position: Director of Nursing (DON), showed the following: Summary provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistants Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility.Essential Duties and responsibilities: .direct the day-to-day functions of the LPN's, nursing assistants .in accordance with rules, regulations, and guidelines that govern the long-term care industry.Ensure that all nursing personnel assign to you comply with the written policies and procedures established by the facility .Confirm that LPN's and CNAs ae aware of the resident care plan. Review of facility Job Description Position: Registered Nurse, showed the following:Summary: Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility.Provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistant Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility. Essential Duties and responsibilities: Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.Review of facility Job Description Position: Charge Nurse (LPN) showed the followingSummary: Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility .Essential Duties and responsibilities: Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.A review of the facility's General Orientation Agenda undated, . showed on orientation day #2 the Life Safety/ Codes includes: Code Blue, CPR, DNR, and Stop, Think, PerformA review of the facility checklist titled Code Status Competency showed staff competency verifications include the following:1. Verbalizes Understanding and acknowledges process with New admission New DNR responsibilities.2. Verbalizes Understanding and acknowledges process with New admission New DNR time implementation3. Verbalizes Understanding and acknowledges process with New admission New DNR obtaining order from physician, entering order into Point Click Care.4.Verbalizes Understanding and acknowledges process with New admission New DNR initiating Yellow DNR Form with resident/representative signature.5.Verbalizes Understanding and acknowledges process with New admission New DNR copies placed in all code status binders.6. Verbalizes Understanding and acknowledges process with New admission New DNR copy to Social Services for physician signature.7.Verbalizes Understanding and acknowledges process with re-admission New DNR responsibilities. 8. Verbalizes Understanding and acknowledges process with re-admission New DNR time implementation.9. Verbalizes Understanding and acknowledges process with re-admission New DNR obtaining order from physician, entering order into Point Click Care.10. Verbalizes Understanding and acknowledges process with re-admission New DNR initiating Yellow DNR Form with resident/resident representative signature . A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives.In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2.If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:1a. In accordance with the resident's advance directives .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On [DATE]-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] reviewed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes.

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent falls for three (#3, #8, and #9) of three residents sampled for fall events out of a total of nine sampled residents, related to lack of an IDT (Interdisciplinary Team) assessment post fall and identifying and / or implementing appropriate post fall interventions for Resident #3, #8 & #9, and accurate neuro check monitoring for Resident #3.Findings included: 1. A review of Resident #3’s clinical chart, the admission Record, documented an admission of 10/2023, with a readmission of 07/11/2025. His diagnosis information included but not limited to dementia, muscle weakness, and need for personal care. An observation and interview were conducted on 07/15/2025 at 10:15 a.m. with Resident #3, sitting in a wheelchair, dressed in seasonally appropriate clothing, he stated he had fallen two times. Nothing broken. Hurt, yes, his right leg. He was observed to pat his right leg which had a soft brace that wrapped around his leg above and below his knee. He did not remember how he fell. Review of Resident #3’s progress notes revealed the following: Dated 06/29/2025 at 7:28 p.m.: While providing care to (Resident #3’s) roommate. The Certified Nursing Assistant (CNA) observed (Resident #3) attempting to exit his bed independently. The CNA promptly responded and assisted the resident to the bathroom. During this interaction, (Resident #3) reported that he had stood up using the bed for support and then slowly lowered himself to his knees on the floor. The CNA and Registered Nurse subsequently utilized a (mechanical) lift to safely return the resident to bed. A full assessment was completed revealing no impairment to the integumentary system. The resident communicated to the Spanish-speaking nurse that he was not experiencing any pain. … Review of the fall report log revealed this fall was not on the fall report log. Progress note dated 06/30/2025 at 11:22 a.m.: Patient experienced a fall while attempting to transfer without assistance. Right elbow is bruised with no open areas noted. Patient reported pain at the site. Md (Medical Doctor) has been notified of fall and x-ray will be ordered. Dated 07/03/ 2025 at 12:44 p.m.: Resident was seen lying on the floor at the nurses’ station facing park hallway. He was lying on his right side. There were multiple drops of blood on the floor near his head. A 3 cm (centimeter) laceration noted to right eyebrow. He was assessed by floor nurse and (provider nurse practitioner) who was at facility when fall occurred. Resident’s eyeglass arm was broken off. He remained on the floor with nursing supervisor until 911 arrived. Resident right eyebrow laceration was assessed by wound nurse. … Resident was last seen sitting outside of dayroom in his w/c (wheelchair) with no concern. A review of Resident #3’s Care Plan, reflected a focus: (Resident #3) is at risk for falls and fall related injury…, initiated 01/10/2023. A review of the interventions revealed on 06/29/2025, an intervention of “staff education” was added. No specific instructions were identified in the intervention. On 06/30/2025, an intervention of “Increased toileting”. No further additional interventions were revealed. A review of the facility’s Neuro check Assessment Form, copyright 2020, documented instructions for Neuro checks: q (every) 15 min (minutes) x 1 hr (hour). q 30 min x 1 hr q 1 hr x 4 hrs q 4 hrs x 24 hrs q shift until 72 hours For Resident #3, the facility provided two Neuro check forms, for the 06/30/25 fall, which occurred at 8:15 a.m. The form recorded monitoring from 06/30/25 to 07/03/25. Review of the form revealed staff did not document the time Resident #3 was monitored during the “q shift until 72 hours”, but documented the type of shift, i.e. “night”, “day”, or “eve” (evening), through 07/03/25 evening shift. On 07/03/25, Resident #3 had another fall at 11:55 a.m., he had a laceration above right eyebrow. He was transferred to a higher level of care. On 07/15/2025 at 3:26 p.m., an interview and review of Resident #3’s falls was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing. During the review of the Neuro check forms, the RNC stated that the times of observation should have been recorded, not the shift. For Resident #3’s 06/30 fall, the RNC said the fall occurred at 8:15 a.m., unwitnessed, the post fall assessment said they were going to remove clutter from the resident’s room and assist with toileting. When asked about the clutter, she said there was not enough detail to determine the clutter issue. For the toileting, she said he was near the bathroom, his shoelaces were untied, they tied his shoes, and he was able to stand. When asked if the Interdisciplinary Team (IDT) had reviewed the fall event, she stated they reviewed the 06/30, 07/02/25, and 07/03/25 fall events on 07/07/2025. “The usual practice is for IDT to review everything after the fall, or the morning after the fall. The RNC said the 07/02/25 fall occurred at 10:50 p.m., unwitnessed, the resident was found on the bathroom floor. The proactive measure implemented was “assist with toileting again”. This fall was reviewed by IDT on 07/07/2025. The RNC said the 07/03/25 fall occurred at 11:55 a.m., unwitnessed, she did not have the location of the fall. She said the resident had a laceration above the right eyebrow. He was transferred out and then came back. Progress notes were reviewed for the 07/02/25 fall event description without successful location of the event documentation. For Resident #3, he had a fall at 10:50 a.m. in the bathroom on 07/02/25. No new Neuro check sheet was provided that would indicate the monitoring had been re-implemented for the 07/02 fall. 2. Resident #8 was admitted on [DATE]. Review of the Admissions record showed diagnoses included but not limited to cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, other specified disorders of the brain, frontal lobe and executive function deficit following cerebral infarction, myocardial infarction, chronic obstructive pulmonary disease (COPD), epilepsy, occlusion and stenosis of right carotid artery, hypertension, muscle weakness, and lack of coordination. Review of the progress notes on 07/01/2025 showed, during med pass resident was observed rolling out of bed while drowsy in blankets with pillow, Review of the Post Fall Evaluation dated 07/01/2025 showed fall occurrence was 07/01/2025 at 5:00 a.m. the fall was witnessed. The resident rolled out of bed in the resident’s room. The resident was sleeping. Environmental factors present was poor lighting. Vital signs were documented. Neuro checks were normal. No changes observed in mental status. Resident was not experiencing any pain. Range of Motion was within normal limits. Injuries? Yes. Bruise left forearm, 7.62 cm (centimeter) x 5.08 cm, superficial and not bleeding. Immediate New measures included low bed and frequent checks to coincide with neuro checks. Physician was notified on 07/01/2025 at 5:47 a.m. Family notified on 07/01/2025 at 5:48 a.m. Review of the IDT (Interdisciplinary Team) Post Fall Review dated 07/08/2025 showed fall occurred on 07/01/2025 at 7:00 a.m. (different time). Conditions that may have contributed included unsteady gait and history of falls. 5. IDT recommendations included a. equipment (specify below). 5a. if equipment was selected, specify: staff education. Review of the care plans showed Resident #8 was at risk for falls and fall related injury related to metabolic encephalopathy, chronic alcohol dependence, seizure disorder as of 11/16/2023. Interventions included but were not limited to Early Get Up as of 07/05/2025; staff education was initiated on 07/01/2025 and resolved on 07/10/2025. During an interview on 07/15/2025 at 4:52 p.m., the Regional Nurse (RN) and Director of Nursing (DON) stated the Post Fall Evaluation under the assessment section was to show the description of the fall. The RN stated the IDT Post Fall Review was to occur the next day after a fall or within 1-2 days. The RN reviewed the IDT Post Fall Review dated 07/08/2025 for Resident #8 and verified it was completed 6 days after the fall. The RN stated she would expect to see it completed on 07/02/2025 or 07/03/2025. The DON stated the staff was educated to make sure a resident was not tangled up in the sheets or comforters. The DON verified the “staff education” provided was not documented in the e-medical record. The RN and the DON reviewed the care plan and stated the interventions should have addressed the resident’s needs at the time of the fall. The DON stated the fall was unwitnessed even though the documentation in the progress notes showed it was witnessed. The RN stated the documentation was confusing as to whether the fall was witnessed or unwitnessed. The DON stated the Unit Managers (UM) bring a fall “packet” to the morning meetings for review. The UMs do not necessarily keep all the documentation they bring to the morning meetings. 3. Resident #9 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Huntington’s disease, dementia, history of falls, and muscle weakness. Review of the progress notes showed on 07/10/2025, Certified Nursing Assistant (CNA) entered the room for rounds and observed the resident lying in a supine position in the bathroom with his head towards the toilet. The resident was lying on the raised toilet seat which was lying in front of toilet on its side. Vital Signs and neuro checks were within normal limits. No signs and symptoms (s/s) of a head injury. The resident was fully clothed with non-slip socks on. The resident was removed from the bathroom. Full range of motion at baseline for the resident with no deficits noted. The CNA and I assisted the resident to bed. Scratches noted to mid/upper back and chest with no bleeding. A 3cm scratch noted to right upper chest with scant amount of bleeding noted. Redness noted to upper back and back of neck. No s/s of pain noted. Scratch to right upper chest cleansed with Normal saline, patted dry and covered with dry dressing. ARNP (Advanced Practice Registered Nurse), resident's family, hospice and nurse management notified of incident. Review of the Post Fall Evaluation dated 07/11/2025 at 12:21 a.m. showed the fall occurred on 07/10/2025 at 9:45 p.m. The fall was unwitnessed. CNA entered room for rounds and observed resident lying in supine position in bathroom with head towards the toilet. Resident was lying on the raised toilet seat which was lying in front of toilet. Resident fell in the bathroom. Resident was unassisted transfer, unassisted ambulation, Huntington’s disease progression. The resident was in bed prior to fall. The resident had non-skid socks on and raised toilet seat. No environmental factors. Vital signs were taken. Neuro checks were normal. No changes in mental status. Not experiencing any pain. Range of motion was within normal limits. Injuries included abrasion and redness right upper chest, medial chest and mid/upper back. Skin integrity alteration was 3 cm by 1 cm, superficial and not bleeding. Immediate new measures included other. Vital signs and neuro checks. APRN notified on 07/10/2025 at 10:00 p.m. and family notified on 07/10/2025 at 10:00 p.m. Review of the IDT Post Fall Review dated 07/11/2025 at 4:52 p.m. showed time of fall was 07/10/2025 at 4:52 p.m. (different times). Predisposing diseases included Hunting Disease. Conditions that may contribute were unsteady gait, history of falls, muscle weakness. IDT recommendations included Medication Regimen Review. Review of the care plans showed Resident #9 was at risk for falls and fall related injury related to impaired mobility, medication usage, chronic disease process as of 11/07/2023. No new interventions were found for the 07/01/2025 fall. During an interview on 07/15/2025 at 4:52 p.m. the Regional Nurse (RN) and the DON verified the fall care plan had not been updated with a new intervention for the 07/01/2025 fall. The DON stated the hospice doctor would be responsible for the Medication Regimen Review for the resident. She verified there was no documentation in the medical record verifying this recommendation had been performed. The DON verified there was no documentation the neuro checks had been performed. The DON stated they would have been completed yesterday (07/14/2025), maybe they had not been scanned into the medical record yet. A review of the facility’s policy and guidelines for Accidents and Supervision, dated 11/03/2020, last reviewed on 10/18/2022, documented the policy: The resident environment will be free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Included in the definitions: “Supervision/Adequate Supervision” refers to intervention and means of mitigating risk of an accident. The policy explanation and compliance guidelines included: 1. Identification of Hazards and risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. … b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. … 4. Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions. 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident’s assessed needs and identified hazards in the resident environment.

Based on observation, record review, and interview, the facility failed to ensure accurate generally accepted accounting principles were implemented for two residents (#3 and #7) of three residents reviewed for Resident Trust Fund monies out of nine sampled residents. Resident #3 was not being charged the correct patient liability (cost of care) or allocated his personal needs allowance of $160.00 per month; Resident #7, a Supplemental Security Income (SSI) recipient, was not being charged the correct patient liability and the facility had not safeguarded his funds by ensuring the Social Security office had been notified of his residence in the Nursing Home.Findings included: 1. A review of Resident #3's clinical chart, the admission Record, documented an admission of 10/2023, with a readmission of 07/11/2025. His diagnosis information included but not limited to: dementia, muscle weakness, and need for personal care.A family member was listed as the resident's responsible party, power of attorney for financial and care. An observation and interview were conducted on 07/15/2025 at 10:15 a.m. with Resident #3, sitting in a wheelchair, dressed in seasonally appropriate clothing, he stated his family will bring in what he needs, and takes care of his finances. A review of Resident #3's eligibility recipient information for Medicaid for the dates of 07/2024 through 12/2024, documented Resident #7 had been determined eligible for Medicaid in the nursing home with a monthly patient liability (room and board) of $1,303.63 and for 01/2025 on going, a monthly patient liability of $1,338.63. A review of Resident #3's Resident Fund Management System (RFMS) (patient trust account) for the date of 12/13/2024 through the date of survey (07/15/2025) reflected Resident #3's Social Security check was direct deposited into his patient trust account. Review of the patient trust account debit column, which reflected the withdrawal by the facility for the monthly cost of care for room and board (patient liability) documented the following cost being charged the resident:01/03/2025=$1,438.0001/31/2025=$272.6302/03/2025=$1,438.0003/03/2025=$1,438.0004/03/2025=$1,438.0005/03/2025=$1,438.0006/03/2025=$1,466.0007/03/2025=$1,466.00 Further review of the RFMS (patient trust account) for 12/2024 through 07/15/2025 reflected no evidence the facility was setting aside Resident #3's personal needs allowance of $160.00 per month A review of Medicaid ESS (Economic Self Sufficiency) policy manual section 2640.0118 reflected Florida allows nursing home residents on the Medicaid long-term care program to retain a personal needs allowance of $160.00 per month. A review of Resident #3's billing statement for room and board, print date of 07/15/2025, for the time period of 01/01/2024 through the date of survey, 07/15/2025, was reviewed.For the 06/2024 through 12/2024, the charge for room and board was reflected to be $1,303.63 per month.For the 01/2025 through 04/2025, the charge for room and board was reflected to be $1,338.63.For 05/2025, $1,295.45;For 06/2025, $1,338.63;For 07/2025, $1,209.09As of 07/15/2025, Resident #3's room and board charge statement reflected a credit of $3,163.02. (over payment). The BOM was interviewed on 07/15/2025 at 2:48 p.m. while reviewing the RFMS statement and the room and board billing. The BOM confirmed what had been billed for room and board was not the same as what was being pulled from the RFMS (patient trust system). 2. A review of Resident #7's clinical chart, the admission Record, documented an admission to the facility in 01/2023; readmission in 11/2024. His diagnosis information included, but not limited to: Dementia, muscle weakness, and chronic kidney disease. A review of Resident #7's eligibility recipient information for Medicaid for the dates of 07/2024 through 07/2025, documented Resident #7 had been determined eligible for Medicaid in the nursing home with a monthly patient liability (cost of care) of $0.00. A review of Resident #7's RFMS (patient trust) Account for the dates of 12/13/2024 through the date of survey, 07/15/2025, documented Resident #7 had been charged a monthly patient liability (cost of care) each month of $807.00. The RFMS account reflected a monthly SSI (Supplemental Security Income) check deposit of $967.00. The BOM was interviewed on 07/15/2025 at 1:13 p.m. regarding Resident #7. She stated she became aware the facility was Representative Payee for Resident #7 when the Social Security office reached out, they were auditing his account. She stated prior to Social Security reaching out, she was unaware the facility was Representative Payee for Resident #7. When asked if the facility had notified the Social Security office of Resident #7's residing in a nursing home, she said she would see. When asked if the facility had a process to notify the Social Security office, she stated she did not have a form, but she could ask what the process was for the corporation. A review of the Social Security website, SSA.gov, section GN 00502.114 Representative Payee Responsibilities and Duties, included: The payee responsibilities and duties are to: report events that may affect the beneficiary's entitlement or amount of payment. A review of the Social Security website, SSA.gov, regarding living arrangements for an SSI recipient and reduction of SSI benefits when: Are in a public or private medical treatment facility and Medicaid is paying for more than half of the cost of your care. If you are in the facility for the whole month, your SSI benefit is limited to $30 (plus any supplementary State payment).

Based on record review and interviews, the facility failed to ensure a prompt effort to resolve a grievance for one resident (#3) of three residents sampled for grievances of a total of nine sampled residents. Resident #3's family member had voiced a concern on 02/24/2025 regarding Resident #3's patient trust monies, an accounting of the withdrawals, an inquiry of a $400.00 deposit, an $1800.00 refund, and a concern regarding the posting of Resident #3's $160.00 monthly patient allowance. The concern was still outstanding as of 07/15/2025.Findings included: A review of Resident #3's clinical chart, the admission Record, documented an admission of 10/2023, with a readmission of 07/11/2025. His diagnosis information included but not limited to dementia, muscle weakness, and need for personal care.A family member was listed as the resident's responsible party, power of attorney for financial and care. An observation and interview were conducted on 07/15/2025 at 10:15 a.m. with Resident #3, sitting in a wheelchair, dressed in seasonally appropriate clothing, he stated his family will bring in what he needs and takes care of his finances.A review of a grievance for Resident #3 was conducted with the Social Service Director on 07/15/2025 at approximately 11:20 a.m. She stated, the (family member) is complaining about $400.00; it has not been resolved. A review of a grievance / complaint form, dated 06/19/2025, documented a concern: has multiple ongoing concerns about (Resident #3's) account. Issue has been ongoing since 2024. The form documented the staff assigned responsibility for the investigation was the Business Office Manager (BOM), assigned on 06/19/2025 with a due date of 06/23/2025. Further review of the grievance reflected no findings of an investigation, and no plan to resolve the complaint.A letter was attached to the complaint, dated 06/19/2025, from the family member which listed concerns regarding Resident #3's personal trust account, regarding a $400.00 deposit to the account she had made in August of last year, that Resident #3 should have $160.00 allocated monthly for personal expenses from his gross income, and that she had a concern about the balance in the account due to the limited number of expenses he had incurred. I need to know the balance in his account and an accounting of what monies was used.An attached e-mail, dated 05/27/2025, documented a note to the facility's corporate Account Receivable Specialist from the BOM: I am so confused about this one; the (family member) is saying that there was supposed to be a refund check since last year of $1,800.00 something. Can you please check on this account for me.An attached e-mail, dated 05/14/2025, from the (family member), This email is a follow up regarding (Resident #3's) funds. I still have not received his funds please provide status.An attached e-mail, dated 03/20/2025, from the (family member), which listed concerns identical to the 06/19/2025 e-mail from the family member regarding Resident #3's personal trust account, regarding a $400.00 deposit to the account she had made in August of last year, that Resident #3 should have $160.00 allocated monthly for personal expenses from his gross income, and she had a concern about the balance in the account due to the limited number of expenses he had incurred. I need to know the balance in his account and an accounting of what monies was used.An e-mail, dated 02/24/2025, from the (family member), which stated, here is the receipt of the $400.00 I had put in his trust account. In addition to his monthly personal allowance of $160.00 which the nursing home was supposed to be putting away each month. That's the amounts that I am concerned about. An interview was conducted on 07/15/2025 at 11:00 a.m. with the Assistant Business Office Manager. She stated, for Resident #3, there was a grievance submitted by the (family member) of the resident. She wanted a printout of how the transactions for the resident trust account were debited and credited to the account. An interview was conducted on 07/15/2025 at 1:13 p.m. with the Business Office Manager. When asked about the 06/19/2025 grievance, she stated the (family member) had a concern about $1800.00 amount; $400.00, which was located in a different account; and the dental premiums. We switched banks with the RFMS (Resident Fund Management System). The BOM was unable to present documentation that would indicate the (family member's) concern had been addressed as of 07/15/2025.A review of the facility policies and procedures: Resident Right-Grievances, issued 11/07/2024, documented the policy: It is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights.The procedure included: .2. The resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have in accordance with this paragraph. 8. The facility will establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights.

Based on observation, interview, and record review, the facility failed to ensure resident documentation was accurate and complete for four (#1, #2, #3, #4) of four sampled residents. Findings included: 1. Resident #1 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the Admission Record showed diagnoses included but not limited to cellulitis of other sites, Methicillin resistant Staphylococcus Aureus infection, pressure ulcer stage 4 in sacral region, diabetes, hypertension, quadriplegia, contractures of multiple sites, and muscle weakness. Review of the physician orders showed cleanse left/right buttock wound with normal saline and apply collagen and cover with absorbent dressing and secure with tape daily and as needed. Review of the LTC (Long-Term Care) Notes showed On 09/03/2024 section G, SKIN/WOUND: No wounds present. 2. Resident #2 was admitted on [DATE] and discharged on [DATE]. Review of the Admission Record showed the diagnoses included but not limited to benign neoplasm of meninges, diabetes, Chronic Obstructive Pulmonary Disease, hypertensive chronic kidney disease stage III, adult failure to thrive, protein-calorie malnutrition, hypotension, and encounter for palliative care. Review of the Admit/Readmit Screener dated 10/30/2024, Section SK / Skin Integrity 1. Skin Color: normal for ethnic group; 2. Skin turgor: normal; 3. Does resident have any areas of skin breakdown? Yes. 3 a. Describe skin issues and location below: bruise to both eyes, bruising to BUE (Bilateral Upper Extremities), both heels red, open area to coccyx. Review of the Skilled Nurses Note showed On 10/31/2024, no Skilled Nurse Note documentation On 11/01/2024, no Skilled Nurse Note documentation On 11/02/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/03/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/04/2024, no Skilled Nurse Note documentation On 11/05/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/06/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/07/2024, days, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/07/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. Review of the Weekly Skin Evaluation showed On 10/31/2024, bruises to face and both arms; open areas are blank. On 11/02/2024, skin tear on left elbow, bruises to BUE to arms and hands, right breast, left and right eyes. Open area to sacrum, pressure stage III and pressure stage I to left and right heels. On 11/06/2024 Bruises on Left and right eye, left and right arms, left and right hands. Open areas are blank. Review of the baseline care plan dated 10/30/2024 showed, I have impaired skin integrity. Location / Stage (if applicable) was blank. Goal showed, I will remain free from new areas of skin breakdown through next review date. Approaches included perform skin evaluation upon admission, weekly and as needed. See current physician's orders / TAR for current treatments as ordered by physician was not checked. The care plan lacked pressure ulcer interventions. 3. Resident #3 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and diabetes. Review of the Admit/Readmit Screener dated 11/05/2024 showed SK. Skin Integrity. 1. Skin Color: normal for ethic group. 2. Skin turgor: normal. 3. Does resident have any areas of skin breakdown? Yes. 3a. Describe skin issues and location below: DTI to left buttocks; scab (s) to BLE (Bilateral Lower Extremities). Review of the Skilled Nurses Note showed On 11/09/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/11/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/13/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: anterior bilateral lateral lower extremities. Dressing change: 4. Treatment to wound (s) performed on this shift as ordered. 5. Signs and Symptoms of Wound Infection: 2. redness (erythema) 4. purulent drainage. Comments/Notes: Resident continues on ABT for lower leg possible infection. Redness and swelling noted. On 11/16/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/17/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. Review of the Weekly Skin Evaluation dated 11/11/2024 showed: skin intact. Review of the Weekly Skin Evaluation dated 11/12/2024 showed 3. Blanchable redness of buttocks. 4. Skin tear to left lower leg. Review of the Baseline Care Plan dated 11/05/2024 showed, I have impaired skin integrity. Location/Stage (if applicable) left buttocks. I will remain free from new areas of skin breakdown through next review date. Approaches included perform skin evaluation upon admission, weekly and as needed. See current physician's orders / TAR for current treatments as ordered by physician was not checked. The care plan lacked pressure ulcer interventions. 4. Resident #4 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to severe protein calorie malnutrition, Chronic Obstructive Pulmonary Disease, muscle weakness, rheumatoid arthritis, pulmonary fibrosis, and adult failure to thrive. Review of the LTC Nurses Note showed On 11/05/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: cool / clammy. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/05/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm / dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/06/2024, day, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: Has wounds. 3a. sacrum. Dressing Change: 4. Treatment to wound(s) performed on this shift as ordered. 5. Signs and Symptoms of wound infection: none of the above. On 11/06/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: Has wounds. 3a. sacrum. Dressing Change: 4. Treatment to wound(s) performed on this shift as ordered. 5. Signs and Symptoms of wound infection: none of the above. On 11/07/2024, night, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: Has wounds. 3a. sacrum. Dressing Change: 4. Treatment to wound(s) performed on this shift as ordered. 5. Signs and Symptoms of wound infection: none of the above. On 11/07/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: Has wounds. 3a. sacrum. Dressing Change: 4. Treatment to wound(s) performed on this shift as ordered. 5. Signs and Symptoms of wound infection: none of the above. On 11/08/2024, no LTC Nurse Note documentation On 11/09/2024, night, Section G, SKIN/WOUND: 1. Skin Description: warm / dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/10/2024, night, Section G, SKIN/WOUND: 1. Skin Description: warm / dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. Review of the Weekly Skin Evaluations showed On 11/01/2024, open area, wound noted to sacrum, treatment in progress. On 11/05/2024, open area on sacral area. On 11/12/2024, open areas, sacral wound. Review of care plans showed has actual skin breakdown related to unstageable pressure wound to sacrum as of 05/20/2024 and revised 09/09/2024. Interventions included but not limited to complete Weekly Skin Evaluation. Consult wound physician as needed. Wound care as ordered, see current treatment record and physician's orders; monitor effectiveness of / response to treatment as ordered. 5. During an interview on 11/18/2024 at 3:39 p.m. The DON reviewed Resident #1's LTC note for 09/03/2024 and stated that the note should have documented the resident had a wound. The DON verified Resident #2 was admitted on [DATE] and wound care was not started until 11/03/2024 based on the documentation on the Treatment Administration Record (TAR). The DON stated there was not a progress note showing Resident #2 had wound care on 10/30/24, 10/31/24, 11/01/24 or 11/02/24. The DON stated Resident #2's admission does not have a description of the sacrum wound, the heels nor the skin tear on the elbow. The DON verified the Weekly Skin Evaluation dated 10/31/2024 did not describe Resident #2's skin completely. She stated she would expect to see wound care orders starting on 10/30/2024 (admission). The DON verified there were no wound care orders written on admission. The DON verified Resident #2's Weekly skin sheets dated 11/06/2024 did not addressed the coccyx wound and should have. The DON stated the Skilled Nursing notes should have been started on 10/30/2024 for second and third shift. The DON stated there should have been Skilled Nursing notes performed on 10/31/24, 11/01/24, and 11/04/24. The DON reviewed the Skilled Nursing notes documented and verified they did not address the wounds. She stated they showed, no wounds. The DON stated Resident #3's should have had Skilled Nursing Notes from 11/05/2024, at least every day. The DON stated the Skilled Nursing Notes should have addressed the wounds in the documentation. She verified the Skilled Nursing Notes lacked wound documentation. The DON reviewed Resident #3's TAR. She stated the TAR showed the ulcer care was not started until 11/08/2024 even though he was admitted on [DATE]. The DON stated she does not know why the care was not started until 11/08/2024 when the order was received on 11/06/2024. The DON reviewed the Weekly Skin Evaluation dated 11/11/2024 and it should have addressed the wounds. She stated a change in the wound should be documented in the progress notes or a Skilled Nursing Note. The DON reviewed the LTC Nurses Note and stated Resident #4 should have LTC Nurses note on 11/08/2024. She stated she did not know why the LTC nursing note was not done. The DON stated the LTC Nursing Notes should have addressed the wound in the documentation. She verified the LTC notes lacked wound documentation.

Based on observation, interview, and record review, the facility failed to obtain wound care orders and perform wound care timely for one (#3) of four sampled residents. Findings included: Resident #3 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and diabetes. Review of the physician orders showed: Cleanse with normal saline, pat dry with gauze. Apply Calcium Alginate over ulcers and then apply secondary dressing, kerlix wrap, and secure with tape daily and as needed for left lower extremity venous ulcers with order and start date of 11/13/2024. Cleanse with normal saline, pat dry with gauze. Apply Calcium Alginate over ulcers and then apply secondary dressing, kerlix wrap, and secure with tape daily and as needed for left lower extremity venous ulcers with order and start date of 11/14/2024. Barrier cream with zinc every shift to bilateral buttocks and sacrum for pressure ulcer for 14 days as of 11/13/2024. Review of the November Treatment Administration Record (TAR) showed: Cleanse with normal saline, pat dry with gauze. Apply calcium alginate over ulcers and then apply secondary dressing, border gauze to left lower extremity (LLE) every day and as needed for venous ulcers as of 11/08/2024 to 11/13/2024. Documented as performed on 11/08/24, 11/09/24, 11/11/24, 11/12/24, and 11/13/24. Cleanse with normal saline, pat dry with gauze. Apply Calcium Alginate over ulcers and then apply secondary dressing, kerlix wrap, and secure with tape daily and as needed for left lower extremity venous ulcers with order and start date of 11/14/2024. Documented as performed on 11/14/24, 11/15/24, 11/16/24, 11/17/24, 11/18/24. Barrier cream with zinc every shift to bilateral buttocks and sacrum for pressure ulcer for 14 days as of 11/06/2024. Documented as performed every shift starting 11/06/2024, night shift. Review of the Admit/Readmit Screener dated 11/05/2024 showed Skin Integrity 1. Skin Color: normal for ethic group. 2. Skin turgor: normal. 3. Does resident have any areas of skin breakdown? Yes. 3a. Describe skin issues and location below: DTI to left buttocks; scab (s) to BLE (Bilateral Lower Extremities). Review of the Skilled Nurses Note showed On 11/09/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/11/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/13/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: anterior bilateral lateral lower extremities. Dressing change: 4. Treatment to wound (s) performed on this shift as ordered. 5. Signs and Symptoms of Wound Infection: 2. redness (erythema) 4. purulent drainage. Comments/Notes: Resident continues on ABT for lower leg possible infection. Redness and swelling noted. On 11/16/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. On 11/17/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 2. Resident have a surgical wound, No. 3. Other wounds: no wounds present. Review of the Weekly Skin Evaluation dated 11/11/2024 showed: skin intact. Review of the Weekly Skin Evaluation dated 11/12/2024 showed 3. Blanchable redness of buttocks. 4. Skin tear to left lower leg. Review of the Weekly Pressure Wound Evaluation dated 11/07/2024 showed 1a. Date MD / Alternative Notified / Last Update: 11/06/2024. B. Observations / Data: 1. Location: left buttocks. 2a. present on admission. 2b. date acquired was blank. 4. Pressure Ulcer Stage: 3a. II. 5. Visible Tissue: 5b. epithelial tissue present; 5c. Granulation tissue present. 5g. dry. 6. Drainage: none. 7. Odor: no odor. 8. Measurements: 1.5 cm long x 1 cm wide x 0.1 depth. Barrier cream with zinc every shift. Leave open to air. Review of the Weekly Pressure Wound Evaluation dated 11/17/2024 showed Date MD / Alternative Notified / Last Update: 11/13/2024. B. Observations / Data: 1. Location: left buttocks. 2a. present on admission. 2b. date acquired was blank. 4. Pressure Ulcer Stage: 3a. II. 5. Visible Tissue: healed. Review of the Weekly Non-Pressure Wound Evaluation dated 11/07/2024 showed 1a. Date MD / Alternative Notified / Last Update: 11/06/2024. B. Observations / Data: 1. Vascular ulcer. 1a. LLE. 1b. Venous Partial Thickness. 2b. wound noted on 11/05/2024. 5. Visible tissue: 5a. first impression. 5c. granulation. 5f. moist. 6. Drainage: 6a. serosanguinous. 6b. moderate. 7. Odor: no odor. 8. Wound Measurements: 1.0 cm long x 1.0 cm wide x 0.1 cm deep. 9. Peri-wound tissue: 9a. edema, erythema. Treatment: cleanse with normal saline, apply calcium alginate, and cover with border dressing. Wound Progress: Presented on admission. Review of the Weekly Non-Pressure Wound Evaluation dated 11/17/2024 showed 1a. Date MD / Alternative Notified / Last Update: 11/13/2024. B. Observations / Data: 1. Vascular ulcer. 1a. LLE. 1b. Venous Partial Thickness. 2b. wound noted on 11/05/2024. 5. Visible tissue: 5a. improving. 5b. epithelial tissue present. 5f. moist. 6. Drainage: 6a. serous. 6b. moderate. 7. Odor: no odor. 8. Wound Measurements: 0.8 cm long x 0.8 cm wide x 0.1 cm deep. 9. Peri-wound tissue: 9a. erythema. Treatment: cleanse with normal saline, apply calcium alginate, and cover with border dressing. Wound Progress: improving with delayed wound healing. Review of the Baseline Care Plan dated 11/05/2024 showed, I have impaired skin integrity. Location/Stage (if applicable) left buttocks. I will remain free from new areas of skin breakdown through next review date. Approaches included perform skin evaluation upon admission, weekly and as needed. See current physician's orders / TAR for current treatments as ordered by physician was not checked. The care plan lacked pressure ulcer interventions. During an interview on 11/18/2024 at 2:14 p.m., Staff A, Licensed Practical Nurse (LPN) Wound Care nurse stated either she or Staff B, LPN, Wound Care nurse worked every day including weekends and performed the wound care for the residents. Staff A stated when a resident was admitted , the floor nurse was supposed to check the skin on admission and then either Staff A or Staff B came behind them and double checked the skin. Staff A stated when the consultant wound nurse came in, she saw all new admissions whether they had a wound or not. The consultant wound nurse came on Wednesday. Staff A stated, We (Staff A or Staff B) see the new admission resident on the same day of admission before we go home or the next day. Staff A stated if the resident had a wound, they got treatment orders. Staff A stated they usually called the Nurse Practitioner (NP) of the attending physician, or the consultant wound nurse. Staff A stated they usually called the NP of the attending physician first. The consultant wound nurse saw the resident on their next scheduled day. Staff A stated if the resident did not have anything on their skin the consultant wound nurse would not pick them up. If there was something, they would see them weekly. Staff A stated the consultant wound nurse was the only person who measured wounds in the facility. Staff A stated if a resident was admitted on Thursday and the consultant wound nurse did not come in until the following Wednesday, no wound sizes or description were documented. Staff A stated they (Staff A, Staff B, or the admitting nurse) described the wound to the attending physician or consultant wound nurse and received orders based on their description. Staff A stated the E- MAR (Electronic Medication Administration Record) system would not let them document until the next day after the start date of an order. Staff A stated they did not document the day they performed the wound care if it was on the date of the order because the system would not let them enter the documentation. When asked how they documented treatments performed, she stated they don't. During an interview on 11/18/2024 at 3:39 p.m., the DON stated wound care would be performed on admission. If the resident was admitted on the day shift, either Staff A or Staff B would perform the wound care. The floor nurse performing the admission should do a head-to-toe assessment. The floor nurse should document the wounds. The admission nurse had to assess the wounds and should get initial wound care orders to re-dress the wound after the initial assessment. The DON stated if the resident was admitted at night, the nurse would still do a head-to-toe assessment and document the wound. The DON stated they did not do measurements until the consultant wound care nurse saw the resident. The DON stated the nurses could do a wound description, but it was not in their policy to measure the wounds. The DON stated, If a resident was admitted on Thursday and the consultant wound nurse did not come until the following Wednesday, the wound would not be measured for 6 days, but the wound would be cared for. The DON stated the wound care orders should be obtained on admission. The floor nurse performing the admission had to look at the wound and the wound care would start on the day of admission, because they had to take the dressing off to assess the wound. The DON stated the nurses should call the physician at that point for orders. The DON stated a Skilled Nursing Note was needed for any resident having skilled care which included but not limited to therapy, Intravenous (IV) therapy, wound care, wound vac. The DON stated the Skilled Nursing Note was scheduled per shift but had to be done at least daily. The DON stated if the resident had a wound, it should be documented in the Skilled Nursing Notes. The DON stated that if the nurse entered the wound order into the electronic system they could not document on the TAR until the next day. The DON stated if they could not document on the TAR, they could do a nursing note. The DON stated the care plans should be followed related to wound assessments and care. The DON stated Resident #3 should have had Skilled Nursing Notes from 11/05/2024, at least every day. She stated she did not know why the Skilled Nursing Notes were not done. The DON stated the Skilled Nursing Notes should have addressed the wounds in the documentation. She verified the Skilled Nursing Notes lacked wound documentation. The DON reviewed Resident #3's TAR. She stated the TAR showed the ulcer care was not started until 11/08/2024 even though he was admitted on [DATE]. The DON stated she does not know why the care was not started until 11/08/2024 when the order was received on 11/06/2024. The DON reviewed the Weekly Skin Evaluation dated 11/11/2024 and said it should have addressed the wounds. The DON stated not documenting the wound description or care could possibly cause a negative outcome. She stated a change in the wound should be documented in the progress notes or a Skilled Nursing Note. The DON also verified the care plans were not being followed or addressing the wounds. Review of the facility's policy, Wound Treatment Management, revised 11/23/2022 showed to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside their frequency parameters in certain situations. 4. Dressings will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: a. Etiology of the wound: I. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. I I. Surgical. III. Incidental. IV. Atypical. B. Characteristics of the wound: I. Pressure injury stage. II. Size - including shape depth and presence of tunneling and / or undermining. III. Volume and characteristics of exudate. IV. Presence of pain. V. Presence of infection or need to address bacterial bioburden. VI. Condition of the tissue in the wound bed. VII. Condition of Peri- wound skin. C. Location the wound. D. Goals and preferences of the of the resident / representative. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: A. Lack of progress towards healing period B. Changes in the characteristics of the wound. C. Changes in the residence goals and preferences, such as at end of life or in accordance with his / her rights.

Based on observation, interview, and record review, the facility failed to obtain pressure ulcer wound care orders and provide pressure ulcer wound care in a timely manner for one (#2) of four sampled residents. Findings included: Resident #2 was admitted on [DATE] and discharged on [DATE]. Review of the Admission Record showed the diagnoses included but not limited to benign neoplasm of meninges, diabetes, adult failure to thrive, protein-calorie malnutrition, and encounter for palliative care. Review of the Admit/Readmit Screener dated 10/30/2024, Section SK / Skin Integrity 1. Skin Color: normal for ethnic group; 2. Skin turgor: normal; 3. Does resident have any areas of skin breakdown? Yes. 3a. Describe skin issues and location below: bruise to both eyes, bruising to BUE (Bilateral Upper Extremities), both heels red, open area to coccyx. Review of the physician orders showed Cleanse stage III sacrum wound with normal saline, apply Medi-honey, apply calcium alginate and then cover with border foam dressing daily and as needed, with an order date of 11/02/2024 to start on 11/03/2024. Cleanse with normal saline, apply single layer of Xeroform and then cover with dry dressing every other day to left elbow (skin tear) as of 11/02/2024 with a start date of 11/04/2024. Cleanse with normal saline, apply single layer of hydrogel and then cover with dry dressing every other day to left elbow (skin tear) as of 11/06/2024 to 11/12/2024. Skin prep to both heel every shift as of 11/02/2024. Licensed skin check every week on Tuesday as of 10/30/2024 to start on 11/05/2024 was discontinued on 11/04/2024. Licensed skin check every week on Wednesday as of 11/04/2024 to 11/06/2024. Review of the October 2024 Treatment Administration Record (TAR) showed no care was provided to the sacrum pressure ulcer, bilateral heels, or skin tear to the left elbow on 10/30/2024 or 10/31/2024. Licensed skin check every week on Tuesday as of 10/30/2024 to 11/05/2024 was not documented as performed. Review of the November 2024 TAR showed Cleanse stage III sacrum wound with normal saline, apply Medi-honey, apply calcium alginate and then cover with border foam dressing daily and as needed, with an order date of 11/03/2024 and discontinued on 11/12/2024. Documentation showed the sacrum wound care was performed on 11/03/24, 11/04/24, 11/05/24, 11/06/24, 11/07/24, 11/08/24. Cleanse with normal saline, apply single layer of Xeroform / hydrogel and then cover with dry dressing every other day to left elbow (skin tear) as of 11/02/2024 with a start date of 11/04/2024 and discontinue on 11/06/2024. Documentation showed the left elbow care was provided on 11/04/2024, 11/06/2024. Cleanse with normal saline, apply single layer of hydrogel and then cover with dry dressing every other day to left elbow (skin tear) as of 11/06/2024 to 11/12/2024. Documentation showed the left elbow was provided on 11/06/2024. Skin prep to both heel every shift as of 11/02/2024. Documentation showed care was started on evening shift of 11/02/2024. Licensed skin check every week on Wednesday as of 11/04/2024 to 11/06/2024. Documentation showed it was performed on 11/06/2024. Review of the Weekly Pressure Wound Evaluation dated 11/07/2024 showed Date MD/Alternate Notified/ Last updated: 11/06/2024. Date Family/POA (Power of Attorney) notified/ Last update: 11/06/2024. B. Observations / Data: 1. Location: sacrum. 2a. Present on admission. 2b. date acquired was blank. 4. Pressure Ulcer Stage: 3a. III. 5c. granulation tissue present, 5d. slough tissue present. 5f. moist. 6. Drainage: serosanguinous, small amount. 7. Odor: no odor. 8. Measurements: 2 cm (centimeters) long x 2 cm wide x 0.2 depth. Review of the Weekly Pressure Wound Evaluation dated 11/07/2024 showed Date MD/Alternate Notified/ Last updated: 11/06/2024. Date Family/POA (Power of Attorney) notified/ Last update: 11/06/2024. B. Observations / Data: 1. Location: Right heel. 2a. Present on admission. 2b. date acquired was blank. 4. Pressure Ulcer Stage: 3a. STDI (suspected deep tissue injury). 5b. epithelial tissue present, 5g. dry. 7. Odor: no odor. 8. Measurements: 0.8 cm (centimeters) long x 0.8 cm wide x 0.1 depth. Cleanse with normal saline, apply skin prep every shift and leave open to air. Review of the Weekly Pressure Wound Evaluation dated 11/07/2024 showed Date MD Date MD/Alternate Notified / Last updated: 11/06/2024. Date Family/POA (Power of Attorney) notified/ Last update: 11/06/2024. B. Observations / Data: 1. Location: Left heel. 2a. Present on admission. 2b. date acquired was blank. 4. Pressure Ulcer Stage: 3a. STDI (suspected deep tissue injury). 5b. epithelial tissue present, 5g. dry. 7. Odor: no odor. 8. Measurements: 0.8 cm (centimeters) long x 2.0 cm wide x 0.1 depth. Cleanse with normal saline, apply skin prep every shift and leave open to air. Review of the Skilled Nurses Note showed On 10/31/2024, no Skilled Nurse Note documentation On 11/01/2024, no Skilled Nurse Note documentation On 11/02/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/03/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/04/2024, no Skilled Nurse Note documentation On 11/05/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/06/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/07/2024, days, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. On 11/07/2024, evening, Section G, SKIN/WOUND: 1. Skin Description: warm/dry. 3. Other wounds: no wounds present. Review of the Weekly Skin Evaluation showed On 10/31/2024, bruises to face and both arms; open areas was blank. On 11/02/2024, skin tear on left elbow, bruises to BUE to arms and hands, right breast, left and right eyes. Open area to sacrum, pressure stage III and pressure stage I to left and right heels. On 11/06/2024 Bruises on Left and right eye, left and right arms, left and right hands. Open areas was blank. Review of the baseline care plan dated 10/30/2024 showed, I have impaired skin integrity. Location / Stage (if applicable) was blank. Goal showed, I will remain free from new areas of skin breakdown through next review date. Approaches included perform skin evaluation upon admission, weekly and as needed. See current physician's orders / TAR for current treatments as ordered by physician was not checked. The care plan lacked pressure ulcer interventions. During an interview on 11/18/2024 at 2:14 p.m., Staff A, LPN looked up Resident #2 and said the resident was admitted on [DATE] with bruises to both eyes, bruising to BUE (Bilateral Upper Extremities), both heels red, and an open area to the coccyx. Staff A stated she performed a Weekly Skin Evaluation on 11/02/2024 and it showed a skin tear on the left elbow, bruises to Bilateral Upper Extremities (BUE), hands, right breast, and both eyes. Resident #2 had an open area to her sacrum, pressure ulcer stage III and pressure ulcers stage I to left and right heels. Staff A verified on 10/31/2024 the Weekly Skin Evaluation was performed by Staff B, LPN and it showed bruising to the face and both arms, and the open area was blank. Staff A, LPN verified the Weekly Skin Evaluation dated 11/06/2024 showed bruises to both eyes, left and right arms, and left and right hands. Open areas were blank, no sacrum wound noted. Staff A stated she expected the floor nurse to do the admission for Resident #2 on 10/30/2024. Staff A stated Staff B should have seen Resident #2 and assessed her on 10/31/2024 and asked for wound care orders. Staff A stated the skin prep for the heels was started on 11/02/2024. Staff A stated she found the heels and put in the skin prep order on 11/02/2024 and started doing it on 11/02/2024. Staff A stated she assessed Resident #2's sacral wound and skin tear on 11/02/2024. Staff A stated Resident #2 had a bandage on the skin tear on her left elbow that was dated 10/30/2024. Staff A stated the orders should have been obtained to start wound care on the 10/31/2024 for Resident #2. Staff A stated, I was off the 30th and 31st. She said her counterpart (Staff B) saw Resident #2 on 10/31/2024. Staff A stated Resident #2's wounds could have gotten worse without care. Staff A reviewed Resident #2's Skilled Nurse Note for 11/07/2024 which showed skin area: warm and dry; no surgical wounds; no other wounds presented. Staff A stated that, Yes, it should be documented there. During an interview on 11/18/2024 at 3:39 p.m., the DON verified Resident #2 was admitted on [DATE] and wound care was not started until 11/03/2024 based on the documentation on the TAR. The DON stated there was not a progress note showing Resident #2 had wound care on 10/30/24, 10/31/24, 11/01/24 or 11/02/24. The DON stated the care plans should be followed related to wound assessments and care. The DON stated Resident #2's admission did not have a description of the sacral wound, the heels nor the skin tear on the elbow. The DON verified the Weekly Skin dated 10/31/2024 did not describe Resident #2's skin completely. She stated she would expect to see wound care orders starting on 10/30/2024 (admission). The DON verified there were no wound care orders written on admission. The DON verified Resident #2's Weekly skin sheets dated 11/06/2024 did not address the coccyx wound and should have. The DON stated the Skilled Nursing notes should have been started on 10/30/2024 for second and third shift. The DON stated there should have been Skilled Nursing notes performed on 10/31/24, 11/01/24, and 11/04/24. The DON reviewed the Skilled Nursing notes documented and verified they did not address the wounds. She stated they showed, no wounds. Review of the facility's policy, Pressure Injury Prevention and Management, revised 7/25/2022 showed the facility is committed to the prevention of avoidable pressure ulcers, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcers / injury, prevent infection and the development of additional pressure ulcers / injuries. Policy Explanation and Compliance Guidelines: 1. There are multiple terms used to describe the type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bedsore. For purposes of this policy, pressure injury, as the current standard terminology will be used. 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions that's appropriate. 3. Assessment of Pressure Injury Risk A. Licensed nurse will conduct a pressure injury risk assessment, using the Braden Scale for Predicting Pressure Score Risk on residents upon admission / readmission, then quarterly or whenever the residence condition changes significantly. C. Licensed nurses will conduct a full body skin assessment on residents upon admission / readmission, weekly or routinely, and after any newly identified pressure injury. Findings will be documented in the medical record. 4. Interventions for Prevention and to Promote Healing A. After completing a thorough assessment / evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries and appropriate interventions. B. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. C. Evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. D. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. I. Pressure injuries will be differentiated from non-pressure injuries such as arterial, venous, diabetic, moisture or incontinence related skin damage. II. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate, presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics. E. The goals and preferences of the resident and / or authorized representative will be included in the plan of care F. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring A. The Director of Nursing or designee will review all relevant documentation regarding skin assessments, pressure injury risk, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. B. The attending physician will be notified of: I. The presence of a new pressure injury upon identification. II. The progressions towards healing, or lack of healing, of any pressure injuries weakly. III. Any complications as needed. C. The effectiveness of current preventive and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule and as needed when actual or potential problems are identified. 6. Modifications of Interventions A. Any changes to the facility's pressure injury prevention and management processes will be communicated to the relevant staff in a timely manner. B. Interventions on a residence plan of care will be modified as needed. Considerations for needed modifications include I. Changes in residence degree of risk for developing pressure injury. II. New onset or recurrent pressure injury development. III. Lack of progression towards healing period IV. Resident non-compliance. V. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his / her rights.

Based on observations, interviews, and record review, the facility failed to ensure the right to formulate an advance directive was honored for two residents (#109 and #212) out of three residents sampled for Advanced Directives related to a resident receiving CPR (cardiopulmonary resuscitation) for 3 minutes when they had wished to not be resuscitated and a resident without an advance directive order who wished to have one. Findings Included: 1) Resident #109 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization , with diagnoses including chronic kidney disease Stage 3B, acute respiratory failure with hypoxia, and chronic diastolic Congestive Heart Failure. Review of Resident #109's medical record revealed the following: -A State of Florida Do Not Resuscitate form was signed by a physician and a family member of Resident #109 on [DATE]. -The resident was receiving hospice services. -A Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form was signed by a medical provider and completed on [DATE]. The form revealed under Advanced Care Planning a check under yes for Do Not Resuscitate (DNR). -On [DATE] a baseline care plan was developed for Resident #109. Review of the care plan revealed the resident expressed a preference for DNR. The goal was My wishes for code status will be followed through next review date, and an approach to be followed by nursing was documented as Follow Code Status per physician order. -Review of Resident #109's physician order summary report revealed a telephone order, dated [DATE], as DO NOT RESUSCITATE. The order was signed by the physician on [DATE]. An interview was conducted with Staff CC, Certified Nursing Assistant (CNA) on [DATE] at 3:20 p.m. Staff CC stated she had Resident #109 in her assignment on the 11 p.m. to 7 a.m. shift on [DATE]. Staff CC stated she was conducting her rounds and found Resident #109 lying on her side and unresponsive. Staff CC stated she got a nurse (Staff AA) and told the nurse that Resident #109 was unresponsive. She stated Staff AA, Registered Nurse (RN), tried to obtain a response from Resident #109 without success. She stated Staff AA, RN then Called a code. Staff CC stated she asked Staff AA if she was sure as she had overheard a nurse talking about Resident #109 being on hospice and a DNR. Staff CC stated Staff AA told her the last time she had checked Resident #109 was a full code because a signature was needed. Staff CC stated Staff AA called the code over the intercom. Staff CC stated she participated in the resuscitation attempt of Resident #109 until another nurse (Staff DD, Licensed Practical Nurse, LPN) told them Resident #109 had a signed DNR order and Cardiopulmonary Resuscitation (CPR) was stopped. An interview was conducted with Staff DD, LPN on [DATE] at 2:34 p.m. Staff DD stated she was working on the other side of the building when the Code Blue announcement was made, and she came to Resident #109's room. She stated when she arrived at Resident #109's room CPR had already been initiated and she asked if anyone had contacted 911. She stated she was told no one had called 911 so she went to the nurse's station to call. Staff DD stated while she was on the phone with 911, she looked in the electronic medical record on the computer and found Resident #109 had a signed DNR order. She stated she went to Resident #109's room and yelled out the staff performing CPR that Resident #109 had a DNR order. Staff DD stated someone in the room, who was later identified as Staff AA, RN, stated it was a pending order. Staff DD stated she went back to the nurse's station, and she was confused as to why someone was stating it was pending as she could see the signed DNR order and the signed State of Florida Do Not Resuscitate form. She stated she showed the nurse, Staff AA, RN the DNR order and The paper in the code book. She stated Staff AA then went back to room and told the staff to stop CPR. Staff DD, LPN stated, She didn't listen to me when I told her the resident was a DNR, she didn't take my word. Staff DD stated she left it to Staff AA, RN to call the family of Resident #109. An interview was conducted with Staff B, LPN, on [DATE] at 2:07 p.m. Staff B stated she was on the other side of the building when she heard a nurse call for a Code Blue. She stated she went into Resident #109's room and CPR was in progress. She stated she took over the ambu bag. She stated she remembered someone coming and stating Resident #109 was a DNR. She stated she just came into help with CPR that was already in progress and did not find out until after it was in progress the resident had a DNR order. A phone interview was conducted with the Medical Director on [DATE] at 11:35 a.m. The Medical Director stated he was also Resident #109's attending physician and her hospice physician. The Medical Director confirmed Resident #109 was a DNR when she was admitted , and he signed an order for DNR on [DATE]. He stated the facility informed the Nurse Practitioner (NP) of the circumstances and the NP called him immediately and informed him. The Medical Director stated it was a nurse who works at the hospital full time and worked for the facility part time, the nurse said the protocol at the hospital was to start CPR and verify later. The Medical Director stated it was an unfortunate event and should not have happened. Review of a form entitled Record of Death revealed the time of death for Resident #109 was documented as 4:05 a.m. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:30 a.m. The DON stated CPR was performed on Resident #109 for approximately three minutes. She stated the timeline for the event was as follows: 4:00 a.m. on [DATE] Staff CC, CNA found resident unresponsive. 4:01 a.m. Staff CC notified Staff AA, RN that resident was unresponsive. 4:02 a.m. Code was called, simultaneously Staff AA, RN started compressions without checking code status. Staff CC, CNA questioned Staff AA, RN who stated resident was Pending DNR. 4:03 a.m. Staff DD, LPN called 911, noted the DNR, hung up and walked to room to notify Staff AA, RN of DNR. Staff AA, RN insists DNR is pending. 4:05 a.m. Staff DD, LPN notified Staff AA, RN again of DNR and showed her documentation of the DNR. 911 contacted again and Emergency Medical Services (EMS) were already in route. 4:05 a.m. compressions stopped. 4:10 a.m. EMS arrived and pronounced Resident #109 deceased . 2) Review of the record for Resident #212 revealed an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease with acute exacerbation, acute and chronic respiratory failure unspecified whether hypoxia or hypercapnia. A review of the medical record revealed Resident #212 was legally blind and his family member would sign paperwork for him. Review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, dated [DATE], revealed it was not checked for DNR. There was no physician order for DNR found in Resident #212's record and no record of discussion with Resident #212 or his family member as to his wishes Advanced Directives or cardiopulmonary resuscitation. An interview was conducted with Resident #212 on [DATE] at 12:59 p.m. He stated, I told them to not touch me, I'm done, that's what the purple bracelet is for, the hospital put it on me. I am a DNR, Do Not Resuscitate. An interview was conducted with Staff F, LPN on [DATE] at 4:40 p.m. Staff F stated, he thought if it was after hours he was supposed to wait until the next day to obtain the physician order for DNR. Staff F stated he flagged the progress note so it would show up on the 24-hour report. Staff F stated, I should have done it then. An interview was conducted with the DON on [DATE] at 2:50 p.m. The DON stated when residents come in the admitting nurse evaluates paperwork. She stated the 3008 is the order. She stated the nurse converses with the patient and/or verifies orders with the physician. If the 3008 and a Golden Rod are there they go and verify the wishes. She stated the nurse should be calling the physician. Once the resident expresses their wishes the nurse calls the doctor to get orders and two nurses verify the order. The DON reviewed Resident #212's progress note and stated the physician should have been called. Review of a facility policy entitled Standards and Guidelines: Advance Directives Code Status, with an issue date of ,d+[DATE] revealed the following: Standard: It is the policy of the facility to honor Advance Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal Regulations. Definitions: Code Status - Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/ representative's request. Identifies resident's wishes for medical intervention should the resident's heart stop beating and/or should the resident stop breathing. Full Code: Full code means that if a person's heart stopped beating and/ or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, rescue breathing, and/or defibrillation and is referred to as CPR. Do Not Resuscitate (DNR) - A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally if their heart stops beating and/ or they stop breathing. Guidelines: Admission /Readmission: Code status verified upon admission with Resident/Representative by admitting NURSE. Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD). Full Code: Admitting nurse must obtain an order from physician (MD) Order into [NAME] Click Care (PCC) using AA Code Status: FULL CODE (batch order) Green Full Code sheet initiated with Resident Name and Date Green Full Code Sheet is placed in Code Status Binders at all Nurses' stations. Green Full Code Sheet is filed alphabetically (i.e. last name is [NAME] and form is under S alpha tab) DNR: Admitting nurse must review with resident/representative with a witness present (preferably another nurse or social services) Admitting nurse obtains order from physician (MD). Initiates Yellow DNR Form Yellow DNR Form will be signed by the Resident/Representative and the two nurses who obtained the order from the physician (MD). Order entered into Point Click Care (PCC) using AA CODE status: DNR (batch order). Verbal Physician's Order is recognized as Resident's Code Status Yellow DNR Form will be copied, and Social Services notified of new DNR. Yellow DNR form will be expedited to physician for final signature. OR: Resident arrives at facility with Yellow DNR form in place either from hospital / community. Admitting nurse must confirm with the resident/ representative choice for DNR. Nurse obtains order from physician. Order entered into Point Click Care (PCC) using AA CODE status : DNR (batch order). Yellow DNR form is scanned into PCC by a designated facility representative under Documents and appropriate labeled in Documents Tab in PCC. Yellow DNR form is placed in Code Status Binders at all Nurses' stations. Yellow DNR form is filed alphabetically (i.e. last name is [NAME]) and form is under S alpha tab.

Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#19, #48, #13, #17, #34, #33, #16, #97, 78, and #73) out of 24 residents sampled for PASRR review. Findings included: Review of the Admission record showed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, major depressive disorder recurrent, moderate, localization- related symptomatic epilepsy and epileptic syndromes with simple partial seizures, and generalized anxiety disorder. Review of the PASRR, dated 11/15/22, revealed under Section A: MI (Mental Illness) or suspected MI check all that apply showed Depressive Disorder was checked and Anxiety Disorder was not checked. A second PASRR not dated revealed under Section A: MI or suspected MI check all that apply showed Depressive Disorder was checked but Anxiety Disorder was not checked. During an interview on 04/25/24 at 1:52 p.m., the Director of Nursing (DON) stated Resident # 16's PASRR was not correct and should have been updated to reflect the current status. Review of the Admission Record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Epilepsy unspecified, intractable with out status epileptics, generalized anxiety disorder, and major depressive disorder, recurrent, moderate. Review of the PASRR, dated 08/21/22, revealed under Section A: MI or suspected MI check all that apply Anxiety Disorder and Depressive Disorder was not checked. Under Section B. ID (Intellectual Disorder) or suspected ID (check all that apply) Related Conditions Epilepsy and Cerebral Palsy was not checked. During an interview on 04/25/24 at 1:52 p.m., the Director of Nursing (DON) stated Resident #34's PASRR should have been updated to reflect current status. Review of the Admission Record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, current depressed, severe, without psychotic features, and generalized anxiety disorder. Review of the PASRR, dated 02/29/24, revealed under Section A: MI or suspected MI check all that apply showed Anxiety Disorder and Depressive Disorder was checked and Bipolar Disorder was not checked. During an interview on 04/25/24 at 1:53 p.m., the Director of Nursing (DON) stated Resident #48's PASRR was not correct and should have been updated upon admission to reflect current status. 49497 Review of medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute and chronic respiratory failure with hypoxia, schizoaffective disorder bipolar type, anxiety disorder, major depressive disorder. Review of a Level I PASRR, dated 4/15/2024, showed qualifying diagnoses were not checked or indicated and no Level II PASRR was required. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including dementia, other persistent mood disorders, and anxiety disorder. Review of a Level I PASRR, dated 12/11/17, showed qualifying diagnoses were not checked or indicated and no Level II PASRR was required. Review of the medical record revealed Resident #78 was admitted on [DATE] with diagnoses including dementia, major depressive disorder, and Bipolar Disorder. Review of a Level I PASRR, dated 12/05/22, showed qualifying diagnoses were not checked or indicated and no Level II PASRR was required. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, anxiety disorder, and depression. Review of a Level I PASRR, dated 10/17/23, showed qualifying diagnoses were not checked or indicated and no Level II PASRR was required. An interview was conducted on 4/25/24 at 1:40 p.m. with the Director of Nursing (DON). She stated their process is when a resident is admitted to the facility, she receives PASRR paperwork in the admission packet to review. If the PASRR is incorrect she will attempt to have the hospital correct it, if unable to get corrected, she will complete a new Level I PASRR. She said, she will also update PASRR during resident stays when a new diagnosis is added that pertains to PASRR. She stated Resident #13, #33, #78, and #97's PASRR's were all incorrect as diagnoses should have reflected the diagnoses in their medical record and not left blank. She stated the PASRR's should have been updated with admitting diagnoses to have a correct Level I PASRR in medical record and to determine if a Level II PASRR was warranted. 14161 Review of the medical record for Resident # 19 revealed he was originally admitted to the facility in 4/14/13 with diagnoses including of brief psychotic disorder, generalized anxiety disorder, mood disorder. In 2022 a diagnosis of unspecified dementia, unspecified severity with other behavioral disturbance was added to his diagnoses. A PASRR, dated 2/6/24, revealed under Section A: MI or suspected MI check all that apply Anxiety Disorder, Depressive Disorder, Psychotic Disorder, and Substance Abuse was checked and revealed the finding was based on documented history. Section II: Other Indications for PASRR Screen Decision Making item 5 revealed Resident #19 had no primary diagnosis of Dementia or Related Neurocognitive Disorder (including Alzheimer's disease). Item 6 indicated Resident #19 did not have a secondary diagnosis of dementia, related neurocognitive disorder and the primary diagnosis is an Serious Mental Illness or Intellectual Disability. No Level II PASRR was required. A PASRR, dated 3/7/24, revealed under Section A: MI or suspected MI check all that apply Anxiety Disorder, Depressive Disorder and Mood Disorder were checked. Section II : Other Indications for PASRR Screen Decision Making, item 5 revealed a yes check mark for having a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's Disease), and the Primary diagnosis is an Serious Mental Illness or Intellectual Disability No Level II PASRR was required. An interview was conducted with the DON, on 4/25/24 at 1:54 p.m The DON stated both PASRR's were incorrect and she needed to redo them again. 48223 Review of the Admission Record showed Resident #17 was admitted on [DATE] and readmitted on [DATE] with diagnoses of Bipolar Disorder, Anxiety disorder, Major Depressive disorder, Vascular Dementia, and other comorbidities. Review of the Physician's history and physical, dated 01/18/2023, showed Resident #17 with a diagnosis of schizoaffective disorder. Review of Resident #17's PASRR Level I Assessment, dated 03/15/2024, did not reveal the qualifying mental health diagnosis schizoaffective disorder marked in section I A. nor was the diagnosis of Vascular Dementia. A Level II PASRR should be submitted due to the qualifying diagnoses. During an interview on 04/25/2024 at 01:40 PM, the DON confirmed the diagnoses should be listed on the PASRR. The DON confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of Resident #73's Psychiatry Subsequent Note, dated 03/27/2020, showed Resident #73 with the following diagnoses of Psychotic Disturbance, Anxiety disorder, Schizophreniform disorder, Dementia, and other comorbidities. Review of Resident #73's PASRR Level I Assessment, dated 06/20/2023, did not reveal the qualifying mental health diagnosis marked in section I A. nor was the diagnosis of Dementia. A Level II PASRR should be submitted due to the qualifying diagnoses. During an interview on 04/25/2024 at 01:40 PM, the DON confirmed the diagnoses should be listed on the PASRR. The DON confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the facility's policy, dated 9/18/2023, showed the following: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders (MD) or intellectual disabilities (ID) and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and or rehabilitative services the individual needs. 2. The facility will only admit individuals with a MD or ID who the State mental health or ID authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the resident's medical record. 4. Exceptions to the preadmission screening program, dependent upon State requirements, include those individuals who: a. Are readmitted directly from a hospital. b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The Social Service Director or designee shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR Level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transition of care. 8. Any Level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include: a. A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. b. A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment. c. A resident who experiences an improved medical condition - such that the residents' plan of care or placement recommendations may require modifications. d. A resident whose significant change is physical, but has behavioral, psychiatric or mood-related symptoms, or cognitive abilities, that may influence adjustment to the altered pattern of daily living. e. A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not a primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on record review, observations, and interviews, the facility failed to store, prepare and appropriately document food temperatures in accordance with professional standards for food service safety in the facility kitchen area. Findings included: An observation on 04/22/24 at 7:00 a.m., revealed a walk in refrigerator that had bag of orange shredding solid substance and a metal container of fruit like half moon shaped substance not labeled or dated. Further observation showed a head of lettuce in a bag that was brownish/red color, a cucumber in a bag that when picked up has a mushy like feeling and an additional bag of lettuce that was left open to air and not properly sealed for food storage safety. (Photographic evidence obtained.) During an interview on 04/22/24 at 7:05 a.m., Staff H, Dietary Aide (DA) stated all food in the walk in refrigerator should be labeled and dated before storage. Staff H, DA stated the head of lettuce was turning and should have been thrown away and the cucumber was rotting and would also needed to be thrown away. Staff H, DA stated the fruit in the metal container was peach crisp that would be used today for lunch but the metal container should have been labeled and dated. An observation of the East Dietary Pantry on 04/22/24 at approximately 12:00 p.m., showed a pizza box that was not labeled and dated and a container of 46 flowing ounces of Prune juice with a use by date of 02/17/24. Photographic evidence obtained. An observation on 04/23/24 at 11:35 a.m., revealed Staff J, Dietary Manager (DM) preparing Residents' food trays on the tray line. During an interview on 04/23/24 at 11:35 a.m., Staff J, DM stated he took the food temperatures already and the spaghetti was 175 degrees, the spaghetti sauce was 175 degrees and the green beans were 170 degrees. Review of the facility's 04/23/24 lunch food temperature log showed no food temperatures were documented. An interview on 04/23/24 at 11:40 a.m., Staff J, DM stated he did not document the lunch food temperatures on the temperature log during completion. During an interview on 04/23/24 at 11:35 a.m., Staff I, Regional Dietary Consultant (RDC) stated the practice of not recording the food temperatures in the log book while tempting food was not the best practice. Staff I, RDC stated Staff J, DM had only been recently hired about a week ago and he would be sure to re-educate Staff J, DM on the best practices for the food tempting process. The RDC also confirmed all food located in both the walk in refrigerator in the kitchen area and all refrigerators in the pantries should be labeled and dated. Review of the facility's policy Use and Storage of Food brought in by Family or Visitor with revised date 01/2023 revealed: Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator b. The prepared food must be consumed by the resident within 3 days c. If not consumed within 3 days, food will be thrown away by the facility staff. d. The facility will not be responsible for maintaining and reusable items. Review of the facility's policy Food Storage: Cold dated October 2019, revealed, Policy Statement: It is the center policy to all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. Action Steps .4. The Dining Services Director/Cook(s) insures that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures is recorded. 2. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to: 1.) failing to ensure a medication administration error rate of less than five percent. A total of ten medication administration opportunities were observed with two errors for one (Resident #8) of three residents observed. This resulted in a medication administration error rate of 20% (F759) and 2.) failed to ensure proper storage, labeling and dating of food and beverages in accordance with professional standards for food service safety in one pantry (East) of two pantries and one of one facility kitchen (F812) during the revisit survey conducted [DATE] to [DATE]. Findings included: 1.) A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and metabolic encephalopathy. A review of Resident #8's physician orders revealed an order, dated [DATE] for insulin glargine 100 units per milliliter (ml) via (brand name) pen injector, inject 40 units subcutaneously every morning and at bedtime for a diagnosis of type 2 diabetes mellitus. Resident #8's physician orders also revealed an order, dated [DATE] for insulin lispro 100 units per ml via pen injector, inject 18 units subcutaneously before meals and at bedtime for a diagnosis of type 2 diabetes mellitus. An observation of medication administration was conducted on [DATE] at 9:46 AM on the facility's Recovery Hall with Staff A, Licensed Practical Nurse (LPN). After removing Resident #8's insulin glargine pen injector from the medication cart, Staff A, LPN dialed the dosage selector on the injector pen to 2 units and pressed on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN performed the same procedure with Resident #8's insulin lispro pen injector, dialing the dosage selector on the injector pen to 2 units and pressing on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN also removed two insulin pen injector needles and alcohol preparation pads from the medication cart. Staff A, LPN cleansed the top of each of the insulin pen injectors with alcohol and applied an insulin needle to each pen injector. Staff A, LPN gathered the pen injectors and entered Resident #8's room. After explaining the procedure to the resident, performing hand hygiene, and donning clean gloves, Staff A, LPN dialed the dosage selector on the insulin glargine injector pen to 40 units and administered the insulin to Resident #8. Staff A, LPN dialed the dosage selector on the insulin lispro injector pen to 18 units and administered the insulin to Resident #8. After removing the gloves, disposing of the needles in the sharps container, and performing hand hygiene, Staff A, LPN exited Resident #8's room. An interview with Staff A, LPN was conducted following the observation. Staff A, LPN stated the purpose of priming the insulin injector pen was to ensure there were no air bubbles in the insulin pen prior to injecting the insulin to the resident. Staff A, LPN demonstrated again how to prime the insulin injector pen by dialing the dosage selector on the injector pen to 2 units and pressing on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN addressed there was no way for air bubbles to escape the insulin pen injector without attaching an insulin needle and stated she was not aware a needle needed to be applied to the injector pen prior to priming the insulin injector pen. After the interview, Staff A, LPN attached an insulin needle to the insulin pen injector and primed the insulin injector pen by dialing the dosage selector on the injector pen to 2 units and pressing on the plunger. After pressing on the plunger to the injector pen and observing insulin come out of the insulin needle Staff A, LPN stated that does make more sense. Staff A, LPN stated she had been employed at the facility for just under two months and did not remember receiving education related to the use of insulin pens. An interview was conducted on [DATE] at 1:41 PM with the facility's Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated following the survey completed on [DATE], the facility's Interdisciplinary Team (IDT) met to discuss the findings of the survey and areas of concern identified by the survey team. The IDT discussed what immediate corrections needed to take place, education needing to be initiated, and audits needing to be implemented following the survey. The DON stated the main concern related to the F749 citation was related to the priming of the insulin pens prior to administration of insulin. The DON also stated the facility's pharmacy staff conducted education with the nursing staff to ensure they knew how to prime the insulin pens. The DON stated insulin injector pens should be primed prior to administration by applying the needle to the pen injector, dialing the dosage selector on the injector pen to 2 units and pressing on the plunger. The DON also stated it would not be correct to prime the insulin injector pen before applying the needle to the injector pen. A review of the facility policy titled Insulin Pen, last revised on [DATE], revealed under the section titled Policy it is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines the procedure for using the insulin pen: - Gather supplies needed. - Perform hand hygiene. - Don gloves. - Verify resident identification using picture, ID bracelet, verbally, etc. - Examine the appearance of the insulin. - Attach pen needle: remove the pen cap from the insulin pen, wipe the rubber seal with an alcohol pad, screw the pen needle onto the insulin pen, and twist open and remove the outer cover from the pen needle. - Prime the insulin pen: dial 2 units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. - Set the insulin dose. - Inject the insulin. - Remove gloves and perform hand hygiene. - Document the dosage, site, and time in the medication record along with nurse signature. 50570 2.) An observation on [DATE] at 10:25 a.m. revealed a walk-in refrigerator with a bag of lettuce heads with no open date or labeling and a quarter-size rip in the plastic packaging. An observation of the bag of lettuce heads revealed one lettuce head had a mushy, dark brown spot. Staff B, Certified Dietary Manager (CDM) observed the bag with the lettuce heads and stated he had not previously observed the rip or dark brown spot; he proceeded to discard the entire bag. Further observation of the walk-refrigerator revealed a half gallon of half and half milk with an expiration date of [DATE]. The Staff B, CDM observed the milk, read the date out loud and proceeded to discard the milk. Observations of the dry storage area revealed bread loaves with no opened date. Staff B, CDM stated he usually labeled when the bread was received and opened. Staff B, CDM pointed to the container holding various loaves of bread which revealed a blank label. He stated he didn't know why it was not labeled. Staff B, CDM proceeded to discard some bags and loaves of bread with no date of when they were received or opened. Further observation of the dry storage area revealed unlabeled, dry cereal bags that were not in their original packaging. Staff B, CDM proceeded to discard them and stated they should have been labeled with the date they were opened. An interview on [DATE] at 10:44 a.m. with Staff B, CDM revealed there are two dietary pantries. He stated he checks the East and [NAME] dietary pantry every day or every other day. Observations on [DATE] at 10:50 a.m. of the East dietary pantry revealed one carton of thickened orange juice and one carton of thickened cranberry juice with no labeling of when they were opened. Staff B, CDM proceeded to discard them and stated they were open and didn't have a date of when they were opened. (Photographic Evidence Obtained). An observation of the East dietary pantry refrigerator revealed multiple food and beverages with no label or date to include applesauce, hazelnut creamer, [vendor name] juice, and a [vendor name] cup of macaroni and cheese. (Photographic Evidence Obtained). An observation of the East dietary pantry freezer revealed a burrito with a use by date of [DATE]. (Photographic Evidence Obtained). Observation of the East dietary pantry counter revealed hamburger buns with no label of who it belongs do. (Photographic Evidence Obtained). An interview on [DATE] at 1:55 p.m. with Staff B, CDM and Staff C, CDM in the East dietary pantry revealed the items that were not labeled, dated or expired should be thrown away. The CDMs proceeded to discard the items observed with no label or date. Staff C, CDM stated the expectation is for CDMs to check the pantry refrigerator and freezer more often since the nursing staff are the ones who put the items in the refrigerator and freezer. Staff C, CDM stated she checks the pantries in the morning and during the nursing staff change of shift. Staff C, CDM stated the activities department shares the refrigerator as well and the creamer most likely belonged to them. An interview on [DATE] at 9:55 a.m. with Staff C, CDM revealed she conducts a daily walk through of the freezer, cooler and dry storage. Staff C, CDM stated during stock and delivery days she is hands-on and assists staff with dating and putting away items using the first in, first out (FIFO) method. Staff D, Regional Director of Operation (RDO)/CDM, was present during the interview and initially stated Staff B, CDM was supposed to be completing daily audits and reporting his findings to the Nursing Home Administrator (NHA). During the interview, Staff D, RDO/CDM, corrected himself and stated the expectation was that Staff B, CDM should be conducting weekly audits since the last annual survey. He stated the NHA started that process with Staff B, CDM and they planned the corrections and audits together. A review of the in-service signature sheet revealed the topic as, Temperature Control for Safety (TCS) food labeling, cold storage, dated ,d+[DATE], and signatures of staff who received the in-service. A review of the facility's policy titled, Food Storage: Cold, dated [DATE], revealed Policy Statement: It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Action Steps .5. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. A review of the facility policy titled Quality Assessment and Assurance Committee, last revised on [DATE], revealed under the section titled Policy the facility will maintain a Quality Assessment and Assurance (QAA) committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach.

2.) An observation on 6/10/24 at 10:25 a.m. revealed a walk-in refrigerator with a bag of lettuce heads with no open date or labeling and a quarter-size rip in the plastic packaging. An observation of the bag of lettuce heads revealed one lettuce head had a mushy, dark brown spot. Staff B, Certified Dietary Manager (CDM) observed the bag with the lettuce heads and stated he had not previously observed the rip or dark brown spot; he proceeded to discard the entire bag. Further observation of the walk-refrigerator revealed a half gallon of half and half milk with an expiration date of June 4, 2024. The Staff B, CDM observed the milk, read the date out loud and proceeded to discard the milk. Observations of the dry storage area revealed bread loaves with no opened date. Staff B, CDM stated he usually labeled when the bread was received and opened. Staff B, CDM pointed to the container holding various loaves of bread which revealed a blank label. He stated he didn't know why it was not labeled. Staff B, CDM proceeded to discard some bags and loaves of bread with no date of when they were received or opened. Further observation of the dry storage area revealed unlabeled, dry cereal bags that were not in their original packaging. Staff B, CDM proceeded to discard them and stated they should have been labeled with the date they were opened. An interview on 6/10/24 at 10:44 a.m. with Staff B, CDM revealed there are two dietary pantries. He stated he checks the East and [NAME] dietary pantry every day or every other day. Observations on 6/10/24 at 10:50 a.m. of the East dietary pantry revealed one carton of thickened orange juice and one carton of thickened cranberry juice with no labeling of when they were opened. Staff B, CDM proceeded to discard them and stated they were open and didn't have a date of when they were opened. (Photographic Evidence Obtained). An observation of the East dietary pantry refrigerator revealed multiple food and beverages with no label or date to include applesauce, hazelnut creamer, [vendor name] juice, and a [vendor name] cup of macaroni and cheese. (Photographic Evidence Obtained). An observation of the East dietary pantry freezer revealed a burrito with a use by date of 6/8/24. (Photographic Evidence Obtained). Observation of the East dietary pantry counter revealed hamburger buns with no label of who it belongs do. (Photographic Evidence Obtained). An interview on 6/10/24 at 1:55 p.m. with Staff B, CDM and Staff C, CDM in the East dietary pantry revealed the items that were not labeled, dated or expired should be thrown away. The CDMs proceeded to discard the items observed with no label or date. Staff C, CDM stated the expectation is for CDMs to check the pantry refrigerator and freezer more often since the nursing staff are the ones who put the items in the refrigerator and freezer. Staff C, CDM stated she checks the pantries in the morning and during the nursing staff change of shift. Staff C, CDM stated the activities department shares the refrigerator as well and the creamer most likely belonged to them. An interview on 6/11/24 at 9:55 a.m. with Staff C, CDM revealed she conducts a daily walk through of the freezer, cooler and dry storage. Staff C, CDM stated during stock and delivery days she is hands-on and assists staff with dating and putting away items using the first in, first out (FIFO) method. Staff D, Regional Director of Operation (RDO)/CDM, was present during the interview and initially stated Staff B, CDM was supposed to be completing daily audits and reporting his findings to the Nursing Home Administrator (NHA). During the interview, Staff D, RDO/CDM, corrected himself and stated the expectation was that Staff B, CDM should be conducting weekly audits since the last annual survey. He stated the NHA started that process with Staff B, CDM and they planned the corrections and audits together. A review of the in-service signature sheet revealed the topic as, Temperature Control for Safety (TCS) food labeling, cold storage, dated 4/24, and signatures of staff who received the in-service. A review of the facility's policy titled, Food Storage: Cold, dated October 2019, revealed Policy Statement: It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Action Steps .5. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. A review of the facility policy titled Quality Assessment and Assurance Committee, last revised on 8/8/2022, revealed under the section titled Policy the facility will maintain a Quality Assessment and Assurance (QAA) committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to: 1.) failing to ensure a medication administration error rate of less than five percent. A total of ten medication administration opportunities were observed with two errors for one (Resident #8) of three residents observed. This resulted in a medication administration error rate of 20% (F759) and 2.) failed to ensure proper storage, labeling and dating of food and beverages in accordance with professional standards for food service safety in one pantry (East) of two pantries and one of one facility kitchen (F812) during the revisit survey conducted 6/10/2024 to 6/11/2024. Findings included: 1.) A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and metabolic encephalopathy. A review of Resident #8's physician orders revealed an order, dated 12/17/2023 for insulin glargine 100 units per milliliter (ml) via (brand name) pen injector, inject 40 units subcutaneously every morning and at bedtime for a diagnosis of type 2 diabetes mellitus. Resident #8's physician orders also revealed an order, dated 2/5/202 for insulin lispro 100 units per ml via pen injector, inject 18 units subcutaneously before meals and at bedtime for a diagnosis of type 2 diabetes mellitus. An observation of medication administration was conducted on 6/11/2024 at 9:46 AM on the facility's Recovery Hall with Staff A, Licensed Practical Nurse (LPN). After removing Resident #8's insulin glargine pen injector from the medication cart, Staff A, LPN dialed the dosage selector on the injector pen to 2 units and pressed on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN performed the same procedure with Resident #8's insulin lispro pen injector, dialing the dosage selector on the injector pen to 2 units and pressing on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN also removed two insulin pen injector needles and alcohol preparation pads from the medication cart. Staff A, LPN cleansed the top of each of the insulin pen injectors with alcohol and applied an insulin needle to each pen injector. Staff A, LPN gathered the pen injectors and entered Resident #8's room. After explaining the procedure to the resident, performing hand hygiene, and donning clean gloves, Staff A, LPN dialed the dosage selector on the insulin glargine injector pen to 40 units and administered the insulin to Resident #8. Staff A, LPN dialed the dosage selector on the insulin lispro injector pen to 18 units and administered the insulin to Resident #8. After removing the gloves, disposing of the needles in the sharps container, and performing hand hygiene, Staff A, LPN exited Resident #8's room. An interview with Staff A, LPN was conducted following the observation. Staff A, LPN stated the purpose of priming the insulin injector pen was to ensure there were no air bubbles in the insulin pen prior to injecting the insulin to the resident. Staff A, LPN demonstrated again how to prime the insulin injector pen by dialing the dosage selector on the injector pen to 2 units and pressing on the plunger without attaching an insulin needle to the pen injector. Staff A, LPN addressed there was no way for air bubbles to escape the insulin pen injector without attaching an insulin needle and stated she was not aware a needle needed to be applied to the injector pen prior to priming the insulin injector pen. After the interview, Staff A, LPN attached an insulin needle to the insulin pen injector and primed the insulin injector pen by dialing the dosage selector on the injector pen to 2 units and pressing on the plunger. After pressing on the plunger to the injector pen and observing insulin come out of the insulin needle Staff A, LPN stated that does make more sense. Staff A, LPN stated she had been employed at the facility for just under two months and did not remember receiving education related to the use of insulin pens. An interview was conducted on 6/11/2024 at 1:41 PM with the facility's Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated following the survey completed on 4/25/2024, the facility's Interdisciplinary Team (IDT) met to discuss the findings of the survey and areas of concern identified by the survey team. The IDT discussed what immediate corrections needed to take place, education needing to be initiated, and audits needing to be implemented following the survey. The DON stated the main concern related to the F749 citation was related to the priming of the insulin pens prior to administration of insulin. The DON also stated the facility's pharmacy staff conducted education with the nursing staff to ensure they knew how to prime the insulin pens. The DON stated insulin injector pens should be primed prior to administration by applying the needle to the pen injector, dialing the dosage selector on the injector pen to 2 units and pressing on the plunger. The DON also stated it would not be correct to prime the insulin injector pen before applying the needle to the injector pen. A review of the facility policy titled Insulin Pen, last revised on 5/3/2022, revealed under the section titled Policy it is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines the procedure for using the insulin pen: - Gather supplies needed. - Perform hand hygiene. - [NAME] gloves. - Verify resident identification using picture, ID bracelet, verbally, etc. - Examine the appearance of the insulin. - Attach pen needle: remove the pen cap from the insulin pen, wipe the rubber seal with an alcohol pad, screw the pen needle onto the insulin pen, and twist open and remove the outer cover from the pen needle. - Prime the insulin pen: dial 2 units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. - Set the insulin dose. - Inject the insulin. - Remove gloves and perform hand hygiene. - Document the dosage, site, and time in the medication record along with nurse signature.

Based on observations, interviews, and record review, the facility failed to implement facility wide procedures to maintain a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. 1) The facility failed to ensure hand hygiene was provided to five residents (#416, #102, #100, #97, and #22) prior to meal service out of five residents sampled. 2) The facility failed to ensure two residents (#214 and #416) was identified as isolation precautions at the room entrance out of two residents sampled. 3) The facility failed to ensure nebulizer masks were stored in appropriate storage bags for two residents (#16 and #48) of three residents reviewed for appropriate storage of nebulizer masks. 4) The facility failed to ensure reusable equipment was cleaned for two residents (#67 and #93) out of six residents sampled during medication pass. 5) The facility failed to ensure one resident (#214) out one resident with a catheter was stored in a sanitary manner. Findings included: 1) An observation on 04/22/24 at 8:16 a.m., revealed the morning breakfast tray pass for rooms 40- 52. Staff were not observed offering or providing any form of hand hygiene to residents prior to meal service. An observation on 04/22/24 at 11:33 a.m., revealed the preparation of lunch service in the dining room. There were four staff in the dining room assisting residents with hydration. Staff were not observed offering or providing hand hygiene to residents. An observation on 04/22/24 at 11:50 a.m., revealed staff in the dining room served nine residents food trays. Staff were not observed offering or providing hand hygiene to residents. During an interview on 04/22/24 at 12:45 p.m., Resident #416 stated, I was not offered hand hygiene before breakfast or lunch today. Resident #416 stated, I have never been offered hand hygiene here at the facility at all. A review of the Admission Record revealed Resident #416 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus, Chronic Respiratory Failure, Presence of right artificial knee, Chronic Obstructive Pulmonary Disease and extended spectrum beta lactamase (ESBL) resistance. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #416 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During an interview on 04/22/24 at 12:49 p.m., Resident #102 stated, No I have have never been offered any hand hygiene before meals. A review of the Admission Record revealed Resident #102 was admitted to the facility on [DATE] with diagnoses that included acute Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Recurrent Moderate, Muscle Weakness and Unspecified Lack of Coordination. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During an interview on 04/25/24 at 9:10 a.m., Resident #100 stated, No hand hygiene has never been offered to me since I have been here. A review of the Admission Record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, Type II Diabetes, Pain in right shoulder, Cellulitus of left lower limb, Muscle weakness, Heredity and Idiopathic neuropathy and the need for assistance with personal care. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During an interview on 04/25/24 at 9:15 a.m., Resident #97 stated, I have never been asked if I wanted hand hygiene. Resident #97 confirmed, she had never been provided hand hygiene before meals. A review of the Admission Record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses that included Arthrodesis, Cellulitus, a breakdown (mechanical) of internal fixation of bones of foot and toes, unspecified fracture of unspecified lower leg, encounter for closed fracture with routine healing, Unspecified abnormalities of gait and mobility, lack of coordination and Neuralgia and Neuritis. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During an interview on 04/25/24 at 9:20 a.m., Resident #22 stated, he had never been asked or offered hand hygiene before meals. A review of the Admission Record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Acute Pulmonary Edema, Type II Diabetes Mellitus, Muscle Weakness and Lack of coordination. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During an interview on 04/25/24 at 9:25 a.m., Staff D, Certified Nursing Assistant (CNA) stated, they were supposed to provide hand hygiene to residents before and after meals. During an interview on 04/25.24 at 9:30 a.m., Staff E, Certified Nursing Assistant (CNA) stated she sometimes provided hand hygiene to residents. Staff E, CNA stated she made sure resident's hands that were visible dirty or sticky after meals were provided hand hygiene. During an interview on 9:35 a.m., Staff F, Certified Nursing Assistant (CNA) stated, I provide hand hygiene when the resident asks me, when I assist them to the restroom and when they are visibly dirty. During an interview on 04/25/24 at 3:44 p.m., the Director of Nursing (DON) stated that all residents should be provided hand hygiene prior to meals. Review of the facility's policy Hand Hygiene reviewed date on 05/21/22 showed, Policy: Staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors . The Hand Hygiene Table showed before and after eating soap and water hand hygiene should be performed. An observation on 04/22/24 at 9:05 a.m., revealed Resident #416's room had no transmission based precautions signage posted on the door and no personal protective equipment (PPE) located near the door. During an interview on 04/22/24 at 9:05 a.m., Resident #416 stated, she had a pressure ulcer on her right heel. A second observation on 04/22/24 at 10:26 a.m., revealed Resident #416's room had no transmission based precautions signage posted on the door and no personal protective equipment (PPE) located near the door. An observation on 04/22/24 at 10:26 a.m., revealed Resident #416's pressure ulcer located on the right heel. Resident #416 had a black non-skid sock over the right foot and Staff C, Certified Nursing Assistant (CNA) removed the black non-skid sock for the observation. A review of the Admission Record revealed Resident #416 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus, Chronic Respiratory Failure, Presence of right artificial knee, Chronic Obstructive Pulmonary Disease and extended spectrum beta lactamase (ESBL) resistance. Review of a physician order, dated 04/11/24, revealed, Contact Isolation. A review of the Medicare 5-Day Minimum Data Set (MDS), dated [DATE], revealed Resident #416 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). A review of the medical record page under physicians orders showed Special Instructions: Contact Isolation: [Extended Spectrum Beta-Lactamase] ESBL in urine. During an interview on 04/24/24 at 10:50 a.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #416 was on Contact Precautions for ESBL and once the precautions were discontinued Resident #416 discharged on [DATE]. Staff A, LPN stated if a Resident had an active order for contact precautions or any other transmission based precautions, it was expected there be a sign on the door and PPE available at the door. During an interview on 04/24/24 at 1:30 p.m., Staff C, Certified Nursing Assistant (CNA) stated, I identify residents on transmission based precautions by the sign on the door and the PPE available in the bin outside the door. Staff C, CNA stated she was aware Resident #416 was on contact precautions because this information was given to her in morning report. Staff C, CNA stated she was aware Resident #416 was on contact precautions for ESBL in the urine and because she did not touch her urine she knew she was good when pulling her sock off on 04/22/24. Review of the facility's policy Transmission- Based (Isolation) Precautions reviewed date 08/15/2022 showed, 8. Contact Precautions- a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. b. Make decision regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential of adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the residents or potentially contaminated areas in resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. e. Resident experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggested an increased potential for an extensive environment before a specific organism has been identified. f. Contact precautions will be used for residents infected or colonized with [Multi-drug Resistant Organism] MDROs in the following situations: i- When a resident has wounds, secretions, or excretion that are unable to be covered, or contained; and ii- On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring. An observation on 04/22/24 at 8:25 a.m., revealed Resident #16's nebulizer mask sat on the nightstand next to Resident #16's bed beside the nebulizer machine. The nebulizer mask was not in the stored properly in the storage bag that hung on the nightstand right below the nebulizer machine. Photographic evidence obtained. An observation on 04/22/24 at 10:07 a.m., revealed Resident #48's nebulizer mask sat on the bedside table next to Resident #48's bed beside the nebulizer machine. The nebulizer mask was not stored properly in the storage bag that hung on the nightstand. Photographic evidence obtained. An observation on 03/23/24 at 10:00 a.m., revealed Resident #16's nebulizer mask sat on the nightstand next to Resident #16's bed beside the nebulizer machine. The nebulizer mask was not in the stored properly in the storage bag that hung on the nightstand right below the nebulizer machine. An observation on 04/23/24 at 10:10 a.m., revealed Resident #48's nebulizer mask sat on the nightstand next to Resident #48's bed beside the nebulizer machine. The nebulizer mask was not stored properly in the storage bag that hung on the nightstand right below the nebulizer machine. An observation on 03/24/24 at 12:43 p.m., revealed Resident #16's nebulizer mask sat on the nightstand next to Resident #16's bed beside the nebulizer machine. The nebulizer mask was not stored properly in the storage bag that hung on the nightstand right below the nebulizer machine. Photographic evidence obtained. An observation on 04/24/24 at 12:46 p.m., revealed Resident #48's nebulizer mask sat on the nightstand next to Resident #16's bed beside the nebulizer machine. The nebulizer mask was not stored properly in the storage bag that hung on the nightstand right below the nebulizer machine. Photographic evidence obtained. During an interview on 04/24/24 at 12:50 p.m., Staff A, Licensed Practical Nurse (LPN) stated nurses were responsible for storing all unused nebulizer masks into the storage bags after treatment. Staff A, LPN stated Resident #48 did not wish to have the nebulizer mask placed in the storage bag and refused. Staff A, LPN stated any resident who refused to have their nebulizer mask placed in the storage bag would have a care plan for refusal. Staff A, LPN stated Resident #48 was not care planned for the refusal of nebulizer mask storage yet. Staff A, LPN stated Resident #16 had never refused to have the nebulizer mask stored in the storage bag so the mask should be been placed in the storage bag after treatment was administered. During an interview on 04/24/24 at 12:55 p.m., Resident #48 stated that she had never refused to have the nebulizer mask placed in the storage bag. Resident #48 stated, There would be no reason why I wouldn't want it in the bag. Resident #48 stated staff have never stored the nebulizer mask in the bag, it was just always stored in open are next to the nebulizer machine. A review of the Admission Record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses that included Cellulitus of chest wall, Chronic Obstructive Pulmonary Disease and Type II Diabetes with Diabetic Neuropathy. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). A review of the facility's policy Nebulizer Therapy reviewed date 12/23/22 showed, Policy: It is the policy of the facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: . Care of Equipment 7. Once completed dry, store the nebulizer cup and the mouthpiece in the zip lock bag. 48223 2) On 04/23/2024 from 7:30 AM to 8:30 tray pass observation of breakfast for the residents in their rooms for all six wings, staff did not offer resident's hand hygiene prior to leaving the room after tray set up. On 04/23/2024 at 12:35 PM to 12:50 PM, tray pass observation of lunch for the residents in their rooms for the Heritage Wing, staff did not offer resident's hand hygiene prior to leaving the room after tray set up. An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 04/23/2024 at 7:50 AM. Staff A, CNA stated, I did not offer hand sanitation to the residents when I pass trays, I never thought about it. An interview was conducted with Staff D, CNA on 04/23/2024 at 8:15 AM. Staff D, CNA stated, no hand hygiene was provided to residents when passing trays. An interview was conducted with Staff CC, CNA on 04/23/2024 at 7:50 AM. Staff CC, CNA stated, no hand hygiene was provided to residents when passing trays. An interview was conducted with Staff E, CNA on 04/23/2024 at 8:25 AM. Staff E, CNA stated, no hand hygiene was provided to residents when passing trays. An interview was conducted with Staff C, CNA on 04/23/2024 at 7:50 AM. Staff C, CNA stated, no hand hygiene was provided to residents when passing trays. An interview was conducted with Staff B, License Practical Nurse, (LPN) on 04/23/2024 at 8:25 AM. Staff B, LPN stated, no hand hygiene was provided to residents when passing trays. 37999 3) On 4/22/24 at 7:22 a.m., an observation was made of the room for Resident #214. A Personal Protective Equipment (PPE) caddy was hanging from the door which was posted with one sign Please Stop, See Nurse Before Entering, Thank You. The observation revealed the caddy held one box of large gloves and one box of medium glove, and no other PPE. The sign on door did not reveal the type of precautions staff or visitors should observe when entering the resident's room. An unknown staff member brought gowns to the caddy reporting (Resident #214) had MRSA. The staff member reported the resident was under contact precautions and required staff to wear gowns, gloves, and mask. On 4/23/24 at 11:31 a.m., Resident #214's room continued to have a PPE caddy hanging from the door without signage showing the type of precaution staff/visitors should observe when entering the room. On 4/23/24 at 10:08 a.m, an observation revealed Resident #214's urinary catheter drainage bag attached to the bed frame which was in the lowest position and was lying on the floor. An observation and interview was conducted with Staff Q, Certified Nursing Assistant (CNA) on 4/23/24 at 11:49 a.m., the staff member confirmed the catheter was on the floor due to the bed being in the low position and began raising the bed till the catheter was no longer on the floor. Review of Resident #214's Admission Record showed the resident had been admitted on [DATE] and included a diagnosis of Methicillin Resistant Staphylococcus Aureus infection as the cause of disease classified elsewhere. Review of Resident #214's Clinical Physician Orders, showed the resident was to be observed and cared for under Contact precautions, revised on 4/23/24. The dashboard special instructions revealed Contact Precautions through 4/25 then Enhanced Barrier Precautions. A physician order, dated 4/24/24 at 3:00 p.m. revealed Enhanced Barrier Precautions every shift for Peg Tube. The facility provided a list of residents on Transmission-Based Precautions which included one resident, Resident #214. Review of Resident #214's care plan showed the following concerns with associated interventions: - Resident #214 has active infection' g-tube site, initiated 4/14/24. The interventions included: Observe facility policies for infection control. The care plan did not document the resident's urinary catheter. Review of the policy - Catheter Care, revised 1/6/23, revealed It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy did not show how the catheter bag should be stored. During an interview on 4/25/24 at 11:16 a.m., the Infection Preventionist (IP) stated a urinary catheter soul be in a privacy bag and not on the floor, should be clipped to the frame of the bed, never on the floor but can be stored in a basin (sitting on floor). The IP stated PPE should be available in the door caddy at all times, when running low, we can restock, and the type of precaution should be posted on the resident's door. Photographic evidence was obtained. On 4/23/24 at 4:51 p.m., Staff O, Licensed Practical Nurse (LPN) was observed preparing and administering medications with Resident #67. The staff member removed a manual blood pressure cuff and stethoscope from the cart and entered the resident's room. Staff O attempted to place the cuff around the upper left arm of resident, revealing it did not fit, the staff member placed the cuff above the left wrist obtaining a blood pressure of 124/74. The staff member returned to the medication cart in the hallway and placed both the cuff and stethoscope on the medication cart. Staff O administered insulin and oral medications to the resident before returning to the cart. On 4/23/24 at 5:07 p.m., the observation of medication administration continued with Staff O. The staff member dispensed medications for Resident #93, removed the previously manual cuff and stethoscope from the end of the medication cart, and entered the resident room. The staff member assisted resident with medications, placed cuff on left upper arm, laid meter on the underpad next to the resident and obtained a blood pressure of 101/60. The staff member returned to the cart and laid the cuff and stethoscope on the handle of the medication cart. An interview was conducted on 4/23/24 at 5:27 p.m. with Staff O after the administration of medications with Resident #93. The staff member confirmed not cleaning the manual cuff or stethoscope in between using them for Resident #67 and #93. During an interview on 4/25/24 at 11:16 a.m, the IP stated the blood pressure cuff and stethoscope should be cleaned between residents. Review of the policy - Transmission-Based (Isolation) Precautions, revised 8/15/22, revealed It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. The compliance guidelines revealed: 7. Initiation of Transmission-Based Precautions (Isolation Precautions)- e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the Centers of Disease Control and Prevention (CDC) category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. g. Use disposable or dedicated noncritical resident-care equipment (e.g., blood pressure cuff, bedside commode). If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA-registered disinfectant after use. 8. Contact Precautions- c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. The policy - This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The compliance guidelines revealed All reusable items and equipment requiring special cleaning, disinfection, or sterilization be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on observations, record reviews, and interviews the facility failed to adhere to the smoking assessment of one resident (#79) out of the twenty smoking residents, and allowed three residents (#79, #9, and #213) to possess unsecured smoking paraphernalia outside of the supervised smoking times. Findings included: 1. On 4/22/24 at 6:30 a.m., Resident #79 was observed sitting at the main entrance of the facility, next to a trash bin/ashtray alone. The resident informed team of having to use the doorbell to get back into the facility. The entrance area smelled of fresh cigarette smoke and a pack of cigarettes was observed sitting on top of the trash bin. The resident entered the building with the survey team. On 4/23/24 at 3:02 p.m., Resident #79 was observed lying in bed and stated the facility started taking away smoking materials about 7-8 months ago, but have gotten lax about it. The resident stated Staff P, Activity Assistant, informed residents' today of having to take the cigarettes away again, saying it was policy. The resident reported not feeling it was right to take them away, feeling other residents who don't have any are given cigarettes from other residents'. Resident #79 confirmed being at the main entrance smoking when the survey team entered the building at 6:30 a.m. on 4/22/24. The resident stated staff let the resident out and sometimes it takes 45-60 minutes to be let in after ringing the doorbell. On 4/24/24 at 5:53 p.m., Resident #79 was observed, with the Director of Nursing (DON), the resident unzipped a case to obtain the business card from an outside Wound Care Physician and a purple pack of cigarettes fell out of the case. The resident acknowledged he was not supposed to have them the cigarettes. Review of Resident #79's Admission Record showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses of uncomplicated unspecified nicotine dependence, unspecified respiratory failure with hypoxia, unspecified chronic obstructive pulmonary disease, and unspecified pulmonary hypertension. Review of the Quarterly Minimum Data Set, dated dated [DATE], showed Resident #79's Brief Interview of Mental Status (BIMS) score was 12 out of 15, indicating moderate cognitive impairment. Review of Resident #79's Smoking Evaluation, dated 4/17/24, showed the resident did not have a history of smoking-related incidents, smoked 5-9 times per day, did not exhibit signs of confusion, vision was adequate with glasses, has fine-motor dexterity, was able to extinguish cigarette safely, and understood the policy related to smoking times and storage of smoking materials. Review of Resident #79's care plan revealed the resident Must smoke with supervision. Establishes own choices related to declining to adhere to smoking policy, initiated 1/30/24 and revised 4/22/24. The goals regarding the residents smoking was the resident would smoke safely with supervision, initiated 1/30/24, and would understand risks and benefits of choices made through next review date, initiated 4/22/24. The goals target date was 7/22/24. The interventions included: - Notify charge nurse if it is suspected resident has violated facility smoking policy, date Initiated 1/30/24. - Resident oriented to smoking procedures and areas, date Initiated: 1/30/24. - Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas, date Initiated 1/30/24. - Explain risks and benefits of resident's choices date Initiated 4/22/24. - Respect resident choices, date Initiated 4/22/24. During an interview on 4/25/24 at 1:12 p.m., the DON stated Resident #79 was supposed to be supervised while smoking. She stated the resident's non-compliance with smoking policy has been addressed. The smoking issue regarding others smoking other residents' cigarettes was an ongoing battle. 2. On 4/22/24 at 10:14 a.m., Resident #9 was observed and interviewed while lying in bed. The resident reported the facility does not allow resident's to smoke unattended. The resident reported having personal cigarettes and a lighter due to missing cigarettes if kept in facility box and if not keeping lighter the resident's would not be able to light cigarettes as the facility does not provide lighters. Resident #9 acknowledged not suppose to have lighter and hoped (pronoun) wasn't getting facility in trouble. The resident confirmed being the Resident Council President. On 4/23/24 at 2:08 p.m., Resident #9 was observed smoking with other residents' in the area designated as the smoking patio. Review of Resident #9's census showed the resident was admitted on [DATE]. The medical diagnoses of the resident included chronic systolic (congestive) heart failure, unspecified chronic obstructive pulmonary disease, and functional quadriplegia. Review of Resident #9's Quarterly Minimum Data Set, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. Review of Resident #9's Smoking Evaluation, dated 3/5/24, revealed the resident was a current smoker, had no history of smoking-related incidents, did not exhibit signs of confusion, verbalizes or demonstrates an understanding of the times and place to smoke, able to communicate if lit materials fall on them, has the fine-motor dexterity to hold a cigarette safely and dispose of ashes without a device, and able to extinguish safely. The evaluation showed the resident had the policy related to smoking times and storage of smoking materials and understands the policy. Review of Resident #9's care plan revealed the resident Must smoke with supervision. Establishes own choices related to declining to adhere to smoking policy created 7/25/22, initiated 8/3/23, and revised on 4/22/24 by Unit Manager. The goals for showed the resident will smoke safely with supervision throughout next review date created 7/25/22, initiated 8/3/23, and revised on 9/21/23 with a target date of 6/9/24. An additional goal initiated and created on 4/22/24 revealed the resident Will understand risks and benefits of choices made through next review date with a target date of 6/9/24. The interventions regarding Resident #9's smoking included: - Notify charge nurse if it is suspected resident has violated facility smoking policy, created 7/25/22, initiated and revised on 8/3/23. - Remind resident not to share smoking materials with other resident who may be unsafe created 7/25/22, initiated and revised on 8/3/23. - Explain risks and benefits of resident's choices, initiated and created by Staff T, Unit Manager on 4/22/24. - Respect resident choices, initiated and created by Staff T on 4/22/24. 3. On 4/22/23 at 11:34 a.m., Resident #213 was observed with a green-colored pack of cigarettes on top of bedside dresser. The resident reported not being outside to smoke since being here. Resident #213 stated being in room [ROOM NUMBER] and having belongings brought over recently. Photographic evidence was obtained. Review of Resident #213's Admission Record revealed an admitted [DATE] and re-admitted [DATE]. The record included diagnoses of unspecified uncomplicated nicotine dependence, and chronic respiratory failure with hypoxia. Review of Resident #213's Quarterly Brief Interview of Mental Status, dated 3/15/24, revealed a score of 13 out of 15, indicating an intact cognition. Review of Resident #213's Smoking Evaluation, dated 4/17/24, revealed the resident currently smoked, did not have a smoking-related incidents, smoked 1-2 times per day, did wish to quit smoking, did exhibit signs of confusion, and was able to communicate the need for help if lit materials fell on them. The evaluation showed the resident had the fine-dexterity to hold cigarette safely and properly dispose of ashes, had the ability to extinguish cigarette safely, acknowledged the understanding of the smoking policy, and did not require a protection device while smoking. Review of Resident #213's care plan revealed the resident Must smoke with supervision. Establishes own choices related to declining to adhere to smoking policy initiated and created 10/2/23 and revised on 4/22/24 by Staff T, Unit Manager. The revision showed the statement of Establishes own choices related to declining to adhere to smoking policy was added on 4/22/24 by Staff T. The goals regarding the residents smoking included Resident will smoke safely with supervision throughout next review initiated and created on 10/2/23 with a target date of 6/17/24 and Will understand risks and benefits of choices made through next review date initiated and created on 4/22/24 by Staff T with a target date of 6/17/24. The interventions included: - Notify charge nurse if it is suspected resident has violated facility smoking policy, initiated and created 10/2/23. - Resident oriented to smoking procedures and areas initiated and created 10/2/23. - Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas, initiated and created 10/2/23. - Respect resident choices, initiated and created on 4/22/24 by Staff T. During an interview on 4/25/24 at 1:12 p.m., the Director of Nursing reported being aware of the presence of Resident #213's cigarettes at bedside, They had to have been in (pronoun) possessions. An interview was conducted with Staff P, Activities Assistant on 4/23/24 at 2:08 p.m., while the staff member was supervising smokers on the smoking patio. The observation revealed one unknown female resident lighting her own cigarette with lighter that was placed on the cigarette pack lying on table in front of her. The staff member stated about 50% of the residents, approximately 10-12 residents, currently on the porch keep their cigarettes and lighters. Staff P stated the resident's inform the staff member the cigarettes and lighters are their property. The staff member reported allowing the resident's to keep the materials because Doesn't want to argue with them and the job on the smoking patio was ensuring residents did not fight with each other. A review of the facility's list of smokers showed all twenty (20) current smokers Must smoke with supervision and included Resident #79, #9, and #213. The facility revealed the daily smoking times for residents was at 9:30 a.m., 2:00 p.m., 4:00 p.m., and 7:00 p.m. Review of the facility's policy - Resident Rights, implemented on 11/3/23 and revised on 3/8/23, revealed the following: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. The policy addressed the Respect and dignity of residents revealing the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident for other residents. The facility acknowledged The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility policy - Resident Smoking, reviewed/revised on 9/7/22, revealed the following: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. The compliance guidelines included: 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, in and accordance with his/ her care plan. 12. If a resident or a family does not abide by the smoking policy or care plan (e.g. Smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. 15. Documentation to support decision making will be included in the medical record, including but not limited to: - d. Compliance with smoking policy.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and six (6) errors were identified for four residents (#67, #48, #415, and #24) of six residents observed. These errors constituted a 20% medication error rate. Findings included: 1) On 4/23/24 at 4:51 p.m., an observation of medication administration with Staff O, Licensed Practical Nurse (LPN), was conducted with Resident #67. The staff member scanned the resident's implantable glucose monitor and received a blood glucose level of 190. Staff O, LPN dispensed the following medications: - Insulin Aspart - Staff O applied needle to insulin pen, primed the pen with 2 units holding it parallel to the floor, applied another needle due to insulin not coming out, dialed the pen to 2 units, while holding the pen at approximately 45 degrees tapped the cartridge. The staff member returned to Resident #67's room, obtained a pulse of 73 via pulse oximeter, injected insulin into left upper extremity and immediately removed the needle. Returning to the medication cart Staff O dispensed: - Carvedilol 3.125 milligram (mg) tablet - Docusate sodium 100 mg softgel capsule The staff member confirmed one tablet and one capsule. An interview was conducted with Staff O on 4/23/24 at 5:27 p.m., the staff member reported the reason for priming insulin pens was to get the insulin to the top. Staff O stated the air bubble in cartridge was in the middle of the cartridge if held in 45 degree angle. During an interview on 4/25/24 at 12:59 p.m., the Director of Nursing stated the insulin should be held upright (needle pointing up) to prime. According to https://www.novo-pi.com/novolog.pdf, accessed on 4/26/24, revealed the following for priming of an Insulin Aspart pen: Giving the airshot before each injection. -Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your NovoLog(R) FlexPen(R) with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog(R) FlexPen(R) and contact Novo Nordisk at [PHONE NUMBER]. A small air bubble may remain at the needle tip, but it will not be injected. The policy - Insulin Pen, reviewed 5/3/22, revealed It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The policy revealed the insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The facility failed to provide page 2 of the policy. 2) On 4/24/24 at 8:34 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #48. The staff member dispensed the following medications: - Nicotine 7 mg topical patch - Acetazolamide 250 mg tablet - Amiodarone 200 mg tablet - Carvedilol 3.125 mg tablet - Furosemide 40 mg tablet - Losartan 25 mg tablet - Ferric X-150 tablet - Potassium chloride 20 milliequivalent (meq) Extended Release (ER) tablet - Budesonide 0.5 mg/2 mL inhalation vial - Norco 10-325 mg tablet The staff member confirmed 8 tablets, signed off narcotic, and entered the resident room. Staff A handed the medication cup to Resident #48, poured Budesonide into the nebulizer medication cup, removed Nicotine patch from left front shoulder, and placed the new patch onto the right upper chest. Staff A handed nebulizer mask to resident who held it and machine was turned on. The staff member returned to the medication cart and documented a previously obtained blood pressure of 131/54 and a pulse of 70, which was the pulse of the resident in the room next to Resident #48's. During the medication administration for the resident's roommate on 4/24/24 at 9:02 a.m., Resident #48 was observed with the nebulizer machine turned off and nebulizer mask on the machine. Review of Resident #48's Medication Administration Record (MAR) revealed - Budesonide inhalation suspension 0.5 gm/2 milliliter - 2 mL inhale orally two times a day for shortness of breath/wheezing (SOB). Rinse mouth after use. Staff A did not instruct/ensure or encourage the resident to rinse mouth after use. The policy - Nebulizer Therapy, revised 12/23/22, showed It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. The compliance guidelines included the following instructions for staff: 6. Obtain resident's vital signs and perform respiratory assessment to establish a baseline. 14. Observe resident during the procedure for any change in condition. 16. Disassemble and rinse the nebulizer cup and mouthpiece with water and allow to air dry. The policy revealed staff were to document the date, time, and duration of therapy, vital signs and respiratory assessment, and the resident's response to treatment. During an interview on 4/25/24 at 1:00 p.m., the Director of Nursing stated the staff should wash hands, let resident know what was happening, obtain lung sounds, and pulse. The nebulizer mask should be in a plastic bag, and do a (respiratory) assessment afterwards. 3) On 4/24/24 at 8:51 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #415. The staff member obtained a blood glucose level of 335 from an implantable glucose monitoring system and the resident refused oral medications. The resident informed Staff A of not eating any breakfast and did not want any. The staff member obtained a Humalog Kwikpen from the medication refrigerator, rubbing it in between hands to warm the insulin. Staff A applied a needle, primed with 2 units, primed again with 2 units, dialed the dose selector to 3 units and injected the insulin into Resident #415's right lower quadrant. Review of Resident #415's MAR revealed the Humalog (Insulin Lispro) was scheduled to be administered at 7:30 a.m., one hour and 21 minutes prior to the observation. 4) On 4/24/24 at 9:17 a.m., an observation of medication administration with Staff N, Licensed Practical Nurse (LPN), was conducted with Resident #24. The observation revealed the resident's Gabapentin was scheduled for 8:00 a.m. and the medication was colored red (showing it was late). The staff member stated They scheduled it for 8. Staff N obtained a blood pressure of 113/63 and pulse of 57. Staff N reported not giving Amiodarone because of the resident's pulse was low. The staff member dispensed the following medications: - Gabapentin 100 mg capsule - Baclofen 10 mg tablet - Losartan potassium tablet- 1/2 of 25 mg tablet (12.5 mg) - Lactobacilli probiotic 500 million cells - Sucralfate 1 gram tablet - Sulfasalazine 500 mg tablet - Sertraline 100 mg tablet - Oxycodone Acetaminophen 10-325 mg tablet Review of Resident #24's MAR revealed the following: - Amiodarone 200 mg - Give 1 tablet by mouth every morning and at bedtime related to personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits in the morning and before bedtime. The medication was held for Vitals outside of parameters for administration. The order did not reveal any parameters to hold the medication. - Probiotic Oral Capsule (Saccharomyces boulardii) - Give 1 capsule by mouth every 12 hours for Urinary Tract Infection (UTI). - Gabapentin 100 mg- Give 1 capsule by mouth three times a day for neuropathy. Review of Resident #24's progress notes revealed on 4/24/24 at 9:36 a.m., (thirty-six minutes after hour before/hour after) Staff N had notified MD of the late administration of Gabapentin which the MD stated ok, no new orders was obtained. The progress note did not reveal the physician was notified of holding Amiodarone due to pulse. According to Webmd.com (accessed on 4/26/24), Saccharomyces boulardii (S. boulardii) is a type of probiotic (friendly organism). It's a yeast that is actually a strain of Saccharomyces cerevisiae. Review of Webmd.com revealed Lactobacillus acidophilus (L. acidophilus) is a type of probiotic (good bacteria) found in the human gut, mouth, and vagina, and also in certain foods. During an interview on 4/25/24 at 1:07 p.m. the Director of Nursing revealed liking that Staff N had held the Amiodarone, and when holding a medication, (staff should) contact the physician and ask if they want to continue to hold. The DON stated the Lactobacillus (administered) was not the same medication as Saccharomyces (ordered). The policy - Medication Administration, reviewed 5/24/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, any manner to prevent contamination or infection. The compliance guidelines included the following: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Class III

Based on interviews, observations, and record reviews, the facility failed to ensure two residents (#79 and #213) were assessed for self-administration of treatments and medications out of forty sampled residents. Findings included: An interview was conducted with the Director of Nursing (DON) on 4/24/24 at 5:01 p.m., the DON stated she did not believe any residents in the facility were able to self-administer medications. 1. Review of Resident #79's Admission Record showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus with diabetic chronic kidney disease, cellulitis of left lower limb, and End Stage Renal Disease. An observation on 4/23/24 at 3:02 p.m. revealed Resident #79 lying in bed after returning from dialysis. The observation showed a bottle of nasal spray, a spray bottle of wound cleanser, and a bottle of a dark liquid the resident stated was Betadine. The resident reported an undated foam dressing on the left upper extremity and the open wound on the inner thigh of the left upper leg was dressed by the resident. The resident stated the presence of the collagen pad in the room was used to dress the left leg wound. During an observation and interview on 4/24/24 at 5:33 p.m., with Resident #79 and the Director of Nursing (DON), the DON informed the resident the observed wound cleanser and Betadine would need to removed and the resident refused to allow the removal of items. The DON left the room without any of the treatment items observed on the over-bed table, including the nasal spray. Review of Resident #79's care plan did not reveal the resident was assessed for the self-administration of medications or treatments. The care plan showed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility, preferred to have facial hair at times, (and) preferred to have belongings/toiletries left in bathroom and at bedside. This focus was initiated/created on 1/30/24 and revised on 4/23/24. The interventions did not reveal the resident was able to keep medications at bedside. The resident's care plan did not show the resident was assessed and allowed to self-administer medications and/or medicated treatments. 2. On 4/22/24 at 11:34 a.m., Resident #213 was observed lying in bed, with a bedside dresser/bookcase next to the bed. An opened bottle of Nystatin Topical Powder and a medication cup with a powder substance was observed on the top of the bookcase. The bottle of antifungal powder revealed it was to be applied to the groin/scrotum twice daily for 5 days. Photographic evidence was obtained. Review of Resident #213's Admission Record showed an original admitted [DATE] and a readmission on 4/15/24. The record included diagnoses not limited to encounter for orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with hyperglycemia. Review of Resident #213's April 2024 Treatment Administration Record (TAR) showed the treatment for Nystatin External Powder was to be applied twice daily to the groin/scrotum from 4/16/24 to 4/21/24. Review of Resident #213's medical record did not reveal the resident had been assessed for self-administration of medications. A request was made to the facility on [DATE] for a copy of the resident's Self-Administration Assessment and it was not provided. During an interview with the Director of Nursing (DON) on 4/25/24 at 1:12 p.m., the DON reported being aware of the (name brand) antifungal powder was at Resident #213's bedside, They had to have been in (pronoun) possessions. Review of the policy - Resident Self-Administration of Medication, implemented 11/2020, revealed the following: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely. The compliance guidelines revealed: 1. Each resident has the right to be assessed for self-administration of medications. 2. Resident's preference will be documented on the appropriate form and placed in the medical record as indicated. The results of the interdisciplinary team assessment are recorded on the Self-Administration of Medication Evaluation, which is located in the resident's medical record. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of the policy and procedures regarding resident self-administration when necessary. 13. The care plan must reflect resident self administration and storage arrangements for such medications.

Based on observations, interviews, and record review, the facility failed to complete the smoking assessment for one resident (#364) out of four residents sampled. Findings included: An observation on 04/22/24 at 9:45 a.m. revealed Resident #364 actively smoking a cigarette on the designated smoking patio during a facility specified smoking time. An interview was conducted on 04/24/24 at 12:09 p.m. with Resident #364. She stated she smokes during designated smoking times daily and has been smoking at the facility since she was admitted on [DATE]. An interview was conducted on 04/25/24 at 10:43 a.m. with the Director of Nursing (DON). She stated the smoking assessment process is completed when residents are admitted to the facility. She said there is a section in the admission assessments to address smoking. She stated the expectation is for staff to complete the smoking assessment immediately along with all assessments that are part of the admission. She said smoking assessments are completed at admission to determine resident safety and provide education on the facility policy, and safe smoking practice. She stated all the residents are to be supervised when smoking. She stated Resident #364's smoking assessment was completed on 04/23/24 after she was made aware it had not been done. She stated, It was overlooked and should have been completed at admission. Review of the medical record revealed Resident #364 was admitted on [DATE] with diagnoses that included Bipolar Disorder, generalized anxiety and major depressive disorder, cellulitis of right lower limb, lymphedema, and unspecified cirrhosis of liver. Review of the facility provided list of the residents who smoke, dated 04/22/24 at 7:58 a.m., had Resident #364 as #19 of 20 residents listed on the form. Review of the medical record revealed Resident #364 had no smoking assessment completed. Review of care plan, dated 04/17/2024, showed Resident #364 a focus of Must smoke with supervision. Establishes own choices related to declining to adhere to smoking policy. The care plan was initiated on 04/17/24, and revised on 04/22/24. Review of the Smoking Policy section in the admission packet revealed each resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include, Ability to smoke safely with supervision. Review of the facility policy titled Resident Smoking, implemented 07/25/22 and revised on 09/07/22, revealed the following: Residents who smoke will be further assessed using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking or if resident is safe to smoke at all.

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from neglect to ensure two residents (#10, #12) out of 11 residents at risk, with known neurocognitive disorders and/or dementia and a history of wandering and exit seeking, was provided supervision and services to prevent elopement. The facility neglected to maintain an exit door alarm system in proper operation or implement alternate methods to prevent elopements since 08/02/2023. The facility nursing staff neglected to ensure the safety of Resident #10, from approximately 12:40 p.m. until 1:37 p.m. or approximately 57 minutes on 09/02/2023. Resident #10 exited the front door unobserved by staff. She traveled down a steep drive, across a street to an apartment building parking lot which was approximately 600 feet away. She was discovered and returned to the facility by a male resident of the apartment complex. The facility nursing staff neglected to ensure the safety of Resident #12. Resident #12 was able to exit the facility unsupervised on 08/28/2023. Resident #12 was able to tailgate out the front entrance of the facility. The resident was discovered outside by staff and brought back into the facility. The facility was aware the door alarming system was not operating properly since 08/02/2023, and despite this knowledge the facility neglected to put interventions in place to prevent the elopements of Resident #10 and Resident #12. This neglect created a situation that resulted in the likelihood for serious injury and or death to Resident #10 and Resident #12 and resulted in the determination of Immediate Jeopardy on 08/02/2023. The findings of Immediate Jeopardy were determined to be removed on 10/06/2023 and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: During a phone interview on 10/06/2023 at 9:21 a.m. a customer service representative from the [contracted technology company] stated, On 09/05/2023, they had issues with the [wandering alarm system] reception. It was not picking up the transmissions all the time. On 08/02/2023 we initially talked to them about the issue. We did some trouble shooting steps over the phone but was unable to solve the issue. We sent them a service agreement form (Authorization Form) for signature. We did not get the form back. We have to have a signature on an Authorization Form before we send anyone out. On 09/02/2023, the Maintenance Director called back about the same issue. Again, one of the techs tried to troubleshoot over the phone but was unable to. We resent the form that day, 09/02/2023, and received it back the same day. We dispatched it for 09/05/2023. On 09/05/2023 the tech arrived, he checked the main entrance, and adjusted the antennas. He adjusted the wire termination for a timer and bypass button. After the test it was working fine. He tested all the other doors. The termination wires on the keypads adjust the schedule of opening and closing of the door. He checked the wiring only it did not have to be replaced or repaired. Resident #10 was admitted on [DATE] and readmitted on [DATE]. Record review showed diagnoses included but were not limited to neurocognitive disorder with Lewy bodies; brief psychotic disorder; adjustment disorder with anxiety; generalized anxiety disorder; unspecified lack of coordination; Diabetes; muscle weakness (generalized); other abnormalities of gait and mobility; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent moderate; and essential hypertension. Record review of the annual, Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Function, a Brief Interview Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section G: Functional Status showed the resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, limited assistance of two for transfers, and she was independent on and off the unit. Section E: Behaviors showed wandering behavior were not exhibited. Review of the Physician Orders Summary for September 2023 showed the following: Actively Exit Seeking Record Intervention Code (s): 1. N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting (every shift) as of 07/22/2022. Actively Exit Seeking Record Outcome Code: 1. N/A, 2. Improved, 3. Worsening, 4. Unchanged, if worsening / unchanged, notify supervisor (every shift) as of 07/22/2022. Behavior Monitoring -Active Exit Seeking Record the Number of Occurrences every shift, (0 if did not occur) as of 07/22/2022. Psychiatric Consult for Evaluation and follow as needed as of 01/09/2023. Wanderguard (wandering device)- check function every night shift for wandering device use as of 07/22/2022. Wandering device - Check placement to LLE (Left lower extremity) every shift for wandering device use as of 07/22/2022. Wandering device to LLE due to: Elopement Risk as of 03/10/2023 and expires 10/08/2023. Depakote Oral Tablet Delayed Release 125 mg (milligram) every 12 hours for anxiety as of 07/30/2023 and was increased to 250 mg every 12 hours for mood disorder as of 09/05/2023. Memantine HCL 10 mg every 12 hours for dementia as of 08/03/2020. Mirtazapine 7.5 mg in the morning for depression as of 02/01/2023. UA with C and S (urine analysis with Culture and Sensitivity) on 09/06/2023. Cipro 500 mg every 12 hours for UTI (Urinary Tract Infection) for 7 days as of 09/10/2023. Review of the September 2023 Behaviors Record showed the following: Actively Exit Seeking Record Intervention Code (s): 1. N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting (every shift) as of 07/22/2022. On 09/02/23 N/A for day shift was documented. Actively Exit Seeking Record Outcome Code: 1. N/A, w. Improved, 3. Worsening, 4. Unchanged, if worsening / unchanged, notify supervisor (every shift) as of 07/22/2022 on 09/02/23 N/A for day shift. Behavior Monitoring -Active Exit Seeking Record the Number of Occurrences every shift, (0 if did not occur) as of 07/22/2022. On 09/02/2023 0 was documented. Review of the September 2023 Treatment Administration Record (TAR) showed the following: Wandering device - check function every night shift for wandering device use as of 07/22/2022. On 09/01/2023 it was documented as checked by nursing. Wandering device - Check placement to LLE (Left lower extremity) every shift for wandering device use as of 07/22/2022. On 09/02/2023 it was documented as checked on the day shift. Review of Resident #10's progress notes showed no documentation regarding an elopement on 09/02/2023. Review of the nursing progress notes dated 09/05/2023 at 2:48 p.m. showed the following: Psychiatric Nurse Practitioner on site for visit with resident. New orders were given to increase her Depakote from 125 mg PO [by mouth] BID [twice a day] to 250 mg PO BID. Entered into PCC [Point Click Care or electronic medical record]. Review of Resident #10's Elopement Risk Evaluation, dated 07/02/2023 showed the following: 1. Is resident ambulatory and / or able to self-propel wheelchair? Yes. 2. Presence of any of the following risk factors indicates the resident is a risk for elopement. 2b. Resident displays behaviors indicting desire to leave the facility, i.e., packing belongings, tailgating, searching for exits from facility or searching for someone/something from past life events, verbalizing desire to go home/elsewhere. 2d. Resident's family/responsible party expressed concerns resident may attempt to leave. 3. Resident is 1. At risk for elopement. Review of Resident #10's Elopement Risk Evaluation. dated 09/02/2023 showed the following: 1. Is resident ambulatory and / or able to self-propel wheelchair? Yes. 2. Presence of any of the following risk factors indicates the resident is a risk for elopement. 2b. Resident displays behaviors indicting desire to leave the facility, i.e., packing belongings, tailgating, searching for exits from facility or searching for someone/something from past life events, verbalizing desire to go home/elsewhere. 3. Resident is 1. At risk for elopement. During an interview on 10/05/2023 at 12:30 p.m. with the Advanced Practice Registered Nurse (APRN) she stated Resident #10 had a little bit of confusion, and thought she was going home, and she went out to the park. That was not her normal. She did a urinalysis (UA) and culture and sensitivity (C/S) and placed her on antibiotics. She was back to normal. Her Depakote was increased on 09/05/2023. Her urinalysis was on 09/06/2023 and results on 09/09/2023. Cipro was started on 09/10/2023 for 10 days. The facility told her when she came into the facility the resident had eloped, they did not call her. They called the psychiatric nurse because it was exit-seeking. Record review of the UA and C/S, dated 09/06/2023, showed over 100,000 Escherichia Coli microorganisms in the urine. Review of the care plans showed as of 08/18/2022 Resident #10 was at risk for elopement / exit seeking activity, exit seeking, aimless wandering due to cognition, has the potential to approach exit doors. A goal initiated on 08/18/2022 showed the resident will not leave facility unattended through the review date of 10/15/2023. The interventions included but were not limited to the following: On 08/18/2022, checking for proper functioning of the audible alarm system daily and prn (as needed). On 08/18/2022, check functioning of wandering device every night. Revised on 05/25/2023, check placement of wandering device every shift - LLE. On 08/18/2022, Discuss with resident / family the risk of elopement and wandering. On 07/27/2023, Encourage resident to participate in activities and redirect resident when exit seeking. Revised on 5/25/2023, Every 1-hour safety checks monitor resident due to identified elopement risk. On 08/18/2022, Indicate risk in Care Profile and Kardex, Place demographics in Risk Binders. On 08/18/2022, Monitor resident for tailgating when visitors are in the building. On 08/18/2022, Monitor resident for active exit seeking behavior each shift. On 08/18/2022, Use audible monitoring system to alert staff of exit seeking behaviors. On 08/18/2022, Use diversional activities when exit-seeking behavior is occurring (i.e., offer food, activities, one-on-one company). An observation and interview were conducted on 10/02/2023 at 10:15 a.m., Resident #10 was lying in bed, awake. Her wandering device was observed on her RUE (Right Upper Extremity). The head of the bed was elevated. She stated, I went on a walk last week, to the mall, went by myself because no one could take me. I went up a hill. During an interview and observation on 10/02/2023 at 1:15 p.m. Staff B, LPN (Licensed Practical Nurse) was asked to locate Resident #10's wandering device. Staff B was unable to find the wandering device on Resident #10's LLE. She stated, It is supposed to be there (lifting up the resident's pants legs). Staff B went into the bathroom to look at the resident's wheelchair and it was not present. Staff B was observed locating the wandering device on her RUE. She stated, It's on her RUE. Staff B, LPN attempted to remove the wandering device, and stated it could not be taken off even with effort. An observation was conducted on 10/04/2023 at 10:35 a.m. Resident #10 was dressed and groomed for the day and seated in her wheelchair. She was located in the dining room looking out the dining room door. She was alone. She demonstrated she was able to move herself in her wheelchair with her feet. The wandering device was observed on her RUE. During an interview on 10/03/2023 at 8:57 a.m. the DON was asked for a timeline. A timeline provided on 10/03/2023 at 11:20 a.m. revealing the following: 09/02/23, approximately 12:40 p.m. resident observed exiting dining room after lunch. 09/02/23, approximately 12:45 p.m. nurse reports seeing resident wheel herself down hall. 09/02/23, approximately 1:37 p.m., resident returned to facility by neighbor, Staff F, receptionist was alerted by sounding of the alarm. 09/02/23, approximately 1:38 p.m., resident assessed by social services, floor nurse to have no injuries. 09/02/23, approximately 1:50 p.m., head count initiated on facility residents with no other issues noted. 09/02/23, approximately 2:00 p.m., Social Service Director (SSD) placed on door monitoring. 09/02/23, approximately 2:35 p.m., DON arrived at the facility to assess the event, and complete head to toe assessment on Resident #10. The resident was placed on 1:1 supervision. 09/02/23 approximately 3:15 p.m., NHA, Maintenance Director arrived to assess doors. Review of the [contracted technology company] On-Site Service Charge Authorization Form dated 08/02/2023 showed, Customer Described Problem: Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's ANT (antenna) range as some residents have been able to escape without setting off the alarm. On the lower half of the form, it showed, My signature on this agreement certifies that I am an authorized agent for the facility listed above. It was signed as authorized by the NHA on 09/01/2023. Review of the [contracted electric company] Invoice dated 08/23/23 showed: The following charges are for electrical work performed as listed: Inspected the lobby door. Opened the panel and tested power. Found the panel power was testing for 17 volts AC (alternating current) and 0 volts DC (direct current). Replaced the power supply for 12 volt, applied power to panel. tested receivers and found the receiver on antenna 4 was not functioning. Replaced the receiver from maintenance stock and placed antenna for circuits on antenna 1 terminal. Ranged all three receivers. Receivers picked up transmitter and door annunciates while the transmitter is in range and door is ajar. Found three outdated transmitters before testing with a in date transmitter. Administration was not in the building. Maintenance came in for a brief period of time to check how wandering device range test was going then departed. Labor one tech 4.5 hours weekend labor Review of the Service Call Job Form, dated 09/05/23, [contracted technology company] showed under description Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's antennae range as some residents have been able to escape without setting off the alarm. Documentation showed On site met Maintenance Director and NHA. Checked and tested the main entry 9450 T70 with 3 duo link antennae. Adjusted the door antenna and adjusted wiring terminations for timer and bypass button / IEIKeypad. System working as designed. While on site, checked and tested all remaining Code Alert door systems for working order. System ok. Review of the electronic maintenance system dated 08/28/2023 through 09/01/2023 showed the following: Residents Monitoring Systems: Check operation of door monitors and patient wandering system performed by Maintenance Director revealed all doors including the Main Entrance Pass. On 09/02/2023 a handwritten form showed all doors including the Main Entrance Pass and was completed by the Maintenance Director. Documentation at the bottom of the 09/02/2023 form showed, Spoke with [contracted technology company] tech about adjusting T10 (antenna). We got it dialed in good. Therapy patio longer than usual on door alarm. During an interview on 10/02/2023 at 1:00 p.m. the Maintenance Director was observed checking the following exit doors: Therapy Hall, [NAME] Hall, Magnolia Hall, Smoking Area, Delta Hall, and Park Hall, Laundry door and Dining Room. All alarmed doors were in working order. He stated the alarmed doors had a 15-second delay alarm. He stated he checks the door alarms daily. He stated the front door was unlocked from about 7 a.m. to 5 p.m. but it won't open if a resident has a wandering device on. When asked what happened on 09/02/2023, he stated I do not know. During an observation on 10/02/2023 at 1:40 p.m. the dining room door screeching alarm went off twice. On investigation, the activity assistant was taking residents out for air and guitar playing. No other staff members responded to the alarms. The activity assistant set it off again and again and no one responded, this included the kitchen staff. During an observation on 10/02/23 at 1:50 p.m. the Maintenance Director tested a wandering device at the front door. The door did alarm during the test. He stated the door will not open if a wandering device comes near the door. If the door was open it would alarm. He again said he did not know what went wrong (09/02/2023). He stated, I just called the company, and they adjusted the antennas. On 10/02/23 at 2:55 p.m. Resident #10's elopement route was observed with the DON and the Regional Nursing Home Administrator (RNHA). This included walking down a steeply sloped driveway and crossing a 2-lane street with a speed limit of 30 miles per hour. There was an occasional car observed going down the street. Resident #10 entered the grounds of an apartment complex. She was found by a gentleman at the back of the apartment complex parking lot. The DON stated she and the NHA went door-to-door in the apartment complex and found the gentleman who brought Resident #10 back. He informed them where he found her in the parking lot. He told the DON and the NHA the resident had told him she wanted to get to the playground, which is part of the apartment complex where she was found. He told them she was calm and was just sitting in her wheelchair. He said he tried to change her mind about going to the playground. (Photographic evidence obtained). During an interview on 10/02/2023 at 3:12 p.m. the Maintenance Director was asked about the statement on the On-Site Charge Authorization Form. He stated, I just was trying to get them (contracted technology company) to come for the antennas. He stated, It was the only thing I can think of. He verified a work order had been placed 30 days prior to the elopement. He stated he did check the main door, on 09/02/2023, when they came in, post elopement, he documented it was working. During an interview on 10/02/2023 at 3:30 p.m. the Regional Nursing Home Administrator (RNHA) and the DON stated they verified there were two forms from the contracted technology company, Form 1 was On-site Service Charge Authorization Form, dated 08/02/2023 (a month before elopement), stating Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's antennae range as some residents have been able to escape without setting off the alarm. It was signed by the NHA on 09/01/23 (a day before the elopement). The NHA was unavailable for an interview during the dates of the survey. Form 2 was Service Call Job Form, dated 09/05/2023. The RNHA stated when he was told about the elopement and the door problems, he told them to put someone on the door and get someone out to fix it as soon as possible (ASAP). The DON stated the NHA had chewed the contracted technology company out (for not responding timely). The RNHA stated the Maintenance Director told him they had receipts from another company, and the Maintenance Director was looking for the receipts. The RNHA and Maintenance Director produced an invoice from a (contracted electric company). They stated they came out on 08/23/23. The RNHA stated they then called the manufacturer [contracted technology company] because the antennas were still not working properly. The RNHA, the Maintenance Director and the DON stated they could not get the contracted technology company to come out, so they called the contracted electric company to come out. The RNHA stated the main door was not alarming the way it should, so he told the facility to get the manufacturer (contracted technology company). The DON stated the door was supposed to be functioning but was not alarming. The contracted electric company installed new antennas. The contracted technology company came in and did not add any equipment but adjusted the antennas. The Maintenance Director stated he did not know if the antenna was adjusted by the contracted electric company, but it had to be readjusted. During an interview with the DON on 10/03/2023 at 8:57 a.m. the DON stated she did a head-to-toe assessment on the resident, with no abnormal findings. The resident was fine. The resident told the DON she was going to work. The DON called the management team in. The DON stated no one saw her, she was able to leave the dining room on her own. The DON verified for approximately 57 minutes it was unknown where the resident was located. The DON stated Staff M, CNA was assigned to care for Resident #10 that day. The DON stated she interviewed Staff M and she saw the resident in the dining room at about 11:30 a.m. on 09/02/2023. The DON stated staffing was good on 09/02/2023, it was meeting the 2.0 minimum. The DON stated the documentation of the event (elopement) was part of the resident's risk notes. Those notes are not found in the resident's electronic medical records. The DON verified there was no documentation in the electronic medical record of the incident. She verified there was only a post evaluation which did not state she eloped. There was no documentation that the attending physician and / or responsible party had been notified. It was documented in the risk report. She stated they had psych (psychiatric services) in to see the resident. They had the attending physician in to see the resident. The DON verified the Psych note on 09/05/2023 showed She elopes and has outdoor privileges. Patient is now on 1:1 observation for safety measures and does not remember. DON stated, she does not have outdoor privileges. The DON stated she would ask medical records if there were any other notes that had not been uploaded. A Post Incident was in the chart. The DON stated, We had an IDT (Interdisciplinary Team) meeting and reviewed the care plan and made sure everything was there. We have an IDT meeting every morning and review all incidents that happen. The note for the IDT meeting was documented in the risk notes by the DON. They did not document the IDT meeting in the electronic medical chart. She stated they reviewed the care plans. They reassessed her elopement risk, performed labs, did a UA and C/S on 09/06/2023. On 09/05/23 they changed the Depakote order. The resident did have a UTI and was treated with antibiotics. She stated the care plan was updated with 1:1 supervision on 09/02/23. During an interview on 10/03/2023 at 3:01 p.m. the DON stated, She (Resident #10) does not get up as much as she did. She had a UTI. She was used to seeing her up and about. The UTI kind of took her down a little bit. The Depakote may be making her sleepier. I will talk to psych the Advanced Practice Registered Nurse Practitioner (APRN). You have to approach her 'Resident #10 it is time to get up', vs. 'Do you want to get up?'. The DON stated she did not know of any other residents going out. The door was not sounding. She stated, I was used to hearing an alarm when a resident with a wandering device on got near the door. Maintenance told her Some residents have been able to escape without setting off the alarm, was stated (on the Service Form) due to it being so hard to get the company (contracted technology company) out. The DON stated the Maintenance Director and NHA were working it out (the door issue on 08/02/2023). She stated she did not know if the resident was tailgating or not. It (door locking and alarming) would sometimes not capture from the wandering device going out but would always capture on coming in. The DON stated no one was sitting at the main door until 09/02/2023. The DON stated if they knew it (the door) wasn't working, they would have put a staff member on the exit door 24/7 to ensure no one left the building who wasn't supposed to. Before the main door was only being monitored by the receptionist. She stated, She was not aware there was anything wrong with the door. The DON stated, It wasn't always consistently picking them up, but they were picked up and staff intervened. During an interview on 10/03/2023 at 4:10 p.m. the Maintenance Director stated, The sound announced but it did not announce like it was supposed to be. The door was functioning like it was supposed to but not the sound. I don't know, it was a while ago. He stated, Am positive it was announcing in the past, it has a speaker in it. I know they have to report if someone escapes. If there is an issue, I have to take care of it. I have to do my part. We have had residents escape before and it was reported to you guys. If a resident got out, you guys know about it. The NHA was aware there was a problem. I handed the On-Site Service Charge Authorization Form to the administrator at the time (08/02/2023). I do not know who it was (that eloped). I explained what was going on and [contracted electric company] did a complete check. We had an antenna in the building, and [contracted electric company] replaced it. He did fix the sound, don't know what was going on, but he fixed it. I may have been on the phone with the company (contracted technology company) on 09/02/2023, trying to get them out here. They (contracted technology company) adjusted the two antennas to their full potential range. They are in a half circle. I tested the doors when everyone came in on Saturday, 09/02/2023. It (the testing) was handwritten that I checked all the doors on 09/02/2023. I can't remember that part, if the NHA checked her (the resident's) wandering device and was it was working part time. During an interview on 10/03/23 at 4:35 p.m. SSD, which was present on the day of the elopement, stated on 09/02/23 she did not know when Resident #10 got out or how. The SSD had gone up front to relieve the receptionist for lunch. Staff F, receptionist, came back from lunch and she stated she came back to her office. Some guy said Resident #10 was across the street. Staff F took her to the nurses' station. Resident #10 then came to my door. She was not sweating; skin was cool to the touch. Resident #10 went down the hall, stated She was going to see her friend. The man (who brought her back) was gone. When she got out the door it was not working. She stated she sat at the main door from about 2 p.m. until 6 p.m. She did not know if the door made a noise or not, but it was supposed to lock down, for residents with a wandering device. It (the door) would lock when they got close to the door, but she did not know about the alarms. Resident #10 would get up and go, she was able to self-propel herself. During an interview on 10/04/23 at 9:02 a.m. Staff M, CNA, who was present on the day of the elopement, stated she was Resident #10's aide that day. She was in the dining room that day. She got her up in the morning and went to the bathroom. The resident wandered. She saw her after lunch. She was walking down the hall and the nurse said she was outside. It was around lunch. She saw her after dining wandering. During an interview over the phone on 10/04/2023 at 12:58 p.m. Staff L, LPN, who was present on the day of the elopement, stated the resident was up and down the hallways in her wheelchair. She had Just seen her 1 minute before that happened. She could have Only been out of the building for 2 or 3 minutes. She thought she went out behind someone. There was no way she got out of the parking lot, she had to be on the patio and brought her back in. There was no way she would have gotten down the driveway in her wheelchair. Stated she did not see how she got in the parking lot. She stated she had just seen her 5 minutes before they called, she was out the door. They tested the wandering device. The wandering device on the way back in, it went off. She was assessed, looked over, nothing was wrong. The aides Put her back to bed. They called a Code Gray and we had to make sure all the residents were accounted for. We looked her over, she had no bruises or skin tears. Staff L said she did not know the door was not working. We have a lot of residents who go out to the patio (outside the front door). Resident #10 was the only one she knew of who got out. The receptionist was right there at the door. During an interview on 10/04/2023 at 1:25 p.m. Staff I, CNA, who was present on the day of the elopement, stated she worked that day but did not have the resident assigned to her. She saw her in the day room in the morning watching TV (before lunch). Staff M, CNA took her to the dining room. Staff I stated, She got out and some guy brought her back in. The alarm did not go off. No Code Gray was called. We looked for all the residents. Stated no other resident has gotten out that she was aware of and had not heard that the door was not working. During an interview on 10/04/23 at 8:55 a.m. Staff G, LPN, who was present on the day of the elopement, stated we had somebody in the front (office). She stated she went up front to make a copy or something. Somebody (SSD) had to go to the bathroom and was gone for 2 - 3 minutes. She was watching the front. She did not remember seeing Resident #10. They (person in the bathroom, SSD) came back and she went back to the floor. A Code Gray was not called that day. We were told to count heads. During an interview on 10/04/2023 at 3:43 p.m. Staff F, receptionist, who was present on the day of the elopement, stated she went to lunch (on 9/2/2023) around 11:30 or 11:45 a.m. and returned around 12:15 p.m. When she got back, the SSD was in the office, the SSD returned to her office. She had gone to the copier and heard the door alarm go off. A gentleman was pushing Resident #10 back in the door, she didn't remember the time. She went up to the door and was turning off the alarm and tried to talk to him. It was hard to hear him due to the alarm sounding. He said he found her and was bringing her back. She took Resident #10 to the nurses' station on the [NAME] Wing where she was from and alerted the nurse. She alerted Staff L and Staff J. She then stated she informed the SSD, and the SSD notified the DON. She went back up front to her desk to watch the door. She stated if someone was coming in and a resident with a wandering device was going out, the door sometimes canceled the alarm out. There had been problems with the doors in the past, they told her they were fixed. It was about 4-6 months ago, and they were fixed within 24 hours. That was the only time she knew the door was malfunctioning. She stated she was at lunch and not aware Resident #10 was out of the building. She was not aware of any other residents getting out. She stated, It was hard to be vigilant with only one person in the office on the weekends. During an interview on 10/04/23 at 12:00 p.m. Staff J, restorative CNA stated she was doing the dining room that day. Resident #10 left the dining room. That was the last time she saw her. She did see her going up and down the hallways. She left the dining room around 12:00 p.m.to 12:30 p.m. During an interview on 10/04/2023 at 3:11 p.m. Staff N, Admissions Coordinator stated if a resident with a wandering device was near the door there was no alarm, but the door would stay closed. If a resident with a wandering device went in or out through the open door it (the alarm) would go off. She stated, It was not working properly, in August. She stated she was not sure if the alarms went off when the resident with a wandering device was near it. She was not positive about the alarms. During an interview on 10/04/2023 at 10:51 a.m. the DON, the RNHA and the Nurse Consultant stated they did ask the staff why the wandering device was placed on the upper right extremity when the physician order was for the left lower extremi [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure two residents (#10, #12) out of 11 residents at risk, with known neurocognitive disorders and / or dementia and a history of wandering and exit seeking, was provided supervision and services to prevent elopement. The facility failed to maintain an exit door alarm system in proper operation to prevent elopements since 08/02/2023. The facility nursing staff failed to ensure the safety of Resident #10, from approximately 12:40 p.m. until 1:37 p.m. or approximately 57 minutes on 09/02/2023. Resident #10 exited the front door unobserved by staff. She traveled down a steep drive, across a street to an apartment building parking lot which was approximately 600 feet away. She was discovered and returned to the facility by a male resident of the apartment complex. The facility nursing staff failed to ensure the safety of Resident #12. Resident #12 was able to exit the facility unsupervised on 08/28/2023. Resident #12 was able to tailgate out the front entrance of the facility. The resident was discovered outside by staff and brought back into the facility. This failure created a situation that resulted in the likelihood for serious injury and or death to Resident #10 and resulted in the determination of Immediate Jeopardy on 08/02/2023. The findings of Immediate Jeopardy were determined to be removed on 10/06/2023 and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: During a phone interview on 10/06/2023 at 9:21 a.m. a customer service representative from the [contracted technology company] stated, On 09/05/2023, they had issues with the [wandering alarm system] reception. It was not picking up the transmissions all the time. On 08/02/2023 we initially talked to them about the issue. We did some trouble shooting steps over the phone but was unable to solve the issue. We sent them a service agreement form (Authorization Form) for signature. We did not get the form back. We have to have a signature on an Authorization Form before we send anyone out. On 09/02/2023, the Maintenance Director called back about the same issue. Again, one of the techs tried to troubleshoot over the phone but was unable to. We resent the form that day, 09/02/2023, and received it back the same day. We dispatched it for 09/05/2023. On 09/05/2023 the tech arrived, he checked the main entrance, and adjusted the antennas. He adjusted the wire termination for a timer and bypass button. After the test it was working fine. He tested all the other doors. The termination wires on the keypads adjust the schedule of opening and closing of the door. He checked the wiring only it did not have to be replaced or repaired. Resident #10 was admitted on [DATE] and readmitted on [DATE]. Record review showed diagnoses included but were not limited to neurocognitive disorder with Lewy bodies; brief psychotic disorder; adjustment disorder with anxiety; generalized anxiety disorder; unspecified lack of coordination; Diabetes; muscle weakness (generalized); other abnormalities of gait and mobility; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent moderate; and essential hypertension. Record review of the annual, Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Function, a Brief Interview Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section G: Functional Status showed the resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, limited assistance of two for transfers, and she was independent on and off the unit. Section E: Behaviors showed wandering behavior were not exhibited. Review of the Physician Orders Summary for September 2023 showed the following: Actively Exit Seeking Record Intervention Code (s): 1. N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting (every shift) as of 07/22/2022. Actively Exit Seeking Record Outcome Code: 1. N/A, 2. Improved, 3. Worsening, 4. Unchanged, if worsening / unchanged, notify supervisor (every shift) as of 07/22/2022. Behavior Monitoring -Active Exit Seeking Record the Number of Occurrences every shift, (0 if did not occur) as of 07/22/2022. Psychiatric Consult for Evaluation and follow as needed as of 01/09/2023. Wanderguard (wandering device)- check function every night shift for wandering device use as of 07/22/2022. Wandering device - Check placement to LLE (Left lower extremity) every shift for wandering device use as of 07/22/2022. Wandering device to LLE due to: Elopement Risk as of 03/10/2023 and expires 10/08/2023. Depakote Oral Tablet Delayed Release 125 mg (milligram) every 12 hours for anxiety as of 07/30/2023 and was increased to 250 mg every 12 hours for mood disorder as of 09/05/2023. Memantine HCL 10 mg every 12 hours for dementia as of 08/03/2020. Mirtazapine 7.5 mg in the morning for depression as of 02/01/2023. UA with C and S (urine analysis with Culture and Sensitivity) on 09/06/2023. Cipro 500 mg every 12 hours for UTI (Urinary Tract Infection) for 7 days as of 09/10/2023. Review of the September 2023 Behaviors Record showed the following: Actively Exit Seeking Record Intervention Code (s): 1. N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting (every shift) as of 07/22/2022. On 09/02/23 N/A for day shift was documented. Actively Exit Seeking Record Outcome Code: 1. N/A, w. Improved, 3. Worsening, 4. Unchanged, if worsening / unchanged, notify supervisor (every shift) as of 07/22/2022 on 09/02/23 N/A for day shift. Behavior Monitoring -Active Exit Seeking Record the Number of Occurrences every shift, (0 if did not occur) as of 07/22/2022. On 09/02/2023 0 was documented. Review of the September 2023 Treatment Administration Record (TAR) showed the following: Wandering device - check function every night shift for wandering device use as of 07/22/2022. On 09/01/2023 it was documented as checked by nursing. Wandering device - Check placement to LLE (Left lower extremity) every shift for wandering device use as of 07/22/2022. On 09/02/2023 it was documented as checked on the day shift. Review of Resident #10's progress notes showed no documentation regarding an elopement on 09/02/2023. Review of the nursing progress notes dated 09/05/2023 at 2:48 p.m. showed the following: Psychiatric Nurse Practitioner on site for visit with resident. New orders were given to increase her Depakote from 125 mg PO [by mouth] BID [twice a day] to 250 mg PO BID. Entered into PCC [Point Click Care or electronic medical record]. Review of Resident #10's Elopement Risk Evaluation, dated 07/02/2023 showed the following: 1. Is resident ambulatory and / or able to self-propel wheelchair? Yes. 2. Presence of any of the following risk factors indicates the resident is a risk for elopement. 2b. Resident displays behaviors indicting desire to leave the facility, i.e., packing belongings, tailgating, searching for exits from facility or searching for someone/something from past life events, verbalizing desire to go home/elsewhere. 2d. Resident's family/responsible party expressed concerns resident may attempt to leave. 3. Resident is 1. At risk for elopement. Review of Resident #10's Elopement Risk Evaluation. dated 09/02/2023 showed the following: 1. Is resident ambulatory and / or able to self-propel wheelchair? Yes. 2. Presence of any of the following risk factors indicates the resident is a risk for elopement. 2b. Resident displays behaviors indicting desire to leave the facility, i.e., packing belongings, tailgating, searching for exits from facility or searching for someone/something from past life events, verbalizing desire to go home/elsewhere. 3. Resident is 1. At risk for elopement. During an interview on 10/05/2023 at 12:30 p.m. with the Advanced Practice Registered Nurse (APRN) she stated Resident #10 had a little bit of confusion, and thought she was going home, and she went out to the park. That was not her normal. She did a urinalysis (UA) and culture and sensitivity (C/S) and placed her on antibiotics. She was back to normal. Her Depakote was increased on 09/05/2023. Her urinalysis was on 09/06/2023 and results on 09/09/2023. Cipro was started on 09/10/2023 for 10 days. The facility told her when she came into the facility the resident had eloped, they did not call her. They called the psychiatric nurse because it was exit-seeking. Record review of the UA and C/S, dated 09/06/2023, showed over 100,000 Escherichia Coli microorganisms in the urine. Review of the care plans showed as of 08/18/2022 Resident #10 was at risk for elopement / exit seeking activity, exit seeking, aimless wandering due to cognition, has the potential to approach exit doors. A goal initiated on 08/18/2022 showed the resident will not leave facility unattended through the review date of 10/15/2023. The interventions included but were not limited to the following: On 08/18/2022, checking for proper functioning of the audible alarm system daily and prn (as needed). On 08/18/2022, check functioning of wandering device every night. Revised on 05/25/2023, check placement of wandering device every shift - LLE. On 08/18/2022, Discuss with resident / family the risk of elopement and wandering. On 07/27/2023, Encourage resident to participate in activities and redirect resident when exit seeking. Revised on 5/25/2023, Every 1-hour safety checks monitor resident due to identified elopement risk. On 08/18/2022, Indicate risk in Care Profile and Kardex, Place demographics in Risk Binders. On 08/18/2022, Monitor resident for tailgating when visitors are in the building. On 08/18/2022, Monitor resident for active exit seeking behavior each shift. On 08/18/2022, Use audible monitoring system to alert staff of exit seeking behaviors. On 08/18/2022, Use diversional activities when exit-seeking behavior is occurring (i.e., offer food, activities, one-on-one company). An observation and interview were conducted on 10/02/2023 at 10:15 a.m., Resident #10 was lying in bed, awake. Her wandering device was observed on her RUE (Right Upper Extremity). The head of the bed was elevated. She stated, I went on a walk last week, to the mall, went by myself because no one could take me. I went up a hill. During an interview and observation on 10/02/2023 at 1:15 p.m. Staff B, LPN (Licensed Practical Nurse) was asked to locate Resident #10's wandering device. Staff B was unable to find the wandering device on Resident #10's LLE. She stated, It is supposed to be there (lifting up the resident's pants legs). Staff B went into the bathroom to look at the resident's wheelchair and it was not present. Staff B was observed locating the wandering device on her RUE. She stated, It's on her RUE. Staff B, LPN attempted to remove the wandering device, and stated it could not be taken off even with effort. An observation was conducted on 10/04/2023 at 10:35 a.m. Resident #10 was dressed and groomed for the day and seated in her wheelchair. She was located in the dining room looking out the dining room door. She was alone. She demonstrated she was able to move herself in her wheelchair with her feet. The wandering device was observed on her RUE. During an interview on 10/03/2023 at 8:57 a.m. the DON was asked for a timeline. A timeline provided on 10/03/2023 at 11:20 a.m. revealing the following: 09/02/23, approximately 12:40 p.m. resident observed exiting dining room after lunch. 09/02/23, approximately 12:45 p.m. nurse reports seeing resident wheel herself down hall. 09/02/23, approximately 1:37 p.m., resident returned to facility by neighbor, Staff F, receptionist was alerted by sounding of the alarm. 09/02/23, approximately 1:38 p.m., resident assessed by social services, floor nurse to have no injuries. 09/02/23, approximately 1:50 p.m., head count initiated on facility residents with no other issues noted. 09/02/23, approximately 2:00 p.m., Social Service Director placed on door monitoring. 09/02/23, approximately 2:35 p.m., DON arrived at the facility to assess the event, and complete head to toe assessment on Resident #10. The resident was placed on 1:1 supervision. 09/02/23 approximately 3:15 p.m., NHA, Maintenance Director arrived to assess doors. Review of the [contracted technology company] On-Site Service Charge Authorization Form dated 08/02/2023 showed, Customer Described Problem: Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's ANT (antenna) range as some residents have been able to escape without setting off the alarm. On the lower half of the form, it showed, My signature on this agreement certifies that I am an authorized agent for the facility listed above. It was signed as authorized by the NHA on 09/01/2023. Review of the [contracted electric company] Invoice dated 08/23/23 showed: The following charges are for electrical work performed as listed: Inspected the lobby door. Opened the panel and tested power. Found the panel power was testing for 17 volts AC (alternating current) and 0 volts DC (direct current). Replaced the power supply for 12 volt, applied power to panel. tested receivers and found the receiver on antenna 4 was not functioning. Replaced the receiver from maintenance stock and placed antenna for circuits on antenna 1 terminal. Ranged all three receivers. Receivers picked up transmitter and door annunciates while the transmitter is in range and door is ajar. Found three outdated transmitters before testing with a in date transmitter. Administration was not in the building. Maintenance came in for a brief period of time to check how wandering device range test was going then departed. Labor one tech 4.5 hours weekend labor Review of the Service Call Job Form, dated 09/05/23, [contracted technology company] showed under description Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's antennae range as some residents have been able to escape without setting off the alarm. Documentation showed On site met Maintenance Director and NHA. Checked and tested the main entry 9450 T70 with 3 duo link antennae. Adjusted the door antenna and adjusted wiring terminations for timer and bypass button / IEIKeypad. System working as designed. While on site, checked and tested all remaining Code Alert door systems for working order. System ok. Review of the electronic maintenance system dated 08/28/2023 through 09/01/2023 showed the following: Residents Monitoring Systems: Check operation of door monitors and patient wandering system performed by Maintenance Director revealed all doors including the Main Entrance Pass. On 09/02/2023 a handwritten form showed all doors including the Main Entrance Pass and was completed by the Maintenance Director. Documentation at the bottom of the 09/02/2023 form showed, Spoke with [contracted technology company] tech about adjusting T10 (antenna). We got it dialed in good. Therapy patio longer than usual on door alarm. During an interview on 10/02/2023 at 1:00 p.m. the Maintenance Director was observed checking the following exit doors: Therapy Hall, [NAME] Hall, Magnolia Hall, Smoking Area, Delta Hall, and Park Hall, Laundry door and Dining Room. All alarmed doors were in working order. He stated the alarmed doors had a 15-second delay alarm. He stated he checks the door alarms daily. He stated the front door was unlocked from about 7 a.m. to 5 p.m. but it won't open if a resident has a wandering device on. When asked what happened on 09/02/2023, he stated I do not know. During an observation on 10/02/2023 at 1:40 p.m. the dining room door screeching alarm went off twice. On investigation, the activity assistant was taking residents out for air and guitar playing. No other staff members responded to the alarms. The activity assistant set it off again and again and no one responded, this included the kitchen staff. During an observation on 10/02/23 at 1:50 p.m. the Maintenance Director tested a wandering device at the front door. The door did alarm during the test. He stated the door will not open if a wandering device comes near the door. If the door was open it would alarm. He again said he did not know what went wrong (09/02/2023). He stated, I just called the company, and they adjusted the antennas. On 10/02/23 at 2:55 p.m. Resident #10's elopement route was observed with the DON and the Regional Nursing Home Administrator (RNHA). This included walking down a steeply sloped driveway and crossing a 2-lane street with a speed limit of 30 miles per hour. There was an occasional car observed going down the street. Resident #10 entered the grounds of an apartment complex. She was found by a gentleman at the back of the apartment complex parking lot. The DON stated she and the NHA went door-to-door in the apartment complex and found the gentleman who brought Resident #10 back. He informed them where he found her in the parking lot. He told the DON and the NHA the resident had told him she wanted to get to the playground, which is part of the apartment complex where she was found. He told them she was calm and was just sitting in her wheelchair. He said he tried to change her mind about going to the playground. (Photographic evidence obtained). During an interview on 10/02/2023 at 3:12 p.m. the Maintenance Director was asked about the statement on the On-Site Charge Authorization Form. He stated, I just was trying to get them (contracted technology company) to come for the antennas. He stated, It was the only thing I can think of. He verified a work order had been placed 30 days prior to the elopement. He stated he did check the main door, on 09/02/2023, when they came in, post elopement, he documented it was working. During an interview on 10/02/2023 at 3:30 p.m. the Regional Nursing Home Administrator (RNHA) and the DON stated they verified there were two forms from the contracted technology company, Form 1 was On-site Service Charge Authorization Form, dated 08/02/2023 (a month before elopement), stating Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's antennae range as some residents have been able to escape without setting off the alarm. It was signed by the NHA on 09/01/23 (a day before the elopement). The NHA was unavailable for an interview during the dates of the survey. Form 2 was Service Call Job Form, dated 09/05/2023, and stated Maintenance Director called in requesting a Service Call to have a tech work on the Main Entrance's antennae range as some residents have been able to escape without setting off the alarm. The Service Notes showed On site met Maintenance Director and the NHA. Checked and tested the main entry 9450 T70 with 3 duo link antennae. Adjusted the door antenna and adjusted wiring terminations for timer and bypass button / IEIKeypad. System working as designed. While on site, checked and tested all remaining Code Alert door systems for working order. System ok. The RNHA stated when he was told about the elopement and the door problems, he told them to put someone on the door and get someone out to fix it as soon as possible (ASAP). The DON stated the NHA had chewed the contracted technology company out (for not responding timely). The RNHA stated the Maintenance Director told him they had receipts from another company, and the Maintenance Director was looking for the receipts. The RNHA and Maintenance Director produced an invoice from a (contracted electric company). They stated they came out on 08/23/23. The RNHA stated they then called the manufacturer [contracted technology company] because the antennas were still not working properly. The RNHA, the Maintenance Director and the DON stated they could not get the contracted technology company to come out, so they called the contracted electric company to come out. The RNHA stated the main door was not alarming the way it should, so he told the facility to get the manufacturer (contracted technology company). The DON stated the door was supposed to be functioning but was not alarming. The contracted electric company installed new antennas. The contracted technology company came in and did not add any equipment but adjusted the antennas. The Maintenance Director stated he did not know if the antenna was adjusted by the contracted electric company, but it had to be readjusted. During an interview with the DON on 10/03/2023 at 8:57 a.m. the resident told the DON she was going to work. The DON called the management team in. The DON stated no one saw her, she was able to leave the dining room on her own. The DON verified for approximately 57 minutes it was unknown where the resident was located. The DON stated Staff M, CNA was assigned to care for Resident #10 that day. The DON stated she interviewed Staff M and she saw the resident in the dining room at about 11:30 a.m. on 09/02/2023. The DON stated staffing was good on 09/02/2023, it was meeting the 2.0 minimum. The DON stated the documentation of the event (elopement) was part of the resident's risk notes. Those notes are not found in the resident's electronic medical records. The DON verified there was no documentation in the electronic medical record of the incident. She verified there was only a post evaluation which did not state she eloped. There was no documentation that the attending physician and / or responsible party had been notified. It was documented in the risk report. She stated they had psych (psychiatric services) in to see the resident. They had the attending physician in to see the resident. The DON verified the Psych note on 09/05/2023 showed She elopes and has outdoor privileges. Patient is now on 1:1 observation for safety measures and does not remember. DON stated, she does not have outdoor privileges. The DON stated she would ask medical records if there were any other notes that had not been uploaded. A Post Incident was in the chart. The DON stated, We had an IDT (Interdisciplinary Team) meeting and reviewed the care plan and made sure everything was there. We have an IDT meeting every morning and review all incidents that happen. The note for the IDT meeting was documented in the risk notes by the DON. They did not document the IDT meeting in the electronic medical chart. She stated they reviewed the care plans. They reassessed her elopement risk, performed labs, did a UA and C/S on 09/06/2023. On 09/05/23 they changed the Depakote order. The resident did have a UTI and was treated with antibiotics. She stated the care plan was updated with 1:1 supervision on 09/02/23. During an interview on 10/03/2023 at 3:01 p.m. the DON stated, She (Resident #10) does not get up as much as she did. She had a UTI. She was used to seeing her up and about. The UTI kind of took her down a little bit. The Depakote may be making her sleepier. I will talk to psych the Advanced Practice Registered Nurse Practitioner (APRN). You have to approach her 'Resident #10 it is time to get up', vs. 'Do you want to get up?'. The DON stated she did not know of any other residents going out. The door was not sounding. She stated, I was used to hearing an alarm when a resident with a wandering device on got near the door. Maintenance told her Some residents have been able to escape without setting off the alarm, was stated (on the Service Form) due to it being so hard to get the company (contracted technology company) out. The DON stated the Maintenance Director and NHA were working it out (the door issue on 08/02/2023). She stated she did not know if the resident was tailgating or not. It (door locking and alarming) would sometimes not capture from the wandering device going out but would always capture on coming in. The DON stated no one was sitting at the main door until 09/02/2023. The DON stated if they knew it (the door) wasn't working, they would have put a staff member on the exit door 24/7 to ensure no one left the building who wasn't supposed to. Before the main door was only being monitored by the receptionist. She stated, She was not aware there was anything wrong with the door. The DON stated, It wasn't always consistently picking them up, but they were picked up and staff intervened. During an interview on 10/03/2023 at 4:10 p.m. the Maintenance Director stated, The sound announced but it did not announce like it was supposed to be. The door was functioning like it was supposed to but not the sound. I don't know, it was a while ago. He stated, Am positive it was announcing in the past, it has a speaker in it. I know they have to report if someone escapes. If there is an issue, I have to take care of it. I have to do my part. We have had residents escape before and it was reported to you guys. If a resident got out, you guys know about it. The NHA was aware there was a problem. I handed the On-Site Service Charge Authorization Form to the administrator at the time (08/02/2023). I do not know who it was (that eloped). I explained what was going on and [contracted electric company] did a complete check. We had an antenna in the building, and [contracted electric company] replaced it. He did fix the sound, don't know what was going on, but he fixed it. I may have been on the phone with the company (contracted technology company) on 09/02/2023, trying to get them out here. They (contracted technology company) adjusted the two antennas to their full potential range. They are in a half circle. I tested the doors when everyone came in on Saturday, 09/02/2023. It (the testing) was handwritten that I checked all the doors on 09/02/2023. I can't remember that part, if the NHA checked her (the resident's) wandering device and was it was working part time. During an interview on 10/03/23 at 4:35 p.m. SSD, which was present on the day of the elopement, stated on 09/02/23 she did not know when Resident #10 got out or how. The SSD had gone up front to relieve the receptionist for lunch. Staff F, receptionist, came back from lunch and she stated she came back to her office. Some guy said Resident #10 was across the street. Staff F took her to the nurses' station. Resident #10 then came to my door. She was not sweating; skin was cool to the touch. Resident #10 went down the hall, stated She was going to see her friend. The man (who brought her back) was gone. When she got out the door it was not working. She stated she sat at the main door from about 2 p.m. until 6 p.m. She did not know if the door made a noise or not, but it was supposed to lock down, for residents with a wandering device. It (the door) would lock when they got close to the door, but she did not know about the alarms. Resident #10 would get up and go, she was able to self-propel herself. During an interview on 10/04/23 at 9:02 a.m. Staff M, CNA, who was present on the day of the elopement, stated she was Resident #10's aide that day. She was in the dining room that day. She got her up in the morning and went to the bathroom. The resident wandered. She saw her after lunch. She was walking down the hall and the nurse said she was outside. It was around lunch. She saw her after dining wandering. During an interview over the phone on 10/04/2023 at 12:58 p.m. Staff L, LPN, who was present on the day of the elopement, stated the resident was up and down the hallways in her wheelchair. She had Just seen her 1 minute before that happened. She could have Only been out of the building for 2 or 3 minutes. She thought she went out behind someone. There was no way she got out of the parking lot, she had to be on the patio and brought her back in. There was no way she would have gotten down the driveway in her wheelchair. Stated she did not see how she got in the parking lot. She stated she had just seen her 5 minutes before they called, she was out the door. They tested the wandering device. The wandering device on the way back in, it went off. She was assessed, looked over, nothing was wrong. The aides Put her back to bed. They called a Code Gray and we had to make sure all the residents were accounted for. We looked her over, she had no bruises or skin tears. Staff L said she did not know the door was not working. We have a lot of residents who go out to the patio (outside the front door). Resident #10 was the only one she knew of who got out. The receptionist was right there at the door. During an interview on 10/04/2023 at 1:25 p.m. Staff I, CNA, who was present on the day of the elopement, stated she worked that day but did not have the resident assigned to her. She saw her in the day room in the morning watching TV (before lunch). Staff M, CNA took her to the dining room. Staff I stated, She got out and some guy brought her back in. The alarm did not go off. No Code Gray was called. We looked for all the residents. Stated no other resident has gotten out that she was aware of and had not heard that the door was not working. During an interview on 10/04/23 at 8:55 a.m. Staff G, LPN, who was present on the day of the elopement, stated we had somebody in the front (office). She stated she went up front to make a copy or something. Somebody (SSD) had to go to the bathroom and was gone for 2 - 3 minutes. She was watching the front. She did not remember seeing Resident #10. They (person in the bathroom, SSD) came back and she went back to the floor. A Code Gray was not called that day. We were told to count heads. During an interview on 10/04/2023 at 3:43 p.m. Staff F, receptionist, who was present on the day of the elopement, stated she went to lunch (on 9/2/2023) around 11:30 or 11:45 a.m. and returned around 12:15 p.m. When she got back, the SSD was in the office, the SSD returned to her office. She had gone to the copier and heard the door alarm go off. A gentleman was pushing Resident #10 back in the door, she didn't remember the time. She went up to the door and was turning off the alarm and tried to talk to him. It was hard to hear him due to the alarm sounding. He said he found her and was bringing her back. She took Resident #10 to the nurses' station on the [NAME] Wing where she was from and alerted the nurse. She alerted Staff L and Staff J. She then stated she informed the SSD, and the SSD notified the DON. She went back up front to her desk to watch the door. She stated if someone was coming in and a resident with a wandering device was going out, the door sometimes canceled the alarm out. There had been problems with the doors in the past, they told her they were fixed. It was about 4-6 months ago, and they were fixed within 24 hours. That was the only time she knew the door was malfunctioning. She stated she was at lunch and not aware Resident #10 was out of the building. She was not aware of any other residents getting out. She stated, It was hard to be vigilant with only one person in the office on the weekends. During an interview on 10/04/23 at 12:00 p.m. Staff J, restorative CNA stated she was doing the dining room that day. Resident #10 left the dining room. That was the last time she saw her. She did see her going up and down the hallways. She left the dining room around 12 to 12:30 p.m. During an interview on 10/04/2023 at 3:11 p.m. Staff N, Admissions Coordinator stated if a resident with a wandering device was near the door there was no alarm, but the door would stay closed. If a resident with a wandering device went in or out through the open door it (the alarm) would go off. She stated, It was not working properly, in August. She stated she was not sure if the alarms went off when the resident with a wandering device was near it. She was not positive about the alarms. During an interview on 10/04/2023 at 10:51 a.m. the DON, the RNHA and the Nurse Consultant stated they did ask the staff why the wandering d [TRUNCATED]

Based on observation, interview and record review the facility failed to: 1) follow the plan of care for two of three residents (Resident #1 and #5) related to a two-person assist for Activities of Daily Living (ADLs) bed mobility, toileting, and transfers, which resulted in a fall with injuries, a brain bleed, and hospitalization for Resident #1, and a fall with fractures for Resident #5; and 2) provide adequate supervision to prevent multiple falls for one (Residents #4) of three residents, which resulted in injuries and hospitalization . Findings include: 1. Review of the clinical record showed Resident #1 was admitted on [DATE] and discharged on [DATE], with diagnoses that included but were not limited to [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)] (weakness on one side), frontal lobe and executive function deficit, diabetes, weakness, lack of coordination, dementia, heart failure and history of falls. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate impairment). Section G, Functional Status showed the resident required extensive assistance of two for bed mobility and was dependent on two persons assist for transfers and toileting. Record review of physician's orders showed to transfer the resident to the ER (emergency room ) for evaluation and treatment for a laceration to forehead post fall on 04/19/22. Resident was prescribed Aspirin 325 milligrams (mg) daily for clot prevention, and [MEDICATION(S)] 75 mg daily for clot prevention Record review of the Activities of Daily Living (ADL) for bed mobility from April 1 until April 18 showed out of 57 possible opportunities (care provided every shift) 42 times the care was provided with one person (74%), 6 times with two people (11%) and 9 times no documentation of any care given (15%). Record review of care plans showed Resident #1 was at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to [CONDITION(S)], impaired mobility, recent hospitalization . Interventions included but not limited to assist of two with bed mobility, toileting, and transfers. Record review of the progress notes showed: -On 04/19/22 at 20:24 (8:24 p.m.) the Certified Nursing Assistant (CNA) alerted the nurse the resident had rolled out of bed onto the floor. The reviewed revealed she tried to grab him but could not reach him, and he fell on to the floor and hit his head. When this nurse entered the room, he was lying face down with blood pooling under his face with his body up against the wall. He was alert and talking to us, stating I cracked my skull/I need to go to the hospital. I tried to grab the rail but missed it. Two assisted with turning resident face-up. His forehead was actively bleeding in two places. The skin was well approximated and starting to discolor with [CONDITION(S)]. A cold pack was applied with pressure. Two other nurses were present and vital signs were taken. The [family member] was called and made aware and wanted the resident to go to the hospital as well. The wound continued to bleed with pressure. The rescue was called. Three staff with max [maximum] assist log rolled the resident and placed the resident onto a sheet to transport to the EMS [emergency medical system] stretcher. The wound continued to bleed. A pressure bandage was applied by this nurse while EMS secured the resident. Hospice, and the physician were notified of the incident and of transport. Documented by Staff C, Licensed Practical Nurse (LPN) -On 04/20 at 11:33 a.m. the Social Service Director (SSD) spoke to resident's [family member] this morning. The [family member] stated that her father did not want to return to the facility. She stated that the doctor at the hospital told her that her dad had a brain bleed. She had questions about how his fall occurred, i.e., who was present, etc. She agreed to give this writer time to find out more information and have a nurse call her back The Nursing Home Administrator (NHA) informed of the call and questions. -On 4/21/22 at 10:09 a.m., the NHA spoke with the [family member], regarding the incident in which occurred with resident. NHA expressed empathy and asked if POA [power of attorney] had any issues or concern. POA indicated, no concerns and through the caller was very kind. POA advised that resident does not want to return to the facility at this time. POA stated that she will reach out to come get resident belongings. Review of the facility's records showed documentation related to 04/19/22 by Staff C, LPN. At approximately 8:00 p.m. the CNA alerted me that .The skin was well approximated 4 cm [centimeters] long by 0.1 cm wide and a second area above the right eyebrow approximately 0.1 cm x 0.1 cm. The area was starting to discolor and swell. LPN had the CNA grab washcloths and make an ice pack. LPN applied pressure and had the aide go to the east wing for the nurses to help. One nurse did an accucheck [blood glucose] and the second nurse printed the face sheet, etc. Staff C, LPN held pressure on the wounds. The other nurses assisted with call 911 and family. Both [family member] and resident gave consent to be transported to the hospital. While we waited for EMS to arrive the wound continued to bleed with pressure / cold pack applied. Resident remained alert and talking. LPN wrapped gauze around his head while EMS secured him on the stretcher. Staff C, LPN wrote on 04/20/22 at 16:21 (4:21 p.m.) Review of facility's record showed documentation on related to 04/19/22 by Staff B, CNA. On 04/19/22 while providing care to resident, I pivoted him to his right side while proceeding to put on a clean brief under him. He kept pulling and grabbing at the edge of the bed continuously and that caused his upper body to roll off the bed pulling himself off the bed onto the floor. Staff B attempted to grab hold of the resident to prevent the fall but was unable to. During the entire time she was providing resident care and the bed was in the lowest position. Review of the facility's record dated 04/28/22 showed Staff D, LPN stated she had witnessed Resident #1 having ADL care provided with one assist. Review of the facility's record showed on 04/22/22 Staff E, CNA documented she provided care to Resident #1. She stated she always provided ADL including bathing, dressing, bed mobility, peri-care for the resident with one person assist. She documented the resident would always comply and she would ensure he felt comfortable. Review of the facility's record showed on 04/21/22 Staff F, CNA documented when she provided ADL care for the resident, the support that was required was one-person assist. She stated the resident would assist with adjusting himself in the bed and understood care that was being provided. The resident would grab for the mattress to shift his body. The Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Nurse were interviewed on 04/09/22 at 11:15 a.m. The DON stated she received a call from the facility on 04/19 that Resident #1 had fallen out of bed and was being sent to the hospital. She stated he had a laceration on his head., and they could not get the bleeding to stop. The DON said on 04/20/22 during the morning meeting, the fall was brought up and Staff A, Registered Nurse, Unit Manager started the investigation. The family member talked to the SSD on 04/20/22 and informed her the resident did not want to come back the facility because someone pushed him out of bed. She stated the SSD reported the incident to the NHA. They stated they spoke with the Staff B, CNA, who normally works the 3-11 shift and was not scheduled for today. Staff B, CNA told them she was providing ADL care, and he was incontinent. When she rolled him to change his brief, she rolled him onto his dominate side, with the non-dominant side on top. During the turn he kept rolling and he was grabbing for the mattress. She told them he rolled off the side of the bed. She told them she called for the nurse, Staff C, LPN. The nurse came in and assessed the resident. The nurse stated she could not stop the bleeding. They called the physician, and he was sent to the hospital. They stated they followed-up with the hospital on the status of the resident and they did request the CT [computerized tomography] scan; the hospital results were received on 04/22/22 and the resident had a small subdural hemorrhage. They stated they reported the incident to the state agency, and they came to the facility for their investigation. Staff B, CNA was suspended regarding concerns of not following the plan of care for Resident #1. The care plan showed he was a two-person assist for bed mobility, transfers, and toileting. The CNA did not follow the care plan regarding caring for the resident. He was transferred out of the bed with a Hoyer lift. Staff, B, CNA was suspended for 6 or 7 days. They initiated a full house education for providing care, reviewing the Kardex and plan of care. The DON stated that 100% of the staff was educated on CNA access to the Kardex and review assistance needed by the resident. They implemented the education in the orientation process of both agency staff and new hires. They completed an audit of the residents' care plans for falls and ADL care. A QAPI [quality assessment performance improvement] and PIP [performance improvement plan] was initiated on 04/21/22 and met again on 05/03/22. Resident #1 did not have side rails and the facility re-audited and evaluated the use of side rails, to ensure the need was there for the side rails. They are currently doing audits during the week of five aides to make sure they are following the care plan. The DON was performing the audits. During an interview on 04/09/22 at 11:35 a.m. Staff D, LPN stated she was working of the other side of the building when called to the resident's room. She said she went over, called hospice, and after the assessment administered first aid. She stated someone else called EMS, and they arrived pretty quick' and took him to hospital. She confirmed staff were educated on safety precautions. During an interview on 04/09/22 at 1:09 p.m. Staff B, CNA stated she was changing the resident and when she went to put the brief under him, he fell out of bed. She stated it happened so quick, and he fell on the floor. She stated the resident did not have rails on the side of the bed and confirmed he was a dependent resident, stating he could not do anything for himself. The CNA said she did not care for him routinely, stating You go where they put you. How to care for them was in their care plan. Staff B, CNA stated, I did not check it. You will know if needed. She stated she was new to the CNA job, saying I feel bad about it. Don't like to talk about it. I am going to make mistakes. Learning process. Don't know much about the charting part. She stated she worked part time, 3 or 4 days a week. She confirmed she had been educated and knew to look at the Kardex. During an interview on 04/19/22 at 2:41 p.m. Staff C, LPN stated the resident was not able to walk. He had one arm paralyzed and he was incontinent. The LPN said the resident required at least 2 persons assist with transfers. Staff C said she was in another room, and the resident was face down on the floor when she entered his room, with a brief on but not attached. She stated she did not know if there was a second aide or not, and confirmed the incident happened around 7:30 p.m. The LPN said she stayed on the floor with the resident, while another nurse called the rescue family member, hospice, and the physician. Staff C confirmed the resident was on blood thinners and he was still bleeding on the stretcher during transport. Record review of the hospital record dated 04/20/22 showed a resident with a past medical history of massive stroke presents with acute fall at skilled nursing facility. Resident stated they were cleaning his bed when he fell out of bed and hit his head. He had a laceration on forehead came to the ER to be evaluated. Found to have a small subarachnoid hematoma. Physician recommended continue observation and repeat CT. Repeat CT was performed which did show the subarachnoid hematoma had not increased and resident will be discharged back to hospice. 2. Record review showed Resident #5 was admitted on [DATE] with diagnoses that included but not limited to a fracture of left femur, weakness, difficulty walking, chronic pain syndrome, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]). Record review of the admission Minimum Data Set (MDS) dated [DATE] showed a BIMS score of 15 (cognitively intact). Section G, Functional Status showed the resident required extensive assistance of two for bed mobility, toileting, and transfers. She had impairment of one lower extremity. Record review of the care plan showed she was at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, and toileting due to impaired mobility. Interventions included but not limited to assist of 2 persons for bed mobility, toileting, and transfers. Baseline care plan showed to assist the resident with two for transfers, ambulation, and toileting. Record review of the Fall Risk Evaluation showed on 04/25/22 a risk of 13. And continued review revealed the resident had a fall on 05/02/22 and 05/03/22. Record review of the Post Fall Review dated 05/02/22 showed Resident #5 fell at 06:26 a.m. It was a witnessed fall and lacked injury. The physician and family were notified. Encouraged resident to use the call light. On 05/03/22 at 19:30 (7:30 p.m.) the resident had a witnessed fall which produced no injury. Physician and family were notified. Resident will be provided a Reacher and encouraged to use it for objects that are out of reach. Record review of the Progress Notes showed: -On 05/03 showed report was received that the resident was walking around in room despite the advice of Physical Therapy. Resident has a left lower extremity fracture with a brace in place. She fell on [DATE]. She was encouraged to non-weight bear and to use call light for assistance. -On 05/03, an Interdisciplinary Team meeting occurred it showed the nurse was in the room with the resident assisting her with repositioning. The nurse left the bedside to wash her hands and resident scooted to the side of the bed and landed on her butt. -On 05/08, at 23:48 (11:48 p.m.) the aide went to answer the resident's call light and found the resident on the floor next to the left side of her bed. The resident denies any discomfort and / or of bumping her head. The roommate said she did bump her head. When asked again resident stated that she did bump her head. Her left leg brace was on. Call light was on the bed. The resident had bare feet and the floor was clean and dry. Vital signs were stable, and the skin appeared intact. No changes were noted. Call out the physician. Resident was sent to the hospital for evaluation and treatment. Unable to call family as number given is no longer in use. -On 05/09 at 0503 a.m. she returned from the hospital with no new orders. She denies any discomfort and no change noted. During an interview and observation on 05/09/22 3:50 p.m. observed Resident #5 sitting in her wheelchair in the hallway. She was dressed and groomed for the day. Her long leg brace was on her left leg. She had socks and shoes in place. She stated she slipped at home on water and broke her leg. She said she was not sure how she fell yesterday, saying she slipped down out of bed and did not hit her head. She stated she will get up when the staff does not answer the call light timely. The resident stated, I'm not waiting on them. She stated she can get the wheelchair into the bathroom and pivot. She stated she was supposed to wait on staff but does not always. During an interview on 05/09/22 at 4:00 p.m. with Staff A, Registered Nurse (RN), Unit Manager stated Resident #5 was admitted for wound care of a surgical area, and confirmed she had a history of falls and high anxiety. Staff A stated her Kardex currently showed she was to be a two person assist for toileting, bed mobility and transfers. She said the resident does not adhere to safety measures, and stated, we obtained a Reacher for her after one fall. Her bed was to be low. Staff A stated she still does transfers, saying she was an independent thinking resident. During an interview on 05/09/22 at 4:30 p.m. Staff G, RN MDS stated she was currently working on Resident #5's care plans. She stated her written care plan showed she was a two-person assist. On review she verified her current care plan also showed she was a two-person assist. During an interview on 05/09/22 at 4:40 p.m. with the DON, she verified Resident #5 was a two-person assist for bed mobility, transfers, and toileting. She stated when they started educating some of the aides, they discovered they did not know where the Kardex was located. The DON verified the documentation was not consistent regarding the use of two person assist for the resident. 3. Record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Dementia with behavioral disturbances, [CONDITION(S)] following a cerebral infarction, and [CONDITION(S)], according to the face sheet. The face sheet identified the resident as having a second admission to the facility on [DATE] with diagnoses that included a Pneumothorax and multiple fractures of ribs. Resident #4 was observed during the initial tour on 05/09/2022 beginning at 9:05 a.m. He was observed in a reclined padded chair in the common room. The back of the chair was at an approximate 45-degree angle. The resident was reclined in the chair, but his head and upper back were not resting on the chair surface. The footrest of the chair was extended, and his legs and feet were supported by the footrest. The resident had on dark men's dress socks, without the nonskid surface. At 12:00 p.m. on 05/09/2022, during the resident observation, an interview was conducted with the Unit Manager. She reported the resident was a known fall risk who seems to do better in the recliner-chair with a slight tilt to the chair back. The Unit Manager reported Resident #4 required two staff to assist him in transferring out of the chair or bed. The resident's dress socks were questioned, and she agreed he should have had non-skid socks on. She did not confirm how the resident was transferred but confirmed that it would take two staff. There was no lift sling under the resident to identify a lift as the mode of transfer. A review of Resident #4's medical record revealed he had been found on the floor three times from 04/18/2022 until 04/22/2022, and the resident had been transferred to the ER after a fall from his wheelchair. Resident #4 was readmitted to the facility on [DATE] with diagnosis that included two fractured ribs and a pneumothorax. Additional record review revealed the resident sustained two subsequent falls on 04/29/2022 and 05/03/2022. Continued record review showed four falls were from his bed; two in the morning before 7:00 a.m. and two in the evening, around 8:00 p.m. The fifth fall occurred when a staff member was pushing the resident in his wheelchair, and he was observed to scoot forward in the chair. The fifth fall on 05/03/2022 resulted in the extended hospital visit and fractured ribs. Review of the fall assessment dated [DATE] showed the resident was assessed as not being at risk for falls and had no falls in the past three months. The Fall Risk Evaluation form completed after each fall beginning on 04/18/2022 identified the resident as being at risk for falls. On 04/18/2022 at 3:24 a.m., according to a nurse's note, the resident was found on the floor next to his bed with his blanket wrapped around him. The resident was noted with swelling and a skin abrasion to this right forehead with minimal bleeding, and a 6 red skin discoloration to the rear right rib cage. A second skin evaluation was conducted on 04/18/2022 at 11:13 a.m. which identified bruising to the forehead. The resident was transferred to the ER for a CT of the head and returned to the facility the same day with no new orders or documentation of CT results. Additional review did not reveal documentation related to test result follow-up. A review of the care plan for the focus area of at risk for falls and fall related injury r/t [related to] impaired mobility revealed an intervention dated 04/18 for anti -rollbacks to wheelchair. A review of the Post Fall Review form dated 04/20/2022 at 7:03 a.m. showed the resident was found lying on the floor on his left side with his head pointing toward the door. The description of the fall identified scratches to his left rib cage and left 'glute.' The resident showed no signs of pain and as the fall was unwitnessed the resident was sent to the hospital for evaluation. A form used to describe the fall, located in the resident's medical record, and dated 04/20/2022, indicated the resident had falls prior to this fall and the intervention at that time was for a low bed and no-slip socks. The intervention recommendations for this fall were for floor mats around the bed. A referral to the Physical Therapist was recommended. A note was reviewed in the resident's medical record which revealed the therapy referral had not occurred as the resident had been sent to the hospital before the evaluation could be conducted. Continued review of the progress notes in the resident's medical record revealed on 04/22/2022 at 5:04 p.m., an aide was assisting in the hall by pushing the resident in his wheelchair. The resident began to scoot forward as the aide began to push the wheelchair from behind. The resident fell from his wheelchair to the floor, landing on his right side. The note indicated signs of pain were present and the resident could be seen guarding his right arm. A new order was obtained for an x-ray of his right arm, and he was medicated for his anxiety and discomfort. Another order was noted, dated 04/23/2022, for a hospital transfer related to two fractured ribs and a pneumothorax. The resident was readmitted to the facility on [DATE] under Hospice services. On 04/29/2022 an evaluation reviewed in the progress notes included documentation made at 8:33 p.m. that the resident was having anxiety and was attempting to get out of bed a few times. The note described the resident as showing facial grimacing, holding his body rigid, fists clenched, knees pulled up and pushing staff away. A note written by a Physical Therapist on 05/01/2022 documented that a screening had been requested after a fall, but as the resident was readmitted under the care of Hospice, due to the patient's declining medical condition, the patient would not benefit from therapy services. A progress note, dated 05/03/2022, revealed a fall had occurred at 8:30 p.m., witnessed by the resident's roommate. The roommate reported the resident was sitting on the side of his bed and he slid off the bed. The note included the intervention recommended was a medication review with the Psychiatrist due to the resident's increased anxiety and frequent falls. The form included past interventions that included mats around the bed and non-skid socks. A review of a facility-provided policy titled Fall Prevention Program, dated 2021 showed: -Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -Policy: 7a Interventions will be monitored for effectiveness 7b the plan of care will be revised as needed. 8 When any resident experiences a fall. The facility will: a assess the resident b complete a post-fall assessment c complete an incident report d notify the family and physician e review the resident's care plan and update as indicated f document all assessments and actions g obtain witness statements in case of injury Review of a facility-provided policy titled Accidents and Supervision, dated 2021 showed: Policy: Each resident will receive adequate supervision and assistive devices to prevent accidents. 5 supervision is an intervention and a means of mitigating risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a defined by type and frequency b based on the individual resident's assessed needs and identified hazards in the resident environment.