Every finding on record at Diamond Ridge Health and Rehabilitation Center

Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident mental disorder for 5 of 6 resident reviewed (Residents #1, #12, #14, #87, and #139). Findings include: 1) Review of Resident #12's Preadmission Screening and Resident Review (PASRR) dated 10/4/2023 revealed anxiety disorder was checked under mental illness. No other diagnosis was checked. Review of Resident #12's admission record revealed the resident was admitted on [DATE] and was subsequently diagnosed with recurrent mild major depressive disorder with onset date of 12/12/2023 and Post Traumatic Stress Disorder (PTSD) with onset date of 10/5/2023. Review of Resident #12's clinical records failed to reveal documentation that Resident #12 was later identified with a newly evident or possible serious mental disorder and was referred to the appropriate state designated authority for evaluation. 2) Review of Resident #14's Level I PASRR dated 8/19/2024 revealed anxiety disorder was checked under mental illness. No other diagnosis was checked. Review of Resident #14's admission record revealed the resident was admitted on [DATE] and was subsequently diagnosed with bipolar disorder with onset date of 9/10/2024. Review of Resident #14's clinical records failed to reveal documentation that Resident #14 was later identified with a newly evident or possible serious mental disorder and was referred to the appropriate state designated authority for evaluation. During an interview on 7/22/2025 at 12:50 PM, the Director of Nursing (DON) stated that Resident #12's and Resident #14's Level I PASRR should have been revised to show the new diagnosis and initiate a Level II PASRR screening. 3) Review of Resident #1’s PASRR dated 6/16/2025 revealed no diagnosis was checked under mental illness. Review of Resident #1's admission record showed the resident was admitted on [DATE] and was subsequently diagnosed with major depressive disorder with onset date of 6/20/2025. Review of Resident #1's psychiatry evaluation note dated 6/20/2025 read, “History of Present Illness: This is an [AGE] year old patient with a past psychiatric history of depression and anxiety.” 4) Review of Resident #87’s PASRR dated 6/16/2025 revealed no diagnosis was checked under mental illness. Review of Resident #87's admission record revealed the resident was admitted on [DATE] and was subsequently diagnosed with adjustment disorder with depressed mood with onset date of 6/23/2025 and major depressive disorder with onset date of 6/24/2025. Review of Resident #87's psychiatric evaluation note dated 6/24/2025 read, “History of Present Illness: This is a [AGE] year old patient with past psychiatric history of depression and dementia.” 5) Review of Resident #139’s PASRR dated 6/16/2025 revealed no diagnosis was checked under mental illness. Review of Resident #139's admission record showed the resident was admitted on [DATE] and was subsequently diagnosed with major depressive disorder and anxiety with onset date of 6/20/2025. Review of Resident #139's psychiatry evaluation note dated 6/20/2025 read, “History of Present Illness: This is an [AGE] year old patient with a past psychiatric history of depression.” During an interview on 7/22/2025 at 12:43 PM, the DON stated, “The PASRR's [for Resident #1, #87, and #139] were not correct and should have been updated.”

Based on observation, interview, and record review, the facility failed to implement a person-centered comprehensive care plan for 1 of 3 residents reviewed for falls (Resident #15). Findings include: During an observation on 7/20/2025 at 11:22 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed (Photographic evidence obtained). During an observation on 7/21/2025 at 9:46 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed. During an observation on 7/21/2025 at 3:50 PM, Staff A, Certified Nursing Assistant (CNA), stated, There is no mat on the right side of the bed because she only gets up on the left side of the bed. Review of Resident #15's physician order dated 4/9/2025 read, Floormats at bedside while Res. [Resident] in bed every shift for monitoring. Review of Resident #15's care plan initiated on 1/24/2024 read, Focus: [Resident #15's name] is at risk for falls r/t [related to] visually impaired, poor safety awareness, gait/balance problems, psychotropic med use, hx [history of] fall, weakness. Interventions. Bilateral floor mats on both sides of bed while resident in bed. Date Initiated: 04/10/2025. During an interview on 7/21/2025 at 8:10 AM, the Director of Nursing stated, The physician orders must be followed, and floor mats should be placed on both sides of the bed on the floor.

Based on record review and interview, the facility failed to ensure physician-ordered parameters for administering hypertension medications were followed for 2 of 7 residents reviewed for medication administration (Residents #39, #139). Findings include: 1) Review of Resident #139’s physician order dated 6/20/2025 read, “Olmesartan Medoxomil Tablet 20 MG [milligram], Give 1 tablet by mouth one time a day for hypertension, hold for SBP [Systolic Blood Pressure] less than 130.” Review of Resident #139’s Medication Administration Record (MAR) for July 2025 for administration of Olmesartan Medoxomil showed the medication was administered outside the ordered parameters on 7/2/2025 for blood pressure of 121/63, on 7/3/2025 for blood pressure of 121/66, on 7/12/2025 for blood pressure of 114/63, on 7/16/2025 for blood pressure of 129/62, and on 7/18/2025 for blood pressure of 124/62. During an interview on 7/23/2025 at 7:45 AM, the Director of Nursing (DON) stated that the documentation indicated that the medication was administered outside parameters for the above referenced dates. 2) During an observation on 7/22/2025 at approximately 9:20 AM, Staff C, Licensed Practical Nurse (LPN), picked out medications to administer for Resident #39. Staff C took a manual blood pressure for the resident, which read 128/78 with a pulse of 70 beats. Staff C entered the resident room with a medication cup containing Losartan to administer to the resident. The Surveyor stopped Staff C and requested her to step out of the resident room to interview. Review of Resident #39’s physician order dated 7/18/2025 read, “Losartan Potassium Oral Tablet 25 MG (Losartan Potassium), Give 0.5 tablet by mouth one time a day, hold for SBP < 130.” During an interview on 7/22/2025 at 9:27 AM, Staff C, LPN, stated, “I look for SBP parameters at less than 110 or 120. This parameter is 130. I did not see that.” During an interview on 7/22/2025 at approximately 11:30 AM, the DON stated, “My expectation is for the nurses to follow doctors’ orders as written with the parameters should be followed.” Review of the facility policy and procedure titled “Medication Administration General Guidelines” with the last review date of 1/8/2025 read, “Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility’s medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedure… 4) Five Rights- Right resident, right drug, right dose, right route and the right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.”

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory services as per physician order for 1 of 3 residents reviewed for respiratory services (Resident #39). Findings include: During an observation on 7/20/2025 at 10:05 AM, Resident #39's nebulizer mask was lying on the bedside table not covered and dated 7/19/2025. Resident #39 was receiving oxygen via nasal cannula (NC) at 4 liters per minute. There was no padding or ear cushions noted on the NC tubing for skin protection (Photographic evidence obtained). During an interview on 7/20/2025 at 10:05 AM, Resident #39 stated, I receive my nebulizer treatments randomly. I received my treatments last week. My oxygen varies from 2 liter to 4 liters. I do not touch the regulator. Sometime the cushion is on the tubing and other times when the tubing is changed, the cushion is not there. During an observation on 7/21/2025 at 9:36 AM, Resident #39's nebulizer mask was lying on the bedside table not covered and dated 7/19/2025. Resident #39 was receiving oxygen via nasal cannula (NC) at 4 liters per minute. There was no padding or ear cushion noted on the tubing for skin protection. Review of Resident #39's physician order dated 6/4/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [milligram/3 milliliters] 1 vial inhale orally every 6 hours as needed for sob [shortness of breath]. Review of Resident #39's physician order dated 6/5/2025 read, Oxygen Nasal cannula ear cushions/padding every shift for pressure reduction. During an observation on 7/21/2025 at 3:50 PM with Staff B, Licensed Practical Nurse (LPN), Resident #39's nebulizer mask was at bedside not covered and the resident had no padding or ear cushion on the NC tubing. During an interview on 7/21/2025 at 3:50 PM, Staff B, LPN, stated, The nebulizer must be bagged, and I will get him NC with cushion/padding. During an interview on 7/22/2025 at 8:10 AM, the Director of Nursing stated, Nebulizer mask must be bagged, and the physician orders must be followed for the NC cushion/padding. Review of the facility policy ad procedure titled Respiratory Therapy Equipment with the last review date of 1/8/2025 read, Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to residents and staff. procedure. Oxygen Administration. 7. Keep oxygen cannula and tubing used PRN [as needed] in a plastic bag when not in use.

Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include: During an observation on 7/20/2025 at 9:00 AM, the posted nurse staffing information was dated 7/18/2025 (Photographic evidence obtained). During an interview on 7/21/2025 at 9:00 AM, the Administrator stated, Upon my arrival to the facility, I noticed the posting was not updated. The expectation is for the staffing to be posted daily. The Staffing Coordinator is responsible on Friday before leaving to print the reports for the weekend to include Monday.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care to the residents on enhanced barrier precautions (EBP) for 1 of 2 residents reviewed for intravenous medication administration (Resident #159) to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 7/22/2025 at 9:00 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #159's room, which had a signage for enhanced barrier precaution (EBP) on the door indicating the providers and staff must wear gloves and a gown for the high-contact resident care activities such as devise care or use including central line. Staff C donned gloves. Staff C did not wear a gown. Staff C primed the peripherally inserted catheter central catheter (PICC) line on the resident's upper right arm and set the intravenous (IV) pump. Staff C proceeded to connect the PICC line to the IV medication and began to administer Vancomycin. During an interview on 7/22/2025 at approximately 9:10 AM, when asked if a gown was needed for providing care to Resident #159, Staff C, LPN, stated, I thought it was direct contact only. The IV is contained. That is my interpretation of the EBP and IV. During an interview on 7/22/2025 at approximately 11:30 AM, the Director of Nursing (DON) stated, The nurse should be wearing a gown during IV administration. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/8/2025 read, Policy Statement, Enhanced barrier precautions (EBPs) are utilized to prevent spread of multi-drug resistant organisms (MDRO's) to residents. Policy Interpretation and Implementation. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include. g. devise care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.

Based on record review and interview, the facility failed to ensure the resident's physician was immediately informed of an accident that resulted in injury for 1 of 3 residents reviewed, Resident #1. Findings include: Review of Resident #1's health record documented an appointment to see the cardiologist on 7/15/2024. Review of Resident #1's Emergency Department documentation dated 7/15/2024 showed the resident was in a wheelchair in a transfer vehicle and struck the left side of her face. CT (Computed Tomography) of head demonstrated a zygoma (cheekbone) fracture. The resident was anticoagulated but had no intracranial hemorrhage. Minimal blood in the sinus was noted and the resident had no signs of entrapment. During an interview on 12/6/2024 at 11:07 AM, the Administrator stated, I completed a thorough investigation of this incident on 7/16/2024 after the transport van incident, with [Resident #1's name] on 7/15/2024. I interviewed her twice on 7/16/2024 and [Resident #1's name] stated that the van driver [Staff A's name] buckled her down properly and wasn't speeding when this happened. It was just a bumpy road due to construction. The resident stated there was no abuse or neglect. It was just an accident. During an interview on 12/6/2024 at 12:08 PM, Resident #1 stated, I was going to see my cardiologist on 7/15/2024 for a routine appointment. There was a lot of construction on the main road, so I asked the van driver to go a different route since I grew up in this town and am aware of shortcuts to avoid construction and bumpy roads. The van driver took a quick turn which landed my left side of my face on the window. I yelled help and the van driver pulled over immediately, put the hazards [hazard lights] on and transferred me to the ground of the van. It took the van driver 7-8 attempts to get me back in the wheelchair. Once I was back in the wheelchair, I was re-buckled in. During the interview on 12/6/2024 at 12:39 PM, Staff A, Certified Nursing Assistant (CNA), and Transport Driver, stated, I backed her [Resident #1] up next to the window to the left side, placed the seatbelt over her chest and waist and tightened all 4 anchors. The resident told me not to follow the GPS [Global Positioning System] and was telling me the directions turn by turn to go. I took a right turn. Then, I heard an Ouch. I pulled over and put my hazards on. She [Resident #1] was in her wheelchair tipped over with her face on the window. I tried to put the wheelchair up with the straps on it, but I couldn't. I had to unstrap all the seatbelts; I had to slide her [Resident #1] to the floor out of the wheelchair. I lifted her off the floor the first time and put her back in the wheelchair. I had blood on me, and she had blood on her due to skin tear. We went to her doctor's appointment because we were closer there than the facility. During an interview on 12/6/2024 at 1:18 PM, the Director of Nursing (DON) stated, She [Staff A] should have called 911 when she found the resident in the position with her face on the window. She is not qualified to assess the resident for a change in neurologic status. She should have contacted 911 at the time and then waited for 911 to arrive and follow their instructions. During an interview on 12/6/2024 at 2:16 PM, the Cardiology Office Manager/Registered Nurse stated, She [Resident #1] was brought in to have a scan. She advised the ultrasound technician that she had fallen. She had blood on her arm and her face. The tech [ultrasound technician] came to get me. She was in pain and had a large bruise. The doctor looked at her and said to call 911 and send to the ER [emergency room ]. She had hit her head. I was not witness to how it happened. We were worried about possible brain bleeds. Review of American Red Cross website for First [NAME] Steps (https://www.redcross.org/take-a-class/first-aid/performing-first-aid/first-aid-steps) read, Checking an Injured or Ill Person. 1. CHECK the scene for safety, form an initial impression, obtain consent, and use personal protective equipment (PPE) . 3B. If the person is responsive or responds to stimulation and is fully awake and does not appear to have a life-threatening condition: Interview the person (or bystanders, if necessary), ask questions about signs and symptoms, allergies, and medications and medical conditions (SAM); Do a focused check based on what the person told you, how the person is acting and what you see. Note: Do not ask the person to move if you suspect a head, neck or spinal injury. Do not ask the person to move any area of the body that causes discomfort or pain . 4. After completing the CHECK step, CALL 9-1-1 and get equipment, or tell someone to do so (if needed). Then, give CARE based on the condition found and your level of training. Review of an undated facility policy and procedure titled Maintenance/Staff Development-Resident Transportation Safety (Facility Operated Vehicles) read, Policy: Facility operated vehicles used for the purpose of resident transportation will be operated in a manner that will minimize the risk of injury to residents and staff. Procedure . 9. The driver of the van/facility operated vehicle is to report any accident or incident (even if there is no injury or property damage) to the facility administrator and to law enforcement as required by law. 10. If an accident or incident occurs involving a resident that results in suspected or confirmed injury to the resident or if there is a medical emergency involving a resident, seek medical assistance. The administrator is to be notified as soon as possible after requesting assistance for the resident.

Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene during medication administration between residents and failed to ensure resident care reusable items were cleaned and disinfected to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 4/2/2024 at 8:33 AM, Staff A, Licensed Practical nurse (LPN) started preparing medications for Resident #8 without performing hand hygiene. During obtaining medication from the medication cart for Resident #8, Staff A stopped and locked the medication cart and entered the common room to assist Resident #36 with pencils and a coloring book. Staff A, then, returned to the locked medication cart and retrieved additional 8:00 AM medications for Resident #8. Staff A proceeded to Resident #8's room and administered the medications. Staff A did not perform hand hygiene. Staff A proceeded to the medication cart and started preparing medications for Resident #107. Staff A administered the medications for Resident #107 and did not perform hand hygiene. There was one blue pill cutter contaminated with white powdery substance inside the pill cutter in the medication cart. During an interview on 4/2/2024 at 9:10 AM, Staff A, LPN, stated, I should complete hand hygiene before and after each resident. I normally do hand hygiene more often. Staff A confirmed the white powdery substance inside the pill cutter and stated, We clean the pill cutters with purple wipes. I don't use the pill cutter, but it is dirty. During an observation of Back Westminster Medication Cart on 4/2/2024 at 9:42 AM with Staff B, LPN, there was one blue pill cutter contaminated with white powdery substance inside the pill cutter. During an interview on 4/2/2024 at 9:48 AM, Staff B, LPN, confirmed the white powdery substance inside the pill cutter and stated, I did not use this pill cutter, but they are supposed to be cleaned after each use with an alcohol wipe. During an observation of Front Westminster Medication Cart on 4/2/2024 at 09:54 AM with Staff C, LPN, there was one blue pill cutter contaminated with white powdery substance inside the pill cutter. During an interview on 4/2/2024 at 10:00 AM, Staff C, LPN, confirmed the white substance inside the pill cutter and stated, Pill cutters are supposed to be clean after each use. During an observation of Cambridge Court Medication Cart on 4/2/2024 at 10:08 AM with Staff D, Registered Nurse (RN), there was one blue pill cutter contaminated with white powdery substance inside the pill cutter. During an interview on 4/2/2024 at 10:08 AM, Staff D, RN, confirmed the white substance in the pill cutter and stated, I don't know what this facility cleans the pill cutters with, but I will use a tissue or alcohol wipe. During an interview on 4/2/2024 at 3:47 PM, the Director of Nursing stated, Pill cutters should be cleaned with purple wipes after each use. Review of the facility policy and procedure titled Handwashing/Hand Hygiene last reviewed on 1/10/2024 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. Before preparing or handling medications. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment last reviewed on 1/10/2024 read, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard . d. Reusable items are cleaned and disinfected between residents (e.g., stethoscopes, durable medical equipment) . 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be disinfected and sterilized between residents according to manufacturers' instructions.

Based on record review and interview, the facility failed to ensure residents received as needed narcotic pain medication as per physician order for 2 of 5 reviewed residents, Residents #9 and #15. Findings include: Review of Resident #9's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included chronic kidney disease, fracture of neck of left femur, osteoarthritis, dementia, and type 2 diabetes mellitus. Review of Resident #9's physician order dated 3/21/2024 read, Oxycodone HCl [hydrochloride] oral tablet 5 mg [milligram] (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for pain 6-10. Review of Resident #9's Medication Administration Record (MAR) for March and April 2024 showed the resident received Oxycodone 5 mg on 3/21/2024 (pain level 5), 3/22/2024 (pain level 5), 3/23/2024 (pain level 5), 3/26/2024 (pain level 5), 3/30/2024 (pain level 5), 4/1/2024 (pain level 5), 4/3/2024 (pain level 5). Review of Resident #9's care plan dated 2/1/2024 read, Focus: [Resident #9's name] has chronic pain r/t [related to] arthritis, diabetic neuropathy, spinal stenosis, degenerative disc disease, Fx [fracture] to left hip . Intervention: Administer medication as ordered. Review of Resident #15's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included chronic obstructive pulmonary disease, chronic systolic heart failure, type 2 diabetes mellitus with diabetic polyneuropathy, and peripheral vascular disease. Review of Resident #15's physician order dated 3/20/2024 read, Oxycodone HCl Oral Tablet 10 mg (Oxycodone HCl), Give 1 tablet orally every 6 hours as needed for pain 6-10. Review of Resident #15's MAR for March showed the resident received Oxycodone 10 mg on 3/25/2024 (pain level 5). Review of Resident #15's care plan dated 12/8/2023 read, Focus: [Resident #15's name] has chronic pain r/t arthritis, diabetic neuropathy, peripheral vascular disease . Interventions: Administer medication as per orders. During an interview on 4/3/2024 at 7:20 AM, Staff A, Licensed Practical Nurse (LPN), stated, If a pain medication order is written with parameters for pain such as administer for pain on scale 6-10, then that medication can only be given if the pain is rated by the resident between the parameters. If the pain is less than the parameter written for that narcotic, then the resident is to be given something less such as Tylenol as long as there is an order. If resident needed something stronger, I would call the doctor and request additional orders for pain medication. During an interview on 4/3/2024 at 7:55 AM, Staff C, LPN, stated, The pain medication with parameters can only be given if the pain is rated on the scale denoted in the orders and parameters, such as medication to be administered for pain on scale 6-10. Then, the resident must rate their pain and if the pain is between 6-10, the narcotic can be given. If not, I would administer Tylenol or whatever pain medication that is ordered instead of the narcotic. I would have to call the doctor for additional orders if the resident needed medication or inform the resident that her pain would need to be rated at least a 6 before she could receive the medication. During an interview on 4/3/2024 at 9:00 AM, the Assistant Director of Nursing stated, Physician orders must be followed. The nurse would need to call the doctor and document in the eMAR [electronic medication administration record] that the doctor was notified, and new orders received. The new orders for different parameters or different pain medication would be documented and initiated. During an interview on 4/3/2024 at 10:05 AM, the Director of Nursing stated, Physician orders were not followed. [Resident #9's Name] was administered narcotic Oxycodone 5 mg five times when [Resident #9's Name]'s pain was not rated within the parameters of the physician orders (acute pain 6-10) and one time for [Resident #15's Name]. Pain is to be assessed on a scale from 1-10 and documented each shift before administering pain medication and after administering pain medication for reassessment. [Resident #9's Name] pain was assessed using PAINAD [pain assessment in advanced dementia scale) used for the cognitively impaired rated 1-10 based on observation. [Resident #9's Name] should have been scored between 6-10 for pain prior to administering the oxycodone. Review of the facility's policy and procedures titled Pain Management reviewed on 1/10/2024 read, The pain intensity scale used to describe resident pain will be based on the cognitive ability of the resident. For those residents who are cognitively intact, the Numerical (0-10) Rating Scale and/or the Wong-Baker FACES Pain (0-10) Rating Scale may be used. For those residents who are cognitively impaired, the Wong-Baker FACES pain (0-10) Rating Scale may be used. For the resident with severely impaired cognition, The Behavioral Observation Scale (B.O.S) may be used.

Based on observation, record review, and interview, the facility failed to ensure resident records were complete and accurate for 2 of 4 residents reviewed for intravenous infusion, Residents #103 and# 176. Findings include: 1. Review of Resident #103's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the nervous system, Methicillin susceptible staphylococcus aureus infection, unspecified dementia, and bilateral primary osteoarthritis of hip. During an observation on 4/1/2024 at 9:57 AM, Resident #103 had a transparent dressing on his left upper arm, covering Peripherally Inserted Central Catheter (PICC) line, which was dated 3/22/2024. Review of Resident #103's physician order dated 3/18/2024 read, IV [Intravenous]: Central Line- PICC Line: Change transparent dressing every day shift every Wed [Wednesday] for preventative care. Review of Resident #103's Treatment Administration Record for March 2024 showed the dressing change was completed on 3/22/2024 and 3/27/2024. During an interview on 4/1/2024 at 11:40 AM, the Director of Nursing stated, That's my initials. I completed that dressing change on 3/22/2024. I don't know why it was signed off on 3/27/2024 as being completed. 40559 2. Review of Resident #176's admission record showed the resident was admitted on [DATE] with diagnoses including fracture of right acetabulum, fracture of one rib, chronic obstructive pulmonary disease, pneumonia, type II diabetes mellitus, chronic kidney disease stage 3, and heart failure. During an observation on 4/1/2024 at 10:37 AM, Resident #176 had a transparent dressing on his right upper arm, covering the PICC line. The dressing was dated 3/22/2024. Review of Resident #176's physician order dated 3/28/2024 read, Order Summary: Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush), Use 5 ml [milliliters] intravenously two times a day for flushing . Order Status: Discontinued . Order Summary: 2. Monitor IV site for S/SX [signs and symptoms of ] infection . Check dressing and ensure the IV is secure and infusing properly, every shift for routine monitoring . Order Status: Discontinued. Review of Resident #176's Medication Administration Record for March 2024 showed no documentation of after the morning shift of March 29, 2024. During an interview on 4/2/2024 at 2:00 PM, Staff G, RN, Unit Manager, stated, The nurses who provided care for [Resident #176's Name] have said that they continued to provide care according to standards of care until his line was removed. My expectation is that they would document it on the MAR. During an interview on 4/3/2024 at 10:32 AM, Staff F, LPN stated, We continued to flush [Resident #176's Name]'s IV twice a day and monitored for signs of infection, but we did not have anywhere to document it on the MAR. Review of the facility policy and procedure titled Nursing- Documentation, Clinical last reviewed on 1/10/2024 read, Policy: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements . Documentation in the medical record of each resident should provide: 1. A complete account of resident's care treatment and response to the care Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated and timed.

Based on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge review, Resident #115. Findings include: Review of Resident #115's Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing Home Discharge (BD) Item Set dated 9/15/2022, reads, Section A. Identification Information. A0310. Type of Assessment . F. Entry/discharge reporting: 10. Discharge assessment- return not anticipated. A1800. Entered From: 03. Acute hospital. A1900. admitted (Date this episode of care in this facility began): 08/30/2022. A2000. discharge date : 09/15/2022. A2100. Discharge Status: 03. Acute Hospital. Review of Resident #115's Discharge Planning Review dated 9/15/2022 reads, 7. Where resident discharged to at time of discharge: a. Private residence. Revie of Social Service Note dated 9/13/22 reads, [Family Member's name and Resident #115's name] want to discharge to VA hospital to treat his cancer. requested for following provider to advise and it will be a regular discharge so he can go straight to VA. [Family Member's name] will come pick him up in the morning between 730 am and 8 am. Has wheel chair, walker and cane at home and will bring wheel chair. Staff is aware. During an interview on 12/7/2022 at 8:49 AM, Staff D, Social Services, stated, He went home. He was full of cancer and the wife wanted to take him to the VA for the cancer. He was discharged home then after a couple of days went to the VA. He was supposed to go straight to the VA, but I think they wanted to go home for a couple of days. It is a long trip there. We would not have sent any discharge paperwork to the VA because he was discharged home. During an interview on 12/7/2022 at 9:40 AM, Staff E, MDS Coordinator, stated, It looks like there may have been a data entry error on that. The daughter picked him up to take him to the VA hospital. I'm guessing that is where the confusion was. We discharged him home. We wouldn't know if the daughter took him to the VA or not. It looks like we need to do and modification and resubmit the MDS.

Based on observation, interview, and record review, the facility failed to ensure residents received wound care services consistent with professional standards of practice for 1 of 4 sampled residents with pressure ulcers, Resident #8. Findings include: Review of Resident #8's medical records revealed the resident wat admitted on [DATE] with diagnoses including pneumonia, acute respiratory failure with hypoxia, chronic diastolic heart failure, dehydration, chronic obstructive pulmonary disease, interstitial pulmonary disease, muscle weakness, paroxysmal atrial fibrillation, anemia, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, essential hypertension, morbid obesity due to excess calories, stage 3 chronic kidney disease, unspecified severe protein-calorie malnutrition, restless leg syndrome, generalized edema, cystocele, and myocardial infraction type 2. Review of physician orders dated 11/30/2022 for Resident #8 reads, Wound Care: Coccyx shear, apply calmaceptine and cover with dry protective DSG [Dressing] daily as needed if DSG is soiled or dislodged. During an observation on 12/7/2022 at 9:11 AM, Resident #8 had soiled wound dressing placed on coccyx dated 12/4/2022. During an interview on 12/7/2022 at 9:25 AM, the Wound Care Nurse confirmed the dressing date was 12/4/2022, verified the physician order, and stated the dressing changes should be done daily. During an interview on 12/7/2022 at 9:56 AM, the Assistant Director of Nursing (ADON) stated, Wound dressing should be done as ordered. Review of the facility policy and procedure titled Wound Care and Dressing [NAME], Dry/Clean revised on 1/12/2022 reads, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol).

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 6 medication carts reviewed. Findings include: During an observation of medication cart #2 on [DATE] at 9:58 AM with Staff B, Licensed Practical Nurse (LPN), there was a bottle of Alphagan P Solution 0.15% expired on [DATE] and a Levemir insulin pen with expiration date of [DATE]. During an interview on [DATE] at 9:59 AM, Staff B, LPN, stated, Alphagan Solution 0.15% is expired and Levemir insulin pen not sure if it has been labeled incorrectly. During an observation of medication cart #3 on [DATE] at 10:09 AM with Staff C, LPN, there was a Humalog insulin with no opened or expiration dates. During an interview on [DATE] at 10:10 AM, Staff C, LPN, stated, Not sure why it is not labeled. During an interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) stated, Medication in medication carts should be labeled and dated when opened. Once medication is expired, it should be disposed of. Review of the facility policy and procedure titled Medications, Labeling of revised on [DATE] reads, Purpose: The purpose of this procedure is to insure all medications maintained in the facility are properly labeled in accordance with current state and federal regulation. General Guidelines . 3. Labels for individual drug containers must include . h. The expiration date. Review of the facility policy and procedure titled Storage of Medications revised on [DATE] reads, Procedures . H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medical disposal, and reordered from the pharmacy, if a current order exists.

Based on record review, observation, and interview, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 3 of 5 residents reviewed for respiratory care, Residents #1, #4, and #6. Findings: 1. Review of Resident #1's medical record noted the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's record revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's O2 sats Summary [oxygen saturation summary] for February 2022 revealed Resident #1 was on oxygen via nasal cannula on 01/01/2022 at 11:00 PM, 02/14/22 at 7:06 PM, 02/15/2022 at 3:11 AM, 02/16/2022 at 7:00 PM, 02/17/2022 at 3:19 AM, 02/17/2022 at 7:31 AM, 02/18/2022 at 8:02 AM, 02/21/2022 at 12:33 AM, 02/21/2022 at 7:01 AM, and 02/22/2022 at 3:22 AM. Resident #1's oxygen saturation was always greater than or equal to 91% when on room air. Provider assessment dated [DATE] reads, Patient seen and examined on 2L [liters] NC [nasal cannula] . Patient states she did not use oxygen at home. Clinical staff to re-assess patient and discontinue O2 if sats are 88% or greater. Patient has [CONDITION(S)]. During an interview conducted on 3/7/22 at approximately 3:00 PM, the Director of Nursing (DON) stated Residents should not be on oxygen without an order. 2. Review of Resident #4's medical records revealed the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's record revealed an active physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's care plan dated 9/16/21 read, [Resident #4's name] has oxygen therapy r/t [related to] ineffective gas exchange: Give medications as ordered by physician .; Monitor for s/sx [signs and symptoms] of respiratory distress and report to MD PRN [as needed] .; OXYGEN SETTINGS: O2 via nasal prongs @ [at] 2L Humidified On 3/7/22 at 3:20 PM, Resident #4 was observed asleep in bed with oxygen being administered at 3 liters per minute via nasal cannula. On 3/7/22 at 3:46 PM, Resident #4 was observed asleep in bed with oxygen being administered at 3 liters per minute via nasal cannula. On 3/7/22 at 3:56 PM, Resident #4 was observed asleep in bed with oxygen being administered at 3 liters per minute via nasal cannula. During an interview conducted on 3/7/22 at 3:56 PM, the DON stated, it [the oxygen] is running at three liters. 3. Review of Resident #6's medical records revealed the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's record revealed an active physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's care plan dated 2/28/22 read, [Resident #6's name] has oxygen therapy r/t [related to] [CONDITION(S)]: Monitor for s/sx [signs and symptoms] of respiratory distress and report to MD PRN [as needed] .; OXYGEN SETTINGS: O2 via nasal cannula as ordered. On 3/7/22 at 3:20 PM, Resident #6 was observed resting in bed with oxygen being administered at 2.5 liters per minute via nasal cannula. On 3/7/22 at 3:48 PM, Resident #6 was observed resting in bed with oxygen being administered at 2.5 liters per minute via nasal cannula. On 3/7/22 at 3:57 PM, Resident #6 was observed resting in bed with oxygen being administered at 2.5 liters per minute via nasal cannula. During an interview conducted on 3/7/22 at 3:57 PM, the DON stated, it [the oxygen] says 2.5. During an interview conducted on 3/7/22 at 3:59 PM, the DON acknowledged both Resident #4 and Resident #6's oxygen was being administered at rates not ordered by their attending physicians and stated, Nurses are expected to check the oxygen flow rate and make sure it is running at the amount ordered. Review of the policy and procedure titled, 2001 Med-pass, revised in October 2010, last reviewed on 12/28/2020 reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the policy and procedure titled, Nursing - Oxygen Administration reads, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: .9. Turn on the oxygen. Start the flow of oxygen at the prescribed rate

Based on record review and interview, the facility failed to ensure the accuracy of an assessment for 1 of 3 residents, Resident #56, in a total sample of 38 residents. Findings: Review of Resident #56's admission record revealed Resident #56 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #56's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's Admission Minimum Data Set, dated dated : 03/29/2021, under Section J - Prognosis revealed an entry response of No to the question, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (requires physician documentation). During an interview on 5/24/2021 beginning at 11:30 AM, Staff A, LPN (Licensed Practical Nurse), confirmed Resident #56 was admitted to the facility under hospice services. During an interview on 5/25/2021 at 1:29 PM, Staff C, MDS Coordinator (Minimum Data Set Coordinator), confirmed Resident #56's Minimum Data Set needed a correction to reflect Resident #56's life expectancy of less than 6 months.

Based on observation, interview, and record review, the facility failed to implement the written abuse policy and procedure related to reporting an injury of unknown origin for 1 of 4 residents, Resident #41, in a total sample of 38 residents. Findings: An observation of Resident #41 on 5/24/2021 at 11:48 AM showed the resident had a large red area on his right forearm. During an interview on 5/24/2021 at 11:48 AM with Resident #41, when asked what happened to his arm, he stated, It happened at work. An observation of Resident #41 on 5/25/2021 at 9:30 AM showed the resident had a large red area approximately two inches by two inches on his right forearm. An observation of Resident #41 on 5/26/2021 at 11:30 AM shoed the resident had a large red area on his right forearm. During an interview on 5/26/2021 at 9:09 AM with Staff I, Licensed Practical Nurse (LPN), when asked regarding Resident #41 having a large red area to his right forearm, he stated, That is an old bruise and was already there, so I didn't initiate an incident report. He also stated it was documented on the bath sheets and incident reports and stated, This is done for bruises in order to determine the cause. Review of the C.N.A (Certified Nursing Assistant) Bath Sheet dated 5/13/2021 for Resident #41 reads, Comments: Received his shower today nothing new to report. Review of the C.N.A Bath Sheet dated 5/17/2021 for Resident #41, reads, Comments: Received his shower nothing new to report. Review of the C.N.A Bath Sheet dated 5/20/2021 for Resident #41, revealed no comments related to the resident's skin. Review of the C.N.A Bath Sheet dated 5/24/2021 for Resident #41 reads, Comments: Good skin. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation, with a revision date of December 2016, last reviewed on January 20, 2021, reads Policy. It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and The Director of Nursing . Procedure: . 4. Identification: Reporting of suspected maltreatment is required of all staff . 6. Reporting: All staff members are required to report suspected maltreatment. They may report to the Abuse Hotline at 1-800-96ABUSE (the number is posted in the facility; however, they are also obligated to report to a supervisor or department manager in the facility so that the resident may immediately be protected from further maltreatment. The Administrator, Risk Manager, Social Service Director, and Director of Nursing are to be informed of the situation immediately. The DON [Director of Nursing]/designee shall notify the physician and the resident's representative concerning the suspected maltreatment and the findings of the assessment . The Risk Manager/designee will file the Immediate Federal report with AHCA [Agency for Health Care Administration] and then submit the summary and findings of the investigation with the 5-Day Federal Report . 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate procedures for conducting the investigation. During an interview on 5/26/2021 at 10:00 AM, the Director of Nursing confirmed there was no documentation in Resident #41's record of a red area to his right forearm. She stated, The reddened area should be reported, risk management is to investigate, and the incident should be reported to the abuse hot line.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure hand hygiene was performed during medication administration and meal service. Findings: 1. An observation on 5/25/2021 beginning at 7:57 AM showed Staff F, Licensed Practical Nurse (LPN), had prepared medications for administration for Resident #102. Staff F entered the resident's room and repositioned the resident in a high fowlers position using the bed's remote control. Staff F, with bare hands, lifted the resident's shoulders, removed one pillow, re-adjusted the resident's position, pulled the bedside table closer to the resident, and observed the resident taking the medications. Staff F set up the resident's breakfast tray, opened the dome lid to the resident's food, then exited the resident's room. Staff F did not perform hand hygiene before or after direct contact with the resident and returned to the medication cart. Staff F was observed to swipe both of her hands on the back of her scrubs uniform. Staff F did not perform hand hygiene, unlocked the medication cart, and prepared Resident #103's medications. Staff F entered Resident #103's room, adjusted the resident's bedside table closer to the resident, and administered the medications. Staff F exited the room and returned to the medication cart. Staff F did not perform hand hygiene before or after direct contact with the resident. During an interview on 5/25/2021 at 8:15 AM, Staff F, LPN, confirmed that she failed to perform hand hygiene in between the residents and stated, I have to reposition the resident to take his medications. 2. An observation in the restorative dining room on the West Wing on 5/24/2021 at 12:21 PM showed Staff D, Certified Nursing Assistant (CNA), was assisting Resident #65 with lunch. Staff D was observed to leave Resident #65 and go and assist Resident #23. Staff D picked up Resident 23's utensils and gave the resident a bite of food. Staff D then returned and continued to assist Resident #65. Staff D did not perform hand hygiene between assisting the residents. At 12:23 PM, Staff D was assisting Resident #65 with dining. She left Resident #65 and assisted Resident #23, and by using the resident's utensils, she gave Resident #23 another bite of food. Then Staff D returned and continued to assist Resident #65. Staff D did not perform hand hygiene between assisting the residents. An observation on 5/24/2021 at 12:27 PM, Staff E, CNA, was observed assisting Resident #71 with lunch. Staff E was observed to run her fingers through her hair, pushing the hair off her forehead. Staff E continued to assist Resident #71 with the meal, refilling the resident's juice glass. Staff E did not perform hand hygiene after touching her hair during the meal service. Review of the facility policy titled, Handwashing/Hand Hygiene with a revision date of May 2020, last reviewed on January 20, 2021, reads, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing and handling medications; . l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; . o. Before or after eating or handling food; p. Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure a resident's abilities in activities of daily living do not diminish for 1 of 4 residents, Resident #7, in a total sample of 38 residents. Findings: An observation of Resident #7 on 5/24/2021 at 11:59 AM revealed the resident was sitting in a wheelchair next to his bed, with his left arm resting on an arm trough (medical device to help maintain comfortable positioning for forearms and hands). The resident was alert and oriented. During an interview on 5/24/2021 at 11:59 AM, Resident #7 stated, I am supposed to walk but no one comes and walks me. The only thing I do is the cycle for my right arm. An observation of Resident #7 on 5/26/2021 at 8:11 AM revealed the resident was sitting in a wheelchair next to his bed, with his left arm resting on an arm trough. During an interview on 5/26/2021 at 8:11 AM, Resident #7 stated, They do not come and do restorative care. They do not walk me. The only thing they do is for my arm. I use the cycle. I don't like to do the puzzles because I can't; it is too hard. During an interview on 5/26/2021 at 10:10 AM, Staff H, Restorative Certified Nursing Assistant (RCNA), stated, It takes two persons to ambulate [walk] [Resident #7's name], but we haven't ambulated him since 5/7/21 because we haven't had two people to do the ambulation. During an interview on 5/26/2021 at 10:15 AM, Staff D, RCNA, stated, We need two people to ambulate [Resident #7's name], so we have not been able to ambulate him three times a week. The last time he was ambulated was 5/7/21. During an interview on 5/26/2021 at 10:20 AM, the Assistant Director of Nursing (ADON), stated she was not aware that Resident #7 was not being ambulated. She confirmed that the resident needed two restorative aides to ambulate and if they were short staffed, the restorative aides were reassigned to patient care, so the facility maintained the required number of staff. She stated that there was a breakdown in communication with her restorative staff and she did not follow up with them weekly to find out if the restorative care was being completed. Review of the Minimum Data Set, Quarterly Comprehensive Assessment, dated 4/20/2021, revealed Resident #7 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). Review of the physician's order dated 5/7/2021 for Resident #7 reads, Restorative nursing 3 x week x 3 weeks [three times a week for three weeks] for ambulation and omnicycle- stop date 5/28/21. Review of Resident #7 medical records revealed no restorative documentation. Review of Resident #7's care plan, dated 5/7/2021, revealed the resident was on restorative nursing for ambulation and strength maintenance with a goal to maintain functional ability, and an intervention of using omnicycle x 10 minutes and ambulate in hallway with rail. Review of the facility policy titled Restorative Nursing- Overview, with an effective date of September 2010, last reviewed on January 20, 2021, reads: Overview: Restorative nursing programming refers to a formal nursing program which includes interventions that serve to assist the resident in restoring or attaining the ability to live as independently as possible . The Functional Maintenance Program is an individualized program to assist the resident in maintaining current optimal physical, mental, and psychosocial level . Restorative nursing care is carried out by staff within the nursing department.

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical needs that were identified in the comprehensive assessment for 2 of 5 residents, Residents #153 and #87, in a total sample of 38 residents. Findings: 1. Review of Resident #153's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #153's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #153's 5-Day Minimum Data Set, with a target date of 5/4/2021, revealed Resident #153 was administered insulin for seven days during the lookback period. Review of Resident #153's care plan, with a revision date of 5/17/2021, failed to reveal documentation the facility had addressed Resident #153's use of insulin and the risks associated with use of insulin. During an interview on 5/25/2021 at 12:55 PM, Staff A, LPN (Licensed Practical Nurse), confirmed Resident #153 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/25/2021 at 1:23 PM, Staff C, MDS Coordinator (Minimum Data Set Coordinator), verified Resident #153's care plan, with a revision date of 5/17/2021, did not address Resident #153's use of insulin and the risks associated with the use of insulin. 2. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), Quarterly Comprehensive Assessment, dated 4/8/2021, revealed Resident #87 received an anticoagulant. Review of Resident #87's care plan revealed no documentation of a plan of care for the risks of bleeding related to anticoagulant use. During an interview on 5/27/2021 at 8:30 AM, Staff J, RN (Registered Nurse), Minimum Data Set Coordinator, confirmed there was no developed comprehensive care plan for the risk of bleeding due to anticoagulants for [CONDITION(S)] fibrillation.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors by failing to administer the ordered medications for 1 of 3 sampled residents, Resident #1. As a result of this deficient practice, Resident #1's symptoms were not managed to maintain his comfort and dignity. Findings include: Review of Resident #1's records revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress note dated 08/19/2020 at 7:00 AM read, Per CNA (Certified Nursing Assistant) they reported to this nurse that patient was having a [MEDICAL CONDITION]. When arrived to his room, pt (patient) was lying supine in his bed. He had mild tremors noted of hands and twitching of face. He appeared to be in postictal state (state of altered consciousness after a [MEDICAL CONDITION]). B/P (Blood Pressure) 134/88, HR (Heart rate) 106, R (Respirations) 24, O2 (Oxygen) sat (Saturation) 96%, T (Temperature) 99. Patient was unresponsive to verbal or tactile (touch) stimuli. Noted some dried blood around his lip. Skin warm dry, color slightly pale. RRR (Respiratory Rate Regular), lungs clear bilaterally. Notified hospice. (Hospice Nurse's Name) arrived and assessed. She faxed medication orders from (Doctor's name) to start [MEDICATION NAME] for tooth gum infection, Oxycarbazine daily and [MEDICATION NAME] PRN (as needed) for [MEDICAL CONDITION]. Review of Resident #1's nursing progress note dated 08/19/2020 at 7:00 PM read, Pt (patient) has been stable throughout the shift. Still remains unresponsive to verbal or tactile stimuli. No medications attempted po (by mouth) due to risk of aspiration. Review of the physician orders for Resident #1 dated 08/19/2020, read, [MEDICATION NAME] 875 mg-125 mg (milligram) po BID (by mouth twice a day) x 7 days for tooth infection, [MEDICATION NAME] 300 mg 1 tablet twice a day for [MEDICAL CONDITION], and [MEDICATION NAME] 2 mg/ml (milliliters) inject 4 mg IM (intramuscular) one time only as needed for [MEDICAL CONDITION]. Review of Resident #1's Medication Administration Record [REDACTED]. During an interview on 09/10/2020 at 12:15 PM, Staff A, LPN, stated, I took care of (Resident #1's name) on the evening of the 20th. He was moved to my unit. (Resident #1's name) was not alert at all, with no response when I took over his care. He was having intermittent [MEDICAL CONDITION] activities twitching and clenching his teeth. He bit his lip which was swelling, and he had some bleeding in his mouth. I was on Facetime with the physician. I told him that the antibiotic and [MEDICATION NAME] was never given because the patient was not responsive, that I had administered [MEDICATION NAME] 4 mg IM when I received the patient. He continued to have [MEDICAL CONDITION] and that is when I face timed the physician and he also observed [MEDICAL CONDITION] activity. I saw he had been biting on his lip. He gave me an order to give additional [MEDICATION NAME] 4 mg IM and I was given a new order for routine [MEDICATION NAME] IM 4 mg every 12 hours for [MEDICAL CONDITION] prevention because he couldn't take any medications orally. I did not administer any [MEDICATION NAME] that evening, and he continued with [MEDICAL CONDITION] activity intermittently. I did not think the patient was in any pain. I did not call the physician back and tell him that he was still having [MEDICAL CONDITION]. I just thought it was a high dose of [MEDICATION NAME] and I didn't think about calling him. I should have let him know. During an interview on 09/10/2020 at 2:10 PM, Staff B, Licensed Practical Nurse (LPN) stated, I took over care of (Resident #1's name) on 08/19/2020 on the day shift. He had a change in his condition and a [MEDICAL CONDITION] early in the morning at 5 or 6 AM. At about 7:30 AM, the CNA came and told me he was having a [MEDICAL CONDITION]. I went in and he was unresponsive and had slight twitching, seemed postictal to me. I did not perform a neurological assessment. I did not assess his pupils. I knew that the hospice nurse would be coming in to see him. I think she came in around 8:30 AM. She spoke to the family after she assessed him and called the doctor. I know that she had gotten orders from the doctor for [MEDICATION NAME] and an anti-[MEDICAL CONDITION] medication orally and an order for [REDACTED]. I was not able to give him any medicines by mouth. He was unresponsive. I suppose that would be considered a medication error not to give an ordered medication. I suppose it is not following doctor' orders when you do not or cannot administer medications. We should document that we cannot administer them and call and let the doctor know. During an interview on 09/10/2020 at 2:57 PM, Staff J, LPN, stated, (Resident #1's name) was moved to a different room so he could be placed in isolation. He was having [MEDICAL CONDITION] at the time that he was transferred. He did not receive any medications or [MEDICATION NAME]. I did not speak to the doctor and tell him. I thought he already knew the resident was having [MEDICAL CONDITION]. He was moved around 2 in the afternoon. I could not administer any of his oral medications because of his level of consciousness. He was lethargic and unarousable. I did not call the hospice nurse or the doctor. Omission of medications would be considered a medication error. I just didn't think it mattered and that the hospice team already knew. I guess I really should have called and let them know. During an interview on 09/10/2020 at 3:05 PM, the Director of Nursing stated, I expect all nurses to administer all ordered medications. If they are unable to administer their medications, they should notify the doctor and document that they spoke with them and any new orders that were given. I was not aware that (Resident #1's name) did not get medications that were ordered. It appears that he was not given [MEDICATION NAME] and [MEDICATION NAME] along with any other ordered medications on 08/19/2020 and 08/20/2020. The nurses did not document the reason they were held and whether they called the doctor. In this case, I would consider this as a significant error. The resident was unable to take these medications orally and was not given any [MEDICATION NAME] and had further [MEDICAL CONDITION]. The doctor should have been called and notified. During a telephone interview on 09/10/2020 at 3:46 PM, Resident's Physician stated, I was called by the facility when (Resident #1's name) had a change of condition on 08/19/20. It was 5 or 6 in the morning. The nurse told me that he had [MEDICAL CONDITION] activity, but he had stopped. Our nurse had visited 2 days before that and the patient was his usual self, so this was an acute change in his condition. When our nurse visited that morning, she witnessed [MEDICAL CONDITION] activity, called and I gave orders for [MEDICATION NAME] and [MEDICATION NAME] for his [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg IM x 1 PRN dose for [MEDICAL CONDITION] until he could be given [MEDICATION NAME] for his [MEDICAL CONDITION]. I ordered the [MEDICATION NAME] because the only change noted in the patient was that he developed tooth pain, which might have [MEDICAL CONDITION] (an overwhelming infection) and this type of swift change in his status might have been related to his immunocompromised (an impaired immune system) state and an overwhelming infection. I also considered that he had suffered another [MEDICAL CONDITION] event and the [MEDICAL CONDITION] might have been related to that. I was not aware that the patient remained unresponsive and did not receive the antibiotic or anticonvulsant. If I had known that the patient was unable to take these, I would have administered his antibiotic IM and administered [MEDICATION NAME] IM for [MEDICAL CONDITION] prevention until his condition improved and to prevent any potential discomfort from repeated [MEDICAL CONDITION] activity. I expect that in the hospice end of life care setting that the nurses inform me if my orders cannot be carried out. It allows me to readjust the plan of care and maintain patient comfort and dignity. I adjusted the medication regime when I was notified that the patient continued with [MEDICAL CONDITION] activity and had not received oral anticonvulsants as I ordered. I actually did a telemedicine visit the following afternoon at about 5 PM, when I was notified that he continued to have [MEDICAL CONDITION] activity and witnessed the [MEDICAL CONDITION]. He was having what appeared to be petit mal [MEDICAL CONDITION] and was biting his lip and tongue. There was active bleeding from his mouth on my telemedicine visit. I instructed the nurse to complete mouth care frequently, give additional [MEDICATION NAME] IM and to call me with any other concerns or continued [MEDICAL CONDITION] activity. I asked her to administer [MEDICATION NAME] as ordered for any discomfort. I spoke with (Resident #1's name)'s granddaughter during the telemedicine visit. I explained the plan to her and answered any questions she had. It was then that I learned that he had not received any oral medications. That was not the time to discuss that I was not informed that he was not receiving medications. It was the time to assure her that her grandfather would be cared for and his [MEDICAL CONDITION] activity and discomfort would be addressed. I can understand why his granddaughter was upset. It appeared that we were not managing his symptoms to maintain his comfort and dignity. Review of the facility policy and procedure titled Change in Resident's Condition or Status, effective January 1999, revised in September 2020, read: The facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care) . 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: A reaction to medication and/or a medication error. A significant change in the resident's physical/emotional/mental condition which includes the loss of vital bodily functions. A need to alter the resident's medical treatment significantly. Review of the facility policy titled Oral Medications with effective date of January 1999, and revision date of September 2020 read, Reporting and Documentation: . 3. Any adverse reaction experienced, 4. If a drug is withheld or if a drug is refused by the resident (note: circle the time it should have been given on the Medication Administration Record [REDACTED].

Based on record review and interview, the facility failed to ensure the physician was notified when medications were not administered per the physician orders for 1 of 3 sampled residents, Resident #1. As a result of this deficient practice, Resident #1's symptoms were not managed to maintain his comfort and dignity. Findings include: Review of Resident #1's records revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress note dated 08/19/2020 at 7:00 AM read, Per CNA (Certified Nursing Assistant) they reported to this nurse that patient was having a [MEDICAL CONDITION]. When arrived to his room, pt (patient) was lying supine in his bed. He had mild tremors noted of hands and twitching of face. He appeared to be in postictal state (state of altered consciousness after a [MEDICAL CONDITION]). B/P (Blood Pressure) 134/88, HR (Heart rate) 106, R (Respirations) 24, O2 (Oxygen) sat (Saturation) 96%, T (Temperature) 99. Patient was unresponsive to verbal or tactile (touch) stimuli. Noted some dried blood around his lip. Skin warm dry, color slightly pale. RRR (Respiratory Rate Regular), lungs clear bilaterally. Notified hospice. (Hospice Nurse's Name) arrived and assessed. She faxed medication orders from (Doctor's name) to start [MEDICATION NAME] for tooth gum infection, Oxycarbazine daily and [MEDICATION NAME] PRN (as needed) for [MEDICAL CONDITION]. Review of Resident #1's nursing progress note dated 08/19/2020 at 7:00 PM read, Pt (patient) has been stable throughout the shift. Still remains unresponsive to verbal or tactile stimuli. No medications attempted po (by mouth) due to risk of aspiration. Review of the physician orders for Resident #1 dated 08/19/2020, read, [MEDICATION NAME] 875 mg-125 mg (milligram) po BID (by mouth twice a day) x 7 days for tooth infection, [MEDICATION NAME] 300 mg 1 tablet twice a day for [MEDICAL CONDITION], and [MEDICATION NAME] 2 mg/ml (milliliters) inject 4 mg IM (intramuscular) one time only as needed for [MEDICAL CONDITION]. Review of Resident #1's Medication Administration Record [REDACTED]. During an interview on 09/10/2020 at 12:15 PM, Staff A, LPN, stated, I took care of (Resident #1's name) on the evening of the 20th. He was moved to my unit. (Resident #1's name) was not alert at all, with no response when I took over his care. He was having intermittent [MEDICAL CONDITION] activities twitching and clenching his teeth. He bit his lip which was swelling, and he had some bleeding in his mouth. I was on Facetime with the physician. I told him that the antibiotic and [MEDICATION NAME] was never given because the patient was not responsive, that I had administered [MEDICATION NAME] 4 mg IM when I received the patient. He continued to have [MEDICAL CONDITION] and that is when I face timed the physician and he also observed [MEDICAL CONDITION] activity. I saw he had been biting on his lip. He gave me an order to give additional [MEDICATION NAME] 4 mg IM and I was given a new order for routine [MEDICATION NAME] IM 4 mg every 12 hours for [MEDICAL CONDITION] prevention because he couldn't take any medications orally. I did not administer any [MEDICATION NAME] that evening, and he continued with [MEDICAL CONDITION] activity intermittently. I did not think the patient was in any pain. I did not call the physician back and tell him that he was still having [MEDICAL CONDITION]. I just thought it was a high dose of [MEDICATION NAME] and I didn't think about calling him. I should have let him know. During an interview on 09/10/2020 at 2:10 PM, Staff B, Licensed Practical Nurse (LPN) stated, I took over care of (Resident #1's name) on 08/19/2020 on the day shift. He had a change in his condition and a [MEDICAL CONDITION] early in the morning at 5 or 6 AM. At about 7:30 AM, the CNA came and told me he was having a [MEDICAL CONDITION]. I went in and he was unresponsive and had slight twitching, seemed postictal to me. I did not perform a neurological assessment. I did not assess his pupils. I knew that the hospice nurse would be coming in to see him. I think she came in around 8:30 AM. She spoke to the family after she assessed him and called the doctor. I did not call his family. I know that she had gotten orders from the doctor for [MEDICATION NAME] and an anti-[MEDICAL CONDITION] medication orally and an order for [REDACTED]. I did not call and let the doctor know that he was not able to take these medications. I should have. During an interview on 09/10/2020 at 2:57 PM, Staff J, LPN, stated, (Resident #1's name) was moved to a different room so he could be placed in isolation. He was having [MEDICAL CONDITION] at the time that he was transferred. He did not receive any medications or [MEDICATION NAME]. I did not speak to the doctor and tell him. I thought he already knew the resident was having [MEDICAL CONDITION]. He was moved around 2 in the afternoon. I could not administer any of his oral medications because of his level of consciousness. He was lethargic and unarousable. I did not call the hospice nurse or the doctor. I just didn't think it mattered and that the hospice team already knew. I guess I really should have called and let them know. During an interview on 09/10/2020 at 3:05 PM, the Director of Nursing stated, I expect all nurses to administer all ordered medications. If they are unable to administer their medications, they should notify the doctor and document that they spoke with them and any new orders that were given. I was not aware that (Resident #1's name) did not get medications that were ordered. It appears that he was not given [MEDICATION NAME] and [MEDICATION NAME] along with any other ordered medications on 08/19/2020 and 08/20/2020. The nurses did not document the reason they were held and whether they called the doctor. In this case, I would consider this as a significant error. The resident was unable to take these medications orally and was not given any [MEDICATION NAME] and had further [MEDICAL CONDITION]. The doctor should have been called and notified. During a telephone interview on 09/10/2020 at 3:46 PM, Resident's Physician stated, I was called by the facility when (Resident #1's name) had a change of condition on 08/19/20. It was 5 or 6 in the morning. The nurse told me that he had [MEDICAL CONDITION] activity, but he had stopped. Our nurse had visited 2 days before that and the patient was his usual self, so this was an acute change in his condition. When our nurse visited that morning, she witnessed [MEDICAL CONDITION] activity, called and I gave orders for [MEDICATION NAME] and [MEDICATION NAME] for his [MEDICAL CONDITION] and [MEDICATION NAME] 4 mg IM x 1 PRN dose for [MEDICAL CONDITION] until he could be given [MEDICATION NAME] for his [MEDICAL CONDITION]. I ordered the [MEDICATION NAME] because the only change noted in the patient was that he developed tooth pain, which might have [MEDICAL CONDITION] (an overwhelming infection) and this type of swift change in his status might have been related to his immunocompromised (an impaired immune system) state and an overwhelming infection. I also considered that he had suffered another [MEDICAL CONDITION] event and the [MEDICAL CONDITION] might have been related to that. I was not aware that the patient remained unresponsive and did not receive the antibiotic or anticonvulsant. If I had known that the patient was unable to take these, I would have administered his antibiotic IM and administered [MEDICATION NAME] IM for [MEDICAL CONDITION] prevention until his condition improved and to prevent any potential discomfort from repeated [MEDICAL CONDITION] activity. I expect that in the hospice end of life care setting that the nurses inform me if my orders cannot be carried out. It allows me to readjust the plan of care and maintain patient comfort and dignity. I adjusted the medication regime when I was notified that the patient continued with [MEDICAL CONDITION] activity and had not received oral anticonvulsants as I ordered. I actually did a telemedicine visit the following afternoon at about 5 PM, when I was notified that he continued to have [MEDICAL CONDITION] activity and witnessed the [MEDICAL CONDITION]. He was having what appeared to be petit mal [MEDICAL CONDITION] and was biting his lip and tongue. There was active bleeding from his mouth on my telemedicine visit. I instructed the nurse to complete mouth care frequently, give additional [MEDICATION NAME] IM and to call me with any other concerns or continued [MEDICAL CONDITION] activity. I asked her to administer [MEDICATION NAME] as ordered for any discomfort. I spoke with (Resident #1's name)'s granddaughter during the telemedicine visit. I explained the plan to her and answered any questions she had. It was then that I learned that he had not received any oral medications. That was not the time to discuss that I was not informed that he was not receiving medications. It was the time to assure her that her grandfather would be cared for and his [MEDICAL CONDITION] activity and discomfort would be addressed. I can understand why his granddaughter was upset. It appeared that we were not managing his symptoms to maintain his comfort and dignity. Review of the facility policy and procedure titled Change in Resident's Condition or Status, effective January 1999, revised in September 2020, read: The facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care) . 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: A reaction to medication and/or a medication error. A significant change in the resident's physical/emotional/mental condition which includes the loss of vital bodily functions. A need to alter the resident's medical treatment significantly.

Based on resident record review and staff interviews, the facility failed to ensure its resources were used effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for 1 of 4 sampled residents with a full code status (Resident #88) who suffered a delay in the initiation of CPR (Cardio [MEDICAL CONDITION] Resuscitation) when found unresponsive and absent of life, the resident died . This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on (MONTH) 20, 2019. The Administrator was informed of the Immediate Jeopardy on (MONTH) 24, 2019. The Immediate Jeopardy was on-going. This has the potential to affect 43 residents with a Full Code Status of a total population of 117 residents. Cross reference to F678 and F867. The findings included: Review of the POS [REDACTED]. Characteristic Duties and Responsibilities - Essential Functions: 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions, etc.). 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 6. Ensure that patients'/residents' rights to fair and equitable treatment, self determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. Supervision Exercised - the Administrator exercises administrative and functional supervision over the entire facility. Review of the POS [REDACTED]. Characteristic Duties and Responsibilities - Essential Functions: 1. Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 3. Ensures effective and efficient organization and staffing of the nursing department. 4. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identity, independence, choice and opportunity for social interaction. 5. Monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitoring the effective and efficient use of budgeted resources (personnel, supplies, equipment). 6. Ensures a safe and sanitary environment for patients/residents, employees and visitors. Minimum Performance Standards - 5. Communicates violation of the Nurse Practice Act to the State Board of Nurse examiners. Ensures effective and efficient organization and staffing of the nursing department - 1. Ensures that the nursing department is properly organized and adheres to accepted organization and management principles. 5. Provides orientation and education programs for nursing service personnel and ensures that all personnel can demonstrate the abilities required to function appropriately in their positions. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identity, independence, choice and opportunity for social interaction. Monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitoring the effective and efficient use of budgeted resources (personnel, supplies, equipment). Review of the Medical Director Services Agreement dated (MONTH) 14, (YEAR) read: 3. Medical Director of Facility. during the Term, Physician agrees to serve as Medical Director for Facility. Physician agrees to perform the services identified on Exhibit A attached hereto and incorporated herein by reference. Review of Exhibit A Medical Director Services read: 2. Develop, implement, and evaluate resident care policies, procedures and guidelines, based on the current standards of practice, and collaborate with Facility leadership, staff, and other practitioners and consultants, regarding the following: a. Admissions, discharge, infection control, safety, restraints, fall risks, pain management, significant weight loss or gain, [MEDICAL CONDITION] medications, physician privileges and practices, responsibilities of non-physician health care workers and other aspects of residents' care to ensure adequate and comprehensive services; b. Accidents and incidents, use of medications, use and release of clinical information ancillary services such as laboratory, radiology, and pharmacy and overall quality of care. k. Medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed health care practitioners. 4. Participate in Facility's Resident Care Management System, which will include attendance and active participation in Facility's monthly Quality Assessment and Assurance/Risk Management Committee. Participate in any meetings of the Facility's attending physicians and make credentialing recommendations to Facility about such attending physicians (as applicable). 5. Advise and consult with the Facility Administrator regarding: f. Improving performance of medical services as an integral part of improving Facility's performance. 6. Direct and coordinate: a. The medical care in Facility and ensure that Facility is providing appropriate care as required; e. In-service education by providing information for Facility personnel as may be required by accrediting bodies and Facility, including pertinent education regarding existing and proposed procedures within Facility. 9. Review and update, as applicable: b. All incident and accident reports from Facility to identify possible clinical risks and safety hazards. Review of the policy and procedure titled, Resident Incident Reporting dated ,[DATE] read: The facility will document any incident or accident involving a resident using the Resident Incident/Accident Investigation Report as soon as possible after the accident or incident. The completed Incident Report will assist in the investigation of the incident or accident and will be used for quality improvement purposes. 7. Record the name, title, address and phone numbers of any witnesses. The Risk Manager will maintain a log of accident and incident reports for quality improvement purposes. Review of the policy and procedure titled, Risk Management - Post Incident Evaluation, Root Cause Analysis and Plan dated (MONTH) (YEAR) read: The facility will use a consistent approach for post incident evaluations which will include a thorough investigation to determine how and why the incident occurred. Root Cause Analysis is a process for identifying the basic or contributing causal factors that are responsible for incidents. The root causes/contributing factors of any incident will be determined to reduce the risk of the incident recurring. Root causes/contributing factors will guide changes in systems or processes and/or changes in individual resident care plan interventions in an effort to reduce the risk of the event recurring. Procedure - Post Incident Evaluation: Immediately following any incident - actions to support resident safety will be the priority. Incidents will be reported according to the Reporting Guidelines. The Risk Manager or designee will be notified per the reporting guidelines and will be responsible for investigating and reporting any allegations of Abuse, Neglect, Exploitation or Misappropriation, Injuries of Unknown Origin, any allegations of sexual misconduct and/or any adverse incidents as defined by State or Federal Regulation according to facility policy. The Risk Manager or designee will conduct a thorough investigation of incidents as soon as possible through record review, observation, interviews, development of a timeline of events and/or recreation of the incident. In additional, any applicable Post Incident/Accident Investigative Quality Improvement Tools found in the Risk Management Manual may be used as guidance for data collection. Findings of the investigation are considered confidential, should not be copied and are considered Quality Improvement documents prepared for use by the Committee. Review of the policy and procedure titled, Administrator/Risk Management - Quality Management dated (MONTH) (YEAR) read: Vision Statement - This facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. Mission Statement - This facility's mission statement is to provide Quality Focused Care, One Resident at a Time. To that end we will: Recognize each resident as an individual with unique needs and preferences. Offer choices and support resident decision making. Honor and respect each resident's dignity and rights. Utilize resources effectively. Purpose: Through Quality Assurance and Performance Improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. All employees will participate in ongoing QAPI efforts to support our mission of providing quality focused care one resident at a time. Policy - the Administrator is responsible for the Quality Assessment and Assurance Committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A (Quality Assessment and Assurance) Committee, referred as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and scope - ongoing program and is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 2. Governance and Leadership - the governing body (administration of the facility) will develop a culture of seeking input from facility staff, residents, and families while assuring adequate resources to conduct QAPI efforts. QAPI will be a priority and will include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. 3. Feedback, Data Systems and Monitoring - the facility will put systems in place to monitor care and services through the use of multiple sources. Feedback systems will incorporate input from staff, residents, families, and others. Performance Indicators will monitor a wide range of care and outcomes and findings will be compared to benchmarks or targets established for performance. 4. Performance Improvement Projects (PIP's) - involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. 5. Systemic Analysis and Systemic Action - the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level. Review of the policy and procedure titled, Incident Management dated ,[DATE] read: An incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve an injury or damage to property. It may involve visitors, staff or residents. Review of Resident #88's facility record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. These chambers fibrillate, or quiver, rapidly. The result is a rapid and irregular pumping of blood through the heart). Review of the Licensed Nurses Progress Notes form dated [DATE] at 5:07 AM read: Went to Res. (Resident) room to give AM med. Noted Res unresponsive, check for signs of vital signs, no resp. (respirations) or heartbeat noted. Went to get crash cart and call code blue. Dated [DATE] at 5:10 AM read: CPR initiated per staff. Other nurse placed call to 911 to request EMS (Emergency Medical Services) for code blue. Dated [DATE] at 5:20 AM read: Staff continued CPR until EMS arrived at this time. EMS takes over at this time. Dated [DATE] at 5:47 AM read: EMS calls code - expired at 5:47 AM. All the entries were signed by Staff H, RN (Registered Nurse). Review of the physician's orders [REDACTED]. Review of Resident #88's facility record revealed no documentation in the record of a code sheet (a document used to record the critical interventions during a [MEDICAL CONDITION] resuscitation event). Review of the Policy and Procedure titled, Abuse, Neglect, Exploitation & Misappropriation with an effective date of Feb. 2006 and a Revision Date of: (MONTH) (YEAR) read: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. 3. Prevention: The facility identifies, corrects, and intervenes in situations of alleged abuse, neglect, and exploitation and focuses on the following areas of prevention: f. A commitment to follow through on all complaints and provide feedback to those involved, when possible. R. Identification: Reporting of suspected maltreatment is required of all staff. All incidents will be reviewed by the facility's Quality Assurance Committee for detection of patterns and/or trends. 8. Corrective Action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. The DON/designee may initiate a care plan to reflect the resident's condition and measures to be taken to prevent reoccurrence of the incident. This may include in-services and other measures, as appropriate. All corrective actions will be documented. Any ANE (Abuse, Neglect, Exploitation) incident will be reviewed at the Quality Assurance Committee meeting. Review of the Policy and Procedure titled, Nursing - Emergency Care (CPR) with an effective date of (MONTH) 2014 read: Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order. During an interview on [DATE] at 2:17 PM, the DON (Director of Nursing) stated, The standard of practice for starting CPR when a resident is found to be unresponsive is immediately as soon as you find the resident is without pulse or respirations, if the resident is a full code. The nurse is not to leave the resident once she finds the resident without pulse or respirations. The nurse could call out for assistance if needed. The facility reviews the resident's chart after the death to see how it was handled or if there was anything that needed to be corrected such as was the appropriate action taken during the code. The nurse directly involved has been terminated. The facility did not report it to AHCA (Agency for Healthcare Administration) as an adverse incident specific to there being a delay in CPR. If there was a code sheet it should have been placed in the resident's chart. The Administrator and I reviewed what happened during the code and determined the nurse had violated a known rule or policy by failing to act quickly. I don't know why the incident was not reported to AHC[NAME] The nurse was not reported to the board of nursing. When asked if a plan of correction was developed and implemented, the DON stated, I reviewed best practice with the nurses such as calling out for help, starting CPR immediately, upon finding the resident pulseless and without respirations, signs or life, calling a code. During an interview on [DATE] at 2:27 PM, the Medical Records Director stated, I don't know if a code sheet was completed for (Resident #88's name) when the resident received CPR. She stated: If there was one completed, it should be in the resident's chart. No documentation was provided for a code sheet. During an interview on [DATE] at 7:27 AM, with Staff I, CNA she stated: I was on duty when the incident occurred. I was helping another CNA on another hallway when the door was closed, we couldn't hear a code blue being called. Code blues are usually initiated by the nurse announcing the code overhead by using the phone intercom system. I haven't received any additional training regarding CPR since this incident. During an interview on [DATE] at 10:14 AM, the Administrator stated: There is no code blue buttons in the residents' rooms. The nurse has to step out and go to the nurses' station to call the code blue using the overhead paging system. A request was made for a list of all staff that was present during the code. No documentation was provided. During an interview on [DATE] at 11:20 AM, the Medical Director stated, I was not aware that there was a problem in the delay of CPR for this resident. This is the first I am hearing of this problem with this resident. If the resident is unresponsive, do a quick assessment check, vitals, start CPR immediately after checking vitals, call 911. During an interview on [DATE] at 3:28 PM, Staff E, CNA (Certified Nursing Assistant) stated she had worked at the facility PRN (as needed) for two years. When asked what she would do if she found a resident unresponsive, she stated, I would leave the room and get a nurse then grab the chart to verify the code status. During an interview on [DATE] at 3:33 PM, Staff F, CNA stated she had been employed since 2011. When asked the facility policy and procedure when a resident is found unresponsive, she stated, When finding a resident unresponsive I would first rush to get the nurse and look for other CNAs to help, and grab the chart. During an interview with the Administrator on [DATE] at 3:00 PM, when asked to provide the Adverse Incident report and investigation involving Resident #88 which occurred on [DATE], the Administrator stated the facility had not determined this to be an Adverse Event and did not report it. The Administrator stated a Root Cause Analysis (RCA) was not conducted. During an interview with the Administrator on [DATE] beginning at 7:28 AM, while reviewing the Quality Assurance program, the Administrator confirmed the facility did not initiate a full investigation or report the incident as an Adverse Incident for Resident #88. During an interview on [DATE] at 4:24 PM, the DON stated, The RN who delayed CPR was not reported to the Board of Nursing. The incident was not reported to DCF (Department of Children and Families) and AHCA was not notified. During an interview on [DATE] at 10:52 AM, Staff G, CNA stated: I worked the night shift on the Piccadilly hallway on [DATE] for 11:00 PM to 7:00 AM shift. I remember the night the resident coded. I don't recall hearing the page that a resident was coding. The nurse, (Staff H's name) came to get the CNA (Staff I's name) that was in a resident's room with me providing resident care on the Piccadilly hallway. Review of the facility investigation revealed an unsigned note dated [DATE] which read: After reviewing the note form this morning documenting (Resident #88's name) code blue. The nurse's time lined code in nurses' note. Noted resident was found when she went to give medications. Time CPR initiated was 3 minutes later. Discussed with the Administrator. The charts were reviewed again to be sure information was correct. On ,[DATE] spoke with RN (Registered Nurse) by phone. The nurse was asked to take the DON (Director of Nursing) thru the code. Described as written in note. Questioned her times documented and she said, yeah that's right. On [DATE] RN contacted to come in and meet with the Administrator and myself. The nurse was given the opportunity to discuss what happened that night. Defensive and said she knew we were going to do this. Asked why there was a delay, she replied, Had to go get cart and find (a nurses' name) on PICC (Piccadilly Unit). Asked why she did not just call for help. Said (a nurses' name) is deaf and wouldn't have heard me. So I had to go find her. Asked if she thought that was good nursing judgement and would she do anything differently. She said No I would do the same thing. Terminated at that time. Review of the Termination Action Form dated [DATE] read: Discharge For Misconduct: 19. Violation of known rule or policy (explain). Explanation/Comments: Failed to act quickly when pt. found absent of pulse and respirations and initiate CPR and call for help. Review of The American Heart Association website, at https://www.heart.org/en/news/[DATE]/cpr-is-key-to-survival-of-sudden-cardiac-arrest reads: CPR increases the possibility of surviving sudden [MEDICAL CONDITION] . If someone is unconscious and does not appear to be breathing properly, it's time to start CPR chest compressions . But anyone can - and should - perform CPR. (The author's name) Doing something is the right thing to do. It can only help. Review of the document titled Meeting dated [DATE] read: Codes - there had been some delay with getting codes started. Coding a resident should be started ASAP (as soon as possible). Stay in room. Yell for help (ask them to bring chart). Look in chart for code status then start ASAP. Review of the sign-in sheet dated [DATE] titled Meeting revealed 21 licensed staff signed as having attended, 4 RNs and 17 LPNs (Licensed Practical Nurses). No CNAs (Certified Nursing Assistants) signed as having attended the meeting. Review of the direct care staff employee list revealed there were 21 RNs, to include the Administrator, 29 LPNs and 74 CNAs employed by the facility.

Based on resident record review and staff interviews, the facility failed to prevent neglect by not providing emergency care to one (Resident #88) of four residents reviewed for a full code status. The facility failed to honor Resident #88's Full Code Status order. The facility failed to honor Resident #88's expressed and written wishes to have cardiopulmonary resuscitation (CPR) implemented in the event of respiratory/cardiac failure (Full Code). The facility nursing staff failed to provide basic life support, including immediate CPR, to a resident who was unresponsive and absent of life, and the resident died . This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began (MONTH) 20, 2019. The Administrator was informed of the Immediate Jeopardy on (MONTH) 24, 2019. The Immediate Jeopardy was on-going. This has the potential to affect 43 residents with a Full Code Status of a total population of 117 residents. Cross reference to F678, F835 and F867. The findings included: Review of Resident #88's facility record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. These chambers fibrillate, or quiver, rapidly. The result is a rapid and irregular pumping of blood through the heart). Review of the Licensed Nurses Progress Notes form dated [DATE] at 5:07 AM read: Went to Res. (Resident) room to give AM med. Noted Res unresponsive, check for signs of vital signs, no resp. (respirations) or heartbeat noted. Went to get crash cart and call code blue. Dated [DATE] at 5:10 AM read: CPR initiated per staff. Other nurse placed call to 911 to request EMS (Emergency Medical Services) for code blue. Dated [DATE] at 5:20 AM read: Staff continued CPR until EMS arrived at this time. EMS takes over at this time. Dated [DATE] at 5:47 AM read: EMS calls code - expired at 5:47 AM. All the entries were signed by Staff H, RN (Registered Nurse). Review of the physician's orders [REDACTED]. Review of Resident #88's facility record revealed no documentation in the record of a code sheet (a document used to record the critical interventions during a [MEDICAL CONDITION] resuscitation event). Review of the Policy and Procedure titled, Abuse, Neglect, Exploitation & Misappropriation with an effective date of Feb. 2006 and a Revision Date of: (MONTH) (YEAR) read: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. 3. Prevention: The facility identifies, corrects, and intervenes in situations of alleged abuse, neglect, and exploitation and focuses on the following areas of prevention: f. A commitment to follow through on all complaints and provide feedback to those involved, when possible. R. Identification: Reporting of suspected maltreatment is required of all staff. All incidents will be reviewed by the facility's Quality Assurance Committee for detection of patterns and/or trends. 8. Corrective Action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. The DON/designee may initiate a care plan to reflect the resident's condition and measures to be taken to prevent reoccurrence of the incident. This may include in-services and other measures, as appropriate. All corrective actions will be documented. Any ANE (Abuse, Neglect, Exploitation) incident will be reviewed at the Quality Assurance Committee meeting. During an interview on [DATE] at 2:17 PM, the DON (Director of Nursing) stated, The standard of practice for starting CPR when a resident is found to be unresponsive is immediately as soon as you find the resident is without pulse or respirations, if the resident is a full code. The nurse is not to leave the resident once she finds the resident without pulse or respirations. The nurse could call out for assistance if needed. The facility reviews the resident's chart after the death to see how it was handled or if there was anything that needed to be corrected such as was the appropriate action taken during the code. The nurse directly involved (Staff H) has been terminated. The facility did not report it to AHCA (Agency for Healthcare Administration) as an adverse incident specific to there being a delay in CPR. If there was a code sheet it should have been placed in the resident's chart. The Administrator and I reviewed what happened during the code and determined the nurse had violated a known rule or policy by failing to act quickly. I don't know why the incident was not reported to AHC[NAME] The nurse was not reported to the board of nursing. When asked if a plan of correction was developed and implemented, the DON stated, I reviewed best practice with the nurses such as calling out for help, starting CPR immediately, upon finding the resident pulseless and without respirations, signs or life, calling a code. During an interview on [DATE] at 3:00 PM, Staff C, LPN stated the facility initiates a code blue by pressing the intercom button located on the phone at the nurses' station. During an interview on [DATE] at 7:27 AM Staff I, CNA, stated, I was on duty when the incident occurred. I was helping another CNA on another hallway when the door was closed, we couldn't hear a code blue being called. Code blues are usually initiated by the nurse announcing the code overhead by using the phone intercom system. I haven't received any additional training regarding CPR since this incident. During an interview on [DATE] at 10:14 AM, the Administrator stated: There is no code blue buttons in the residents' rooms. The nurse has to step out and go to the nurses' station to call the code blue using the overhead paging system. A request was made for a list of all staff that was present during the code. No documentation was provided. During an interview on [DATE] at 11:20 AM, the Medical Director stated, I was not aware that there was a problem in the delay of CPR for this resident. This is the first I am hearing of this problem with this resident. If the resident is unresponsive, do a quick assessment check, vitals, start CPR immediately after checking vitals, call 911. During an interview on [DATE] at 3:28 PM, Staff E, CNA (Certified Nursing Assistant) stated she had worked at the facility PRN (as needed) for two years. When asked what she would do if she found a resident unresponsive, she stated, I would leave the room and get a nurse then grab the chart to verify the code status. During an interview on [DATE] at 3:33 PM, Staff F, CNA stated she had been employed since 2011. When asked the facility policy and procedure when a resident is found unresponsive, she stated, When finding a resident unresponsive, I would first rush to get the nurse and look for other CNAs to help and grab the chart. Review of the facility investigation revealed an unsigned note dated [DATE] which read: After reviewing the note from this morning documenting (Resident #88's name) code blue. The nurse's time lined code in nurses' note. Noted resident was found when she went to give medications. Time CPR initiated was 3 minutes later. Discussed with the Administrator. The charts were reviewed again to be sure information was correct. On ,[DATE] spoke with RN (Registered Nurse) by phone. The nurse was asked to take the DON (Director of Nursing) thru the code. Described as written in note. Questioned her times documented and she said, yeah that's right. On [DATE] RN (Staff H) contacted to come in and meet with the Administrator and myself. The nurse was given the opportunity to discuss what happened that night. Defensive and said she knew we were going to do this. Asked why there was a delay, she replied, Had to go get cart and find (a nurses' name) on PICC (Piccadilly Unit). Asked why she did not just call for help. Said (a nurses' name) is deaf and wouldn't have heard me. So I had to go find her. Asked if she thought that was good nursing judgement and would she do anything differently. She said No I would do the same thing. Terminated at that time. During an interview on [DATE] at 10:52 AM, Staff G, CNA stated, I worked the night shift on the Piccadilly hallway on [DATE] from 11:00 PM to 7:00 AM shift. I remember the night the resident coded. I don't recall hearing the page that a resident was coding. The nurse, (Staff H's name) came to get the CNA (Staff I's name) that was in a resident's room with me providing resident care on the Piccadilly hallway. Review of the Termination Action Form dated [DATE] read: Discharge For Misconduct: 19. Violation of known rule or policy (explain). Explanation/Comments: Failed to act quickly when pt. (patient) found absent of pulse and respirations and initiate CPR and call for help. Review of The American Heart Association website, at https://www.heart.org/en/news/[DATE]/cpr-is-key-to-survival-of-sudden-cardiac-arrest reads: CPR increases the possibility of surviving sudden [MEDICAL CONDITION] . If someone is unconscious and does not appear to be breathing properly, it's time to start CPR chest compressions . But anyone can - and should - perform CPR. (The author's name) Doing something is the right thing to do. It can only help. Review of the document titled Meeting dated [DATE] read: Codes - there had been some delay with getting codes started. Coding a resident should be started ASAP (as soon as possible). Stay in room. Yell for help (ask them to bring chart). Look in chart for code status then start ASAP. Review of the sign-in sheet dated [DATE] titled Meeting revealed 21 licensed staff signed as having attended, 4 RNs and 17 LPNs (Licensed Practical Nurses). No CNAs (Certified Nursing Assistants) signed as having attended the meeting. Review of the direct care staff employee list revealed there were 21 RNs, to include the Administrator, 29 LPNs and 74 CNAs employed by the facility.

Based on facility record review and staff interviews, the facility failed to ensure the development and implementation of an appropriate plan of action to correct an identified quality deficiency identified for the delay in initiating CPR (Cardio [MEDICAL CONDITION] Resuscitation) for a resident with a full code status (Resident #88) when found unresponsive and absent of life, and the resident died . This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on (MONTH) 20, 2019. The Administrator was informed of the Immediate Jeopardy on (MONTH) 24, 2019. The Immediate Jeopardy was on-going. This has the potential to affect 43 residents with a Full Code Status of a total population of 117 residents. Cross reference to F678 and F835. The findings included: Review of the policy and procedure titled, Resident Incident Reporting dated ,[DATE] read: The facility will document any incident or accident involving a resident using the Resident Incident/Accident Investigation Report as soon as possible after the accident or incident. The completed Incident Report will assist in the investigation of the incident or accident and will be used for quality improvement purposes. 7. Record the name, title, address and phone numbers of any witnesses. The Risk Manager will maintain a log of accident and incident reports for quality improvement purposes. Review of the policy and procedure titled, Risk Management - Post Incident Evaluation, Root Cause Analysis and Plan dated (MONTH) (YEAR) read: The facility will use a consistent approach for post incident evaluations which will include a thorough investigation to determine how and why the incident occurred. Root Cause Analysis is a process for identifying the basic or contributing causal factors that are responsible for incidents. The root causes/contributing factors of any incident will be determined to reduce the risk of the incident recurring. Root causes/contributing factors will guide changes in systems or processes and/or changes in individual resident care plan interventions in an effort to reduce the risk of the event recurring. Procedure - Post Incident Evaluation: Immediately following any incident - actions to support resident safety will be the priority. Incidents will be reported according to the Reporting Guidelines. The Risk Manager or designee will be notified per the reporting guidelines and will be responsible for investigating and reporting any allegations of Abuse, Neglect, Exploitation or Misappropriation, Injuries of Unknown Origin, any allegations of sexual misconduct and/or any adverse incidents as defined by State or Federal Regulation according to facility policy. The Risk Manager or designee will conduct a thorough investigation of incidents as soon as possible through record review, observation, interviews, development of a timeline of events and/or recreation of the incident. In additional, any applicable Post Incident/Accident Investigative Quality Improvement Tools found in the Risk Management Manual may be used as guidance for data collection. Findings of the investigation are considered confidential, should not be copied and are considered Quality Improvement documents prepared for use by the Committee. Steps for RCA (Root Cause Analysis): Gather initial information about the incident through interviews wit anyone who may have been involved in the incident or witnessed the incident. This could include, but is not limited to residents, staff, visitors, family members etc. It may be necessary to interview persons who did not witness the incident but have knowledge of the resident(s) prior to or following the incident. Recreate the circumstances of the incident if possible or as necessary through role playing or recreate the incident or by drawing a diagram of the scene. Review the medical record, including but not limited to current medical diagnoses, MARS (Medication Administration Records), TARs (Treatment Administration Records), Nurses' Notes Care Plan, SBAR's (Situation, Background, Assessment, Recommendations), Progress notes leading up to and after the incident. Review communication tools used such as 24-hour report(s) or Stop and Watch forms leading up to and/or after the incident. Identify Contributing Factors by reviewing possible contributing factors as applicable to the incident. Using all the information gathered or considered, determine contributing factors/root cause of the incident (there are likely multiple root causes). Complete a written summary of the incident and conclude with the likely root cause(s). Developing a plan - Develop a plan that addresses identified root cause(s) and answers the question what can be done to keep similar events from happening again? For systemic causes - develop QAPI (Quality Assurance and Performance Improvement) action plan. Communicate care plan changes with staff/resident/representative and/or notify staff of QAPI action plan. Monitor effectiveness of care plan interventions and/or QAPI action plan. Review of the policy and procedure titled, Administrator/Risk Management - Quality Management dated (MONTH) (YEAR) read: Vision Statement - This facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. Mission Statement - This facility's mission statement is to provide Quality Focused Care, One Resident at a Time. To that end we will: Recognize each resident as an individual with unique needs and preferences. Offer choices and support resident decision making. Honor and respect each resident's dignity and rights. Utilize resources effectively. Purpose: Through Quality Assurance and Performance Improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. All employees will participate in ongoing QAPI efforts to support our mission of providing quality focused care one resident at a time. Guiding Principles - The facility will use QAPI to make decisions and improve the day-to-day operations. QAPI focuses on systems and processes, rather than individuals. The desired outcome of QAPI in the facility is the improved quality of care and the enhanced quality of life for our residents. Policy - the Administrator is responsible for the Quality Assessment and Assurance Committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A (Quality Assessment and Assurance) Committee, referred as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and scope - ongoing program and is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 2. Governance and Leadership - the governing body (administration of the facility) will develop a culture of seeking input from facility staff, residents, and families while assuring adequate resources to conduct QAPI efforts. QAPI will be a priority and will include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. 3. Feedback, Data Systems and Monitoring - the facility will put systems in place to monitor care and services through the use of multiple sources. Feedback systems will incorporate input from staff, residents, families, and others. Performance Indicators will monitor a wide range of care and outcomes and findings will be compared to benchmarks or targets established for performance. 4. Performance Improvement Projects (PIP's) - involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. 5. Systemic Analysis and Systemic Action - the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level. Composition and duties of the QAPI Committee - 2. The Committee will identify opportunities for improvement as well as recommend, implement, monitor and evaluate changes. The Committee will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 4. The Committee will charter Performance Improvement Projects (PIP's) to provide concentrated efforts to address a particular problem areas identified in one part of the facility or facility wide. The facility conducts PIP's to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement. 5. The facility will be proficient in the use of Root Cause Analysis to determine how Identified problems may be caused or exacerbated and will look across all Involved systems to prevent future events and promote sustained improvement programs. Review of the POS [REDACTED]. Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities. 7. Participate in quality assessment and improvement activities. Review of the POS [REDACTED]. Serves on Quality Improvement Committees that include Patient/Resident Care Management, Pharmaceutical Services, Infection Control, Safety and Utilization Review. 5. Meets with committee members to evaluate activities within the facility and to identify opportunities for continuous improvement in operations. Review of the Medical Director Services Agreement dated (MONTH) 14, (YEAR) read: 3. Medical Director of Facility. during the Term, Physician agrees to serve as Medical Director for Facility. Physician agrees to perform the services identified on Exhibit A attached hereto and incorporated herein by reference. Review of Exhibit A Medical Director Services read: k. Medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed health care practitioners. 4. Participate in Facility's Resident Care Management System, which will include attendance and active participation in Facility's monthly Quality Assessment and Assurance/Risk Management Committee. Participate in any meetings of the Facility's attending physicians and make credentialing recommendations to Facility about such attending physicians (as applicable). 5. Advise and consult with the Facility Administrator regarding: f. Improving performance of medical services as an integral part of improving Facility's performance. 6. Direct and coordinate: a. The medical care in Facility and ensure that Facility is providing appropriate care as required; e. In-service education by providing information for Facility personnel as may be required by accrediting bodies and Facility, including pertinent education regarding existing and proposed procedures within Facility. 9. Review and update, as applicable: b. All incident and accident reports from Facility to identify possible clinical risks and safety hazards. During an interview on [DATE] at 10:59 AM, the Administrator stated, This event with (Resident #88's name) was not discussed at a QAPI meeting. The facility investigation of this incident was not written down. The DON interviewed the nurse. No Root Cause Analysis was completed because we did not believe one was necessary. During an interview on [DATE] at 11:20 AM, the Medical Director confirmed the incident had not been discussed at the QAPI meeting. He was not aware that there was a problem in the delay of CPR for this resident. This is the first the Medical Director heard of a problem with this resident. He stated, If the resident is unresponsive, do a quick assessment check, vitals, start CPR immediately after checking vitals, call 911. The Medical Director was not involved in the development of the current P & P (Policy and Procedures). The facility uses corporate policy and procedures. During an interview on [DATE] at 10:23 AM, the DON stated, I do not know which facility staff was present in the facility at the time of the code blue for (Resident #88's name). During an interview on [DATE] at 10:40 AM, the Administrator stated, I don't know which facility persons responded to the code on [DATE]. The CNAs can perform CPR here in the facility. Review of the facility investigation revealed an unsigned note dated [DATE], which read: After reviewing the note from this morning documenting (Resident #88's name) code blue. The nurse's time lined code in nurses' note. Noted resident was found when she went to give medications. Time CPR initiated was 3 minutes later. Discussed with the Administrator. The chart was reviewed again to be sure information was correct. On ,[DATE] spoke with RN (Registered Nurse) by phone. The nurse was asked to take the DON (Director of Nursing) thru the code. Described as written in note. Questioned her times documented and she said yeah that's right. On [DATE] RN contacted to come in and meet with the Administrator and myself. The nurse was given the opportunity to discuss what happened that night. Defensive and said she knew we were going to do this. Asked why there was a delay, she replied, Had to go get cart and find (a nurse's name) on PICC (Piccadilly Unit). Asked why she did not just call for help. Said (a nurses' name) is deaf and wouldn't have heard me. So I had to go find her. Asked if she thought that was good nursing judgement and would she do anything differently. She said No I would do the same thing. Terminated at that time. Review of the Licensed Nurses Progress Notes form dated [DATE] at 5:07 AM read: Went to Res. (Resident) room to give AM med. Noted Res unresponsive, check for signs of vital signs, no resp. (respirations) or heartbeat noted. Went to get crash cart and call code blue. Dated [DATE] at 5:10 AM read: CPR initiated per staff. Other nurse placed call to 911 to request EMS (Emergency Medical Services) for code blue. Dated [DATE] at 5:20 AM read: Staff continued CPR until EMS arrived at this time. EMS takes over at this time. Dated [DATE] at 5:47 AM read: EMS calls code - expired at 5:47 AM. All the entries were signed by Staff H, RN (Registered Nurse). Review of the physician's orders [REDACTED]. Review of Resident #88's facility record revealed no documentation in the record of a code sheet (a document used to record the critical interventions during a [MEDICAL CONDITION] resuscitation event). Review of the Policy and Procedure titled, Abuse, Neglect, Exploitation & Misappropriation with an effective date of Feb. 2006 and a Revision Date of: (MONTH) (YEAR) read: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. 3. Prevention: The facility identifies, corrects, and intervenes in situations of alleged abuse, neglect, and exploitation and focuses on the following areas of prevention: f. A commitment to follow through on all complaints and provide feedback to those involved, when possible. R. Identification: Reporting of suspected maltreatment is required of all staff. All incidents will be reviewed by the facility's Quality Assurance Committee for detection of patterns and/or trends. 8. Corrective Action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. The DON/designee may initiate a care plan to reflect the resident's condition and measures to be taken to prevent reoccurrence of the incident. This may include in-services and other measures, as appropriate. All corrective actions will be documented. Any ANE (Abuse, Neglect, Exploitation) incident will be reviewed at the Quality Assurance Committee meeting. Review of the Policy and Procedure titled, Nursing - Emergency Care (CPR) with an effective date of (MONTH) 2014 read: Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order. During an interview on [DATE] at 2:17 PM, the DON (Director of Nursing) stated, The standard of practice for starting CPR when a resident is found to be unresponsive is immediately as soon as you find the resident is without pulse or respirations, if the resident is a full code. The nurse is not to leave the resident once she finds the resident without pulse or respirations. The nurse could call out for assistance if needed. The facility reviews the resident's chart after the death to see how it was handled or if there was anything that needed to be corrected such as was the appropriate action taken during the code. The nurse directly involved (Staff H) has been terminated. The facility did not report it to AHCA (Agency for Healthcare Administration) as an adverse incident specific to there being a delay in CPR. If there was a code sheet it should have been placed in the resident's chart. The Administrator and I reviewed what happened during the code and determined the nurse had violated a known rule or policy by failing to act quickly. I don't know why the incident was not reported to AHC[NAME] The nurse was not reported to the board of nursing. When asked if a plan of correction was developed and implemented, the DON stated, I reviewed best practice with the nurses such as calling out for help, starting CPR immediately, upon finding the resident pulseless and without respirations, signs or life, calling a code. During an interview on [DATE] at 2:27 PM, the Medical Records Director stated, I don't know if a code sheet was completed for (Resident #88's name) when the resident received CPR. She stated: If there was one completed, it should be in the resident's chart. No documentation was provided for a code sheet. During an interview with the facility Administrator on [DATE] at 3:00 PM when asked to provide the Adverse Incident report and investigation involving Resident #88 which occurred on [DATE]. The Administrator stated the facility had not determined this to be an Adverse Event and did not report it. The Administrator stated a Root Cause Analysis (RCA) was not conducted. During an interview with the facility Administrator on [DATE] beginning at 7:28 AM during the review of the Quality Assurance program, the incident involving Resident #88 being found unresponsive and absent of life with a delay of 3 minutes before CPR having been initiated was discussed. It was reconfirmed by the Administrator the facility did not initiate a full investigation nor report the incident as an Adverse Incident. During an interview on [DATE] at 7:27 AM with Staff I, CNA, she stated, I was on duty when the incident occurred. I was helping another CNA on another hallway when the door was closed, we couldn't hear a code blue being called. Code blues are usually initiated by the nurse announcing the code overhead by using the phone intercom system. I haven't received any additional training regarding CPR since this incident. During an interview on [DATE] at 10:14 AM, the Administrator stated: There is no code blue buttons in the residents' rooms. The nurse has to step out and go to the nurses' station to call the code blue using the overhead paging system. A request was made for a list of all staff that was present during the code. No documentation was provided. During an interview on [DATE] at 3:28 PM, Staff E, CNA (Certified Nursing Assistant) stated she had worked at the facility PRN (as needed) for two years. When asked what she would do if she found a resident unresponsive, she stated, I would leave the room and get a nurse then grab the chart to verify the code status. During an interview on [DATE] at 3:33 PM, Staff F, CNA stated she had been employed since 2011. When asked the facility policy and procedure when a resident is found unresponsive, she stated, When finding a resident unresponsive I would first rush to get the nurse and look for other CNAs to help, and grab the chart. During an interview on [DATE] at 4:24 PM, the DON stated, The RN who delayed CPR was not reported to the Board of Nursing. The incident was not reported to DCF (Department of Children and Families) and AHCA was not notified. During an interview on [DATE] at 10:52 AM, Staff G, CNA stated, I worked the night shift on the Piccadilly hallway on [DATE] for 11:00 PM to 7:00 AM shift. I remember the night the resident coded. I don't recall hearing the page that a resident was coding. The nurse, (Staff H's name) came to get the CNA (Staff I's name) that was in a resident's room with me providing resident care on the Piccadilly hallway. Review of the Termination Action Form dated [DATE] read: Discharge For Misconduct: 19. Violation of known rule or policy (explain). Explanation/Comments: Failed to act quickly when pt. (patient) found absent of pulse and respirations and initiate CPR and call for help. Review of The American Heart Association website, at https://www.heart.org/en/news/[DATE]/cpr-is-key-to-survival-of-sudden-cardiac-arrest reads: CPR increases the possibility of surviving sudden [MEDICAL CONDITION] . If someone is unconscious and does not appear to be breathing properly, it's time to start CPR chest compressions . But anyone can - and should - perform CPR. (The author's name) Doing something is the right thing to do. It can only help. Review of the document titled Meeting dated [DATE] read: Codes - there had been some delay with getting codes started. Coding a resident should be started ASAP (as soon as possible). Stay in room. Yell for help (ask them to bring chart). Look in chart for code status then start ASAP. Review of the sign-in sheet dated [DATE] titled Meeting revealed 21 licensed staff signed as having attended, 4 RNs and 17 LPNs (Licensed Practical Nurses). No CNAs (Certified Nursing Assistants) signed as having attended the meeting. Review of the direct care staff employee list revealed there were 21 RNs, to include the Administrator, 29 LPNs and 74 CNAs employed by the facility.

Based on resident record review and staff interviews, the facility failed to honor a resident's right to receive adequate and appropriate health care consistent with the resident's care plan and established and recognized practice standards. The facility failed to implement written policies and procedures to provide emergency care for basic life support, including CPR (Cardiopulmonary Resuscitation) for one (Resident #88) of four residents reviewed for a full code status. The facility failed to honor Resident #88's expressed and written wishes to have cardiopulmonary resuscitation implemented timely in the event of respiratory/cardiac failure. The facility nursing staff failed to follow policies and procedures for CPR in a timely manner, and the resident died . This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began (MONTH) 20, 2019. The Administrator was informed of the Immediate Jeopardy on (MONTH) 24, 2019. The Immediate Jeopardy was on-going. This has the potential to affect 43 residents with a Full Code Status of a total population of 117 residents. Cross reference to F835 and F867. The findings included: Review of Resident #88's facility record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. These chambers fibrillate, or quiver, rapidly. The result is a rapid and irregular pumping of blood through the heart). Review of the Licensed Nurses Progress Notes form dated [DATE] at 5:07 AM read: Went to Res. (Resident) room to give AM med. Noted Res unresponsive, check for signs of vital signs, no resp. (respirations) or heartbeat noted. Went to get crash cart and call code blue. Dated [DATE] at 5:10 AM read: CPR initiated per staff. Other nurse placed call to 911 to request EMS (Emergency Medical Services) for code blue. Dated [DATE] at 5:20 AM read: Staff continued CPR until EMS arrived at this time. EMS takes over at this time. Dated [DATE] at 5:47 AM read: EMS calls code - expired at 5:47 AM. All the entries were signed by Staff H, RN (Registered Nurse). Review of the physician's orders [REDACTED]. Review of Resident #88's facility record revealed no documentation in the record of a code sheet (a document used to record the critical interventions during a [MEDICAL CONDITION] resuscitation event). Review of the Policy and Procedure titled, Nursing - Emergency Care (CPR) with an effective date of (MONTH) 2014 read: Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order. During an interview on [DATE] at 2:17 PM, the DON (Director of Nursing) stated, The standard of practice for starting CPR when a resident is found to be unresponsive is immediately as soon as you find the resident is without pulse or respirations, if the resident is a full code. The nurse is not to leave the resident once she finds the resident without pulse or respirations. The nurse could call out for assistance if needed. The facility reviews the resident's chart after the death to see how it was handled or if there was anything that needed to be corrected such as was the appropriate action taken during the code. The nurse directly involved (Staff H) has been terminated. The facility did not report it to AHCA (Agency for Healthcare Administration) as an adverse incident specific to there being a delay in CPR. If there was a code sheet it should have been placed in the resident's chart. The Administrator and I reviewed what happened during the code and determined the nurse had violated a known rule or policy by failing to act quickly. I don't know why the incident was not reported to AHC[NAME] The nurse was not reported to the board of nursing. When asked if a plan of correction was developed and implemented, the DON stated, I reviewed best practice with the nurses such as calling out for help, starting CPR immediately, upon finding the resident pulseless and without respirations, signs or life, calling a code. During an interview on [DATE] at 2:27 PM, the Medical Records Director stated, I don't know if a code sheet was completed for (Resident #88's name) when the resident received CPR. She stated: If there was one completed, it should be in the resident's chart. No documentation was provided for a code sheet. During an interview on [DATE] at 7:27 AM with Staff I, CNA, she stated: I was on duty when the incident occurred. I was helping another CNA on another hallway when the door was closed, we couldn't hear a code blue being called. Code blues are usually initiated by the nurse announcing the code overhead by using the phone intercom system. I haven't received any additional training regarding CPR since this incident. During an interview on [DATE] at 10:14 AM, the Administrator stated: There is no code blue buttons in the residents' rooms. The nurse has to step out and go to the nurses' station to call the code blue using the overhead paging system. A request was made for a list of all staff that was present during the code. No documentation was provided. During an interview on [DATE] at 11:20 AM, the Medical Director stated, I was not aware that there was a problem in the delay of CPR for this resident. This is the first I am hearing of this problem with this resident. If the resident is unresponsive, do a quick assessment check, vitals, start CPR immediately after checking vitals, call 911. During an interview on [DATE] at 3:28 PM, Staff E, CNA (Certified Nursing Assistant) stated she had worked at the facility PRN (as needed) for two years. When asked what she would do if she found a resident unresponsive, she stated, I would leave the room and get a nurse then grab the chart to verify the code status. During an interview on [DATE] at 3:33 PM, Staff F, CNA stated she had been employed since 2011. When asked the facility policy and procedure when a resident is found unresponsive, she stated, When finding a resident unresponsive, I would first rush to get the nurse and look for other CNAs to help and grab the chart. During an interview on [DATE] at 10:52 AM, Staff G, CNA stated, I worked the night shift on the Piccadilly hallway on [DATE] from 11:00 PM to 7:00 AM shift. I remember the night the resident coded. I don't recall hearing the page that a resident was coding. The nurse, (Staff H's name) came to get the CNA (Staff I's name) that was in a resident's room with me providing resident care on the Piccadilly hallway. Review of the facility investigation revealed an unsigned note dated [DATE] which read: After reviewing the note from this morning documenting (Resident #88's name) code blue. The nurse's time lined code in nurses' note. Noted resident was found when she went to give medications. Time CPR initiated was 3 minutes later. Discussed with the Administrator. The charts were reviewed again to be sure information was correct. On ,[DATE] spoke with RN (Registered Nurse) by phone. The nurse was asked to take the DON (Director of Nursing) thru the code. Described as written in note. Questioned her times documented and she said, yeah that's right. On [DATE] RN (Staff H) contacted to come in and meet with the Administrator and myself. The nurse was given the opportunity to discuss what happened that night. Defensive and said she knew we were going to do this. Asked why there was a delay, she replied, Had to go get cart and find (a nurses' name) on PICC. Asked why she did not just call for help. Said (a nurses' name) is deaf and wouldn't have heard me. So I had to go find her. Asked if she thought that was good nursing judgement and would she do anything differently. She said No I would do the same thing. Terminated at that time. Review of the Termination Action Form dated [DATE] read: Discharge For Misconduct: 19. Violation of known rule or policy (explain). Explanation/Comments: Failed to act quickly when pt. (patient) found absent of pulse and respirations and initiate CPR and call for help. Review of The American Heart Association website, at https://www.heart.org/en/news/[DATE]/cpr-is-key-to-survival-of-sudden-cardiac-arrest reads: CPR increases the possibility of surviving sudden [MEDICAL CONDITION] . If someone is unconscious and does not appear to be breathing properly, it's time to start CPR chest compressions . But anyone can - and should - perform CPR. (The author's name) Doing something is the right thing to do. It can only help. Review of the document titled Meeting dated [DATE] read: Codes - there had been some delay with getting codes started. Coding a resident should be started ASAP (as soon as possible). Stay in room. Yell for help (ask them to bring chart). Look in chart for code status then start ASAP. Review of the sign-in sheet dated [DATE] titled Meeting revealed 21 licensed staff signed as having attended, 4 RNs and 17 LPNs (Licensed Practical Nurses). No CNAs (Certified Nursing Assistants) signed as having attended the meeting. Review of the direct care staff employee list revealed there were 21 RNs, to include the Administrator, 29 LPNs and 74 CNAs employed by the facility.