Every finding on record at Egret Cove Center

Based on observations, interviews and record review, the facility did not ensure timely administration of medications for two Residents (#2 and #3) of two Residents reviewed for receipt of prescribed medications and for two of two medication administration passes observed, resulting in thirty-one residents receiving medications outside of the facility's medication timing parameters. Findings Included: 1. A review of Resident #2's Medication Administration Audit Report for the month of October 2024 indicated the following: On 10/8/24, the following medications were scheduled to be administered at 9:00 a.m. and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg (milligrams), give 200 mg by mouth two times a day for moderate pain: Documented as administered at 10:54 a.m. - Lidocaine External patch 5%, apply to lower back topically one time a day for lower back pain, remove at 2100: Documented as administered at 10:56 a.m. - Allopurinol oral tablet 300 mg, give 1 tablet by mouth one time a day for gout: Documented as administered at 10:54 a.m. - Omeprazole oral capsule delayed release 20 mg, give 40 mg one time a day for GERD (Gastroesophageal reflux disease.): Documented as administered at 10:54 a.m. - Digoxin oral tablet 125 mcg (micrograms), give 1 tablet by mouth one time a day for Afib (Atrial Fibrillation.): Documented as administered at 10:54 a.m. On 10/8/24, the following medications were scheduled to be administered at 1700 hours (5:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg: Documented as administered at 1936 hours (7:36 p.m.) - Rivaroxaban oral tablet 20 mg, give 20 mg by mouth in the evening for Afib: Documented as administered at 1937 hours (7:37 p.m.) On 10/9/24, the following medications were scheduled to be administered at 2100 hours (9:00 p.m.) and were not documented on the Medication Administration Audit Report as administered: - Xarelto Tablet (Rivaroxaban), give 5 mg by mouth at bedtime for preventative measure. - Rosuvastatin Calcium oral tablet 5 mg, give one tablet by mouth at bedtime for HLD (Hyperlipidemia) - Metoprolol Succinate oral tablet, give 75 mg by mouth at bedtime for HTN (Hypertension). On 10/10/24, the following medications were scheduled to be administered at 1700 hours (5:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg, give 200 mg by mouth two times a day for moderate pain: Documented as administered at 0015 hours (12:15 a.m.) on 10/11/24. - Rivaroxaban oral tablet 20 mg, give 20 mg by mouth in the evening for Afib: Documented as administered at 0021 hours (12:21 a.m.) on 10/11/24. On 10/10/24, the following medications were scheduled to be administered at 2100 hours (9:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Metoprolol Succinate 25 mg oral tablet, give 75 mg by mouth at bedtime for HTN: Documented as administered at 0018 hours (12:18 a.m.) on 10/11/24. - Rosuvastatin Calcium oral tablet 5 mg, give one tablet by mouth at bedtime for HLD: Documented as administered at 0016 hours (12:16 a.m.) on 10/11/24. On 10/14/24, the following medications were scheduled to be administered at 0900 hours (9:00 a.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg, give 200 mg by mouth two times a day for moderate pain: Documented as administered at 11:05 a.m. - Lidocaine External patch 5%, apply to lower back topically one time a day for lower back pain, remove at 2100: Documented as administered at 11:06 a.m. - Allopurinol oral tablet 300 mg, give 1 tablet by mouth one time a day for gout: Documented as administered at 10:34 a.m. - Omeprazole oral capsule delayed release 20 mg, give 40 mg one time a day for GERD: Documented as administered at 11:05 a.m. - Digoxin oral tablet 125 mcg, give 1 tablet by mouth one time a day for Afib: Documented as administered at 10:34 a.m. - Spironolactone oral tablet 25 mg, give 1 tablet by mouth one time a day every Mon, Wed and Fri for HTN: Documented as administered at 10:34 a.m. A review of Resident #2's Progress Notes for the month of October 2024 did not include notification to the resident's primary physician regarding late administration of medication. (Photographic Evidence Obtained) 48441 2. On 12/2/24 at 11:00 a.m., an observation and interview were conducted in the 400 hallways with Staff A, Registered Nurse/Unit Manager (RN/UM) during medication administration. An observation was made of Staff A, RN/UM's computer screen, which was showing the Medication Administration Record (MAR) for her assigned residents during the Day (7:00 a.m. to 3:00 p.m.) shift. The MAR showed 15 residents requiring their morning medications and all the residents were shown in red, indicating the medications were late. Staff A, RN/UM agreed medications were late for these residents. Staff A, RN/UM stated she arrived at the facility at her usual time of 8:30 a.m., and was unaware there was a sick call on her side of the facility. Staff A, RN/UM stated this was the reason her medications were late this morning. (Photographic Evidence Obtained) On 12/2/24 at 3:00 p.m., an interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff B, LPN/UM stated medications have a window of one hour before and one hour after the ordered medication time to consider medication on time. Staff B, LPN/UM denied the facility had liberalized medication administration times. On 12/03/24 10:32 a.m., an observation and interview were conducted in the 200 hallways with Staff C, RN, during medication administration. An observation was made of Staff C, RN's computer screen, which was showing the MAR for her assigned residents during the Day shift. The MAR showed with 16 residents requiring their morning medications and all the residents were shown in red, indicating the medications were late. Staff C, RN agreed medications were late for these residents. Staff C, RN stated she normally works the night shift and was having difficulty in locating missing medications, which would normally be in the bottom drawer of the medication cart. Staff B, LPN/UM arrived during the interview and stated he would be assisting Staff C, RN with the remainder of Staff C's medication administration. On 12/3/24 at 10:55 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Both the DON and ADON were aware of the late medication administration on 12/2/24 and 12/3/24. The ADON stated Staff C, RN normally works the night shift and may be struggling with the day shifts higher demand of medication administration. The DON stated the pharmacy has a process where automatic renewal should be implemented, and staff can request and/or a par is created by pharmacy to automatically dispense the medication. The DON could not explain why medications were late on 12/3/24. On 12/3/24 at 11:20 a.m., an observation and interview were conducted with Staff B, LPN/UM at med cart 1 pulling medications to assist Staff C, RN. Staff B, LPN/UM stated he was pulling the medications for the residents and Staff C, RN was distributing them to the residents. Staff B, LPN/UM stated the electronic chart was logged in under Staff C, RN's name, but would not state who was documenting in the MAR. On 12/3/24 at 11:30 a.m., an interview was conducted with the DON. The DON stated medication administration should be conducted with one nurse pulling the medication, administering the medication, and documenting the medication. If two nurses are administering from the same cart, an extra computer should be available, or the screen could be split and logged under each nurse individually. On 12/3/24 at 12:20 p.m., an interview was conducted with the ADON. The ADON stated the Medical Director was notified of all the late medication administration for 12/3/24, but the individual physicians for the residents had not. The DON stated the individual physicians will be notified for the late medications for 12/3/24 as well as the late medications from 12/2/24. A review of Resident #3's Medication Administration Audit Report for the month of October 2024 showed medications were administered late on the following dates and times: - 10/7/24: four medications during the 4:00 p.m., 4:30 p.m., and 5:00 p.m. medication passes. - 10/8/24: 19 medications during the 9:00 a.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/9/24: three medications were scheduled to be administered at 9:00 p.m. and were not administered. - 10/10/24: 10 medications during the 11:30 a.m., 4:00 p.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/13/24: four medications during the 4:00 p.m., 4:30 p.m., and 5:00 p.m. medication passes. - 10/14/24: 14 medications during the 9:00 a.m. medication pass. - 10/18/24: 19 medications during the 9:00 a.m., 4:00 p.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/21/24: 15 medications during the 9:00 a.m., 11:00 a.m., and 1:00 p.m. medication passes. - 10/22/24: 16 medications during the 7:00 a.m., 9:00 a.m., and 11:00 a.m. medication passes. A review of Resident #3's Progress Notes for the month of October 2024 did not include notification to the resident's primary physician regarding late administration of medications. (Photographic Evidence Obtained) An interview was conducted with the DON, ADON, and Regional Nurse, on 12/3/24 at 5:10 p.m. regarding the late medications for Residents #2 and #3 for October 2024. There was no explanation provided as to why the medications were administered late on the specific dates. A review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 9/2018 showed the following procedures under the section titled, Medication Administration, to include but not limited to: 3. Medication administration timing parameters include the following: a. Medications to be given on an empty stomach or before meals are not to be scheduled for administration 30 minutes to two hours prior to meals. b. Medications to be given with meals are to be scheduled for administration at the resident's mealtimes. c. Medications to be given after meals or with food are to be scheduled for administration immediately after and up to two hours after meals or with a snack . d. Medications to be given at bedtime are to be scheduled for administration up to one hour prior to the resident's scheduled bedtime. . 5. The person who prepares the dose for administration is the person who administers the dose. . 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtime or in the dining room unless specifically ordered with meal. The policy and procedure also revealed the following under the section titled, Documentation: 1. The individual who administers the medication dose records the administration on the residents MAR immediately following the medication being given. In no case should the individual who administered the medication report off duty without first recording the administration of any medications. A review of the facility's policy titled Physician Notification, effective October 2021, showed the following policy statement: The facility strives to ensure each resident's health is supervised by a qualified attending physician. The attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient. A review of this policy's Procedure showed: 1. Licensed Nurses will ensure the physicians are notified of changes or diagnostic results that occur between visits. Changes may include but are not limited to: - Any time a medication is not administered as ordered.

Based on observation, and interview, the facility failed to ensure adequate placement of call assistance equipment to call for staff assistance for six (#7, #8, #9, #10, #11, and #13) of fourteen sampled residents. Findings include: A tour of the facility was initiated on 10/17/2024 at 9:32 a.m. The following observations were conducted during the tour. During an observation on 10/17/2024 at 9:35 a.m., Resident #7 was seen in bed with severe contractures of his arms and legs, curled in a fetal like position, and with his arm wrapped in his leg. He was observed watching television. Resident #7 was able to answer questions. When asked if he could use his call bell light. the resident did not answer but turned his head towards the feeding tube pole. An observation was conducted of Resident #7's call bell light laying on the floor at the bottom of the tube feeding pole. Photographic evidence obtained. Resident's call bell light was observed to be a push button type call bell that would require dexterity of the hand to hold and depress the button. On 10/17/2024 at 10:06 a.m., an observation was conducted of Resident #8, laying in her bed. She confirmed she could use the call bell light, but she could not reach it. Her call bell light cord was observed looped over the bed's right-side rail with the call light button hanging down to the bottom of the side rail. The bed was observed to have padding on the side rail which would prevent access to the call bell light cord. In the same room, Resident #9, was observed laying in her bed with her eyes open. She greeted the surveyor. The call light cord and button were observed on the floor. On 10/17/2024 at 10:15 a.m., an observation was conducted of Resident #10, in bed with his hand on his chest. He stated his chest hurt. His call bell light was observed wrapped around the bottom leg of his bed. On 10/17/2024 at approximately 10:17 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She was observed working at a medication cart outside of Resident #10's bedroom. She stated she had just provided Resident #10 with Tylenol. On 10/17/2024 at 10:24 a.m., Resident #11 was observed in bed with his eyes closed. His call bell light cord and button were observed to be laying on the floor. On 10/17/2024 at 10:45 a.m., Resident #13 was observed in bed, eyes closed. Observed his call bell light cord and button on the floor under a plastic hygiene bowl, at the foot of the tube feeding pole. An interview was conducted on 10/18/2024 at approximately 10:45 a.m. with the Director of Nursing. She confirmed it was her expectation that the call bell light should be placed within reach of the resident, for every resident. She confirmed for a cognitively impaired resident it was important to be within reach. If they need help, they can call for help.

Based on observation, record review, and interview, the facility failed to have evidence of the provision of a summary of the baseline care plan to the resident and their representative for one (#12) of fourteen sampled residents. Findings included: On 10/17/2024 at 10:30 a.m., Resident #12 was observed in his bed with his eyes closed. An interview was conducted at this time with his spouse. Resident #12's spouse said she had not been able to receive communication about what the plan was for her husband, how long he was going to be at the facility, or what services they were going to provide to him. At approximately 10:40 a.m., Resident #12 was observed to be awake. He stated he wanted to understand the services that were to be provided to him during his stay and why he needed to be at the facility. A review of Resident #12's Admission Record reflected an admission of 10/11/2024. Resident #12's diagnosis list included Urinary Tract infection, Nontoxic Multinodular goiter, and occlusion and stenosis of unspecified carotid artery. On 10/18/2024 at approximately 8:45 a.m., the Nursing Home Administrator was requested to provide a copy of Resident #12's Baseline Care Plan. On 10/18/2024 at approximately 10:45 a.m., the Director of Nursing was requested to provide a copy of the Baseline Care Plan for Resident #12 with evidence of the provision of the baseline care plan to the resident and resident's representative. On 10/18/2024 at approximately 11:12 a.m., the Traveling Minimum Data Set (MDS) Coordinator was requested to provide a copy of Resident #12's Baseline Care Plan and the parties who signed the plan. No evidence was provided during the survey to support Resident #12 and his representative had received a summary of the Baseline Care Plan.

Based on observation, record review, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for four (#7, #8, #9, and #11) of fourteen sampled residents. Findings included: 1. On 10/17/2024 at 9:35 a.m., Resident #7 was observed in bed. He was observed curled in a fetal like position, his arm was wrapped in his leg, watching the television. He was observed to have severe contractures, and dry lips. When asked if staff put moisture product on his lips, he shook his head. When asked if he was provided pleasure foods by mouth, he stated sometimes. When asked if he was allowed to have water by mouth, he said, sometimes. He stated he would like water. He said his arm was stuck. When asked if he could use his call bell light. the resident did not answer but turned his head towards the feeding tube pole. An observation was conducted of Resident #7's call bell light laying on the floor at the bottom of the tube feeding pole. Resident #7's breakfast meal tray, untouched, was observed to be positioned on the sink counter. Photographic evidence obtained. A review of Resident #7's Admission Record documented an original admission in 08/2023, and a re-admission on 09/18/2024. A review of Resident #7's diagnosis information included, but not limited to: Muscle wasting and atrophy, muscle weakness, Dysphagia, and Spinal Stenosis. A review of Resident #7's Care Plan on 10/18/2024 reflected no plan of care for contractures. A review of Resident #7's Care Plan reflected a focus: Nutritional: [Resident #7] has a nutritional problem or potential nutritional problem r/t needed for TF (tube feeding) support to assist with wound healing and meeting ntr (nutritional) needs, initiated on 10/17/2024. Interventions included: Provide [Resident #7] with TF using Jevity at 80 ml (milliliter)/h (hour) over 10 h infusion .Also with PO (by mouth) intake during waking hours along with supplement using Medpass 240 ml BID (two times a day) to assist in meeting nutritional needs, initiated 10/17/2024. Resident is NPO (nothing by mouth)-Do not provide food or fluids by mouth. See nurse, initiated 09/19/2024. An interview was conducted on 10/18/2024 at 11:02 a.m. with the Rehabilitation Director, PTA (Physical Therapist Assistant). Regarding Resident#7, he stated the resident was a recent admission, the resident was on case load. When asked if the aids did anything for the resident's contractures, he stated, Not right now. He is super sensitive, and we want to keep his care with us for a while. When asked how the aids provided the resident incontinence care, he stated, Unroll him, the aids have been able to provide him incontinence care; it is work in progress. An interview was conducted on 10/18/2024 at 11:12 a.m. with the Traveling Minimum Data Set (MDS) Coordinator. When asked if Resident #7 had contractures, she stated, I would have to look. She confirmed Resident #7 did not have a Care Plan Focus area for contractures. When asked about Resident #7's feeding status, she stated, He was NPO when he readmitted on [DATE]. The order was discontinued on 09/30/2024. At that point a regular puree diet came into play on 09/30/2024. For meals, he would get the normal 3 meals per day. He would continue to get the peg tube feeding also. She confirmed the Nutrition Care Plan interventions were not current. An observation of Resident #7 was conducted on 10/18/2024 at 11:35 a.m. with the Traveling MDS Coordinator. She confirmed the resident had contractures. Resident was observed to have beads of sweat on his shoulders. Resident#7's call bell light was observed on top of the tube feeding machine. Resident was observed to be unclothed, on a specialized mattress. He said he was hot, burning up. During the observation at 11:37 a.m., Staff A, Personal Care Attendant (PCA) was observed to come in the room with a cup of water. She stated she was going to provide water to the resident. Staff A was asked if Resident #7 could use the push button call bell light. Staff A stated the resident could. She was observed to remove the call light from the top of the tube feeding machine and put it close to the resident's hand. She said the nurse had just put the cord up there a minute ago. For meal assistance: On 10/18/2024 at approximately 8:45 a.m., the NHA was requested to provide a printout of Resident #7's meal consumption for the last 30 days. On 10/18/2024, the list was provided. A review of Resident #7's meal intake documentation from 09/19/2024 thru 10/17/2024, documented from 09/19/2024 through 09/28/2024, the resident was NPO, or Tube fed. The following entries were documented or not documented by staff after 09/28/2024. 09/29 8:00 a.m., Resident consumed 76-100%. 09/29 11:00 a.m., Resident consumed 76-100%. 09/29 evening, No documentation. 09/30 No documentation. 10/01 morning, No documentation. 10/01 noon, No documentation. 10/01 18:03 (6:03 p.m.), Resident consumed 0-25% 10/02 8:00 a.m., Resident consumed 76-100% 10/02 11:30 a.m., Resident consumed 76-100%. 10/02 evening, No documentation. 10/03 morning, No documentation. 10/03 14:20 (2:20 p.m.), Resident consumed 76-100%. 10/03 22:38 (10:38 p.m.), Resident consumed 76-100%. 10/04 morning, No documentation. 10/04 14:35 (2:35 p.m.) Resident consumed 0-25% 10/05 9:35 a.m., Resident consumed 76-100%. 10/05 noon, No documentation. 10/05 evening, No documentation. 10/06 8:00 a.m., Resident consumed 76-100%. 10/06 11:30 a.m., Resident consumed 76-100%. 10/06 18:40. (6:40 p.m.), Resident consumed 76-100%. 10/07 8:00 a.m., Resident consumed 76-100%. 10/07 11:30 a.m., Resident consumed 0-25%. 10/07 22:08 (10:08 p.m.), Resident consumed 0-25%. 10/08, morning and noon, No documentation. 10/08 22:26 (10:26 p.m.). Resident consumed 76-100%. 10/09 morning and noon, No documentation. 10/09 21:40 (9:40 p.m.) resident refused. 10/10 through 10/14, No documentation. 10/15 8:00 a.m. and 11:30 a.m., resident refused. 10/15 20:12 (8:12 p.m.), Resident consumed 0-25%. 10/16 10:28, Resident consumed 0-25%. 10/16 13:32 (1:32 p.m.), Resident consumed 76-100% 10/16 19:28 (7:28 p.m.), Resident consumed 76-100% 10/17 morning, No documentation. 10/17 12:24, Resident consumed 51-75% 10/17 12:27, Resident consumed 26-50% 10/17 evening, No documentation. Days reviewed, 09/29 through 10/17=19 days. Meal opportunities=19 x 3 = 57 meals 23 meals were documented to be offered. 34 meals had no documentation of being offered. A tour of the facility was initiated on 10/17/2024 at 9:32 a.m. The following observations were conducted during the tour. 2. On 10/17/2024 at 10:06 a.m., an observation was conducted of Resident #8, laying in her bed. She confirmed she could use the call bell light, but she could not reach it. Her call bell light cord was observed looped over the bed's right-side rail with the call light button hanging down to the bottom of the side rail. The bed was observed to have padding on the side rail which would prevent access to the call bell light cord. A review of Resident #8's clinical record, the Admission Record, reflected a re-admission of 06/10/2024. Her diagnosis list included but not limited to: Cerebral Infarction due to embolism of other cerebral artery, chronic obstructive pulmonary disease, and Dysphagia. A review of Resident #8's Care Plan, listed a focus area, Fall: [Resident #8] has had a fall because of history of falls . Interventions included: Provide environmental adaptions: Call light, frequently used items within reach . initiated 12/11/2022, updated 01/08/2023. 3. In the same room, Resident #9, was observed laying in her bed, eyes open, greeted the surveyor. The call light cord and button were observed on the floor. A review of Resident #9's clinical record, the Admission Record, reflected an admission in 06/2023. Her diagnosis list included but not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side and need for assistance with personal care. A review of Resident #9's Care Plan, listed a focus area, Fall: [Resident #9] had a fall injury because of: Deconditioning, Gait/balance problems, medications, initiated 06/23/2023. Interventions included: Provide environmental adaptions: Call light within reach, initiated 06/29/2023. 4. On 10/17/2024 at 10:24 a.m., Resident #11 was observed in bed with his eyes closed. His call bell light cord and button were observed to be laying on the floor. A review of Resident #11's clinical record, the Admission Record, reflected a re-admission of 06/19/2023. Her diagnosis list included but not limited to: Unspecified Dementia, and muscle wasting. A review of Resident #11's Care Plan, listed a focus area, Fall: [Resident #11] is at risk for falls or fall related injuries d/t (due to) her dx (diagnosis) of dementia . Interventions included: Provide environmental adaptions: Call light within reach, initiated 01/04/2021. An interview was conducted on 10/18/2024 at approximately 10:45 a.m. with the Director of Nursing. She confirmed it was her expectation that the call bell light should be placed within reach of the resident, for every resident. She confirmed for a cognitively impaired resident it was important to be within reach. If they need help, they can call for help. Photographic evidence obtained. A review of the facility's Care Plan-Interdisciplinary Plan of Care from Interim to Meeting policy & procedure, effective February 2024, documented the policy: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but not limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives, and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.

Based on interview and record review, the facility failed to provide a timely respiratory assessment and care in accordance with professional standards of practice for one (#2) of three sampled residents related to an assessment of a resident in distress. Findings included: Resident #2 was admitted on [DATE] and discharged on [DATE]. Review of the Admissions Record showed the diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure with hypercapnia, dependent on oxygen, pleural effusion, pulmonary hypertension, Hypertension, and Asthma. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Review of Section GG, Functional Abilities and Goals showed substantial to maximum assistance for bathing. Section O, Special Treatments, Procedures, and Programs showed C1. oxygen therapy. G1. Non-invasive mechanical ventilator was blank (BIPAP/ Bi-level positive airway pressure and CPAP/ Continuous positive airway pressure). Review of the Hospital Records 08/21/2024 to 08/27/2024 showed a progress note dated 08/27/2024 that the patient has had recurrent admissions for this. There is poor compliance at home. Reports no CPAP use with naps and minimal at night as she only wears for short periods as she stated does not sleep well at night. Wean oxygen to keep sats 89 or above and use BIPAP nightly which we will order here. Continue BIPAP at night. Would benefit at home. Discussed importance of home CPAP compliance with sleeping at night and daytime with naps. Review of the physician orders and August and September Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed Resident #2's scheduled 09/15/2024 9:00 a.m. medications were given at 10:01 a.m. per the September MAR by Staff B, RN (Registered Nurse) Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML every 6 hours as needed was given on 09/15/2024 at 10:30 a.m. per the September MAR by Staff B, RN No physician orders for a CPAP machine were found in the physician orders or in the August or September TAR. Review of the nursing progress notes showed On 09/14/2024 at 5:40 p.m., Resident presented with shortness of breath (SOB) and elevated B/P (blood pressure). Physician's office was called to report patient's change in condition and new orders given for Clonidine 0.5mg (milligram) stat by mouth and routine daily and hold for Systolic blood pressure under 140. Blood pressure showed 171/98. On 09/15/2024, at 10:30 a.m., Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) give 1 inhalation by mouth every 6 hours as needed for SOB. On 09/15/2024 at 11:21 a.m., Hospital Transfer Evaluation Summary showed: BP 175/89 - 9/15/2024 10:19 a.m. Position: Lying right arm; Pulse 78 - 9/15/2024 10:30 a.m. Pulse Type: Regular; Respirations 32.0 - 9/15/2024 10:30 a.m.; O2 99.0 % - 9/15/2024 01:53 a.m. Method: Oxygen via Nasal Cannula; Report completed by Staff B, LPN and Report called in by Staff B, LPN; Report called in to: 911. On 09/15/2024, at 11:28 a.m., Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML give 1 inhalation by mouth every 6 hours as needed for SOB was ineffective, resident was sent to hospital, MD (Medical Doctor) notified. On 09/15/2024 at 1:25 p.m. Resident presented with high blood pressure, 175/89 and SOB. Resident was given blood pressure medication and PRN Albuterol solution via nebulizer, and inhaler that was scheduled by mouth. At this time resident was available to take medication by mouth, during the morning. Writer noticed that no medication was successful, that she needed medical attention, and resident was being sent to the hospital for further evaluation and treatment. Spouse was called with no answer back. MD from ER (emergency room ) called to verify resident's spouse telephone number. Dr. does not have at this time a communication with spouse. No answer to MD telephone calls. On 09/15/2024 at 2:04 p.m. Resident MD was notified that resident was sent to the hospital. Review of the Weights and Vitals Summary showed Blood pressure On 09/09/2024 at 11:51 a.m. was 132/76 On 09/14/2024 at 5:40 p.m. was 171/98 On 09/14/2024 at 6:32 p.m. was 171/98 On 09/15/2024 at 10:19 a.m. was 175/89 Respirations On 09/15/2024 at 1:53 a.m. was 18 On 09/15/2024 at 10:30 a.m. was 32 On 09/15/2024 at 10:40 a.m. was 34 O2 saturation On 09/15/2024 at 1:53 a.m. was 99% On 09/15/2024 at 10:40 a.m. was 95% Review of care plans showed Resident #2 was on oxygen therapy related to COPD, pulmonary hypertension, pleural effusion, asthma revised on 09/09/2024. Interventions included but not limited to administer oxygen as ordered, report changes in respiratory status to physician. Resident #2 had an emphysema/COPD care plan revised on 09/09/2024. Interventions included but not limited to give aerosol or bronchodilators as ordered; Monitor/document any side effects and effectiveness. Give oxygen therapy as ordered by the physician; Monitor for difficulty breathing (dyspnea) on exertion.; monitor for signs and symptoms of respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis, somnolence; monitor/document/report to MD prn any signs / symptoms of respiratory infection. During an interview on 10/17/2024 at 12:10 p.m. Staff A, PCA (Patient Care Assistant) stated, I was passing [Resident #2] her breakfast tray, it was around 7 [a.m.] something. She did not look her usual. Something was off. Staff A stated she walked in the room, she was breathing funny to me. Staff A stated she went to the supervisor, (Staff C, LPN / Weekend supervisor) and told her Resident #2 looked like something was wrong. Staff A stated Staff C brushed me off. Staff C told Staff A, the resident has a UTI. Staff A stated to Staff C, She looks funny can you come check on her? She (Staff C) brushed me off. Staff A stated she finished passing the trays. Staff A went back to check on the resident and she was still the same. Staff A stated it was about 20 minutes later that she checked on Resident #2. Staff A stated, She was still breathing funny, not too good. Her oxygen was on. She was gasping. Staff A stated she went back to Staff C and told her again. Staff A asked Staff C, Can you please check on her, I think something is wrong. She told me, you need to worry about your residents. She is not yours. Worry about your hallway, do what you need to do. Staff A stated, Once that happen, I went and got Staff B, RN (Registered Nurse), she was the nurse that was on my hallway, 200 hallway. Staff A asked Staff B, Can you go check on 18? I told her the same story, something is off. Gasping for air. Staff B went in and told Staff C something was wrong. Staff C had been sitting at the nursing station the whole time. She was still sitting there. Staff A stated, Staff B took charge of the resident. Staff A stated that Staff B told her that the resident needed to be sent out. Staff A, stated, Staff C did not budge until the family got here. Staff A, PCA stated Staff C, LPN made up a story to the family and told them that she had told the other nurse (Staff B) the resident needed to go out. Staff A stated that Staff C did not do anything, she did not leave the desk. Staff B took charge, from another hallway. Staff B told Staff A she would take care of it. Staff A stated she saw the EMS and family in the room. The DON asked Staff A, PCT about what happened the next day and I told them the same thing I told you. Staff A stated, I believe Staff B, RN told the DON. During an interview on 10/18/2024 at 9:57 a.m. with Staff B, Registered Nurse (RN), she stated she was the nurse caring for Resident #2 on 09/15/2024. She stated she performed rounds around 7 a.m. Resident #2 was alert and responding at that time. Staff B stated the resident took her morning medications that morning, but she did not remember the exact time. Staff B stated Resident #2's vital signs were normal. The resident's family was not there when she took the resident's medications in. Staff B stated the family was there when she went back to check on the resident and give her a nebulizer treatment. Staff B stated she was waiting for a change (after the nebulizer treatment), but no change occurred, so she sent the resident to the hospital. Staff B stated the resident was not doing well on her second round. Staff B stated an aide told her the resident was not doing well. Staff B stated she did not remember who the aide was that day. Staff B stated that the resident, was not really gasping for air, not really. Staff B stated the resident needed the nebulizer and then she called the doctor. The doctor said to send the resident to the hospital. Staff B stated the resident was on her oxygen. Staff B stated she assessed the resident the first time (she made rounds), took her vital signs at the time she gave the resident her regular medications (10:01 a.m. based on MAR). Staff B stated before the medications were given, she checked the vitals. Staff B stated the resident was breathing okay when she gave her the medications. Staff B stated the aide told her the resident was not feeling well and Staff B stated she, went back again. Staff B stated, when I made the decision to send to hospital, send her to hospital. Staff B stated that Staff C, LPN (Licensed Practical Nurse / Weekend Supervisor) was sitting at the nursing station when she reported she was sending Resident #2 to the hospital. Staff B stated that Staff C was not at the reception desk (out front). Staff B stated she does not know if the aide spoke with Staff C, LPN or not. Staff B stated Staff A, PCA came and got her. Staff B stated the DON (Director of Nursing) did not talk to her about the incident. Staff B stated we gave a report to the DON that day, we do when we send someone to the hospital. Staff B stated she did not remember the resident's vital signs. Staff B stated the resident was her normal color and not gasping. Staff B stated the resident had COPD or asthma. Staff B stated the resident's family member came in after her morning medications were given. Staff B stated when she went back to give the nebulizer, the family member was there. Staff B stated during the nebulizer treatment two other family members came in. The second family members asked if I was going to send the resident to the hospital, and I said, Yes, going to call 911. Staff B stated she notified the doctor that she was sending the resident to the hospital. Staff B stated she went in to see the resident around 7:30 a.m. and she was in bed. Staff B stated, Do not recall what she looked like, had her a couple of time before, not really changed from prior. Staff B stated when giving the resident her meds, she was ok, gave them in pudding, ok. Staff B stated, She was declined that morning. She had a couple of words, yes or no. Staff B stated, at 7:30 a.m. she was fine, At approximately 9 a.m. I noticed she was in a little distressed, a family member was feeding her, gave her a breathing treatment. Staff B stated, I am a nurse. I know when my resident has a change in condition. She had an increased respiration rate, no sounds. Breathing not well. Staff B stated an aide [Staff A] came and told her So and so does not look good, I went back and gave her a nebulizer. Staff B stated she did not remember if the resident was on the aide's assignment or not. Staff B stated, I made my first rounds and gave the 9 a.m. meds. The aide came and got me and assessed her and she needed a nebulizer treatment. Staff B stated, I don't remember or know if the aide talked to Staff C LPN about the resident, only what I did. Staff B stated Staff C helped with the paperwork. During an interview on 10/17/2024 at 4:28 p.m., Staff C LPN / Weekend Supervisor stated she had never been Resident #2's nurse. Staff C stated, The nurse, cannot remember who it was, reported to me if they are going to send someone out. She was not looking good. Her O2 sats were low. She (Staff B) did not tell me the number. I said, fine, it was a nurse judgment. We started the paperwork; I usually print the paperwork off and help them out. Staff C, stated, I then reported to the DON, we sent her out. When I went to the nursing station, the nurse was already in the process. I don't know who it was, just who had her that day as the nurse. Staff C, stated, I was sitting up front in the reception area; we don't have a receptionist on the weekend. I do know earlier the family came in. I cannot even tell you the time frame. Activities usually comes in about 11 and it was before then. Staff C stated, If the nurse asks me to come in (the room), I will. I cannot recall if I went into the (resident's) room. The nurse came to the reception area and told me she needed to send her out. Only thing I remember is the family came to the reception and said they wanted to send her out. The family met me in the hallway, they were irate. Staff C stated, the family stated, We want her to go out, out now. It went very fast. I jumped up and assisted my nurse, it went so fast. Assisted the nurse by getting the paperwork. The nurse did tell me she was sending her out because she was having problem breathing. EMS came in, I did not let EMS in. Staff C stated she was at the south hall nursing station. Staff C stated, If someone is having problems with breathing or doesn't look right. Normally take the vital, O2 sats. Staff C stated if the resident was in distress, and had no oxygen on, would apply, call the MD and let them know. If the resident had COPD, the protocol would be to give a breathing treatment, if needed. Staff C stated, If having distress, give immediate care. Make sure they are breathing, airway is open. Staff C stated her expectation was for an assessment to be done and documented and if they report to her as the manager. Staff C stated, My nurse should have done an assessment, especially that nurse. She is not a brand-new nurse. If she reports to me not looking good, I assume she has already done the protocol of vitals, oxygen, call MD, pulse ox. I am the last call; I help to send resident out to hospital. Staff C, LPN stated, I don't recall. (anyone asking her about the incident). Staff C stated, When I called the DON, she asks me why. I told her. The next day, I don't remember writing a statement about the day. During an interview on 10/17/2024 at 2:00 p.m. the DON verified that Staff B, RN was assigned to Resident #2 on 09/15/2024. She also verified Staff C, LPN weekend supervisor was the charge nurse that day. During an interview on 10/17/2024 at 3:45 p.m. the DON stated they were unable to locate the admitting chart (chart with the hospital admission paperwork). During an interview on 10/18/2024 at 10:30 a.m. the DON stated Staff C, LPN / weekend supervisor calls when someone goes out on the weekend. The DON stated they had to send the resident out. The DON stated that Staff C told her The aide came and got me and said she (Resident #2) does not look good. The DON stated that Staff C told her, She [Staff C] assessed the resident and went and got Staff B, RN and they went in and assessed the resident together and agreed the resident needed to go out. The DON stated she did not know the time of the incident. The DON stated, I spoke with Staff B the next time she worked, Staff B told me 'When the aide got me, as soon as she got to the room, she knew she was in distress'. The DON stated Staff B got vitals; she did tell me her O2. The DON stated she did not remember what it was. The O2 was low, and they decided to get her out. The DON stated during the first conversation with Staff C, she explained that the family was in the room at the time. Staff C informed me Staff B and her [Staff C] both assessed the resident. DON stated, I don't know if Staff C went in first and then Staff B or what, I know they both assessed the resident. The DON stated she did not speak with the aide. The DON stated she knew now who the aide was, but not then. The DON stated, That is all I know; the resident was in distress and sent her out 911. Good call on the CNA. The DON stated, They review the chart on hospitalization s in the clinical meetings. When someone is transferred out, we have a clinical meeting the next day. If it was Saturday, it would have been discussed on Monday. Neither of the nurses involved were involved in the discussions. The weekly Unit Manager was involved. I remember when we reviewed the chart, they tried to call the husband at the time of the event, but was unable to get a hold of him, per the chart. The DON stated that an event was not documented. The DON stated, I did speak with Staff C and Staff B but did not write it down. The DON stated the family did not complain to her. The DON stated, Staff B and Staff C did not say they (the family) complained to them about her (the resident). The DON stated she had a spouse which came to the care planning meetings and another family member. The DON stated they found during an informal investigation they did the right thing. Her vitals were irregular. The DON stated, Just went by what Staff C and Staff B said, not the aide. The DON stated she would have to go see if they had orders for the CPAP machine and if it had been ordered. The DON stated, she can only go by what was told to her. During an interview on 10/18/2024 at 11:45 a.m. Staff E, Traveling MDS stated that Non-invasive Mechanical Ventilator under section O included BPAP and CPAP machines on this MDS due to the type of payor source. If the resident was Medicare, it would be more specific and include BPAP and / or CPAP. If ordered would be in the physician's orders and signed off on the TAR as performed. Staff E stated you would see on the TAR and check it off that way. Staff E reviewed TAR and verified she did not see an order for a BIPAP or CPAP for August and September 2024. During an interview on 10/18/2024 at 11:00 a.m. the DON stated on 10/18/2024 at 11:00 a.m. the facility had to call the hospital for the medication discharge report for the 08/27/2024 admission. They were unable to locate them in the facility. During an interview on 10/18/2024 at 11:52 a.m. the DON stated a CPAP was ordered on 08/29/2024. The DON stated Resident #2 was the only one admitted around that time, so it must be hers. The spreads sheet did not show it was specifically for that resident. The DON stated she had not looked to see if there was an order written for the CPAP. The DON stated she did not go into the resident's room to see if the equipment arrived. The DON stated it must have been sent back. During an interview on 10/18/2024 at 1:05 p.m. the DON verified the MAR showed the 09/15/2024 meds were given at 10:01 a.m. by the nurse (Staff B) and the nebulizer was given at 10:30 a.m. During an interview on 10/18/2024 at 2:00 p.m. the DON stated, Her expectation was for the nurse to assess the resident, get the resident out 911. The DON stated when we call 911, the nurse available gave EMS report. They send the face sheet, order summary, Do Not Resuscitate order, and transfer orders (with the resident). They follow-up with the hospital afterwards to get the admitting diagnosis. The DON stated someone did the paperwork, someone called the doctor, and someone would take care of the resident. Vital signs and a head-to-toe assessment were done. The nurses called the DON if she was not here. She stated all shifts called her. The next day they did the clinical meeting. Review of the facility's policy, Physician Orders, dated October 2021 showed at the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. 16. The night shift nurses will verify orders received within the last 24 hours have been transcribed into the electronic record. The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. Review of the facility's policy, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024 showed the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. Managing risk factors to the extent possible or indicating the limits of such interventions.

Based on observation, record review, and interview, the facility failed to ensure the clinical record contained documentation of the services provided for meal consumption for one (#7) of fourteen sampled residents. Findings included: 1. On 10/17/2024 at 9:35 a.m., Resident #7 was observed in bed. He was observed to have severe contractions, curled in a fetal like position. Resident #7 was able to answer questions. When asked if he was provided pleasure foods by mouth, he stated sometimes. When asked if he was allowed to have water by mouth, he said, sometimes. He stated he would like water. Resident #7's breakfast meal tray was observed to be positioned on the sink counter. The meal tray was observed to be untouched. A review of Resident #7's Admission Record documented an original admission in 08/2023, and a re-admission on 09/18/2024. Resident #7's diagnosis information included, but not limited to: Muscle wasting and atrophy, muscle weakness, Dysphagia, and Spinal Stenosis. A review of Resident #7's Care Plan reflected a focus: Nutritional: [Resident #7] has a nutritional problem or potential nutritional problem r/t needed for TF (tube feeding) support to assist with wound healing and meeting ntr (nutritional) needs, initiated on 10/17/2024. Interventions included: Provide (Resident #7 with TF using Jevity at 80 ml (milliliter)/h (hour) over 10 h infusion .Also with PO (by mouth) intake during waking hours along with supplement using Medpass 240 ml BID (two times a day) to assist in meeting nutritional needs, initiated 10/17/2024. Resident is NPO (nothing by mouth)-Do not provide food or fluids by mouth. See nurse, initiated 09/19/2024. On 10/18/2024 at approximately 8:45 a.m., the NHA was requested to provide a printout of Resident #7's meal consumption for the last 30 days. A review of Resident #7's meal intake documentation from 09/19/2024 thru 10/17/2024, documented from 09/19/2024 through 09/28/2024, the resident was NPO, or Tube fed. The following meal consumptions were not documented by staff after 09/28/2024. 09/29, evening, No documentation. 09/30, No documentation. 10/01, morning, No documentation. 10/01, noon, No documentation. 10/02, evening, No documentation. 10/03, morning, No documentation. 10/04, morning, No documentation. 10/05, noon, No documentation. 10/05, evening, No documentation. 10/08, morning and noon, No documentation. 10/09, morning and noon, No documentation. 10/10 through 10/14, No documentation. 10/17, morning, No documentation. 10/17, evening, No documentation. Days reviewed, 09/29 through 10/17=19 days. Meal opportunities=19 x 3 = 57 meals. 34 meals had no documentation of being offered. On 10/18/2024 at approximately 10:45 a.m. an interview was conducted with the Director of Nursing (DON). She stated for Resident #7 we were doing eat and tube feed. She confirmed the aides could feed Resident #7. Yes, the staff are supposed to document what the resident eats for the meal. She confirmed the aides should document a refusal of the meal also. A review of Resident #7's meal documentation was conducted with the DON. She confirmed the documentation for the last 30 days did not consistently document the offering of three meals a day for Resident #7. 34768

Based on observations, interviews, and record review, the facility 1) failed to initiate an Enhanced Barrier Precautions (EBP) isolation program for thirteen out of thirteen residents on EBP and, 2) failed to implement an effective infection control program related to facility failure to handle, store, process, and transport all linens and laundry in accordance with infection control practices to produce hygienically clean laundry for 105 out of 105 residents in the facility. Findings included: On 05/15/24 at 11:09 a.m., an interview was conducted with the Director of Nursing (DON) regarding infection control for isolation residents. The DON stated newly arrived residents are screened for any isolation precautions from the transferring facility. The placement of the newly admitted residents depends on their isolation needs and if they can cohabitate with another resident. The DON admitted knowledge of the Center for Disease Controls (CDC) new Enhanced Barrier Precautions (EBP) recommendations announced in February 2024, and stated thirteen residents have been identified in the facility requiring EBP. She stated the residents identified had a potential source of increased risk for infection due to tube feedings via percutaneous endoscopic gastrostomy tubes, wounds, medication via peripherally inserted central catheters, intravenous catheters, and indwelling urethral catheters. The DON stated the facility had not had the opportunity to initiate an Enhanced Barrier Precaution program but stated she will be putting bins out by resident's rooms for gloves and gowns, and proper (EBP) signage was ordered. The DON stated education would be starting in May but was unable to present calendar dates assigned for education for the month of May. The DON stated the Enhanced Barrier Precautions would be difficult to have staff and residents comply. She stated education would be deferred to the new Infection Control Preventionist. On 5/16/24 at 10:30 a.m., a tour of the laundry area was conducted with the Housekeeping /Linen Manager (HM). The facility's entrance to the laundry room was located along an outside perimeter of an open courtyard. An observation was made of three laundry carts of clean folded linen. The cart covers were tattered, threadbare and torn, leaving the clean linen exposed to the elements. [Photographic evidence obtained]. Above the laundry carts on the opposite side of the walkway were five bird's nests with active birds flying overhead. Three large gray garbage bins were observed outside the laundry room in the courtyard. One bin was not labeled, the middle bin was labeled, Clean mops, and the third bin was labeled, Clean microfiber mops. [Photographic evidence obtained]. A wire basket cart on wheels was observed next to the garbage bins with a pile of mops heads and torn clothes. The HM stated the basket was how they dried the rags because the facility did not dry the items in the dryers due to the chemicals utilized. The HM proceeded to demonstrate how the rags were dried. The HM moved the wire basked into the center of the courtyard (so the basket would be in the direct sun). The HM stated the items in the wire basket were dry and moved the cart back to the side of the facility. The items were observed to be moist to the touch and had a musty smell to them. The HM stated the rags are then moved to one of the gray bins for the housekeepers use. The HM opened the unlabeled gray bin, and a strong, pungent musty odor was noted. Another gray bin with a lid on it and a washcloth on top, was between the doors to the clean and soiled rooms, no label was observed on the bin. The HM stated the bin was for clean linen. Behind the open door was another blue bin with the lid upside down and a white cloth hanging from the side, no label observed. The HM stated this bin was for soiled laundry. Directly touching this blue bin was a beige cover to another laundry cart that was holding clean donated clothing. The HM stated this clothing was for any staff member to come out and take to a resident. There was clothing observed on the ground and pushed against the facility at the base of the donated clothing rack. The beige cover did not close, leaving the clothing exposed to the elements, including birds' nests which were visualized to the immediate left of the cart. [Photographic evidence obtained]. The soiled laundry entrance was a receiving area. There were two large linen carts, each covered with a blue canvas, a large gray bin covered with a fitted sheet and a pile of clothes in the corner in between the two linen carts and behind the gray bin uncovered [Photographic evidence obtained]. The Housekeeping/Linen Manager stated clean linen was stored in these areas. Next to the linen cart, directly touching were two large bins of soiled laundry covered with a soiled sheet. The Housekeeping/Linen Manager stated there is no place to store clean laundry, that is why the clean is stored in the soiled room. Two washing machines were active with wastewater emptying behind the machines. The level of the wastewater was high. The HM stated sometimes the wastewater will overflow the basin and he has to take all the bins and carts out to squeegee the water out of the laundry room [Photographic evidence obtained]. Proceeding through plastic strips that represent a barrier to the clean laundry room, the plastic strips were observed to be soiled with an orange sticky substance and brown/black spots along the length of the plastic strips. The dryer/clean laundry area revealed two staff members folding clothes with a fan on the ground to keep the area cool. The staff stated the air conditioning (AC) unit works but will freeze up and drip water in the laundry area, then they must run the fan until the AC unit will work again. In the corner of the laundry area was a clean laundry cart sparsely full of clean linen. The Housekeeping/Linen Manager stated staff would come in and grab linen if they need it for emergencies at nighttime [Photographic evidence obtained]. A review of the facility's policy titled, Barrier Precautions, effective April 2024, revealed the following: Enhanced Barrier Precautions (EBP) states an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) that employ targeted gown and gloves used during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing. EBP is indicated for residents with any of the following: 1. Infection or colonization with CDC-targeted multi-drug resistant organism when Contact Precautions do not otherwise apply or, 2. Wounds and /or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Procedure 1. Start will be routinely trained in infection control practices to include when to use Standard Precaution, Contact Precautions, Enhanced Barrier Precautions, and Droplet Precautions. 2. A grid is provided (Appendix A) for staff reference which outlines the differences between Contact Precautions and Enhanced Barrier Precautions. 3. Director of Nursing/ Designee will track resident infections and ensure staff is notified of resident -specific precautions. 4. Signage is used, as appropriate. Appendix A [Photographic evidence obtained]. Review of the Infection Control Overview & Policy, undated, revealed the following: Policy Statement: [Vendor Name] promotes the health and safety of all employees, as well as that of the clients and residents we serve. Infections are a significant source of sickness and death for nursing home residents and account for up to half of all nursing home resident transfers to hospitals. Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of up to $2 billion annually when a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40%. The purpose of this infection control program for [vendor name] and its subsidiaries is to: 1. Investigate, control, and prevent infections in the facility; 2. Communicate the environmental and or dining services procedures that should be applied in the field; 3. To maintain a record of incidents and corrective actions taken related to infections by reporting incidents through the proper facility chain of command; 4. To comply with the Centers for Medicare and Medicaid Services (CMS) guidelines in relation to CMS F880 tag found in CFR 483.80(a)(1)(2)(i)-(iii)(v)-(vi)(e). In addition to this program, it is important that all infection prevention and control practices reflect current Center for Disease Control (CDC) guidelines. Preventing Spread of Infection: preventing the spread of infection is the core of our environmental department, . all employees must be made aware of how they can play a part in preventing the spread of infections including: . * properly store, handle, process, and transport (cover) linens to minimize possible contamination. The first steps to prevent the spread of infection include: . 4. Covering clean linens as they are transported to the units to prevent contamination. Infections and diseases are transmitted in several ways including: . B. Contact with an infected object, person, or surface (touching); . Routes of Disease Transmission Employees can be exposed to or expose residents to disease through: . b. Direct/indirect contact with equipment used to provide care or with health care personnel/visitors/other residents; c. Contact with clothing, uniforms, laboratory coats, or isolation gowns used as PPE may become contaminated with potential pathogens after care of a resident colonized or infected with an infectious agent, (eg.MRSA [methicillin resistant staph aureus], VRE [vancomycin resistant enterococci], and Clostridium difficile [cdiff]). Indirect contact may occur through toilets and bedpans . Review of the policy and procedure for Laundry Operations, dated 3/12/2020, revealed: Descriptions of steps in the laundry process there are 6 steps in the laundry process: 1. Pick up collection of soiled linen 2. Sorting soiled linen 3. Washing (a) wash cycle 4. Drying 5. Folding 6. Delivery . B. Transferring Soiled Linen It is very important to properly transport and store soiled linens to prevent the spread of infection period to do so, all soiled linen and clean linen must be covered during transportation and while being stored on the unit or floors. Additionally, no clean linen may touch floor during transport, if it does, the clean linen is then considered to be soiled. Soiled linen containers must be lined with an impervious (waterproof) liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers are to collect soiled linens from each soiled linen room using a large bin with lid, marked For Soiled Linen Only. . 2. Sorting Soiled Linen the laundry room must have a process in place to effectively sort soiled linen without cross-contaminating clean linen. For example, soiled linen must never come in contact with clean linen. Soiled linens brought down manually must have a separate delivery entrance and must be placed into the soiled linen bins. 48223

Based on observation, interview, and record review, the facility failed to ensure the development, revision, and/or implementation of comprehensive care plans was completed for two (Resident #259 and #73) of six sampled residents. The findings include: Review of the Admission Record for Resident #73 revealed an admitted [DATE] and a recent admission of 3/16/2024 with diagnoses to include: end stage renal disease; heart failure; diabetes type 1; cachexia; hyperkalemia; protein-calorie malnutrition; muscle wasting and atrophy; and other co-morbidities. Review of the Minimum Data Set (MDS) from admitted d 3/18/2024, showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS showed the resident had no identified moods or behaviors and was on hemodialysis. Review of Resident #73's Physician Order Summary dated 5/16/2024, showed an order for a 1500 cc Fluid Restriction Dietary to give 1200cc nursing to give up to 300cc/24hr 7-3 (120cc), 3-11 (120cc), 11-7 (60c) every shift Fluids to be given with medications, no water to be left at bedside order start date of 4/1/2024. Resident to have Dialysis on days: [Dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no order start date of 3/18/2024 and 3/24/2024. Review of Resident #73's Care Plan showed a focus area of: Elopement Risk: Resident is at risk for elopement dated 10/28/2022. Goals and interventions were also listed. Resident #73 had a focus are of: hemodialysis: The resident has renal failure and is on Hemodialysis Resident to have dialysis on days: [dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no date initiated 1/16/2024 and revised on 4/3/2024. Focus area of: Infection: Resident #73 has an infection Respiratory Infection Covid positive date initiated/revised 3/19/2024, with goals and interventions listed. An interview was conducted with Resident #73 on 5/14/2024 at 9:50 a.m Resident #73 stated he did receive a bag meal nor did have an elopement/wandering problem. Resident #73 continued to state he had not been on isolation for some time, he had been free of Covid for a long time. During an interview on 5/16/2024 at 11:35 a.m., Staff A, Registered Nurse (RN), Clinical Reimbursement Director (CRD) confirmed responsibility for updating and developing care plans along with the MDS for each resident. Staff A stated the care plan for Resident #73 should have been reviewed and revised at readmission, and it was not. Staff A, RN stated she would have to investigate the issue. On 5/14/2024 at 9:30 a.m., Resident #259 was observed lying in her bed with the covers over her waste. Resident #259's bed was in the high position, floor mats were not in place and the call light was not within reach. Resident #259 had an Enhanced Barrier Precaution Sign on the door to her room. Review of the Admission Record for Resident #259 revealed an admitted [DATE] with diagnoses to include: history of falling; presence of right artificial hip joint; aftercare following joint replacement surgery; Schizophrenia; Anxiety Disorder; Other Genetic related Intellectual Disability; Malignant Neoplasm of Bladder; Methicillin Resistant Staphylococcus Aureus Infection (MRSA) and other co-morbidities. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008 dated 4/22/2024 signed by a physician revealed Resident #259 had MRSA, Candida auris (C. Auris), Extended Spectrum Beta-Lactamase (ESBL) in the urine, and a history of falls. Review of the Physician Progress note from the hospital dated 4/21/2024 revealed Resident #259 had recent right hip pain and fracture after a fall status post ORIF (open reduction and internal fixation) on 3/30/2024. Review of the MDS from Admission, dated 5/5/2024 revealed Resident #259 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. Section J for Falls history showed: Resident #259 did not have any falls in the last 2-6 months prior to admission/entry or reentry and had not fallen with any fracture in the 6 months prior to admission/entry. Review of Resident #259's Treatment Administration Record dated April, 2024 showed a physician order for Contact Precautions for ESBL in the urine until 4/29/2024. Review of Resident #259's Order Summary Report with an active date of 5/16/2024 showed an order for Transmission Based Precautions Enhanced Barrier Precautions dated 4/23/2024. Review of Resident #259's Care Plan reveals a care plan with a focus of Fall: Resident #259 has had a fall because of: deconditioning, gait/balance problem. date initiated 5/7/2024. A focus of: Resident requires Enhanced Barrier Precautions related to: C. Auris date initiated: 5/5/2024. During an interview on 5/16/2024 at 11:35 a.m. Staff A stated the care plan for Resident #259 should have been developed on 4/24/2024 and revised as needed. Staff A, RN confirmed there was no fall care plan on admission nor was there an infection control care plan and there should have been. Review of the facility's policies and procedures with the Topic: Care Plan - Interdisciplinary (IDT) Plan of Care from Interim to Meeting dated effective February 2024. Policy: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Procedure: . 2. Update to Care Plans: a. Ongoing updates to care plans are added by a member of the ID tea as needed. 3. Dates and documentation on the care plan. a. New, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made. b. Problems and goals have IDT approaches and interventions to assist the resident in their goal attainment. 5. Comprehensive plan of care a. The comprehensive care plan is developed by members of the IDT and the resident, resident's family, or representative, as appropriate, in conjunction with completion of the admission, annual, significant change in assessment for other comprehensive assessment, and the associated care area assessments.

Based on observation, interview, and record review, the facility failed to give the opportunity to choose urinal placement and length of the bed frame for one (Resident #104) of one resident sampled. An interview was conducted with Resident #104 on 5/13/2024 at 10:30 a.m. He stated he did not want the urinal on the over the bed table all of the time. He said he was able to smell the urine all the time, even when the urinal was empty. He said he had numerous conversations with personnel in the past. He stated there was not anywhere else for the urinal to be placed without having to call for assistance. He stated, They [the facility] doesn't have a place for the urinal and they don't listen, I have told them numerous times and continue to tell them, I don't like to eat with the urinal next to my tray. He stated he needed a longer bed due to his height, as his feet were always pressing on the footboard. He said the nurse told him nothing could be done and placed a pillow under his feet. On 5/13/2024 at 12:18 p.m. and 5/15/2024 at 8:30 a.m., Resident #104's urinal was on the over bed table with the meal tray and the resident's feet were pressed to the footboard. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 5/13/2024 at 10:56 a.m. Staff L said nothing could be done with the length of the bed, [the nursing staff] just put a pillow underneath the feet to ensure no breakdown. An interview was conducted with Staff M, Certified Nursing Assistant (CNA) on 5/14/2024 at 1:25 p.m. She said she understood Resident #104 wanted the urinal placed on the over bed table, she was just not sure what the answer was. Staff M confirmed Resident #104's feet were on the footboard normally and again not sure what could be done. An interview was conducted with Staff J, CNA on 5/15/2024 at 2:32 p.m. Staff J confirmed Resident #104 had requested to have the urinal placed elsewhere although there was no other option, so we ended up leaving the urinal on the over bed table. Staff J, CNA stated the resident's bed was probably too short but did not know what to do about, as the nurse knew. An interview was conducted with Staff G, Registered Nurse (RN) on 5/15/2024 at 3:18 p.m. Staff G confirmed Resident #104's urinal on the over the bed tray and there was not really anywhere else to place it and the bed could be longer. A review of the facility grievance log revealed no grievances were filed for Resident #104, during the months of April and May 2024. An interview was conducted with the SSD (Social Service Director) on 5/15/2024 at 12:05 p.m. The SSD confirmed there were no grievances filed for Resident #104. The SSD stated the resident requests should be honored, if possible and care planned. An interview was conducted with the DON (Director of Nursing) on 5/16/2024 at 11:15 a.m. The DON stated she did not know the resident wanted a longer bed and urinal placement changed. The DON said she did not know why the resident's request was not facilitated. Review of Resident #104's Admission Record showed the resident was admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, left foot drop, anxiety disorder, neuropathy unspecified, chronic kidney disease and other co-morbidities. Review of Minimum Data Set (MDS), Section C Cognitive Pattern, dated 4/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident was cognitively intact. A policy for choices or accommodation of need was requested. No policies were produced at the time of the survey.

Based on record review, observation, and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two (Residents #24 and #17) of twenty-six sampled residents. Finding include: During an observation and interview on 05/13/24 at 10:45 a.m., Resident #24 was sitting up in his bed eating peanuts. He said his left hand was contracted. He said he wore a splint on his left hand, but staff had not assisted him with putting it on. He said sometimes he refused to put his splint on because it hurt his hand. Review of an Admission Record dated 05/15/2024 showed Resident # 24 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Non- Dominant Side, Major Depressive Disorder, Recurrent, Unspecified, Bipolar Disorder, Unspecified. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Further review of the MDS section GG for Functional Abilities and Goals showed section GG0115 coded to indicate Resident # 24 did not have any upper extremity impairment. During an interview on 05/16/2024 at 2:00 p.m. with Staff A, Registered Nurse/ Clinical Reimbursement Specialist, she stated the facility did not have a restorative therapy program at that time to assist with putting splints on residents with contractions. She said [Resident #24] had an upper extremity impairment due to left hemiparesis. Staff A stated, I should have identified this on his MDS assessment. This was a mistake on my part. During an interview on 05/16/2024 at 2:00 p.m. with the Director of Nurses (DON), she stated her expectations were that residents' MDS was coded accurately. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument, RAI showed If, the resident can perform all arm, hand, and leg motions on the right side, with smooth coordinated movements. They can perform grooming activities (e.g., brush their teeth, comb their hair) with their right upper extremity and are also able to pivot to their wheelchair with the assistance of one person. They are, however, unable to voluntarily move their left side (limited arm, hand, and leg motion), as they have a flaccid left hemiparesis from a prior stroke. Coding: GG0115A would be coded 1, upper-extremity impairment on one side. GG0115B would be coded 1, lower-extremity impairment on one side. Rationale: Impairment due to left hemiparesis affects both upper and lower extremities on one side. Even though this resident has limited ROM that impairs function on the left side, as indicated above, the resident can perform ROM fully on the right side. Even though there is impairment on one side, the facility should always attempt to provide the resident with assistive devices or physical assistance that allows the resident to be as independent as possible. https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual On 5/13/2024 at 11:50 a.m., Resident #17 was observed in the north unit dining room with a bed sheet over the wheelchair. Resident #17 was sitting in the wheelchair, both legs bent and feet were resting on the seat cushion. Resident #17 did not respond to questions. An interview was conducted with Staff M, Certified Nursing Assistant (CNA) on 5/13/2024 at 11:54 a.m. Staff M stated Resident #17 sat like that all of the time. Staff M stated Resident #17 made it very clear if anything was needed. Resident #17 was originally admitted on [DATE] with a recent readmission of 6/7/2023 with diagnoses of Secondary Parkinsonism, psychosis, seizures, recurrent major depressive disorder, epilepsy, Bipolar disorder, Schizoaffective Disorder, Paranoid personality disorder, Hypertension and other co-morbidities. Review of Resident #17's chart showed a Pre-admission Screening and Resident Review (PASRR) Level II dated 6/4/2021. Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/2023 revealed Section A for PASRR not marked, indicating Resident #17 does not have a Level II PASRR, nor were Resident #17's conditions marked. Section E. Behavior revealed Resident #17 had no potential for psychosis (hallucinations, and delusions). During an interview on 5/16/2024 at 9:09 a.m. with Staff A, Registered Nurse/Clinical Reimbursement Director (CRD), She stated she was responsible for completing the MDS. Staff A verified the resident had a PASRR Level II and had one prior to the completion of the MDS and verified that the Level II PASRR section was inaccurately coded. During an interview on 5/16/2024 at 11:30 a.m. the Director of Nursing (DON) stated her expectation on accuracy of the MDS was important. Review of the facility Policy and Procedure titled: Resident Assessment Instrument: MDS Section Completion by Discipline, with an effective date of October 2023 revealed: Overview: The Interdisciplinary Team members participate in the Resident Assessment Instrument to assess each Resident's individual needs and strengths through an approach that assesses problems or conditions and collaboration on appropriate interventions to achieve a Resident's highest level of functioning possible and maintain their sense of individuality. Guidelines: 1. The resident assessment instrument will be coordinated by a registered nurse that signs and certifies the completion of the assessments. 2. Interdisciplinary Team members participating in the MDS completion process are responsible sign the MDS (physical signature or per electronic signature policy), designate their professional title and date the interview or MDS on date data was gathered on, enter the MDS data into the appropriate sections of the MDS software system and complete corresponding care plan updates, revisions, or reviews in a timely manner. 48223

Based on observation, interview, and record review, the facility failed to develop a care plan related to trauma informed care for one (Resident #103) out of 37 sampled residents. Findings included: Review of Resident #103's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to post traumatic stress disorder (PTSD), schizoaffective disorder, bipolar type, major depressive disorder, and adjustment disorder with anxiety. An interview was conducted on 05/13/24 at 3:40 p.m. with Resident #103. She confirmed she had PTSD but declined to give details about the PTSD. She gave permission to ask the staff and review her record related to the details. She said she saw psychiatry and psychology every week. She said they also gave her medication for it and she felt it helped. Review of Resident #103's physician orders showed an order with a start date of 4/5/24, without an end date, for Prazosin HCl Oral Capsule (Prazosin HCl). Give 3 mg by mouth at bedtime for PTSD related nightmares. Review of Resident #103's medical record did not show an assessment for PTSD. Review of Resident #103's Psychosocial History and assessment dated [DATE] showed .12. Trauma Informed Care 1. Has the resident ever been diagnosed with PTSD (Post Traumatic Stress Disorder), had a life altering event or life changing event? No. Review of Resident #103's Care plans did not reveal a care plan related to PTSD. Review of Resident #103's Psych note dated 5/10/2024 showed .She also acknowledges that a book that she likes to read has helped her understand her PTSD and other trauma. She denies any specific new appetite changes and agrees to maintain the current regimen and ongoing plan . An interview was conducted on 05/16/24 at 8:50 a.m. with the Director of Nursing (DON). She said she was not aware Resident #103 had PTSD until last night (5/15/24). She said there should be a care plan in place related to her PTSD. She said the resident did not come in with many diagnoses because she came from the streets. An interview was conducted on 05/16/24 at 9:09 a.m. with Staff A, RN, Clinical Reimbursement Director. She said when the nurses did the admission assessment that triggered the baseline care plan, she confirmed the PTSD diagnosis was documented in Resident #103's chart. The Social Services Director completed a Psychosocial History and Assessment. PTSD should be identified in the assessment and from that assessment a trauma informed care plan should be developed to identify the resident's trigger. She said, it's a cumulative effort with social services, psych physician, and nursing but Resident #103 has been stable since she has been with us. She said, I have not spoken with the psych doctor about her PTSD. She reviewed Resident #103's care plans and confirmed she did not have a trauma informed care plan in place. Review of the facility's Trauma Informed Care, undated, revealed Policy: The facility will provide services for residents who have experienced mental or psychosocial adjustment difficulty, or who have a history of trauma or have diagnosis of post-traumatic stress disorder (PTSD). Purpose: To ensure that residents who are trauma survivors receive culturally sensitive, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living ADL grooming was provided for one (Resident # 101) out of eight residents sampled. Findings include: During observations made on 05/13/2024 at 10:30 a.m. and on 05/14/2024 at 3:00 p.m., Resident #101 was observed laying down in his bed with his call light within reach, dressed in his nightgown. He was observed with some missing teeth in his mouth and facial hair. The resident's room was observed well-lit and with a homelike environment. Review of Resident #101's Admission Record dated 05/16/2024 showed Resident #101 was admitted on [DATE] with diagnose to included but not limited to respiratory disorder in diseases classified elsewhere, other reduced mobility, and need for assistance with personal care. Review of a Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident 101 was unable to complete the interview. Review of a care plan focusing on Activity of Daily living (ADL) dated 2/27/24 and revised 5/16/24, showed Resident #101 had an ADL self-care Performance Deficit. Review of the care plan interventions showed no interventions related to the resident's hygiene. During an interview on 05/16/2024 at 12:00 p.m., with Staff J, Certified Nursing Assistant (CNA), Staff J said she did not shave Resident # 101 because he did not ask her to shave him. She stated she only provided the resident with shaving assistance when he asked her. During an interview on 05/16/2024 at 3:00 p.m., with the Director of Nursing (DON), she stated her expectation was that staff assisted their resident with personal hygiene care whether the resident asked for assistance or not, especially if the resident was not independent with care. If the resident was refusing care, the CNA should report the resident's refusal to their nurse so that the situation could be addressed. Review of the Certified Nursing Assistant (CNA) Job Description dated 07/01/2019 showed Essential Duties and Responsibilities (To be completed without harming or injuring the resident/patient, co-works, self, or others): Direct care responsibilities: Ensure resident's personal care needs are being met in accordance with the resident's/ patient's wishes. Shaves patients.

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1. transportation for coordination of care to their doctors' appointment for four (Residents # 209, #33, #7, and #58) out of 10 residents sampled and 2. application of a medication patch for one (Resident #81) of one sampled resident. Findings include: During an observation on 05/13/2024 at 10:00 a.m., Resident #209 was observed dressed in a nightgown, sitting in her wheelchair in her room. She was observed with soiled bandages on her right and left foot. Resident said she had been up since 9:00 a.m. this morning waiting to go to her appointment for her skin grafts on her feet. She said she had missed a couple of appointments already because transportation did not always show up to pick her up for her appointments. During an observation on 5/13/2024 at 1:00 p.m., Resident #209 was observed sitting in her room in her wheelchair, with signs of distress. She said she was very upset because she had been waiting for a long time to go to her doctor's appointment. She said she was told that transportation had not shown up again to transport her to her appointment. Resident # 209 began to cry as she explained that she felt like the facility was setting her back with her healing because she had not been able to go to her appointments because of transportation. Review of the admission record dated 05/16/2024, showed Resident #209 was admitted on [DATE] with diagnoses to include but not limited to encounter for other specified surgical aftercare, other abnormalities of gait and mobility, chronic kidney disease, unspecified, unspecified abdominal pain. Review of a Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status, (BIMS) score of 15 which indicated Resident #209 was cognitively intact. Review of the Medication Administration Record showed an order dated 5/13/2024 to follow-up with [name of physician] at 10:00 a.m. Further review showed the order was discontinued on 5/13/2024. Additional review of the medication record dated 5/13/2024 showed another order to follow up with [name of physician] at 1:15 p.m. During an interview on 05/13/2024 at 2:00 p.m. with Staff B, Unit Manager, he stated the resident's appointment was rescheduled because the transport did not pick Resident #209 up for her appointment. He said he would reschedule her doctor's appointment and transportation. Staff B said the resident's appointments and transportation were set up through her insurance company. On 5/15/24 at 9:26 a.m., in an interview with the Medical Records Manager, she stated Resident #209 missed her appointment on Monday, 5/13/2024, because she [Medical Records Manager] was unaware of the appointment and stated the appointment notification sheet was never handed to her. She looked through a binder titled Transportation 2023 to demonstrate no sheet was filled out for Resident #209 to go to her May 13th appointment. The Medical Records Manager was unaware of the new re-scheduled appointment for Resident #209 made for May 20th by Staff I, RN/UM. The Medical Records Manager stated Resident #209 would have missed her appointment for May 20th had this conversation not taken place, stating to arrange transportation efficiently, forty-eight-hour notice was needed. The Medical Records Manager stated the appointment notification sheet was never received for the May 20th appointment. During an interview on 05/16/2024 at 11:30 a.m. with the Nurse Practitioner, he stated Resident # 209 was admitted to the facility because of the wounds she had on her right and left foot. He said skin grafts were not always a guarantee for healing. If [Resident #209] did not make it to her appointments it could cause a delay in the healing of her wounds. On 5/14/24 at 12:00 p.m., an observation was made of Resident #33 being escorted past the nurses' station in her wheelchair by Staff F, Personal Care Attendant (PCA). Staff F stated to Staff G, Registered Nurse / Unit Manager (RN/UM) and Staff H, RN, Resident #33 did not get her CT (Computed Tomography) scan at the hospital because the facility did not provide the proper paperwork for Resident #33 to continue with the CT scan as ordered. Staff G, stated the paperwork was there but she would reschedule the CT scan appointment. On 5/15/24 at 9:26 a.m., an interview was conducted with the Medical Records Manager regarding arrangements for transportation. She stated she was responsible for setting up appointments and transportation for all the residents in the facility. The process for setting up appointments started with the nurses who placed the order(s) into the [electronic medical record software] and filled out the Appointment Notification Sheet [photographic evidence obtained] and either hand it to me or slid it under my office door if I am not in my office. The Medical Records Manager scheduled the appointment(s) and then called the resident's individual insurance company to arrange transportation. The Medical Records Manager stated transportation arrangements were not a major concern but if there was, a discussion would be made with the administration. She said, We will try to get insurance companies to cover the transport but sometimes we will have to rearrange appointments if transport is not covered. From there we will ask if the family can cover the cost, or as a last resort, whether the facility will cover the cost of transport. The Medical Records Manager was unaware of the reason Resident #33 missed her CT scan scheduled for yesterday, 5/14/2024, but stated the resident was rescheduled for this Thursday, 5/16/2024. The Medical Records Manager stated the resident missed her MRI (Magnetic Resonance Imaging) appointment scheduled for today, May 15, 2024, because she was unaware of this appointment and had not made any transportation arrangements. The Medical Records Manager stated her process to communicate to the unit managers was as follows I complete the 'Appointment Notification Sheet' and make two copies, one for my binder and I place the second copy at the resident's nurses' station appointment binder. From there, the unit managers agree to look through the binder to see who had an appointment and review and send the copy of the 'Appointment Notification Sheet' with the resident and/or the resident accompanied by the PCA. I will also send an email and/or a text message to the Nursing Home Administrator, the Director of Nursing, the Unit Managers, staffing coordinator and the front desk of residents' appointments. The Medical Records Manager stated there was a morning meeting of the clinical team but she did not attend those meetings. On 5/15/24 at 10:14 a.m., an interview was conducted with the Director of Nursing (DON). She stated the current process for appointments and transportation started in January. The DON stated a sheet was filled out by the Medical Records Manager once an order was printed out for her by the unit managers. From there, the Medical Records Manager would arrange the appointment and transportation and document on the sheet or the actual printed order. The DON presented Resident #209's printed physician orders with notes made by the Medical Records Manager on the printed-out orders. When Resident #209 missed her appointment, calls were made to the transportation company listed on the printed physician orders. According to the DON, Staff I, RN/UM was unable to contact the transportation company from the number left on the printed physician order sheet. We could have easily paid for her way had we known she was in the process of missing her appointment. The DON stated she knew nothing of Resident #33 missing her MRI appointment today and her expectation was for her to be notified immediately to resolve the issue of a resident missing an appointment. The DON stated Staff I, RN/UM should have notified her of the situation but stated Staff I, RN/UM was used to doing things the old way in which the unit managers arranged the appointments. On 5/15/24 at 10:58 a.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding appointments and transportation for the residents. The NHA stated had she known about the issues she would have arranged for another means of transport. She stated If they ask me, I would have paid for transportation, I'll get an Uber or taxi or we would use petty cash. The NHA stated the Medical Records Manager came to the morning meetings held every morning at 8:30 a.m. and informed the team of a resident's appointment(s) and/or we would get an email or text. If a resident missed an appointment, the expectation was the NHA and the physician were to be informed and a grievance should be submitted on behalf of the resident. On 5/15/24 beginning at 11:37 a.m., an interview was conducted with Staff F, Personal Care Attendant (PCA) regarding transportation of residents for their appointments. Staff F stated she was informed of residents' appointments upon starting her shift. Staff F stated transportation was an issue getting to and from the residents' appointments. Staff F stated she was with Resident #33 yesterday when she could not continue with her CT appointment at a local hospital. Staff F stated she went with the resident and arrived at the appointment before 9:00 a.m. She said the hospital radiology department could not continue because they did not have the actual physician orders of what to scan and the reason for the scan. Staff F stated she attempted three times to call the facility unsuccessfully to have the physician orders faxed over to the hospital. The first call to the front desk went unanswered, the second call was answered by the front desk staff but went unanswered when transferred to the nurses' station. The third call went unanswered at the nurses' station. The hospital was willing to wait for the fax but transport arrangements were made by Staff F to return to the facility. Staff F stated, Transport can take hours and I thought I could time the planning for transport back to the facility and the resident could still get her scan without waiting all day. When transport showed up two hours later, we had to go without the scan getting done and the resident did not have anything to eat that day. Staff F continued with the interview and stated, Today, 5/15/2024, [Resident #7] missed his dental appointment because transportation did not show up. According to Staff F Resident #7 had a pick-up time between 9:10-9:40 a.m. and was waiting in the front lobby. At 10:00 a.m., Staff F stated she went to the nurses' station to inform the unit manager the resident had not been picked up. Staff F stated Staff G RN/UM stated, ok. Staff F stated when she followed up with the resident he wanted to wait in the lobby because he thought transportation was slow this morning. Staff F stated she returned to the nurses' station to inform Staff G the resident wanted to wait in the lobby but Staff G informed her transportation was not coming due to a flat tire. On 5/15/24 at 11:56 a.m., an interview was conducted with Staff G, RN/UM regarding transportation for residents to their appointments. Staff G stated orders were put into the [electronic medical record software] and I will make the appointments or really anyone can. I will print two copies of the order and pass one to the Medical Records Director to arrange transportation. I will create a task for the nursing staff to see so they will get the resident ready the day of the appointment. I will put the second copy into the appointment book and then [Medical Record Manager], will put the information for transport including the telephone contact, confirmation number and if an escort is needed. Staff G, RN/UM could not explain why Resident # 33 missed her CT scan yesterday stating, I got her an appointment for tomorrow for the CT and all the paperwork is there. Staff G stated she saw the order for the first time for the MRI yesterday and informed the Medical Record Manager. Staff G said she did not take the original order but the other unit manager did and stated, I did not know she had an appointment today. Staff G said the Assistant Director of Nursing (ADON) informed her of Resident #7 missing his dental appointment due to the transportation's flat tire and a rescheduled appointment was made for May 31, 2024. The resident was informed as well as his family. [photographic evidence obtained] On 5/15/24 at 2:00 p.m., an interview was conducted with Resident #58 who stated she will make her own transportation arrangements herself because she was tired of the long wait times and missing her appointments. She stated, I call my insurance company and make the arrangements and I never have a problem. Resident #58's roommate added she would arrange her own transportation as well because when the facility arranged for her appointment the transportation company refused to take her in her wheelchair with an extra oxygen tank. A review of the facility's policy and procedures entitled, Transportation Services, effective date of February 2021 states the following statement: The facility will assist and/or provide resident/ patient transportation services when needed to ensure that each resident/ patient receives a complete continuum of services. 1. Enter outside appointments on a calendar 2. Obtain transportation preference as applicable from the resident patient, family, or legal representative. 3. Schedule transportation private or ambulance service as soon as the date and time of appointment is known. 4. Communicate date and time for which the transportation has been scheduled to the staff. 5. Assure resident /patient, family, or legal representative is notified of the appointment. 6. Assure resident /patient is up, dressed, and ready for the scheduled appointment. 2. Review of Resident #81's Admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital. His medical diagnoses included but were not limited to respiratory disorders in disease classified elsewhere, lack of coordination, pneumonia, aphasia, dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. An observation was conducted on 05/13/24 at 10:35 a.m. Resident #81 was observed in bed, his gastrostomy tube was connected to his enteral nutrition, the enteral nutrition pump was turned off, and his head of the bed was elevated. Resident #81 was observed to have a wet, weak cough. The resident said he did not know if his enteral nutrition pump should be on. An interview was conducted with the resident's family member, and he said he came often to visit. He said the resident had a build up of secretions and when he had his patch it brought the secretion's down by 80%. The family member looked at the patch and said the patch needed to be changed. The patch was observed not to be intact with the resident's skin on his neck and the patch was not labeled. The family member said the patch should be changed every 2 days and it should have a date on it. (Photographic evidence obtained) An observation was conducted on 05/13/24 at 3:06 p.m. Resident #81 was observed lying in bed, with his medication patch not intact and not labeled. The resident was alert, had a weak wet cough, and was not in any respiratory distress. An observation was conducted on 5/14/24 at 10:10 a.m. of Resident #81. He was observed in bed, alert, eyes open. There was a large basin with several paper towels on his bed next to him. He was observed to have a buildup of saliva in his mouth as he talked and said the basin was for all the secretion's he had in his mouth. His medication patch was observed not to be intact and was not labeled. Review of Resident #81's physician orders revealed an order with a start date of 2/27/24 and no end date for Levsin Oral tablet 0.125 milligrams (MG), give 1 tablet via PEG-Tube every 8 hours for secretion's. Review of Resident #81's May medication administration record (MAR) revealed no documentation on 5/11/24 at 2:00 p.m. An order dated 4/11/24 with no end date revealed Scopolamine Patch 72 Hour Apply 1 patch transdermal every 72 hours for NAUSEA document the presence of the scopolamine Path every day and remove per schedule. Review of the MAR revealed no documentation on 5/11/24 that the patch was removed or applied as ordered and the last documented removal and applied date was signed off on 5/8/24. The May MAR also revealed Resident #81's patch placement was only documented on 5/2/24, 5/5/24, 5/8/24, and 5/14/24. There was no daily documentation on the presence of the Resident #81's patch. An observation was conducted on 05/15/24 at 8:56 a.m. of Resident #81. He was observed in bed, the head of the bed was elevated, and a basin was on his bed next to him. Staff B, South Unit Manager (UM) was observed in the room at the time of the observation. Staff B went out of Resident #81's room and reviewed Resident #81's MAR and Treatment Administration Record (TAR). He confirmed placement for a scopolamine patch had not come up for him and he was not sure if the resident had one on. He went into the residents room and confirmed the resident had the scopolamine patch on his right neck and it was dated 5/14/24. An interview was conducted on 05/16/24 at 8:53 a.m. with the Director of Nursing (DON). She said the staff called her around 8:0 a.m. to say the Internet was down on 5/11/24 but the staff should have documented medication administration on paper MAR's, but she needed to look into it. She confirmed medication patches should be intact, labeled, and monitored for placement every shift. No additional documentation related to Resident #81's scopolamine patch application was provided by the end of survey. Review of the facility's Transdermal Delivery System (Patches) Policy dated 05/16 revealed the following: Policy To administer medication through the skin by continuous absorption while the patch is in place and maintaining proper placement of the patch and care of the application site. .Procedures .9. Label patch with date and nurse's initials. 10. Apply new patch firmly against skin. Rotate sites in accordance with manufacturer's recommendations. Avoid extremities and hairy body areas. .13. Document placement site on MAR. For patches applied less frequently than daily, check placement and document that patch at least daily 48441 39866

Based on observation, interview, and record review, the facility 1. failed to ensure a physician order was in place for the administration of oxygen for one (Resident #21) out of four residents reviewed for respiratory care, and 2. failed to ensure emergency tracheostomy supplies were readily available for one (Resident #97) out of one resident with a tracheostomy tube. Findings included: 1. An observation was conducted on 05/13/24 at 9:33 a.m. Resident #21 was observed in bed with her eyes closed, an oxygen concentrator was on and set to 1.5 liters per minute (LPM), the oxygen tubing observed to be behind the residents back and not on the resident. An observation was conducted on 05/13/24 at 3:30 p.m. Resident #21 was observed in bed with her eyes open, nasal cannula in her nose, an oxygen concentrator was on and set to 1.5 LPM. The resident said she wore oxygen for her chronic obstructive pulmonary disease (COPD) and she was supposed to be on 6 LPM. She said she had been asking since last week to get oxygen on her wheelchair. She said her wheelchair was in the bathroom. An observation was conducted of the wheelchair in the bathroom without an oxygen tank on her wheelchair. The resident said she was feeling good right now because she had been resting in the bed but when she got out of the bed, she got short of breath. Review of Resident #21's medical record on 05/13/24 at 2:46 p.m. did not reveal an order for oxygen. An interview was conducted on 5/13/24 at 3:32 p.m. with Staff D, Registered Nurse (RN) Supervisor. She confirmed Resident #21 used oxygen, and she thinks the resident was supposed to be on 2 LPM oxygen. She looked at the oxygen concentrator and confirmed the resident was on 1.5 LPM. She said she would have to look at the physician orders to find out how much oxygen the resident was ordered to have. She exited the room and did not review the physician orders. An interview was conducted on 05/13/24 at 4:10 p.m. with Staff D, RN Supervisor, she said she forgot to look up Resident #21's physician orders, but she told the nurse to look it up. The nurse in training assigned to Resident #21 said the resident was supposed to be on 2 LPM oxygen according to the report sheet. Review of the report sheet revealed a handwritten note O2 @ 2L. The note was not written under Resident #21. An observation was conducted on 05/14/24 at 10:14 a.m. Resident #21 was in bed and said someone came in and wanted me to sign paperwork but I was too short of breath. Resident #21's oxygen concentrator was set on 3 LPM via nasal cannula. Resident #21's breathing was observed to be rapid and shallow. An interview was conducted on 5/14/24 at 10:15 a.m. with Staff E, Licensed Practical Nurse (LPN). She confirmed she was Resident #21's nurse and she said Resident #21 was usually on oxygen I think it's 2 liters but I would need to check. I have not experienced her being short of breath today. She normally is not up this early and I know she likes to be left alone when she's tired. Staff E, LPN reviewed Resident #21's physician orders and said, I don't see an order for oxygen, but she has been on oxygen since I started in January of 2024. I don't know what happened to the order. An interview was conducted on 5/14/24 at 10:17 a.m. with Staff B, South Unit Manager. He reviewed Resident #21's physician orders and confirmed he could not find an order for oxygen and said, she used to have oxygen orders for 2 liters PRN [as needed]. On 5/14/24 at 10:20 a.m., Staff E, LPN went into the Resident #21's room and confirmed the oxygen was set to 3 LPM and adjusted the concentrator to 2 LPM. The resident said, please help me I can't breathe Resident #21 was observed to still have shallow rapid breaths. Staff E said she was going to get the machine to check her oxygen and the resident said please hurry. Staff E left the room. Resident #21 was observed to be in the bed eyes closed, saying a healthy baby boy. On 5/14/24 at 10:24 a.m., Staff E entered Resident #21's room and placed the pulse oximeter machine on the resident and confirmed her oxygen saturation was 92%, adjusted her nasal cannula, and confirmed the resident's oxygen saturation went up to 93% and then back down to 92%. Staff E said. I'll call the doctor. She asked the resident if she was having any shortness of breath and the resident said yes. The nurse said are you having any pain? The resident said, yes in my chest. Review of Resident #21's care plan revised on 10/3/23 revealed The resident has Oxygen Therapy r/t [related to] Ineffective gas exchange. dx [diagnosis] with COPD. The goals revealed Will be able to participate in activites [sic] of choice. Will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date. Will have no untreated s/s [signs and symptoms] of SOB [shortness of breath] through next review. The interventions were as follows: o Special Equipment: Oxygen o Administer Oxygen/Nebs as ordered. (Refer to current POS [physician order set]/MAR [medication administration record] for current order) o Give medications as ordered by physician. Monitor/document side effects and effectiveness. o Turn and Reposition resident to facilitate ventilation/perfusion matching: Use upright, high-Fowler's position whenever possible to allow for optimal diaphragm. o Promote lung expansion and improve air exchange by positioning with proper body alignment. o Monitor for changes in or development of signs & symptoms of breathing difficulty and report: SOB, cough (productive or nonproductive), fever, chills, difficulty speaking, bluish skin color, changes in cognition. o Report changes in respiratory status to physician. Change and date respiratory equipment tubing weekly & prn [as needed]. o Keep exterior of respiratory equipment clean. Review of Resident #21's progress note dated 5/14/24 at 3:50 p.m. revealed Resident complained of SOB [shortness of breath] and mild chest pain. Vitals assessed. MD [medical doctor] notified. orders received for STAT CXR [chest x-ray] and lab work. Resident received PRN [as needed] inhaler. Continued on 7-3 [7:00 a.m.-3:00 p.m.] shift without issue, no further complaints of pain or signs of distress. Family at bedside. Review of Resident #21's physician orders revealed an order with a start date of 5/14/24 Stat CXR PA [posterior anterior]and Lateral. An order with a start date of 5/15/24 and an end date of 5/22/24 revealed Zithromax Oral Tablet 500 MG (Azithromycin) Give 1 tablet by mouth one time a day for PNEUMONIA for 7 Days. Review of Resident #21's Chest X-ray 2 view radiology report dated 5/14/24 revealed Conclusion: Left lower lobe infiltrates suspicious for pneumonia. 46498 2. An observation and interview was conducted on 5/16/24 at 11:40 a.m. Staff K entered Resident # 97's room and said the resident had a [brand name] tracheostomy tube (6.0 XL) she searched the resident's room and confirmed there was not an extra or an emergency tracheostomy tube in the room. She confirmed there were extra trach (tracheostomy) ties, suction machine, suction kits, and a [brand name] tracheostomy tube (6.0 x l) inner cannula and ambu bags at the bedside. Review of Resident # 97's admission record dated 05/16/2024 showed he was admitted to the facility on [DATE] with diagnose to include but not limited to Acute Respiratory Failure with Hypoxia, Tracheostomy Status, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of a Medication Administration Record for the mouth of May 2024 showed an order dated 03/28/2024 to maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside, every shift for preventative measures. Maintain suction set up at bedside on every shift. An interview was conducted on 5/16/24 at 11:43 a.m. with the Director of Nursing (DON). She said, [Resident # 97's] room was set up with extra trachs. She directed Staff K, LPN to get an extra trach and a size smaller trach to put in the resident's room. Staff K obtained a [brand name] tracheostomy tube (6.0 XL), and a [brand name] tracheostomy tube (5.0 XL), and put it in the resident's room. Review of the facility policy titled, Tracheostomy Care undated, showed 2) Gather the necessary equipment and proceed to the patient's room. Equipment should include. C. Emergency tracheotomy tube replacement, the same size and 1 size smaller.

Based on observation, interview, and record review, the facility failed to follow the comprehensive person-centered care plan and physician orders for one (Residents #73) of one sampled resident who required dialysis, which included providing dietary needs (breakfast/snacks). Findings included: During an interview on 5/14/2024 at 8:45 a.m., Resident #73 stated he did not receive breakfast or a snack to take to dialysis. If needed, he had the driver of the transport stop at the convenience store. Resident #73 stated it would be nice if breakfast was provided as I have to leave at 5:45 a.m. and am gone until lunch, that is a long time without food. Review of the Admission Record for Resident #73 showed an admitted [DATE] and a recent admission of 3/16/2024 with diagnoses to include: end stage renal disease; heart failure; diabetes type 1; cachexia; hyperkalemia; protein-calorie malnutrition; muscle wasting and atrophy; and other co-morbidities. Review of Resident #73's physician Order Summary dated 5/16/2024 revealed an order for Resident to have Dialysis on days: [Dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no, order start date of 3/18/2024 and 3/24/2024. Review of Resident #73's Care Plan revealed a focus area of: hemodialysis: The resident has renal failure and is on Hemodialysis Resident to have dialysis on days: [dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no date initiated 1/16/2024 and revised on 4/3/2024. Further review of the care plans showed the resident was at risk for impaired nutrition related to chronic kidney disease stage as of 8/1/2023. Interventions included but not limited to honor food requests and preferences as appropriate initiated 4/5/2023, diet as ordered (refer to POS for current order) initiated 10/4/2022, fluid restrictions 1500 cc/hr revised on 4/3/2024. During an interview on 5/16/2024 at 6:55 a.m. with Staff O, Certified Nursing Assistant (CNA), she said she provided care to Resident #73 on a regular basis. Staff O stated she had not been able to give a bag meal to Resident #73 for a while as the refrigerator was broken. The kitchen staff provided the bags (meals). An interview was conducted on 5/16/2024 at 7:15 a.m. with Staff N, Cook. She stated the kitchen did provide bag meals to residents who needed them. Staff N stated nursing gave dietary a list and they prepared the meals, and passed them out. Staff N stated she not made a bag meal in a long time, as nursing had not provided a list of anyone who was in need of one. An interview was conducted with the Staff G, Registered Nurse/Unit Manager on 5/16/2024 at 8:30 a.m. She stated Resident #73 received his lunch bag from the kitchen, nursing did not have anything to do with it. Review of the facility policy and procedure with the topic: Dialysis Management (Hemodialysis) dated October 2021 revealed: the facility will coordinate care and services for hemodialysis residents. The facility will coordinate routine transportation for the resident. Contractual agreement will include, but may not be limited to, the following: * medical and non-medical emergencies, * development and implementation of resident care plan, * interchange of information useful/necessary for the care of the resident. Guidelines: 1. Obtain a physician's order to include but not limited to: . 6. Manage special dietary regimen and dietary/fluid restrictions as ordered. 7. Verify that travel meal is provided in a thermal bag and has an ice pack . 11. Review and revise care plan/Kardex as needed.

Based on observation and interview, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during two of four days of survey. Findings included: On 5/13/2024 at 9:52 a.m., an observation revealed the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care was not posted. On 5/16/2024 at 8:52 a.m. an observation revealed the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care was not posted. During an interview on 5/16/2024 at 11:15 a.m., Staff P, CNA staffing coordinator stated responsibility for posting the staffing numbers. Staff P stated posting the numbers for two days at a time to ensure the weekends are covered. Staff P, stated with the surveyors coming in on Monday the posting was delayed and the same must have happened this morning. Staff P stated posting the information today although it was later in the morning. Review of the facility policy and procedure with the topic: Staffing dated effective April 2015 revealed: policy: each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by the federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). The projected staffing plans are reevaluated on an ongoing basis in response to changes in the facility, resident population, or other circumstances. Staffing is monitored on an ongoing basis through a combination of offsite and onsite facility reviews conducted by facility, consulting and compliance staff. The facility administrator and/or the director of nursing should evaluate staffing on a daily basis. Procedure: Other: 1. Post the daily staffing hours.

Based on interview and record review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for one (Resident #259) of three residents sampled. Findings included: During an interview on 5/14/2024 at 10:04 a.m., the Nursing Home Administrator (NHA) stated there was only one resident who had signed an arbitration agreement. The NHA stated all residents were presented the option to review and sign the arbitration agreements upon admission. The NHA stated the Admission Director (AD) was responsible for the arbitration agreements and expectation was that everyone understood what was being signed. Review of the Admission Record for Resident #259 showed an admitted [DATE], with diagnoses to include Schizophrenia; Anxiety Disorder; Other Genetic related Intellectual Disability; Malignant Neoplasm of Bladder; and other co-morbidities. The Responsible Party/Guarantor listed indicated it was not Resident #259. Review of the Arbitration Agreement - Resident Booklet, was signed by Resident #259 and the Admission Coordinator (AC) on 4/24/2024. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008 dated 4/22/2024 signed by a physician showed under section U. Mental/Cognitive Status at Transfer - Resident #259 alert, disoriented, but can follow simple instructions. Review of the hospital physician progress note dated 4/21/2024, showed resident was pleasantly confused. Review of the Occupational Therapy Plan of Care dated 4/25/24 revealed Resident #259's Cognition ** orientation person (x 1); Cognition **Memory profound (0-10% ability; dependent, coma/vegetative state, delirium, acute psychosis episode); Cognition **Safety-Judgment Moderately impaired (25-50% intact); Cognition **sequencing moderate (51-70 % ability; frequent direction required in occasional situations). Review of an Admission Minimum Data Set (MDS) for Resident #259, dated 4/28/2024, showed Resident #259 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. During an interview on 5/15/2024 at 11:44 a.m., the AD stated the goal was to have residents signed in within 48-72 hours, herself, and the Admission Coordinator (AC) both completed sign ins. This included the Admission Agreement and Arbitration Agreement. The AC worked part-time at the facility and not at the facility today, 5/15/2024. The AD stated, We utilize the resident's 3008 [Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008] and nurse to nurse to determine if a resident can sign themselves into the center. The AD provided a list of residents who had and had not signed the Arbitration Agreement. The AD continued to state the Arbitration Agreement was optional and the resident did not have to sign to be able to be admitted . The AD stated, I focus on the agreement being optional. The AD stated the AC completed R#259's Admission Agreement which included the Arbitration Agreement. The AD confirmed Resident #259 had signed the arbitration agreement with the AC as the facility representative on 4/24/2024. The AD stated R#259's signature was in the form of a line and lower-case cursive letters in the bottom right corner of the agreement. The AD stated the facility would sign the corner of the agreements if the residents were not able. An interview was conducted on 5/13/2024 at 3:57 p.m. Resident #259 's Resident Representative (RR). She said had not had communication with the facility with regards to admission paperwork or anything else. The RR stated there had been very little to almost no communication with the facility. The RR explained Resident #259 had been diagnosed with Intellectual Disability in school age years. The RR stated Resident #259 never was able to learn how to read or write. The RR stated Resident #259 usually would request for her to review documents. Policy and Procedure for Arbitration Agreements was requested on multiple days, one was not provided prior to the survey exit on 5/16/2024.

Based on observation, interview, record review, and policy review, the facility failed to appropriately secure medications in the entrance of two resident rooms (Rooms #18 and #305); and failed to ensure appropriate storage of medications in three of three medication carts located on 100 (South Hall), 300 and 400 (North Halls). Findings included: During an observation of room [ROOM NUMBER], on 05/03/2022 at 9:42 a.m., a small oval blue pill was observed at the entrance of the resident room. An immediate interview of Staff A, Licensed Practical Nurse (LPN), revealed the nurse was in the middle of medication administration and confirmed the presence of the unsecured tablet at the entrance of resident room [ROOM NUMBER]. She stated, I can't own it, I don't think it is mine. (PHOTOGRAPHIC EVIDENCE OBTAINED) On 05/03/2022 at 1:15 p.m., during an interview with Staff A, (LPN), she said she informed the Director of Nursing (DON) of the unsecured pill and disposed of the medication in the pill buster. On 05/03/2022 at 3:34 p.m., an interview was conducted with the DON. The DON indicated Staff A informed her of the observations and revealed Staff A performed all her medication checks, and counted her medications earlier in the day. The DON stated, I haven't identified this as a trend, but I will bring it to the Quality Assurance (QA) committee. On 05/03/2022 at 9:59 a.m., an observation was conducted of room [ROOM NUMBER]. During the observation, one round white pill was located at the entrance of the room. An immediate interview was conducted with Staff B, Registered Nurse (RN), assigned to room [ROOM NUMBER]. Staff B, (RN) verified the presence of the unsecured white pill at the entrance of the resident room, and stated, Looks like it was spit out, it has some blurred scoring on it. I have no idea how that got there. An interview was conducted with the DON on 05/04/2022 at 11:37 a.m. She was informed of the observation of an unsecured tablet at the entrance of room [ROOM NUMBER]. The DON indicated she had not known there was another room that had a loose pill in the entrance. The DON stated, There should be no loose pills located anywhere in the facility. She further indicated that when the survey team found the unsecured tablet earlier in the day, she and the Nursing Home Administrator (NHA), held an in-service for staff related to watching for unsecured medications, and ensuring the residents consumed their medications prior to leaving resident rooms. On 05/05/2022 at 9:59 a.m , an observation of the 400 Hall (North) medication cart included eight unsecured tablets. Staff C, Registered Nurse (RN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 10:20 a.m., an observation of the medication cart on 300 Hall (North) included one half of an unsecured blue tablet located in the narcotic box, one loose white capsule located on the side in a small open space in the narcotic drawer, and two loose tablets located in the third and sixth drawer from the top of the medication cart. Staff D Licensed Practical Nurse (LPN) confirmed the presence of the unsecured medications. (Photographic Evidence Obtained.) On 05/05/2022 at 10:40 a.m., an observation of 100 Hall (South) medication cart revealed one unsecured white tablet in the second draw, one unsecured tablet in the 4th draw, and one unsecured yellow capsule sitting on top of the medication box. Staff E, (LPN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 11:33 a.m., an interview was conducted with the DON who was informed of the unsecured tablets located in all three (3) medication carts. During the interview the DON said the nursing staff brought her the unsecured tablets and she directed the staff to destroy the tablets in the pill-buster. She said the nursing staff rip the packages with pills, and the pills had the potential to fall out in the cart and box. She stated, There should be no loose pills in the medications in the carts. She further indicated the facility would immediately initiate audits. A review of the facility policy titled Medication Storage Section 4.1, dated of 09/2018, Pages 01 and Page 02, revealed under Policy Statement: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 15. Medication storage should be kept clean, well lit, organized and free of clutter.

Based on interview and record review, the facility failed to notify the physician and document the refusal of laboratory blood tests on two occasions for one (Resident #59) of five residents reviewed for unnecessary medications. Findings included: Review of Resident #59's admission record revealed she was admitted to the facility on [DATE] from the community with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's Change in Condition Evaluation form dated 4/30/22 revealed Resident #59 had a [CONDITION(S)] that started the morning of 4/30/22. Review of the mental status evaluation documented on the change in condition form revealed, altered level of consciousness with sudden change in level of consciousness or responsiveness. The physician was notified on 4/30/22 at 8:00 a.m. and recommended labs (blood tests). Review of Resident #59's treatment administration record (TAR) revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was signed off as completed on 5/1/22 at 1:52 a.m. Review of the lab company's documentation dated 5/1/22 at 2:31 a.m. revealed patient refused Review of Resident #59's medical record did not indicate the physician was notified of the refused blood tests. Further Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident # 59's TAR revealed the physicians order was signed off as completed on 4/21/22. Review of the lab company's documentation dated 4/21/22 revealed Resident #59 refused the blood tests. Review of Resident #59's medical record did not indicate the physician was notified of the refused blood tests. An interview was conducted with the Director of Nursing (DON) on 5/5/22 at 1:52 p.m. she said, I did a building wide sweep on anticoagulants and [CONDITION(S)] medications at the end of April to see who needs yearly labs or labs at certain intervals. The DON confirmed Resident #59 refused her labs on 4/21/22 and said, But, she just had her [MEDICATION(S)] and [MEDICATION(S)] labs taken on 2/28/22 and I just talked to the physician and he said she wouldn't need labs in April if she just had them in February because she's ordered to have them every 6 months . one thing we could have done better is documented the resident refused and the nurse should not have signed it off as completed when it was not. Review of the facility's policy Laboratory Services effective January 1, 2020, revealed Policy: The facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provides by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. Procedure: 1. Assure laboratory tests are completed and results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by the physician. 3. Assure Nursing notified the physician promptly of the findings .

Based on observation, interviews, and record review, the facility failed to provide hygiene products (shampoo and body wash) for one (Resident #11) of eleven sampled residents, and in one of one communal shower rooms, which had the potential to affect all facility residents. Findings included: An interview was conducted on 1/27/22 at 2:45 p.m. with Resident #11. The resident stated, is the facility supposed to supply body wash? Because I've been told if we don't have our own body wash then they will use the hand soap. My mom buys me body wash but when I run out of it before my mom can get me more, they will use the hand soap to give me a bath. An interview and observation was conducted on 1/27/22 at 2:55 p.m. with Staff A, Certified Nursing Assistant (CNA). She stated we have body wash in the supply room. The CNA opened the cabinet in the supply room, which was noted to contain 6 individual bottles of shampoo/body wash. An interview was conducted on 1/27/22 at 3:10 p.m. with Staff B, CNA, Staffing Coordinator and Central Supplier. She stated, I order supplies every week. I order hand soap and body wash. We did stop buying the individual body wash containers because they were disappearing faster than we could order them. But I buy the big body wash antimicrobial soap to put in the soap dispensers in the showers. She continued, The antimicrobial soap I order for the showers is different than the hand soap. The body wash soap should be in dispensers located in both the shower room, and the resident showers located in their rooms. The dispensers in the shower room and the resident showers are labeled shampoo/body wash. I did have a box in the back of the individual body wash that I put out this morning. An observation and interview was conducted on 1/27/22 at 4:00 p.m. with Staff B, CNA, Staffing Coordinator and Central Supplier in the community shower room, located on the South Unit. Staff B removed the covering to the dispenser located in the community shower room that was labeled shampoo/body wash. She confirmed the community shower room dispenser was filled with hand soap and not the body wash she orders. Further observation of Resident #11's shower located in her room in the North Unit was conducted with Staff B. Staff B removed the dispenser covering and confirmed hand soap was filled in the dispenser, not body wash/shampoo. An interview was conducted with the Director of Nursing on 1/27/22 at 4:20 p.m. She stated the dispensers in the showers contain the body wash. She indicated she was unaware the shower dispensers had hand soap in them. Review of the facility's admission packet dated 1/2017 revealed personal hygiene supplies will be covered and provided.

Based on review of clinical record and facility policies and procedures, interviews with the nursing and administrative staff, a family member, and the resident's physician, it was determined that the facility failed to protect the rights of one (#1) of seven sampled residents related to accurate implementation of Advance Directives. The facility failed to honor Resident #1's expressed wishes related to Advance Directives and end of life decisions. The facility failed to ensure that the resident did not receive cardio-pulmonary resuscitation according to her wishes and the physician's orders [REDACTED]. The facility initiated CPR (Cardiopulmonary Resuscitation) against the wishes of this [AGE] year-old who had multiple [DIAGNOSES REDACTED]. Resident #1 had recently been transferred from the [MEDICAL TREATMENT] Center to the hospital due to Altered Mental Status. While at the hospital, the resident had a significant decline in her condition. She had a State of Florida DNR order form signed by her Health Care Proxy. The facility violated Resident #1's right to refuse treatment and protect her from unwanted, potentially violent interventions in her last moments of life. The facility's failure to follow their own policies and procedures represented a system wide failure that could lead to failure to provide CPR to a resident who wanted it. The facility's failure to follow their policies and procedures resulted in findings of Immediate Jeopardy, past noncompliance on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE], prior to the survey. Findings Included: A review of the medical record for Resident #1 was conducted and revealed a nurse's note that was written by Staff A, LPN that read as follows: Effective date: [DATE] 10:19 p.m.: CNA reported resident unresponsive, assessed resident and had no response to sternal rub or pulse, code blue was called, 911 was called, Emergency Medical Services (EMS) responded and pronounced resident as deceased , MD and family notified. A review of the Code Blue Worksheet revealed that on [DATE] at 8:19 p.m. Staff E, CNA found the resident unresponsive. At 8:19 p.m. Staff A, Licensed Practical Nurse (LPN) brought the emergency cart to the resident's room and initiated CPR. At 8:19 p.m. Staff F, Certified Nurse Assistant (CNA) called 911. At 8:20 p.m. Staff D, LPN brought the chart to the room and checked the code status. At 8:40 p.m., EMS arrived. At 8:42 p.m., the EMS technician pronounced the resident expired. A review of the Hospital Discharge summary dated, [DATE], and signed by the attending physician was reviewed. The hospital Discharge Summary reflected Resident #1 was admitted to the hospital on [DATE] after she was noted to have a change in mentation while in [MEDICAL TREATMENT]. The resident underwent [REDACTED]. Infectious Disease was consulted secondary to possibility of underlying osteo[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection). The resident was noted to have elevated troponin and a cardiac consult was done. The decision was made to not pursue cardiac catheterization secondary to her comorbidities and severe valvular [MEDICAL CONDITION]. Because the resident appeared to be malnourished, the decision was made to proceed with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Overall prognosis is poor; risk of re-hospitalization is high considering multiple comorbidities. Resident #1 was initially admitted to the facility in (MONTH) 2011 and readmitted to the facility in (MONTH) 2019. The resident was [AGE] years old and had multiple diagnoses, including End Stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week, heart failure, [MEDICAL CONDITIONS], acquired absence of right leg above the knee, acquired absence of left leg below the knee, muscle wasting and atrophy, and chronic [MEDICAL CONDITION]. On [DATE], she was transferred from the [MEDICAL TREATMENT] Center to the hospital due to Altered Mental Status. While at the hospital, the resident had a significant decline in her condition and, subsequently, underwent an above the knee right leg amputation due to persistent osteo[DIAGNOSES REDACTED] and underlying [MEDICAL CONDITION]. Based on her BIMS (brief interview for mental status) summary score dated [DATE], her cognition was coded as an 11 indicating that the resident had moderate cognitive impairment. Three months later [DATE], her BIMS summary score was coded as a 4 indicating a decline to severe cognitive impairment. On [DATE] at 10:20 a.m., a telephone interview was conducted with Staff A, LPN. She confirmed that she initiated CPR without checking Resident #1's chart on [DATE]. She stated that she reported to the room of Resident #1 after she was alerted by the resident's direct care Certified Nurse's Assistant (CNA) that the resident was unresponsive. Staff A confirmed that the resident was unresponsive, initiated the code and asked the CNA to call emergency response services and overhead page staff to assist. She stated that she had been a nurse for several years and felt terrible for not checking the code status of the resident before initiating CPR. Staff A further confirmed that the resident had a Full Code status prior to her recent, ,[DATE]-[DATE], hospitalization . The nurse said she thought the resident still had a full code status. On [DATE] at 10:09 a.m., a telephone interview was conducted with Staff C, LPN. She confirmed that she responded to Resident #1's room after hearing the overhead Code Blue page on [DATE]. When she entered the room, she stated that Staff A had already initiated CPR. She said she began to assist without asking about the Advance Directive wishes of the resident. On [DATE] at 9:58 a.m., a telephone interview was conducted with Staff D, LPN. He confirmed that he responded to Resident #1's room when the Code Blue was called and brought the chart with him. When he entered the room, he saw three nurses (LPNs), Staff A, B, and C performing CPR on the resident. At that time, he informed them of her Do Not Resuscitate status. He stated that the Director of Nursing was notified, and she instructed them to continue performing CPR until the paramedics arrived. He stated that the nurses continued performing CPR for approximately 20 minutes until paramedics arrived on the scene. According to the American College of Chest Physicians (US) study at https://journal.chestnet.org/article/S,[DATE](15),[DATE]/fulltext: In a prospective study of the complications of cardiac resuscitation, 705 cases were autopsied to identify the cause of death and the pathologic findings attributable to cardiac resuscitation. [MEDICATION NAME] complications were observed in 42.7% of the cases. A total of 31.6% had rib fractures, 21.1% had sternal fractures, and 18.3% were reported as having anterior mediastinal hemorrhage; 20.4% of the cases had an upper airway complication. Abdominal visceral complications were noted in 30.8% of the cases, and [MEDICAL CONDITION] complications occurred in 13% of the resuscitation population. Life-threatening complications, such as heart and great vessel injuries, occurred in 5% of the cases. An interview was conducted with the facility administrator on [DATE] at 11:15 a.m. She confirmed that Resident #1 had been found unresponsive on the evening of [DATE]. The resident received CPR by Staff A, LPN, even though she had a current DNR order and did not want life saving measures. The administrator stated that the DON had notified her by phone right after the event occurred. She said she returned to the facility immediately after calling her key staff to meet her there. They began corrective action before the shift ended by suspending the nurse involved and initiating education with the nursing staff on duty. She confirmed that corrective action was complete on [DATE]. On [DATE] at 10:40 a.m., an interview was conducted with the Social Services Director (SSD). She confirmed that Resident #1 returned from the hospital on [DATE]. She met with the resident's mother on [DATE], who stated that she wanted the resident to be changed from a Full Code status to a DNR status. She felt her daughter had suffered enough for such a long time because of her significantly declining condition. She had been a resident of the facility since 2011. The SSD stated that she received an order from the physician to change to DNR status, had a State of Florida DNR order form completed and signed, changed the care plan to reflect the new DNR status and met with the nurse on duty for Resident # 1 to discuss the changes. All changes were effective on [DATE], as confirmed by her interview. She also stated at that time, it was her responsibility to inform new residents of their Advance Directive options and inform nursing of the changes. On [DATE] at 12:05 p.m., an interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) who had cared for Resident #1. He confirmed he was aware of the fact that Resident #1 had a code status change on [DATE] and he was aware that CPR was performed on her on [DATE], against her wishes for Advance Directives. He understood that corrective action had been completed by the management staff. On [DATE] at 9:05 a.m., a telephone interview was conducted with the acting Director of Nursing (DON). She said that she had been the acting DON on [DATE] when CPR was performed against the Advance Directive wishes of Resident #1. She confirmed that she was notified by the facility that CPR was in progress by three nurses against the DNR wishes of the resident and her family. She verified that since the CPR had already been initiated, she instructed the staff to continue performing CPR until EMS arrived on the scene in accordance with the facility's policy. 0n [DATE] at 9:08 a.m., an interview was conducted with the facility's Medical Director. He said he was informed that CPR was initiated and continued until EMS arrived for Resident #1. He said he was not in agreement the CPR could not be stopped once the facility discovered the resident was a DNR. He said he was working with the facility through the Quality Assurance Performance Improvement (QAPI) program to change the policy. He said he was pleased with the immediacy of the facility's response after the event. A telephone interview was conducted with the mother (health care proxy) of Resident #1 on [DATE] at 10:05 a.m. The resident's mother confirmed she was aware that CPR had been performed on her daughter even after she had signed a DNR the week before when her daughter returned from the hospital in declining condition. She said it was so hard seeing her daughter suffer and she was glad she was at peace now. Review of Resident #1's medical record revealed a Determination of Incapacity document signed by the physician on [DATE], as the resident lacks the capacity to give informed consent to make medical decisions and does not have reasonable medical probability of recovering mental and physical capacity to directly exercise his/her rights. Further review of the medical record revealed a State of Florida Do Not Resuscitate Order, dated [DATE], and signed by the resident's Health Care Surrogate and physician that indicated the resident did not wish to receive cardiac resuscitation. Continued review of the medical record revealed a Health Care Proxy Designation and Acceptance Letter (FL). The document was dated [DATE] and signed by the resident's mother/heath care surrogate and the Social Services Director. A review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], and the Significant change MDS assessment, dated [DATE], revealed that in three months the resident had a significant decline in her functional and cognitive abilities. The assessments were as follows: The Resident #1's annual Minimum Data Set (MDS) assessment, with an assessment reference dated, [DATE] Section C, Cognitive Patterns, sub-section C0500, showed a BIMS (brief interview for mental status) summary score was eleven, indicating the resident had moderate cognitive impairment. Section B of the MDS assessment, Hearing, Speech, and Vision. Sub-section B0700, showed the resident could sometimes be understood, as indicated by the code '2', Sometimes Understood-ability is limited to making concrete requests. Sub-section B0800 Ability to understand others, showed she could sometimes understand others as indicated by the code '2' Sometimes Understands-responds adequately to simple, direct communication only. At that time, Resident # 1 was frequently incontinent of bladder and bowel as indicated by Section H, Bowel and Bladder. Sub-section H0300, Urinary Continence: Occasionally incontinent, as indicated by the code 2 (less than seven episodes of incontinence). Sub-section H0400, Bowel continence: Frequently incontinent as indicated by the code 3 (two or more episodes of bowel incontinence, but at least one episode of continent bowel movement). Section G of the MDS, Functional Status, sub-section G0600. Mobility Devices reflected the resident was using a wheelchair, with extensive assistance of staff for locomotion. According to sub-section G0110[NAME] Bed mobility: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0110B. Transfers: The resident needed extensive assistance, as indicated by the code 3 with the assistance of two persons, as indicated by the code 3. Sub-section G0110G. Dressing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Section G0110I. Toilet use: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0110[NAME] Personal hygiene: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0120. Bathing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Section F, Preference for Customary Routine and Activities. Sub-section F0500. Interview for Activity Preferences showed that the resident enjoyed music, group activities, religious services, going outside for fresh air as indicated by the code 1 - Very Important. Resident #1's most recent significant change MDS assessment, dated [DATE], showed her BIMS score had declined, from sub-section C-Cognitive Patterns, C0500, '4', indicating severe cognitive impairment (rarely ever understood). Section B of the MDS assessment, Hearing, Speech, and Vision, B0700, showed the resident could sometimes be understood, as indicated by the code '2', Sometimes Understood-ability is limited to making concrete requests. Sub-section B0800 Ability to understand others, showed she could sometimes understand others as indicated by the code '2' Sometimes Understands-responds adequately to simple, direct communication only. Section G of the MDS, Functional Status, Sub-Section G0600. Mobility Devices showed the resident was using a wheelchair, with extensive assistance of staff for locomotion. According to Sub-Section G0110[NAME] Bed mobility: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-Section G0110B. Transfers: The resident needed extensive assistance, as indicated by the code 3 with the assistance of two persons, as indicated by the code 3. Sub-Section G0110G. Dressing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-Section G0110I. Toilet use: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. Sub-Section G0110[NAME] Personal hygiene: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. G0120. Bathing: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. A review of the policy, Standard and Procedure -Florida, dated ,[DATE], revealed the following information. Topic: CPR Code Status Orders and Response. Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's orders [REDACTED]. Advance Directive will be honored. Do Not Resuscitate (DNR) order: Cardiopulmonary resuscitation (CPR) will not be initiated in the absence of pulse or respirations. In the absence of Advance Directives or physician's orders [REDACTED]. Code status orders and wishes will be reviewed on admission, quarterly, PRN, and with significant change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Code status, physician's orders [REDACTED]. Social Services will be notified if resident has any general questions and concerns about Advance Directives. Procedure for initiating CPR 1. Upon identification that resident is unresponsive the person making the identification will check for pulse and respirations, and immediately call for help, loudly calling Code Blue room number. 2. Staff will respond to room with medical record and emergency cart. 3. Chart will be checked for code status and, if resident is a Full code CPR will be initiated. Once CPR is started, CPR will continue until: * Relieved by EMS * Relieved by another staff member who will take over CPR * Physician orders [REDACTED].>* Resident pulse and respirations are palpable/observable. Policy and Procedure Effective Date (MONTH) (YEAR) Topic: Advance Medical Directives Policy: At the time of admission, the Admissions Coordinator shall furnish residents/patients/family members, and/or the resident representative with information regarding Advance Directives. The resident/patient and/or resident representative shall be instructed to provide Social Services at the facility with a copy of any current Advance Directives, for placement in the resident medical record. Completion of an Advance Directive is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further guidance and/or information on Health Care Advance Directives as required or requested. Procedure 1. Verify that information on Advance Directives was provided to the resident/patient and/or family/resident representative at the time of admission. 2. Evaluate for factors that may affect the resident/patient capacity to communicate a decision. Notify physician of any concerns * Consider for vision/hearing deficits. * Obtain language translation /interpreter as needed. 3. Provide culturally appropriate discussion/education for patient and/or responsible party 4. Obtain any current Advance Directive from the resident/patient and /or family/resident representative, place in the medical record and update the care plan. 5. Document the Advance Directives that are current and in place on the medical record. 6. Document the Advance Directive/DNR log upon admission, quarterly, with change in condition, and/or change in Advance Directive status. 7. Update medical record with new or revised Advance Directives as indicated. 8. When a resident rescinds or changes his/her Advance Directives, have the resident draw a line through the old document, note rescinded/changed, then sign and note date rescinded /changed. Remove the old document from the record and return to medical records for filing in closed chart. 9. Review medical record at least quarterly and document verification of Advance Directives in place in the progress note. DNR; How Implemented: An order by the physician that, should the resident's heart stop, and/or should respirations cease, CPR is not to be initiated. Specific to CPR initiation; does not address other life support measures. Considerations: Signed by resident or authorized healthcare decision-maker if resident lacks capacity. Means only that CPR will not be initiated; treatable conditions will still be treated Without a DNR order, CPR will be initiated. State specific documentation may also be required e.g. yellow form (FL) for EMS. Facility actions to remove the Immediate Jeopardy: On [DATE] at 1:59 a.m., an interview was conducted with the Nursing Home Administrator, Regional Nurse Consultant, Regional Risk Manager, Traveling Regional Nurse Consultant, and the incoming Nursing Home Administer. The Nursing Home Administrator answered questions and provided the following information. Before the end of the 3:00 p.m.-11:00 p.m. shift on [DATE] the Administrative staff arrived at the facility and began in-servicing on Advance Directives related to CPR and Abuse, Neglect, and Exploitation as it related to their jobs. At that time, the staff in the facility were not allowed to leave before receiving the in-services. No other staff were allowed to return to work until they too received the in-services. This was verified by random audit conducted by the survey team. The NHA confirmed that on [DATE], 100% of all staff were in-serviced on CPR, Advance Directives, and Abuse/Neglect/Exploitation. Corrective Action: 1. Investigation initiated on [DATE]. 2. Staff A, LPN was suspended immediately on [DATE]. 3. Staff B, LPN, Staff C, LPN and Staff D, LPN were suspended on [DATE]. All four LPN's were terminated and reported to the Department of Health. 4. The NHA met with resident's mother on [DATE] to discuss the event. 5. House wide audits were completed to ensure resident code status, Advance Directives, care plans, and correlating MD orders were accurate and reflected the resident's/ representative's current wishes. Started on the evening of [DATE]. 6. The facility initiated education with licensed nursing staff regarding following MD orders regarding Advance Directives, identification of resident code status. Started [DATE]. Completed on [DATE]. After the event, no one was allowed to work until they had completed the in-service. 7. Resident rights, abuse neglect, and exploitation. Started [DATE]. Completed on [DATE]. After the event, no one was allowed to work until they had completed the in-service. 8. In an abundance of caution, CNAs and therapists were also educated on their role in Code Blue events/CPR. Started on [DATE]. Completed on [DATE]. After the event, no one was allowed to work until they had completed the inservice. 9. Code blue drills were initiated on [DATE] and continued every shift until 100% of licensed nursing staff had all participated. Completed on [DATE]. 10. Code Blues are now incorporated into new hire orientation to ensure licensed nurses experience drill upon hire. 11. Facility has added laminated cards to emergency carts stating, STOP CHECK CHART BEFORE DOING CPR. 12. Facility QA&A Compliance Committee met on [DATE] to review the event and progress with the QAPI that was initiated on [DATE]. Committee will continue to review until it is satisfied that the corrective actions are successful. 13. Facility did conduct a root cause analysis. Started on [DATE]. Adverse incident was submitted on [DATE]. Upon survey team request on [DATE], the facility conducted a facility wide audit to ensure accuracy of Advance Directive status. One hundred percent were completed with no discrepancies. The survey team verified the accuracy of their results. Prior to the audit, the survey team checked DNR orders in e-record as well as paper charts on two of two units looking for the State of Florida Do Not Resuscitate Order form and the physician orders [REDACTED]. Thirty-seven staff members from all shifts including, 16 CNAs, 6 staff LPNs, 7 staff registered nurses, 6 agency nurses,1 receptionist and 1 Physical Therapy Assistant were interviewed. All those interviewed were knowledgeable about the system to verify code status prior to initiating CPR and Advance Directives. Between ,[DATE] -[DATE], 100% of all 135 staff including housekeeping, dietary, laundry, therapy, and nursing services were in-serviced related to Advance Directives, CPR, and Abuse, Neglect, and Exploitation. The in-services and attendance were verified by a review of the sign in sheets. Between ,[DATE]-[DATE], 100% of all 22 licensed nurses participated in mock drills. The mock drills and attendance were verified by a review of the sign in sheets. The staff's knowledge of recent training, drills and correct procedures was verified by interview. As a result, the Immediate Jeopardy was determined to be past non-compliance, ending on [DATE].

Based on interviews with the facility's nursing and administrative staff, clinical record review, physician interview, and review of the facility's policies and procedures, it was determined that facility personnel neglected a resident by failing to provide the structures and processes to honor the Advance Directives to withhold Cardio-Pulmonary Resuscitation (CPR) for one resident (#1) of seven sampled residents. Upon finding Resident #1 without a pulse or respirations, the resident's assigned Licensed Practice Nurse, Staff A, neglected to check the resident's medical record to verify that the resident's code status was Do Not Resuscitate. Subsequently, the nurse neglected to honor the resident's wishes and initiated CPR. The facility neglected to follow its own policies and procedures for Advance Directives and Do Not Resuscitate (DNR) orders and ensure the resident's Advance Directive wishes for Do Not Resuscitate were verified before proceeding with chest compressions in an attempt to prolong the resident's life. The facility initiated CPR (Cardiopulmonary Resuscitation) against the wishes of this [AGE] year-old that had multiple [DIAGNOSES REDACTED]. She had recently been transferred from the [MEDICAL TREATMENT] Center to the hospital due to Altered Mental Status. While at the hospital, the resident had a significant decline in her condition. She had a State of Florida DNR order form signed by her Health Care Proxy. The facility failed to protect Resident #1 from unwanted, potentially violent interventions in her last moments of life. The facility's failure to follow their policies and procedures resulted in findings of Immediate Jeopardy, past noncompliance on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE], prior to the survey Findings Included: Resident #1 was initially admitted to the facility in (MONTH) 2011 and readmitted to the facility in (MONTH) 2019, according to the admission record. The resident was [AGE] years old and had multiple diagnoses, including End Stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] three times a week, heart failure, [MEDICAL CONDITIONS], acquired absence of right leg above the knee, acquired absence of left leg below the knee, muscle wasting and atrophy, and chronic [MEDICAL CONDITION]. On [DATE], she was transferred from the [MEDICAL TREATMENT] Center to the hospital due to Altered Mental Status. While at the hospital, the resident had a significant decline in her condition and, subsequently, underwent the above the knee right leg amputation due to persistent osteo[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection) and underlying [MEDICAL CONDITION]. Based on her BIMS (brief interview for mental status) summary score, dated [DATE], her cognition was coded as an 11 indicating that the resident had moderate cognitive impairment. Three months later, on [DATE], her BIMS summary score was coded as a 4 indicating a decline to severe cognitive impairment. An interview was conducted with the facility Administrator on [DATE] at 11:15 a.m. She confirmed that Resident #1 had been found unresponsive on the evening of [DATE]. The resident received CPR by Staff A, Licensed Practical Nurse (LPN), even though she had a current DNR order and did not want life saving measures. The administrator stated that the Director of Nursing (DON) notified her by phone right after the event occurred. She said she returned to the facility immediately after calling her key staff to meet her there. They began corrective action before the shift ended by suspending the nurse involved and initiating education with the nursing staff on duty. She confirmed that corrective action was complete on [DATE]. On [DATE] at 10:20 a.m., a telephone interview was conducted with Staff A, LPN. She confirmed that she initiated CPR without checking Resident #1's chart on [DATE]. She stated that she reported to the room of Resident #1 after she was alerted by the resident's direct care Certified Nurse's Assistant (CNA) that the resident was unresponsive. Staff A confirmed that the resident was unresponsive, initiated the code and asked the CNA to call emergency response services and overhead page staff to assist. She stated that she had been a nurse for several years and felt terrible for not checking the code status of the resident before initiating CPR. Staff A further confirmed that the resident had a Full Code status prior to her recent, ,[DATE]-[DATE], hospitalization . The nurse said she thought the resident still had a full code status. On [DATE] at 10:09 a.m., a telephone interview was conducted with Staff C, LPN. She confirmed that she responded to Resident #1's room after hearing the overhead Code Blue page on [DATE]. When she entered the room, she stated that Staff A had already initiated CPR. She said she began to assist without asking about the Advance Directive wishes of the resident. On [DATE] at 9:58 a.m., a telephone interview was conducted with Staff D, LPN. He confirmed that he responded to Resident #1's room when the Code Blue was called and brought the chart with him. When he entered the room, he saw three nurses (LPNs), Staff A, B, and C performing CPR on the resident. At that time, he informed them of her Do Not Resuscitate status. He stated that the Director of Nursing was notified, and she instructed them to continue performing CPR until the paramedics arrived. He stated that the nurses continued performing CPR for approximately 20 minutes until paramedics arrived on the scene. A review of the medical record for Resident #1 was conducted and revealed a nurse's note that was written by Staff A, LPN that read as follows, Effective date: [DATE] 10:19 p.m., CNA reported resident unresponsive, assessed resident and had no response to sternal rub or pulse, code blue was called, 911 was called, EMS responded and pronounced resident as deceased , MD and family notified. A review of the Code Blue Worksheet revealed that on [DATE] at 8:19 p.m. Staff E, CNA found the resident unresponsive. At 8:19 p.m. Staff A, LPN brought the emergency cart to the resident's room and initiated CPR. At 8:19 p.m. Staff F, CNA called 911. At 8:20 p.m. Staff D, LPN brought the chart to the room and checked the code status. At 8:40 p.m., Emergency Medical Services (EMS) arrived. At 8:42 p.m., the EMS technician pronounced the resident expired. According to the American College of Chest Physicians (US), study at https://journal.chestnet.org/article/S,[DATE] (15),[DATE]/full text: In a prospective study of the complications of cardiac resuscitation, 705 cases were autopsied to identify the cause of death and the pathologic findings attributable to cardiac resuscitation. [MEDICATION NAME] complications were observed in 42.7% of the cases. 31.6% had rib fractures, 21.1% had sternal fractures, and 18.3% were reported as having anterior mediastinal hemorrhage; 20.4% of the cases had an upper airway complication. Abdominal visceral complications were noted in 30.8% of the cases, and [MEDICAL CONDITION] complications occurred in 13% of the resuscitation population. Life-threatening complications, such as heart and great vessel injuries, occurred in 5% of the cases. A review of the Hospital Discharge summary, dated [DATE] and signed by the attending physician, was reviewed and revealed the following information. Resident #1 was admitted to the hospital on [DATE] after she was noted to have a change in mentation while in [MEDICAL TREATMENT]. The resident underwent [REDACTED]. Infectious Disease was consulted secondary to possibility of underlying osteo[DIAGNOSES REDACTED]. The resident was noted to have elevated troponin and a cardiac consult was done. The decision was made to not pursue cardiac catheterization secondary to her comorbidities and severe valvular [MEDICAL CONDITION]. Because the resident appeared to be malnourished, the decision was made to proceed with a Percutaneous Endoscopic Gastrostomy (PEG) tube. On [DATE], the resident underwent [REDACTED]. Overall prognosis is poor; risk of re-hospitalization is high considering multiple comorbidities. A review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], and the Significant change MDS assessment, dated [DATE], revealed that in three months the resident had a significant decline in her functional and cognitive abilities. The assessments are as follows: The Resident #1's annual Minimum Data Set (MDS) assessment, with an assessment reference dated, [DATE] Section C, Cognitive Patterns, sub-section C0500, showed a BIMS (brief interview for mental status) summary score was eleven, indicating the resident had moderate cognitive impairment. Section B of the MDS assessment, Hearing, Speech, and Vision. Sub-section B0700, showed the resident could sometimes be understood, as indicated by the code '2', Sometimes Understood-ability is limited to making concrete requests. Sub-section B0800 Ability to understand others, showed she could, sometimes, understand others as indicated by the code '2' Sometimes Understands-responds adequately to simple, direct communication only. At that time, she was frequently incontinent of bladder and bowel as indicated by Section H, Bowel and Bladder. Sub-section H0300, Urinary Continence: Occasionally incontinent, as indicated by the code 2 (less than seven episodes of incontinence). Sub-section H0400, Bowel continence: Frequently incontinent as indicated by the code 3 (two or more episodes of bowel incontinence, but at least one episode of continent bowel movement). Section G of the MDS, Functional Status, sub-section G0600. Mobility Devices showed the resident was using a wheelchair, with extensive assistance of staff for locomotion. According to sub-section G0110[NAME] Bed mobility: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0110B. Transfers: The resident needed extensive assistance, as indicated by the code 3 with the assistance of two persons, as indicated by the code 3. Sub-section G0110G. Dressing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Section G0110I. Toilet use: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0110[NAME] Personal hygiene: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-section G0120. Bathing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Section F, Preference for Customary Routine and Activities. Sub-section F0500. Interview for Activity Preferences showed that the resident enjoyed music, group activities, religious services, going outside for fresh air as indicated by the code 1 - Very Important. Resident #1's most recent significant change MDS assessment, dated [DATE], showed her BIMS score had declined, from sub-section C-Cognitive Patterns, C0500, '4', indicating severe cognitive impairment (rarely ever understood). Section B of the MDS assessment, Hearing, Speech, and Vision, B0700, showed the resident could sometimes be understood, as indicated by the code '2', Sometimes Understood-ability is limited to making concrete requests. Sub-section B0800 Ability to understand others, showed she could sometimes understand others as indicated by the code '2' Sometimes Understands-responds adequately to simple, direct communication only. Section G of the MDS, Functional Status, Sub-Section G0600. Mobility Devices showed the resident was using a wheelchair, with extensive assistance of staff for locomotion. According to Sub-Section G0110[NAME] Bed mobility: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-Section G0110B. Transfers: The resident needed extensive assistance, as indicated by the code 3 with the assistance of two persons, as indicated by the code 3. Sub-Section G0110G. Dressing: The resident needed extensive assistance, as indicated by the code 3 with the assistance of one person, as indicated by the code 2. Sub-Section G0110I. Toilet use: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. Sub-Section G0110[NAME] Personal hygiene: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. G0120. Bathing: The resident was totally dependent on staff, as indicated by the code 4 with the assistance of one person, as indicated by the code 2. On [DATE] at 10:40 a.m., an interview was conducted with the Social Services Director (SSD). She confirmed that Resident #1 returned from the hospital on [DATE]. She met with the resident's mother on [DATE], who stated that she wanted the resident to be changed from a Full Code status to a DNR status. She felt her daughter had suffered enough for such a long time because of her significantly declining condition. She had been a resident of the facility since 2011. The SSD stated that she received an order from the physician to change to DNR status. She said a State of Florida DNR order form was completed and signed by the Health Care Proxy, who was the resident's mother, and the physician. She changed the care plan to reflect the new DNR status and met with the nurse on duty for Resident # 1 to discuss the changes. All changes were effective on [DATE], as confirmed by her interview. The SSD also stated at that time, it was her responsibility to inform new residents of their Advance Directive options and inform nursing of the changes. On [DATE] at 12:05 p.m., an interview was conducted with the Advanced Registered Practitioner (ARNP) who had cared for Resident #1. He confirmed that he knew Resident #1 had a code status change on [DATE] and he was aware that CPR was performed on her on [DATE], against her wishes for Advance Directives. He understood that corrective action had been completed by the management staff. On [DATE] at 9:05 a.m., a telephone interview was conducted with the acting Director of Nursing (DON). She said that she had been the acting DON on [DATE] when CPR was performed against the Advance Directive wishes of Resident #1. She confirmed that she was notified by the facility that CPR was in progress by three nurses against the DNR wishes of the resident and her family. She verified that since the CPR had already been initiated, she instructed the staff to continue performing CPR until EMS arrived on the scene in accordance with the facility's policy. On [DATE] at 9:08 a.m., an interview was conducted with the facility's Medical Director. He said he was informed that CPR was initiated and continued until EMS arrived for Resident #1. He said he was not in agreement the CPR could not be stopped once the facility discovered the resident was a DNR. He said he was working with the facility through the Quality Assurance Performance Improvement (QAPI) program in an attempt to change the policy. He said he was pleased with the immediacy of the facility's response after the event. A telephone interview was conducted with the mother (health care proxy) of Resident #1 on [DATE] at 10:05 a.m. The Surveyor expressed deepest sympathy for the loss of her daughter. The resident's mother confirmed that she was aware that CPR had been performed on her daughter even after she had signed a DNR the week before when her daughter returned from the hospital in declining condition. She said it was so hard seeing her daughter suffer and she was glad she was at peace now. Review of Resident #1's medical record revealed a Determination of Incapacity document signed by the physician on [DATE], as the resident lacks the capacity to give informed consent to make medical decisions and does not have reasonable medical probability of recovering mental and physical capacity to directly exercise his/her rights. Continued review of the medical record revealed a Health Care Proxy Designation and Acceptance Letter (FL). The document was dated [DATE] and signed by the resident's mother/heath care surrogate and the Social Services Director. Further review of the medical record revealed a State of Florida Do Not Resuscitate Order, dated [DATE], and signed by the resident's Health Care Surrogate and physician that indicated the resident did not wish to receive cardiac resuscitation. A review of the facility's Abuse Prevention Program Effective: 2012. Reviewed: ,[DATE] was conducted and detailed the following information: Policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. Definition: Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Procedure: The facility has implemented the following processes in the effort to provide residents, visitors, and staff with a safe and comfortable environment. 1. The Administrator is responsible for designation an Abuse Coordinator 2. The designated staff supervisor is identified as responsible for immediate initiation of the reporting process. 3. The Administrator, Director of Nurses (DON) and Risk Manager Specialist are responsible for the investigation and reporting of suspected or alleged abuse, neglect, exploitation, and misappropriation. 4. The Administrator, DON and Risk Manager Specialist are also ultimately responsible for the following: [NAME] Implementation B. Ongoing Monitoring C. Investigation D. Reporting E. Tracking and trending Implementation and Ongoing Monitoring Screening. Potential employees will be screened, per federal and/or state regulations, during the hiring process for history of abuse, neglect, or mistreatment of [REDACTED]. 1. Inquiries into state licensing authorities 2. Inquiries into state nurse aide registry 3. Reference checks from previous and/or current employees 4. Criminal background checks will be completed to identify any potential employee unfit to work in long-term care. 5. Results of the screenings will be recorded to include the date, name, and title of person contacted for reference, and name of the person obtaining the reference. This documentation is filed with other employee records. Training. Facility orientation program and ongoing training programs will include, but may not be limited to: 1. Freedom from abuse, neglect, and exploitation 2. Activities that constitute abuse, neglect, exploitation and misappropriation of resident property 3. Procedures for reporting incidents of abuse, neglect, exploitation and misappropriation of resident property 4. Dementia management and resident abuse prevention 5. Elder Justice Act 6. Identification of abuse, neglect, exploitation and misappropriation of resident property 7. Utilization of appropriate interventions to deal with resident behaviors that might result in harm to the resident or staff, aggressive and/or catastrophic resident to residents 8. How staff should report their knowledge related to allegations without fear of reprisal 9. How to provide protection for residents 10. Components of a complete and thorough investigation 11. Methods to reduce the risk of abuse, neglect, exploitation and misappropriation of resident property that may include but may not be limited to, recognizing signs of burnout, frustration, and stress; stress management and relaxation techniques. 12. Staff training will be documented and maintained with facility education records. Prevention: 1. The facility will post a statement that the resident may file a complaint with the state survey agency concerning any suspected violation of state or federal nursing facility regulations including but not limited to abuse, neglect, exploitation and misappropriation of resident property 2. The facility will post information and contact information for fining grievance or complaints concerning any suspected violation of state or federal nursing facility regulations including but not limited to abuse, neglect, exploitation and misappropriation of resident property 3. Residents and families are encouraged to report concerns, incidents and grievances without fear of retribution 4. Staff is instructed to report concerns, incidents, and grievances. 5. Facility leadership will identify situations in which concerning any suspected violation of state or federal nursing facility regulations including but not limited to abuse, neglect, exploitation and misappropriation of resident property may be more likely to occur. 6. Analyze the occurrence to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Identification: 1. An event report is initiated upon identification of actual, suspected, or alleged abuse. 2. Should the issue be reported initially on a concern/grievance report and later identified as actual, suspected or alleged concerning any suspected violation of state or federal nursing facility regulations including but not limited to abuse, neglect, exploitation and misappropriation, the concern/grievance report and grievance log will be notated Referred to Risk Management. 3. Event reports and resident concern/grievance reports are reviewed, tracked, and trended for indicators suspicious for concerning abuse, neglect, exploitation and misappropriation. Protection: Upon identification of actual, suspected, or alleged abuse, neglect, exploitation and misappropriation system are in place to provide for the protection of the resident. These systems may include, but not limited to: 1. Suspension (Investigatory Leave) for accused, suspected employee(s), pending the outcome of the investigation to protect the victim and alleged abuser from retaliation. 2. Initiation of discharge process if the resident is a danger to him/herself or others 3. Moving a resident to another room or unit if indicated. 4. Provision of 1:1 monitoring if indicated 5. Initiation of behavioral interventions per Behavior Management Program as indicated. Investigation: 1. An event report is initiated 2. The Administrator or designee is notified and, in collaboration with the Risk Management Specialist will initiate and conclude a complete and through investigation within specific time frame. Reporting: 1. The facility will identify the staff member responsible for the initial reporting, investigation of alleged violation and reporting abuse to determine the direction of the investigation 2. Facility staff will be in compliance with federal regulations and state specific reporting requirements Tracking and Trending: 1. A report of reportable events is prepared and provided to the QA&A compliance committee for review monthly. 2. Events are tracked and trended to identify similarities, causative factors and any other area that may increase the risk of repeat occurrences of the same or similar nature. A review of the policy, Standard and Procedure -Florida dated ,[DATE] revealed the following information. Topic: CPR Code Status Orders and Response. Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's orders [REDACTED]. Advance Directive will be honored. Do Not Resuscitate (DNR) order: Cardiopulmonary resuscitation (CPR) will not be initiated in the absence of pulse or respirations. In the absence of Advance Directives or physician's orders [REDACTED]. Code status orders and wishes will be reviewed on admission, quarterly, PRN, and with significant change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Code status, physician's orders [REDACTED]. Social Services will be notified if resident has any general questions and concerns about Advance Directives. Procedure for initiating CPR 1. Upon identification that resident is unresponsive the person making the identification will check for pulse and respirations, and immediately call for help, loudly calling Code Blue room number. 2. Staff will respond to room with medical record and emergency cart. 3. Chart will be checked for code status and, if resident is a Full code CPR will be initiated. Once CPR is started, CPR will continue until: * Relieved by EMS * Relieved by another staff member who will take over CPR * Physician orders [REDACTED].>* Resident pulse and respirations are palpable/observable. Policy and Procedure Effective Date (MONTH) (YEAR) Topic: Advance Medical Directives Policy: At the time of admission, the admissions Coordinator shall furnish residents/patients/family members, and/or the resident representative with information regarding Advance Directives. The resident/patient and/or resident representative shall be instructed to provide Social Services at the facility with a copy of any current Advance Directives, for placement in the resident medical record. Completion of an Advance Directive is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further guidance and/or information on Health Care Advance Directives as required or requested. Procedure 1. Verify that information on Advance Directives was provided to the resident/patient and/or family/resident representative at the time of admission. 2. Evaluate for factors that may affect the resident/patient capacity to communicate a decision. Notify physician of any concerns * Consider for vision/hearing deficits * Obtain language translation /interpreter as needed. 3. Provide culturally appropriate discussion/education for patient and/or responsible party 4. Obtain any current Advance Directive from the resident/patient and /or family/resident representative, place in the medical record and update the care plan. 5. Document the Advance Directives that are current and in place on the medical record 6. Document the Advance Directive/DNR log upon admission, quarterly, with change in condition, and/or change in Advance Directive status. 7. Update medical record with new or revised Advance Directives as indicated 8. When a resident rescinds or changes his/her Advance Directives, have the resident draw a line through the old document, note rescinded/changed, then sign and note date rescinded /changed. Remove the old document from the record and return to medical records for filing in closed chart. 9. Review medical record at least quarterly and document verification of Advance Directives in place in the progress note. DNR; How Implemented: An order by the physician that, should the resident's heart stop, and/or should respirations cease, CPR is not to be initiated. Specific to CPR initiation; does not address other life support measures Considerations: Signed by resident or authorized healthcare decision-maker if resident lacks capacity Means only that CPR will not be initiated; treatable conditions will still be treated Without a DNR order, CPR will be initiated State specific documentation may also be required e.g. yellow form (FL) for EMS. Facility actions to remove the Immediate Jeopardy: On [DATE] at 1:59 a.m., an interview was conducted with the Nursing Home Administrator, Regional Nurse Consultant, Regional Risk Manager, Traveling Regional Nurse Consultant, and the incoming Nursing Home Administer. The Nursing Home Administrator answered questions and provided the following information. Before the end of the 3:00 p.m.-11:00 p.m. shift on [DATE] the Administrative staff arrived at the facility and began in-servicing on Advance Directives related to CPR and Abuse, Neglect, and Exploitation as it related to their jobs. At that time, the staff in the facility were not allowed to leave before receiving the in-services. No other staff were allowed to return to work until they too received the in-services. This was verified by random audit conducted by the survey team. The NHA confirmed that on [DATE], 100% of all staff were in-serviced on CPR, Advance Directives, and Abuse/Neglect/Exploitation. Corrective Action: 1. Investigation initiated on [DATE] 2. Staff A, LPN was suspended immediately on [DATE]. 3. Staff B, LPN, Staff C, LPN and Staff D, LPN were suspended on [DATE]. All four LPN's were terminated and reported to the Department of Health. 4. The NHA met with resident's mother on [DATE] to discuss the event. 5. House wide audits were completed to ensure resident code status, Advance Directives, care plans, and correlating MD orders were accurate and reflected the resident's/ representative's current wishes. Started on the evening of [DATE]. 6. The facility initiated education with licensed nursing staff regarding following MD orders regarding Advance Directives, identification of resident code status. Started [DATE]. Completed on [DATE]. After the event, no one was allowed to work until they had completed the in-service. 7. Resident rights, abuse neglect, and exploitation. Started [DATE]. Completed on [DATE]. After the event, no one could work until they had completed the in-service. 8. In an abundance of caution, CNAs and therapists were also educated on their role in Code Blue events/CPR. Started on [DATE]. Completed on [DATE]. After the event, no one was allowed to work until they had completed the in-service. 9. Code blue drills were initiated on [DATE] and continued every shift until 100% of licensed nursing staff had all participated. Completed on [DATE]. 10. Code Blues are now incorporated into new hire orientation to ensure licensed nurses experience drill upon hire. 11. Facility has added laminated cards to emergency carts stating, STOP CHECK CHART BEFORE DOING CPR. 12. Facility QA&A Compliance Committee met on [DATE] to review the event and progress with the QAPI that was initiated on [DATE]. Committee will continue to review until it is satisfied that the corrective actions are successful. 13. Facility did conduct a root cause analysis. Started on [DATE]. Adverse incident was submitted on [DATE]. Upon survey team request on [DATE], the facility conducted a facility wide audit to ensure accuracy of Advance Directive status. One hundred percent were completed with no discrepancies. The survey team verified the accuracy of their results. Prior to the audit, the survey team checked DNR orders in e-record as well as paper charts on two of two units looking for the State of Florida Do Not Resuscitate Order form and the physician orders [REDACTED].

Based on staff interview, facility and resident record review and review of the policy and procedure for Elopement and Care Plan, the facility failed to ensure that the care plan was implemented for one (#108) of five sampled residents who were assessed as an elopement and exit seeking risk, from a total census of 116. Resident #108 was found 6.1 miles away from the facility on 2/7/19, with no awareness by facility staff that he had eloped from the facility. Facility staff had not observed Resident #108 for a period of approximately 2.5 hours. The facility demonstrated a lack of action and commitment in implementing identified interventions to adequately address the needs of Resident #108, who based on the facility ' s own documented care plans, observations, and assessments, was known to require close supervision with known whereabouts, need for placement and functioning of his electronic wander device, required supervision with Eating Activities of Daily Living, and required checking for incontinence before and after meals. Failure to implement the written plan of care to provide the level of supervision required to ensure resident safety resulted in the findings of Immediate Jeopardy, occurring on 2/7/19 and removed on 2/14/19 with the scope and severity reduced to a D. Findings included: On 2/7/19 at approximately 6:00 a.m., a survey team entered the facility. The administrative team was informed of the purpose of the visit, which included the general nature of the complaint allegations. On 2/12/19 the Director of Nursing (DON) provided the facility ' s policy and procedure titled, Care Plan – Interdisciplinary Plan of Care from Interim to Meeting (dated 3/2017) for review. The policy revealed: The facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident ' s written plan of care. The overall care plan should be oriented towards the following but not limited to: - Managing risk factors to the extent possible or indicating the limits of such interventions. - Evaluating treatment of [REDACTED]. - Using an appropriate interdisciplinary approach to care plan development to improve the resident ' s functional abilities. - Involve the direct care staff with the care planning process related to the resident ' s expected outcomes. - Addressing additional care planning areas that are relevant to meeting the resident ' s needs in long term care setting. On 2/8/19 the Nursing Home Administrator (NHA) provided the following policy and procedure for review: Elopement Prevention policy and procedure (not dated) revealed: The facility recognizes that elopement preventions is an interdisciplinary process that must include the cognitively impaired residents and family. The facility will implement individualized interventions and strive to prevent elopement. Guidelines 1. Complete admission data collection including, but not limited to, the following - Admission Data Collection and initial Plan of Care - Social Service Assessment/Discharge Evaluation - Psychosocial History and Assessments 2. Review and evaluate risk factor data 3. Determine if the resident is at risk for elopement. (History of) 4. Include resident and family in development of the Plan of Care 5. Present at the next scheduled Interdisciplinary Plan of Care and Standards of Care meeting. 6. Develop individualized interventions which may include, but are not limited to, the following: - Electronic Monitoring/alarm systems - Environmental modifications - Protected list of names and photographs of those at risk for elopement - Psychosocial interventions - Regular rounds - Resident and family education - Staff interventions - Structured group activities 7. Communicate risk and interventions with the resident and family and provide education as needed 8. Discuss Interdisciplinary interventions with the resident and family and provide education as needed 9. Provide staff training as needed 10. Review and revise Plan of Care as needed A medical record review for Resident #108 revealed an Admission Record that noted he was admitted to the facility for long term care services on 10/30/18. Review of the advanced directives revealed Resident #108 was his own decision maker and had a sister who was listed as an emergency contact. Review of the electronic cumulative [DIAGNOSES REDACTED]. Review of the nurse progress notes from 10/30/18 to 2/14/19 related to elopement revealed the following: - 12/2/18 16:22 (4:22 p.m.) – Resident noted to continue to pace from room . to nurse station. - 2/1/19 06:16 (6:16 a.m.) – Resident is at risk for wandering, electronic bracelet on for safety. - 2/7/19 13:45 (1:45 p.m.) – Resident was identified to be at a local business and assisted back to the facility by staff. Resident is independently ambulatory and stated he went to the business via taxi. Resident returned without any complaints of pain or no signs and symptoms of distress. Physician and family notified same. Review of the current physician's order [REDACTED]. a. Electronic Bracelet for safety – check placement every shift and located on person on left ankle, every shift for prevention. Initial order date was 12/7/18. b. Resident requires an electronic bracelet for safety due to poor safety awareness and wandering behavior. Initial order date was 11/1/18. c. Electronic bracelet for safety – check functioning daily on 11-7 shift every night shift replace if not working correctly. Initial order date was 11/1/18. d. (MONTH) go on Leave of Absence with escort and without medications. Initial order date was 10/31/18. A review of a Hospital Consultation and History and Physical form dated 10/27/18, 3 days prior to admission, revealed Resident #108 was found walking into traffic, confused, was unaware of where he was or current events, and was hospitalized involuntarily due to this dangerous behavior. Review of the nursing facility ' s Admission Data Collection assessment dated [DATE], revealed Resident #108 exhibited elopement risk factors to include wandering, utilized an electronic monitoring bracelet and had an interim care plan with a focus area to include elopement risk. The goal of the care plan was: Resident will not exit the facility without staff knowledge and staff will monitor whereabouts on an ongoing basis. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident did not present with any behaviors to include wandering, requires supervision with set up only and independent with Activities of Daily Living (ADLs). Resident only required extensive assistance with Dressing, Hygiene and Toileting. Review of the most current MDS Quarterly assessment dated [DATE], revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The assessment documented no behaviors to include wandering, and the resident was coded as supervision only with all ADLs. Review of Resident #108 ' s current care plans with a next review date 4/25/19, and interviews with the NHA and staff revealed the facility failed to consistently implement care planned interventions that resulted in the elopement of Resident #108. The intervention implementation failures were as follows: a. Elopement: (initiated 10/31/18) - Resident is an elopement risk/wanderer as evidenced by resident presents with cognitive impairments and is independently mobile, resident wanders aimlessly, impaired safety awareness . The goal indicated the resident would not exit the facility without staff knowledge and staff would monitor whereabouts on an ongoing basis. (implemented 10/31/18) to include: 1. Use audible alarm system to alert staff to exit seeking behaviors qs (every shift), 2. Educate resident/responsible party regarding the sign out procedure, 3. Identify pattern of wandering, 4. Psych services as needed, 5. Family available to be called if distressed or exit seeking, 6. Electronic Bracelet, 7. Verify placement Q shift and Verify functioning with transponder q24h (every 24 hours), 8. Assess for fall risk, and 9. Monitor for fatigue and weight loss. It was determined through interviews with the Certified Nursing Assistant (CNA) assigned to Resident #108 on 2/7/19 (Staff FF), the daytime Receptionist (Staff AA), the 11:00 p.m. – 7:00 a.m. Registered Nurse assigned to Resident #108 on 2/6/19 – 2/7/19 (Staff Q), NHA, DON, and the Risk Manager that the functioning of the electronic bracelet was not implemented during the night shift from 2/6/19 to 2/7/19 and supervision/monitoring of Resident #108 ' s whereabouts was not implemented from at least 11:15 a.m. to at least 2:30 p.m. on 2/7/19, when Resident #108 was picked up from a local business by facility staff. It was at least three hours and fifteen minutes where staff was not supervising the resident and staff could not account for Resident #108 ' s whereabouts for two and a half of those hours. b. Cognition: (initiated 11/16/18) - Resident has impaired cognitive function, impaired thought process r/t (related to) severely impaired: Dementia. The goal indicated Resident #108 would maintain current level of cognitive function through the review date, with interventions to cue, reorient and supervise as needed. The facility failed to implement the intervention related to supervision. Resident #108 ' s whereabouts were not known or documented for over two and a half hours and he was unsupervised by facility personnel for a total of three hours and fifteen minutes. c. Incontinence: (initiated 11/16/18) - The resident is Incontinent of Bladder and is not a candidate for a toileting program related to: Involuntary or unpredictable bladder elimination. The goal included Resident #108 would maintain dignity, minimize the risk of skin breakdown, and minimize the risk for infection, with an intervention to include checking for incontinence with routine care, upon arising, before and after mealtime, at bedtime and as needed. It was determined through interviews with Staff FF and record review that Resident #108 was not consistently checked on 2/7/19 for incontinence at the times indicated on the care plan. Review of the CNA ADL work flow sheet, dated 2/7/19 revealed episodes of incontinence did not occur between the hours of 3:52 a.m. and 2:59 p.m. Interviews with Staff FF, CNA could not confirm Resident #108 was checked for incontinence care during her 7:00 a.m. to 3:00 p.m. shift on 2/7/2019 which included the timeframe in which Resident #108 eloped from the facility and was found by a local business, 6.1 miles away. d. ADLs: (initiated 11/6/18) - Self-care performance deficit cannot complete ADL tasks independently to include Eating. The goal indicated Resident #108 would maintain his current level of self-performance with ADLs through next review, and the intervention was to provide supervision with Eating. It was determined through interviews with Staff FF, NHA, DON and Risk Manager and medical record review that staff left the resident ' s lunch tray in his room on 2/7/19 without providing set up for the meal and locating Resident #108 to provide supervision with eating. Interview with CNA (Staff FF) revealed she went to the dining room on 2/7/19 at approximately 11:00 a.m. – 11:15 a.m., immediately left for her lunch break after completing the dining room lunch around 12:00 p.m. and did not return from her lunchbreak until around 1:00 p.m. Staff FF stated the other floor staff were responsible (names unknown), for Resident #108 in her absence to include his meal set up and supervision. She confirmed that she did not assist with that intervention on 2/7/19. Review of the CNA ADL flow sheet for Eating dated 2/7/19 revealed at 11:30 a.m. resident not available. An interview with the NHA and Risk Manager both indicated during their preliminary investigation, it was found that staff placed Resident #108 ' s lunch meal tray in his room and left without first finding him. They both confirmed Resident #108 usually ate in his room. It was determined that staff did not know and could not account for Resident #108 ' s whereabouts during the lunch mealtime on 2/7/19. Review of Resident #108 ' s CNA ADL flow sheet dated 2/7/19, revealed the following but not limited to: - Bowel continence 2/7/19 3:52 a.m. – Bowel continence documented as Not applicable - Bowel continence 2/7/19 2:59 p.m. – Bowel continence documented as Not applicable - Eating 2/7/19 8:00 a.m. – Eating self performance documented as Independent with no help or staff oversight at any time, as documented from Staff FF. - Eating 2/7/19 11:30 a.m. – Eating self performance documented as Resident not available, as documented from Staff FF. Review of the Certified Nursing Assistant (CNA) ADL flow sheet for the month of (MONTH) 2019 revealed Resident #108 was independent with eating. The flow sheet documented on 2/7/19 at 11:30 a.m., resident did not have a lunch tray and resident was not available. On 2/8/19 at 8:15 a.m., the NHA notified the survey team of an incident that occurred on 2/7/19. The NHA revealed that Resident #108 eloped from the facility on 2/7/19 around 11:45 a.m.-12:00 p.m., while the survey team was present in the facility. She stated that the preliminary investigation indicated that somehow the resident removed his electronic monitoring bracelet, made it to the front door and somehow staff let him out. Resident #108 eloped off the facility property and at approximately 1:45 p.m. on 2/7/19 a local business, 6.1 miles away from the facility, called and notified the staff that Resident #108 was there. The business representative indicated that the resident was confused, he had paperwork with the facility ' s address and phone number, and he needed to be picked up. The NHA indicated that they started their Elopement protocol and Missing Persons action plan prior to him returning to the facility, but were unaware that he was missing from the facility prior to receiving the call from the local business. She indicated that she sent two employees to go pick him up. The NHA revealed that upon his return on 2/7/19 around 2:30 p.m., Resident #108 was immediately brought to the NHA ' s office where the DON, Risk Manager and other nursing staff medically assessed him and found no signs or symptoms of dehydration, injuries or pain. She stated that he was not in need of hospitalization . She further indicated that she had already made calls to Resident #108 ' s physician and family. The NHA stated that Resident #108 was immediately placed on 1:1 supervision upon return to the facility, the front doors were being manned twenty-four hours a day by designated staff, and the four additional elopement/exit seeking residents were checked for placement and functioning of their electronic monitoring bracelets. She also indicated that Resident #108 received a new electronic monitoring bracelet upon his return. On 2/8/19 at 9:00 a.m., the NHA, Director of Nursing (DON), Risk Manager and two regional staff members provided a preliminary timeline related to Resident #108 ' s elopement from the facility on 2/7/19. The timeline was verbalized as follows: 1. On 2/7/19, Resident #108 was seen at around 8:00 a.m. for breakfast and provided his meal. After breakfast, around 8:30 a.m., Resident #108 ambulated to the front lobby area and sat in a chair next to the reception table, as he does routinely. From around 8:30 a.m. until 11:15 a.m., Resident #108 was seated in the lobby. 2. Risk Manager and NHA indicated that an agency nurse (Staff EE), Licensed Practical Nurse (LPN) provided medications to the resident on 2/7/19 at 11:15 a.m. 3. After receiving his medications on 2/7/19 at 11:15 a.m., it was unclear where Resident #108 was or if he was wearing his electronic monitoring bracelet at that time. 4. On 2/7/19 from 11:15 a.m. to until 1:45 p.m., there was no evidence or interviews to support the whereabouts of Resident #108 and what he was doing. 5. On 2/7/19 at 1:45 p.m., the manager from a local business, located 6.1 miles east of the facility, called the facility and spoke to the Assistant Business Office Manager (Staff CC) and let her know that Resident #108 was at their place of business. Resident #108 appeared confused and the local business representative requested for them to come and pick him up. 6. On 2/7/19 at 1:47 p.m., the Risk Manager, DON and the NHA were notified by Staff CC of the conversation with the local business manager and that Resident #108 eloped off the property. 7. On 2/7/19 at around 1:49 p.m., the NHA sent Staff CC and the Business Office Manager to go and pick up Resident #108, via automobile. 8. On 2/7/19 at around 2:00 p.m., the Business Office Manager and Staff CC arrived at the local business. They found that Resident #108 was confused, but not presenting with any injuries or signs of dehydration. They put Resident #108 in the car and drove back to the facility immediately. 9. On 2/7/19 at around 2:00 p.m., the NHA started an investigation and immediate reporting related to Resident #108 ' s elopement. She took a statement from Staff AA, Receptionist who was responsible for monitoring the front entrance and allowing residents/visitors to enter and exit the building by pressing a button located at the reception desk. The NHA stated the receptionist was immediately suspended. Additional staff was interviewed (no specifics provided), and the Missing Persons action plan related to elopement was put in place. 10. On 2/7/19 at around 2:30 p.m., the Business Office Manager, Staff CC, and Resident #108 arrived back at the facility. The resident was brought to the NHA ' s office for evaluation. Resident assessment revealed he was not presenting with any injuries or signs of dehydration, and he did not need to go to the hospital. Resident #108 was wearing long pants, shoes/socks, long sleeved shirt and a windbreaker jacket when he was picked up. Continued interview with the NHA, DON, and Risk Manager, on 2/8/19 confirmed that Resident #108 ' s whereabouts on 2/7/19 were unknown for a period of about 2.5 hours (11:15 a.m. to 1:45 p.m.) until a call was received from the local business. The facility had not identified that the resident was missing from the facility prior to this call. The NHA and Risk Manager indicated that they tried to question Resident #108 when he was brought back to the facility on [DATE]. They indicated that the resident told them he had taken off his electronic monitoring bracelet, but did not remember how. They asked the resident how he got out of the building, and how he got to the business. The Risk Manager and NHA indicated that the resident started to get agitated and said, I don ' t know. They asked the resident if he had eaten lunch, and he stated he had a hamburger and milk. When asked where he got the food from, the resident continued to be agitated and told them he was not going to tell them. Staff interviews conducted 2/8/19 to 2/14/19, with Resident #108 ' s assigned C.N.A. (Staff FF), Assistant Business Office Manager/Alternate Receptionist (Staff CC), Receptionist (Staff AA), the North and South 7:00 a.m. to 3:00 p.m. shift Unit Managers, Registered Nurse (Staff Q), CNA (Staff T), DON, Risk Manager, and the NHA, revealed Resident #108 did wear a clear hard rubber type wander electronic bracelet on his left ankle, prior to his elopement on 2/7/19. They also indicated that they were unaware of what time the wander device bracelet was removed from the resident ' s left ankle on 2/7/19 and by what means. It could not be determined if the resident had obtained scissors or some other item to remove the wander device as Resident #108 ' s room was approximately 8 feet from the nurses ' station, and he ambulated ad lib throughout the facility without direct supervision at the time of event. Additionally, it could not be determined if the device was removed when the resident was still inside the facility on 2/7/19 or after he exited the building, as the original wander device bracelet was never located. It was also unknown if the original wander device was functioning on 2/7/19 as Staff Q, RN stated, during interview on 2/12/19 at 7:30 a.m., that she did not check to see if the device was functioning by use of the transponder as ordered by the physician on the 11:00 p.m. – 7:00 a.m. shift, just prior to Resident 108 ' s elopement as she did not know how to check the functioning. A review of Staff Q ' s assignment for the 11-7 shift on 2/6/19 to 2/7/19 revealed Resident #108 was the only resident with an electronic wander device on her assignment. Interview with Staff Q on 2/12/19 at 7:30 a.m. revealed this was her usual assignment. Also, the DON provided evidence that the last Elopement training/in-service prior to this event was conducted on 9/13/18 for all staff as evidenced by the signature sheet provided. An attempt was made to interview Resident #108 on 2/8/19 at approximately 11:00 a.m. when asked if he had gone out the day before to do some business, he stated that he did not want to answer any questions. The resident ' s behavior was guarded and Resident did not wish to speak any further. On 2/13/19 at approximately 10:00 a.m., another attempt to talk to Resident #108 about the events of 2/7/19 was made. Again, he stated he didn ' t want to talk about it. The resident was found to exchange pleasantries and small talk with the Survey Agency but when the topic of him leaving the facility was mentioned, he became agitated and did not want to speak further. Two telephone attempts were made to interview Resident #108 ' s attending physician on 2/12/19 at approximately 11:00 a.m. and 2/13/19 at about 9:45 a.m. A message was left on both occasions and no return call was received. On 2/8/19 at approximately 2:00 p.m., a telephone interview was conducted with the manager of the local business where Resident #108 was found. The manager indicated that her staff noticed Resident #108 walking and rounding their building a couple of times before coming inside. She indicated that she knew Resident #108 as he had been a customer for over forty years, but she had not seen him for a while. She stated, the resident conducted a financial transaction at the business and appeared confused. The manager revealed that she spoke with the resident for a few minutes and realized he had paperwork in his hand with an address. She asked to look at the papers and noted that the address and name were that of the nursing facility. She knew at that point that Resident #108 was a resident at the facility and she began asking him questions. He told her that he just ate a hamburger, had a glass of milk and came to the business, but he did not know how he got there. The manager then called the nursing facility and spoke to staff to let them know Resident #108 was there, he appeared confused, and he did not know how he had gotten there. On 2/12/19 at 8:15 a.m., a telephone interview was obtained with the facility ' s regular weekday receptionist, Staff AA, who was currently at home on suspension. Staff AA confirmed she had worked at the facility as the front desk receptionist starting 11/14/18 and her normal working hours were 8:00 a.m. – 5:00 p.m. She also confirmed that she worked the front desk on 2/7/19. Staff AA revealed that she was aware of Resident #108 ' s elopement risk and that he wore an electronic monitoring bracelet. She indicated that Resident #108 routinely sat in the front lobby area, but in an area near her desk, and not the front doors. She indicated that he was not allowed to go outside but if he had the chance, he would. She revealed that he was easily re-directed when going up to the front entrance doors. Staff AA felt that Resident #108 would quietly watch the front doors looking for opportunities to get out, but he would not do it often. She indicated that she never reported the few opportunities of the resident scoping out the front doors and looking to exit the facility. She indicated that she did not tell staff because he was so easily re-directed. Staff AA revealed that on 2/7/19, she was manning the reception desk and when staff and visitors wanted to enter or exit the building, she had to physically press a button at the desk to open the doors. She indicated she worked on 2/7/19 until just before 12:00 p.m. Staff AA revealed Resident #108 was seated in a chair in the front lobby for most of the morning and at an unknown time, he walked back towards the main hallway. She assumed he was going to his room for lunch. She too left the desk to go to lunch and Staff CC took over for her. Staff AA indicated she returned back from lunch around 12:45 p.m. and sat at the front desk with Staff CC. She stated, they sat their together for a while going over business related tasks and at about 1:45 p.m. the phone at the desk rang. Staff CC answered the call from the local business. It was at that time that they both realized that Resident #108 was not at the facility and that he eloped to the business miles away. She indicated that Staff CC immediately reported the call to the NHA and a short time after that she was interviewed by the NHA who then suspended her pending an investigation. Staff AA was asked about her training related to elopement, missing persons, and resident signing out for Leave of Absence (LOA). Staff AA expressed that during her orientation she did not receive any formal training related to elopement, but only received the definition on elopement. She stated, she had not received any training on missing persons either during orientation. Staff AA stated, I took it upon myself to review the elopement book at the front desk and that is how I learned about elopement, missing person protocol and who the elopement risks were. Staff AA did say she received education training on 1/23/19 after another resident left LOA, did not sign out and never returned. She confirmed that was the only training she had. A review of Staff AA ' s personnel file, revealed an orientation checklist dated 11/20/18. Staff AA initialed and it was checked that she received training on: LOA, Elopement, Missing Residents, search protocols, and reporting. However, an interview on 2/11/19 at 8:45 a.m. with the DON, and NHA, revealed no documentation or evidence of the curriculum and knowledge check related to these trainings could be provided. On 2/12/19 at approximately 11:00 a.m., an interview with Staff CC revealed she took over receptionist duties just before 12:00 p.m. on 2/7/19, while Staff AA went to lunch. Staff CC revealed she did not remember seeing Resident #108 during that time and had not seen him the entire time she was manning the desk. Staff CC knew Resident #108 was an elopement risk and that he usually sat in a chair in the front lobby. She indicated that he had never presented with any exit seeking behaviors during the times she manned the front reception desk. She also was aware of the other facility residents who were elopement risks and the elopement book which was kept at the front desk with information relating to these residents. Staff CC revealed she had received LOA, Missing Persons, and Elopement training upon hire 7/2018, and most recently on 9/13/18 and again on 1/24/19. She explained that when Staff AA returned from lunch around 12:45 p.m. on 2/7/19, they both sat at the front desk and went over work related tasks for a while. Staff CC answered the phone around 1:45 p.m. and it was the local business manager, who indicated Resident #108 was there. This was when she realized Resident #108 eloped. She spoke to the NHA immediately and she and the Business Office Manager were sent to the business to pick up Resident #108. She stated that on arrival to the business, Resident #108 did not present with any signs of dehydration or injuries. She indicated he was asked how he got there and he said he did not know. Staff CC revealed that Resident #108 was very elusive and did not want to answer any questions. She stated, they brought Resident #108 back to the facility without any problems. On 2/20/19 at 3:52 p.m., a telephone interview was conducted with Resident #108 ' s sister, who was listed as the emergency contact on the Admission Record contained in the clinical record. Resident #108 ' s sister indicated she does not live too far from the facility, but she does not visit often. Resident #108 ' s sister stated that he stays at the nursing facility because he has dementia. She further indicated, she mostly has phone conversations with Resident #108 and was not involved with his care and services at this time due to other family responsibilities she was tending to. She confirmed that staff called her on 2/7/19 to let her know that he eloped from the facility and was brought back safely. She was upset to hear that he got out of the facility, but happy he was back. Interview with Staff Q, RN on 2/12/19 at 7:30 a.m. indicated she worked the 11:00 p.m. to 7:00 a.m. shift on 2/6/19 to 2/7/19. She indicated that Resident #108 was wearing his electronic monitoring bracelet during that shift when she checked for placement of the device, but she did not check the function of the battery with a transponder. She indicated, she never received training on how to check the function of the electronic monitoring bracelets and therefore did not check to see if it was working or not. She revealed that Resident #108 would routinely pace up and down the hallways and would go to the front lobby and sit in a chair. She did not recall if he presented with any exit seeking behaviors during her shifts. A review of the Treatment Administration Record for (MONTH) and (MONTH) of 2019 revealed she had initialed off on the functioning and placement of the electronic monitoring device. On 2/11/19 at approximately 8:30 a.m., an interview was conducted with Staff FF, CNA, who has been employed by the facility since 6/24/03. Staff FF revealed she routinely cared for Resident #108 on her 7:00 a.m. – 3:00 p.m. shift assignment, and she did have him on her assignment on 2/7/19. She indicated, he ate breakfast that morning, and he usually goes and sits in the front lobby the rest of the morning. She did see him in the front lobby around 8:30 a.m./9:00 a.m. Staff FF indicated she spoke with him a few times and he did not need anything. Staff FF indicated that on 2/7/19 around 11:00 a.m. - 11:15 a.m., she went to the main dining room as assigned to help with the lunch meal service. Staff FF revealed that she stayed in the dining room until sometime after 12:00 p.m. and then went right to her lunch break. Staff FF revealed she did not return from lunch on 2/7/19 until just before 1:00 p.m. Staff FF explained that the staff on the floor who pass meal trays and assist with lunch in resident rooms were usually responsible to check on her residents. She did not know if anyone saw Resident #108 during the lunch service on 2/7/19. She did find out that a staff member (name unknown) had placed Resident #108's lunch meal tray in his room and did not check to see where he was. Staff FF indicated that the floor staff

Based on observations, medical record review, policy and procedure review and interviews with the facility ' s nursing and administrative staff and a local business manager, the facility failed to ensure one (#108) of five identified elopement risk residents received supervision to prevent elopement and failed to ensure the application and functioning of a physician ordered monitoring device to prevent exit from the facility. Resident #108, an [AGE] year old male, was identified by the facility as a known elopement risk with [DIAGNOSES REDACTED]. On the morning of 2/7/19, Resident #108, removed his electronic monitoring bracelet and exited the facility without detection by facility staff. When a business, 6.1 miles away, contacted the facility front desk some 2.5 hours later, facility staff realized Resident #108 was missing. The facility failed to follow their Elopement Prevention policy and procedure to include making regular rounds to ensure the safety of residents and failed to monitor the placement and function of an electronic wander device used to alert staff of attempts by Resident #108 to exit the facility. This resulted in findings of Immediate Jeopardy, occurring on 2/7/19 and removed on 2/14/19 with the scope and severity reduced to a D. Findings included: On 2/7/19 at approximately 6:00 a.m., a survey team entered the facility to conduct complaint investigations, including an allegation related to supervision/elopement. On 2/8/19 at 8:15 a.m., the Nursing Home Administrator (NHA) notified the survey team of an incident that occurred on 2/7/19. The NHA revealed that Resident #108 eloped from the facility on 2/7/19 around 11:45 a.m.-12:00 p.m. She stated that the preliminary investigation indicated that somehow the resident removed his electronic monitoring bracelet, made it to the front door and somehow staff let him out. Resident #108 eloped off the facility property and at approximately 1:45 p.m. on 2/7/19 a local business, 6.1 miles away from the facility, called and notified the staff that Resident #108 was there. The business representative indicated that the resident was confused, he had paperwork with the facility ' s address and phone number, and he needed to be picked up. The NHA indicated that they started their Elopement protocol and Missing Persons action plan prior to him getting back to the facility, but were unaware that he was missing from the facility prior to receiving the call from the local business. She indicated that she sent two employees to go pick him up. The NHA revealed that upon his return on 2/7/19 around 2:30 p.m., Resident #108 was immediately brought to the NHA ' s office where the Director of Nursing (DON), Risk Manager and other nursing staff medically assessed him and found no signs or symptoms of dehydration, injuries or pain. She stated that he was not in need of hospitalization . She further indicated that she had already made calls to Resident #108 ' s physician and family. The NHA stated that Resident #108 was immediately placed on 1:1 supervision upon return to the facility, the front doors were being manned twenty-four hours a day by designated staff, and the four additional elopement/exit seeking residents were checked for placement and functioning of their electronic monitoring bracelets. She indicated that Resident #108 received a new electronic monitoring bracelet upon his return. Observation of the front-entrance door area on 2/7/19 at 6:07 a.m. revealed two large electronic sliding doors, which allow staff, visitors, and residents to enter and exit. The door must be opened, either by pressing a button at the reception desk or using a key code pad on the wall near the door. Upon entering the doors, there were two half-wall partitions with plastic bars on the sides of each wall, which were part of the electronic alarm system. When reaching approximately three feet from the door, the alarm will sound for those who were wearing electronic bracelets. About twenty feet inside from the sliding doors was a reception desk. This desk was in direct view of the doors and was manned by staff at designated times who answer phones and let people in and out of the electronic doors. Interview with the NHA on 2/8/19 at 9:48 a.m. revealed there were nine exits in the building, and all doors were locked with key pads. The NHA explained that the front lobby reception desk area was manned Mondays through Fridays from 8:00 a.m. to 8:00 p.m. She also indicated that on Saturday and Sunday, the reception desk was manned during the same times from 8:00 a.m. to 8:00 p.m. The NHA revealed that after-hours, from 8:00 p.m. to 8:00 a.m., Monday through Sunday, the Leave Of Absence (LOA) sign out book was given to the head nurse. During after-hours, the head nurse holds responsibility for maintaining the book and ensuring residents, who can go on LOA, sign and fill out the LOA book sheets properly. She also indicated that it was the head nurse ' s duty to know the general whereabouts of residents at all times. On 2/8/19 at 9:00 a.m., the NHA, Director of Nursing (DON), Risk Manager and two regional staff members provided a preliminary timeline related to Resident #108 ' s elopement from the facility on 2/7/19. The timeline was verbalized as follows: 1. On 2/7/19, Resident #108 was seen at around 8:00 a.m. for breakfast and provided his meal. After breakfast, around 8:30 a.m., Resident #108 ambulated to the front lobby area and sat in a chair next to the reception table, as he does routinely. From around 8:30 a.m. until 11:15 a.m., Resident #108 was seated in the lobby. 2. Risk Manager and NHA indicated that an agency nurse (staff EE), Licensed Practical Nurse (LPN) provided medications to the resident on 2/7/19 at 11:15 a.m. 3. After receiving his medications on 2/7/19 at 11:15 a.m., it was unclear where Resident #108 was or if he was wearing his electronic monitoring bracelet at that time. 4. On 2/7/19 from 11:15 a.m. through until 1:45 p.m., there was no evidence or interviews to support the whereabouts of Resident #108 and what he was doing. 5. On 2/7/19 at 1:45 p.m., the manager from a local business, located 6.1 miles east of the facility, called the facility and spoke to the Assistant Business Office Manager (staff CC) and let her know that Resident #108 was at their place of business. Resident #108 appeared confused and the local business representative requested for them to come and pick him up. 6. On 2/7/19 at 1:47 p.m., the Risk Manager, DON and the NHA were notified by staff CC of the conversation with the local business manager and that Resident #108 eloped off the property. 7. On 2/7/19 at around 1:49 p.m., the NHA sent staff CC and the Business Office Manager to go and pick up Resident #108, via automobile. 8. On 2/7/19 at around 2:00 p.m., the Business Office Manager and staff CC arrived at the local business. They found that Resident #108 was confused, but not presenting with any injuries or signs of dehydration. They put Resident #108 in the car and drove back to the facility immediately. 9. On 2/7/19 at around 2:00 p.m., the NHA started an investigation and immediate reporting related to Resident #108 ' s elopement. She took a statement from staff AA, receptionist who was responsible for monitoring the front entrance and allowing residents/visitors to enter and exit the building by pressing a button located at the reception desk. The NHA stated the receptionist was immediately suspended. Additional staff was interviewed (no specifics provided), and the Missing Persons action plan related to elopement was put in place. 10. On 2/7/19 at around 2:30 p.m., the Business Office Manager, staff CC, and Resident #108 arrived back at the facility. The resident was brought to the NHA ' s office for evaluation. Resident assessment revealed he was not presenting with any injuries or signs of dehydration, and he did not need to go to the hospital. Resident #108 was wearing long pants, shoes/socks, long sleeved shirt and a windbreaker jacket when he was picked up. Continued interview with the NHA, DON, and Risk Manager, on 2/8/19 confirmed that Resident #108 ' s whereabouts on 2/7/19 were unknown for a period of about 2.5 hours (11:15 a.m. to 1:45 p.m.) until a call was received from the local business. The facility had not identified that the resident was missing from the facility prior to this call. The NHA and Risk Manager indicated that they tried to question Resident #108 when he was brought back to the facility on [DATE]. They indicated that the resident told them he had taken off his electronic monitoring bracelet, but did not remember how. They asked the resident how he got out of the building, and how he got to the business. The Risk Manager and NHA indicated that the resident started to get agitated and said, I don ' t know. They asked the resident if he had eaten lunch, and he stated he had a hamburger and milk. When asked where he got the food from, the resident continued to get agitated and told them he was not going to tell them. Follow-up interviews with the NHA, Risk Manager and the DON on the morning of 2/8/19 revealed they were still in the early stages of their investigation and it was unclear how Resident #108 got to the local business. A review of an Internet Map Program showed the business was 6.1 miles east of the facility. On route to the business, from the facility, the roads varied from a 2 lane residential neighborhood to a 6 lane major thoroughfare leading in and out of downtown Saint Petersburg. At least seven major intersections of four lanes or greater were present along the route to the local business where the resident was located. Traffic at the time of day for which the resident was unaccounted for would be moderate to heavy in some areas. Internet Map Program indicated this was a two hour and forty-seven minute walk from the nursing facility to the business. By automobile, it was approximately 20 minutes or greater depending on the flow of traffic and traffic lights. By public transportation (bus), it was approximately a one hour trip. General observations of Resident #108 from 2/7/19 to 2/14/19 revealed the resident walked without assistance at a very slow pace with very little stride. An attempt was made to interview Resident #108 on 2/8/19 at approximately 11:00 a.m. Resident #108 was, initially ok with being interviewed, but when asked if he had gone out the day before to do some business, he stated that he did not want to answer any questions. The resident was guarded and did not wish to speak any further. On 2/13/19 at approximately 10:00 a.m., another attempt to talk to Resident #108 about the events of 2/7/19 was made. Again, he stated he didn ' t want to talk about it. The resident was found to exchange pleasantries and small talk but when the topic of him leaving the facility was mentioned, he became agitated and did not want to speak further. Two telephone attempts were made to interview Resident #108 ' s attending physician on 2/12/19 at approximately 11:00 a.m. and 2/13/19 at about 9:45 a.m. A message was left on both occasions and no return call was received. On 2/8/19 at approximately 2:00 p.m., a telephone interview was conducted with the manager of the local business where Resident #108 was found. The manager indicated that her staff noticed Resident #108 walking and rounding their building a couple of times before coming inside. She indicated that she knew Resident #108 as he had been a customer for over forty years, but she had not seen him for a while. She stated, the resident conducted a financial transaction at the business and appeared confused. The manager revealed that she spoke with the resident for a few minutes and realized he had paperwork in his hand with an address. She asked to look at the papers and noted that the address and name were that of the nursing facility. She knew at that point that Resident #108 was a resident at the facility and she began asking him questions. He told her that he just ate a hamburger, had a glass of milk and came to the business, but he did not know how he got there. The manager then called the nursing facility and spoke to staff to let them know Resident #108 was there, he appeared confused, and he didn ' t know how he had gotten there. Interview with the Risk Manager on 2/14/19 at around 10:00 a.m., revealed she had spoken with the business manager and was able to verify through their property cameras that Resident #108 got out of a white colored vehicle. It was still unclear when and where Resident #108 got into that vehicle. It was also unclear who the driver of that vehicle was. The Risk Manager verified that Resident #108 ' s family member does not drive a white colored vehicle. On 2/12/19 at 8:15 a.m., a telephone interview was obtained with the facility ' s regular weekday receptionist, staff AA, who was currently at home on suspension. Staff AA confirmed she had worked at the facility as the front desk receptionist starting 11/14/18 and her normal working hours were 8:00 a.m. – 5:00 p.m. She also confirmed that she worked the front desk on 2/7/19. Staff AA revealed that she was aware of Resident #108 ' s elopement risk and that he wore an electronic monitoring bracelet. She indicated that Resident #108 routinely sat in the front lobby area, but in an area near her desk, and not the front doors. She indicated that he was not allowed to go outside but if he had the chance, he would. She revealed that he was easily re-directed when going up to the front entrance doors. Staff AA felt that Resident #108 would quietly watch the front doors looking for opportunities to get out, but he would not do it often. She indicated that she never reported the few opportunities of the resident scoping out the front doors and looking to exit the facility. She indicated that she did not tell staff because he was so easily re-directed. Staff AA revealed that on 2/7/19, she was manning the reception desk and when staff and visitors wanted to enter or exit the building, she had to physically press a button at the desk to open the doors. She indicated she worked on 2/7/19 until just before 12:00 p.m. Staff AA revealed Resident #108 was seated in a chair in the front lobby for most of the morning and at an unknown time, he walked back towards the main hallway. She assumed he was going to his room for lunch. She too left the desk to go to lunch and Staff CC took over for her. Staff AA indicated she returned back from lunch around 12:45 p.m. and sat at the front desk with Staff CC. She stated, they sat their together for a while going over business related tasks and at about 1:45 p.m. the phone at the desk rang. Staff CC answered the call from the local business. It was at that time that they both realized that Resident #108 was not at the facility and that he eloped to the business miles away. She indicated that Staff CC immediately reported the call to the NHA and a short time after that she was interviewed by the NHA who then suspended her pending an investigation. Staff AA was asked about her training related to elopement, missing persons, and resident signing out for Leave of Absence (LOA). Staff AA expressed that during her orientation she did not receive any formal training related to elopement, but only received the definition on elopement. She stated, she had not received any training on missing persons either during orientation. Staff AA stated, I took it upon myself to review the elopement book at the front desk and that is how I learned about elopement, missing person protocol and who the elopement risks were. Staff AA did say she received education training on 1/23/19 after another resident left LOA, did not sign out and never returned. She confirmed that was the only training she had. A review of Staff AA ' s personnel file, revealed an orientation checklist dated 11/20/18. Employee AA initialed and it was checked that she received training on: LOA, Elopement, Missing Residents, search protocols, and reporting. However, interview with the DON, and NHA, revealed no documentation or evidence of the curriculum and knowledge check related to these trainings could be provided. The DON provided documentation of the last in-service training on the Elopement policy and procedure to all staff on 9/13/18, prior to the 2/7/19 event. Additional documentation dated 1/25/19 revealed in-service training was conducted on the facility LOA books for the three receptionists only, which included staff AA. On 2/12/19 at approximately 11:00 a.m., an interview with Staff CC revealed she took over receptionist duties just before 12:00 p.m. on 2/7/19, while Staff AA went to lunch. Staff CC revealed she did not remember seeing Resident #108 during that time and had not seen him the entire time she was manning the desk. Staff CC knew Resident #108 was an elopement risk and that he usually sat in a chair in the front lobby. She indicated that he had never presented with any exit seeking behaviors during the times she manned the front reception desk. She also was aware of the other facility residents who were elopement risks and the elopement book which was kept at the front desk with information relating to these residents. Staff CC revealed she had received LOA, Missing Persons, and Elopement training upon hire 7/2018, and most recently on 9/13/2018 and again on 1/24/2019. She explained that when staff AA returned from lunch around 12:45 p.m. on 2/7/19, they both sat at the front desk and went over work related tasks for a while. Staff CC answered the phone around 1:45 p.m. and it was the local business manager, who indicated Resident #108 was there. This was when she realized Resident #108 eloped. She spoke to the NHA immediately and she and the Business Office Manager were sent to the business to pick up Resident #108. She stated that on arrival to the business, Resident #108 did not present with any signs of dehydration or injuries. She indicated he was asked how he got there and he said he did not know. Staff CC revealed that Resident #108 was very elusive and did not want to answer any questions. She stated, they brought Resident #108 back to the facility without any problems. On 2/20/19 at 3:52 p.m., a telephone interview was conducted with Resident #108 ' s sister, who was listed as the emergency contact on the Admission Record contained in the clinical record. Resident #108 ' s sister indicated she does not live too far from the facility, but she does not visit often. Resident #108 ' s sister stated that he stays at the nursing facility because he has dementia. She further indicated, she mostly has phone conversations with Resident #108 and was not involved with his care and services at this time due to other family responsibilities she was tending to. She confirmed that staff called her on 2/7/19 to let her know that he eloped from the facility and was brought back safely. She was upset to hear that he got out of the facility, but happy he was back. A medical record review for Resident #108 revealed an Admission Record that noted he was admitted to the facility for long term care services on 10/30/18. Review of the advanced directives revealed Resident #108 was his own decision maker and had a sister who was listed as an emergency contact. Review of the electronic cumulative [DIAGNOSES REDACTED]. Review of the current physician's order [REDACTED]. a. Electronic Bracelet for safety – check placement every shift and located on person on left ankle, every shift for prevention. Initial order date was 12/7/18. b. Resident requires an electronic bracelet for safety due to poor safety awareness and wandering behavior. Initial order date was 11/1/18. c. Electronic bracelet for safety – check functioning daily on 11-7 shift every night shift replace if not working correctly. Initial order date was 11/1/18. d. (MONTH) go on Leave of Absence with escort and without medications. Initial order date was 10/31/18. A review of a Hospital Consultation and History and Physical form dated 10/27/18, 3 days prior to admission, revealed Resident #108 was found walking into traffic, confused, was unaware of where he was or current events, and was hospitalized involuntarily due to this dangerous behavior. Review of the nursing facility ' s Admission Data Collection assessment dated [DATE], revealed Resident #108 exhibited elopement risk factors to include wandering, utilized an electronic monitoring bracelet and had an interim care plan with a focus area to include elopement risk. The goal of the care plan was: Resident will not exit the facility without staff knowledge and staff will monitor whereabouts on an ongoing basis. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident did not present with any behaviors to include wandering, requires supervision with set up only and independent with Activities of Daily Living (ADLs). Resident only required extensive assistance with Dressing, Hygiene and Toileting. Review of the most current MDS Quarterly assessment dated [DATE], revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The assessment documented no behaviors to include wandering, and the resident was coded as supervision only with all ADLs. Review of the nurse progress notes dated 10/30/18 to 2/14/19 revealed the following: - 12/2/18 16:22 (4:22 p.m.) – Resident noted to continue to pace from room . to nurse station. - 2/1/19 06:16 (6:16 a.m.) – Resident is at risk for wandering, electronic bracelet on for safety. - 2/7/19 13:45 (1:45 p.m.) – Resident was identified to be at a local business and assisted back to the facility by staff. Resident is independently ambulatory and stated he went to the business via taxi. Resident returned without any complaints of pain or no signs and symptoms of distress. Physician and family notified same. - 2/8/19 10:00 (10:00 a.m.) – Care plan meeting held with resident, he wants to remain full code, no significant changes noted. - 2/9/19 12:46 (12:46 p.m.) – Resident remains 1:1 supervision. Resident is alert, stable and able to make needs known. Resident took and tolerated all meds well. Electronic monitoring device on right wrist, in working order. Monitoring checks completed. - 2/9/19 18:54 (6:54 p.m.) – Resident remains 1:1 supervision. Resident is alert, stable and able to make needs known. Resident took and tolerated all meds well. Electronic monitoring device on right wrist, in working order. Monitoring checks completed. Review of the Certified Nursing Assistant (CNA) ADL flow sheet for the month of (MONTH) 2019 revealed Resident #108 was independent with eating. The flow sheet documented on 2/7/19 at 11:30 a.m., resident did not have a lunch tray and resident was not available. Review of Resident #108 ' s active care plans with next review date of 4/25/19 revealed the following problem areas to include, but not limited to: · Elopement (initiated 10/31/18) - Resident is an elopement risk/wanderer as evidenced by resident presents with cognitive impairments and is independently mobile, resident wanders aimlessly, impaired safety awareness with interventions (implemented 10/31/18) to include: 1. Use audible alarm system to alert staff to exit seeking behaviors every shift (qs), 2. Educate resident/responsible party regarding the sign out procedure, 3. Identify pattern of wandering, 4. Psych services as needed, 5. Family available to be called if distressed or exit seeking, 6. Electronic Bracelet, 7. Verify placement Q shift and Verify functioning with transponder q24h, 8. Assess for fall risk, and 9. Monitor for fatigue and weight loss. · Fall (Initiated on 10/31/18) - Resident is at Risk for falls or fall related injury because of: Psychoactive drug use, Unaware of safety needs, with interventions to include, but not limited to: Remind resident and reinforce safety awareness. · Incontinence (Initiated on 11/16/18): The resident is Incontinent of Bladder and is not a candidate for a toileting program related to: Involuntary or unpredictable bladder elimination, with interventions to include, but not limited to: Check for incontinence with routine care, upon arising, before and after mealtime, at bedtime and as needed. · Cognition (initiated 11/16/18) - Resident has impaired cognitive function, impaired thought process r/t severely impaired: Dementia with interventions to include, but not limited to: Cue, reorient and supervise as needed. · Discharge Planning (initiated 11/6/18) - Resident wishes to remain long term care · ADLs (initiated 11/6/18) - Self-care performance deficit cannot complete ADL tasks independently and requires individualized interventions to improve function with interventions in place. Interview with Staff Q, Registered Nurse (RN) on 2/12/19 at 7:30 a.m. indicated she worked the 11:00 p.m. to 7:00 a.m. shift on 2/6/19 to 2/7/19. She indicated that Resident #108 was wearing his electronic monitoring bracelet during that shift when she checked for placement of the device, but she did not check the function of the battery with a transponder. She indicated, she never received training on how to check the function of the electronic monitoring bracelets and therefore did not check to see if it was working or not. She revealed that Resident #108 would routinely pace up and down the hallways and would go to the front lobby and sit in a chair. She does not recall if he presented with any exit seeking behaviors during her shifts. A review of the Treatment Administration Record for (MONTH) and (MONTH) of 2019 revealed she had initialed off on the functioning and placement of the electronic monitoring device. On 2/11/19 at approximately 8:30 a.m., an interview was conducted with Staff FF, Certified Nursing Assistant (CNA), who has been employed by the facility since 6/24/03. Staff FF revealed she routinely cared for Resident #108 on her 7:00 a.m. – 3:00 p.m. shift assignment, and she did have him on her assignment on 2/7/19. She indicated, he ate breakfast that morning, and he usually goes and sits in the front lobby the rest of the morning. She did see him in the front lobby around 8:30 a.m./9:00 a.m. Staff FF indicated she spoke with him a few times and he did not need anything. Staff FF indicated that on 2/7/19 around 11:00 a.m. - 11:15 a.m., she went to the main dining room as assigned to help with the lunch meal service. Staff FF revealed that she stayed in the dining room until sometime after 12:00 p.m. and then went right to her lunch break. Staff FF revealed she did not return from lunch on 2/7/19 until just before 1:00 p.m. Staff FF explained that the staff on the floor who pass meal trays and assist with lunch in resident rooms were usually responsible to check on her residents. She did not know if anyone saw Resident #108 during the lunch service on 2/7/19. She did find out that a staff member (name unknown) had placed Resident #108's lunch meal tray in his room and did not check to see where he was. Staff FF indicated that the floor staff likely knew Resident #108 did not need assistance with his meal, and that may be the reason they placed the tray in the room and left. She indicated she had Elopement and Missing Person training on orientation and routinely over the years that she has been employed at the facility. Staff FF revealed that during her shifts, Resident #108 had not presented with eloping or exit seeking behaviors. She further explained that he usually just sat in the front lobby next to the reception desk. On 2/12/19 at approximately 1:00 p.m., an interview was obtained with a service technician that maintained the facility ' s electronic wander guard alarm system. He indicated, the alarm systems that were both at the front door and the back smoking patio were functioning per the manufacturer ' s specifications. He added that the front door operated in a way that when a person who wears an electronic wander bracelet comes to the front door, the door remained locked but would not alarm. He indicated it was set up this way so an audible alarm would not sound every time the electronic bracelet was in the area. He confirmed that even in this setting, the system was still working effectively. The technician stated that the Nursing Home Administrator asked him to change the settings back on 2/12/19 so the alarm would sound when the bracelet was in the area within two to three feet from the door. He indicated, and by reviewing his report, that he changed the hertz settings and transmitters to accommodate the Administrator ' s request. The technician could not speak to the actual electronic bracelets worn by the residents as he was not at the facility to service or maintain those. Observation of the door and alarm operation was made on 2/7/19, prior to the service technician ' s visit and again, on 2/12/19, after his visit. The door and alarm were operating properly in the manner stated by the technician on both occasions. The alarm was sounding to notify staff of residents wearing wander guard bracelets of a possible attempt to exit the doors when breaking the threshold. Interview with the NHA on 2/12/19 at approximately 1:30 p.m. revealed she did not work in the facility when the wander guard system was originally installed and the settings were chosen. The NHA indicated that the system may have originally been set up to only alarm when the door was open so residents and visitors in the therapy gym, located near the front doors, would not be bothered by an alarm going off every time the bracelet was in the vicinity. She confirmed that she asked the technician to change the settings so that the alarm would sound anytime a resident with a wander guard device approached the exit doors regardless of the open or closed door position. Staff interviews conducted 2/8/19 – 2/14/19, with Resident #108 ' s assigned C.N.A. (Staff FF), Assistant Business Office Manager/Alternate Receptionist (Staff CC), Receptionist (Staff AA), the North and South 7-3 shift Unit Managers, Registered Nurse (Staff Q), CNA (Staff T), DON, Risk Manager, and the NHA, revealed Resident #108 did wear a clear hard rubber type wander electronic bracelet on his left ankle, prior to his elopement on 2/7/19. They also indicated that they were unaware of what time the wander guard bracelet was removed on 2/7/19 and by what means. It could not be determined if the resident had obtained scissors or some other item to remove the wander guard device as Resident #108 ' s room was approximately 8 feet from the nurses station, and he ambulated ad lib throughout the facility without direct supervision at the time of event. Additionally, it could not be determined if the device was removed when the resident was still inside the facility on 2/7/19 or after he exited the building as the original wander guard bracelet was never located. It was also unknown if the original wander device was functioning on 2/7/19 as Staff Q stated, during interview on 2/12/19 at 7:30 a.m., that she did not check to see if the device was operational as ordered by the physician on the 11:00 p.m. – 7:00 a.m. shift just prior to his elopement as she did not know how to check the functioning. Interview and observation with the DON, on 2/11/19 at around 5:00 p.m., revealed he used a transponder to test the wander bracelets. He pushed the button on the transponder while placing it near the bracelet. It announced with an alarm and green light to indicate that the bracelet battery was functioning. During this time, all five resident electronic bracelets were tested and verified as functioning, per the transponder. The DON further explained that he had to replace Resident #108 ' s lost electronic bracelet on 2/7/19 with one he obtained from a sister facility as he didn '

Based on observation, interview with facility administration, nursing staff, family members, an attending physician, and a local business manager and record review to include medical records, policies and procedures and administrative job descriptions, the facility failed to utilize its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being for one (#108) of five sampled elopement risk residents and one (#460) of 56 facility residents sampled with orders to sign out independently. Resident #108, an [AGE] year old male, who was identified by the facility as a known elopement risk with [DIAGNOSES REDACTED]. Approximately 2.50 hours after the resident was last observed by staff, a phone call was received from a business, 6.1 miles away, informing the facility that the resident was present in their building. Facility staff were unaware that the resident had left their facility until the time of this call and had no knowledge of the resident ' s whereabouts. Facility administration failed to define, consistently provide staff training and have systems in place to ensure regular rounds were conducted for elopement risk residents and failed to ensure electronic monitoring systems were in place and functioning as indicated in the Elopement prevention policy and procedure. Additionally, the facility failed to ensure the facility ' s Leave of Absence (LOA) policy and procedure was followed, and facility administration failed to fully operationalize the Missing Resident/Patient Action Plan policy and procedure for Resident #460. On the morning of 1/23/19, Resident #460 reported to staff that he was going out for the day, but did not sign out on the LOA log per facility policy and procedure. Resident #460 did not return to the facility on [DATE] after leaving that morning. Administration did not determine the resident ' s whereabouts and conduct a full investigation of the incident involving Resident #460. This resulted in findings of Immediate Jeopardy, occurring on 2/7/19 and removed on 2/14/19 with the scope and severity reduced to a D. Findings included: 1. A review of the administrative job descriptions revealed: Nursing Home Administrator, dated 3/2017. Summary of Position: The Nursing Home Administrator as a member of the Facility Managing Board is responsible and accountable for the Facility Quality Assurance Performance Improvement (QAPI) for all aspects of the Facility including but not limited to; quality of care, quality of life, regulatory compliance, compliance/ethics, business development and financial stewardship. Essential duties to include, but not limited to: - Enacts, implements and enforces the facility policies regarding the management and operation of the facility. - Analyzes quality of care, quality of life, compliance, regulatory and other management reports to determine the appropriate management interventions needed then implements the interventions resulting in improved outcomes. - Implements facility communications to ensure that employees, residents, and families are well informed regarding issues affecting them. - Provides supervision either directly or indirectly to all facility employees including the selection, hiring, orientation, training and coaching of employees. - Identifies facility needs or issues and obtains consulting assistance, as needed, in the root-cause analysis, recommendation for improvement, education assistance or monitoring. Director of Nursing, no date documented. Summary of Position: The Director of Nursing (DON) is responsible for developing, organizing, evaluating and administering patient care programs and services of the Skilled Nursing centers. The DON has twenty four (24) hours responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Essential duties to include, but not limited to: - Leads, organizes, evaluates, and manages nursing and clinical personnel through sound management practices and delegation. - Makes daily patient rounds with the appropriate manager/supervisor(s) to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. - Ensure compliance with applicable local, state, federal and other regulatory agencies and quality assurance standards, certifications and licensure requirements. - Attends regularly conducted staff meetings and participates regularly in continuing education training programs. - Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. Leads and manages the General and Restorative Nursing Services on a 24 hour basis to ensure the delivery of high quality comprehensive patient care. - Continually works to assure compliance to all applicable State and Federal regulation. - Leads and participates in Quality Improvement activities to improve facility services. Risk Manager, no date documented. Summary of Position: The Risk Manager is responsible for planning organizing and coordinating all aspects of the Clinical Risk Management program within the facility. The Risk Manager collaborates with the Nursing Home Administrator, Facility Staff, Physicians, Residents and Families to make available the provision of quality care by the identification of potential and actual problems with subsequent formulation of solutions to alleviate these problems through the facilities internal risk management/quality assurance program. Essential duties to include, but not limited to: - Responsible for implementation and oversight of the facility ' s Risk Management/Quality Assurance program. - Investigate and analyze the frequency and causes of general categories and specific types of resident incidents. - Develops and participates in the implementation of a facility specific risk management reduction plan through the Risk Management/Quality Assurance committee and PI teams. - The development of appropriate measures to minimize the risk of incidents to residents, including, but not limited to, education and training in risk management and risk prevention for personnel. - Provide intervention and education related to risk management issues to promote safe work practices and quality care and series in an environment that is beneficial to the safety, health and wellbeing of all patients, visitors and facility staff. - Responsible for establishing and monitoring methods to avoid, eliminate and /or reduce risk associated with the provision of patient care and services. - Communicate potential risk management and claims issues to the appropriate facility leadership members. - Reporting of resident events to the appropriate authorities to maintain compliance with State and Federal regulations. - Ensure effective and efficient daily operations of the facility ' s risk management program. - Consults with other departments as appropriate to provide for resident care and performance improvement activities. - Plans, develops, and presents educational programs related to risk identification and avoidance. - Routinely review medical records to evaluate the course of treatment and identify issues related to a claim. A review of the facility ' s Elopement Prevention policy and procedure – not dated, revealed the following relevant information: The facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired residents and family. The facility will implement individualized interventions and strive to prevent elopement. (Guidelines included but not limited to): 6. Develop individualized interventions which may include, but are not limited to, the following: - Electronic Monitoring/alarm systems - Environmental modifications - Regular rounds - Staff interventions 9. Provide staff training as needed. On 2/7/19 at approximately 6:00 a.m., a survey team entered the facility and informed Administration of the purpose of the visit and the general nature of the complaint allegations. 2. On 2/8/19 at 8:15 a.m., the Nursing Home Administrator (NHA) notified the team of an elopement incident that occurred on 2/7/19, involving Resident #108. On 2/8/19 at 9:00 a.m., the NHA, DON, Risk Manager and two regional staff members provided a preliminary timeline related to Resident #108 ' s elopement from the facility on 2/7/19. The timeline was verbalized as follows: a. On 2/7/19, Resident #108 was seen at around 8:00 a.m. for breakfast and provided his meal. After breakfast, around 8:30 a.m., Resident #108 ambulated to the front lobby area and sat in a chair next to the reception table, as he does routinely. From around 8:30 a.m. until 11:15 a.m., Resident #108 was seated in the lobby. b. Risk Manager and NHA indicated that an agency nurse (Staff EE), Licensed Practical Nurse (LPN) provided medications to the resident on 2/7/19 at 11:15 a.m. c. After receiving his medications on 2/7/19 at 11:15 a.m., it was unclear where Resident #108 was or if he was wearing his electronic wander device at that time. d. On 2/7/19 from 11:15 a.m. to 1:45 p.m., there was no evidence or interviews to support the whereabouts of Resident #108 and what he was doing. e. On 2/7/19 at 1:45 p.m., the manager from a local business, located 6.1 miles east of the facility, called the facility and spoke to the Assistant Business Office Manager (Staff CC) and let her know that Resident #108 was at their place of business. Resident #108 appeared confused and the local business representative requested for them to come and pick him up. f. On 2/7/19 at 1:47 p.m., the Risk Manager, DON and the NHA were notified by Staff CC of the conversation with the local business manager and that Resident #108 eloped off the property. g. On 2/7/19 at around 1:49 p.m., the NHA sent Staff CC and the Business Office Manager to go and pick up Resident #108, via automobile. h. On 2/7/19 at around 2:00 p.m., the Business Office Manager and Staff CC arrived at the local business. They found that Resident #108 was confused, but not presenting with any injuries or signs of dehydration. They put Resident #108 in the car and drove back to the facility immediately. i. On 2/7/19 at around 2:00 p.m., the NHA started an investigation and immediate reporting related to Resident #108 ' s elopement. She took a statement from Staff AA, Receptionist who was responsible for monitoring the front entrance and allowing residents/visitors to enter and exit the building by pressing a button located at the reception desk. The NHA stated the receptionist was immediately suspended. Additional staff was interviewed (no specifics provided), and the Missing Persons action plan related to elopement was put in place. j. On 2/7/19 at around 2:30 p.m., the Business Office Manager, Staff CC, and Resident #108 arrived back at the facility. The resident was brought to the NHA ' s office for evaluation. Resident assessment revealed he was not presenting with any injuries or signs of dehydration, and he did not need to go to the hospital. Resident #108 was wearing long pants, shoes/socks, long sleeved shirt and a windbreaker jacket when he was picked up. Continued interview with the NHA, DON, and Risk Manager, on 2/8/19 confirmed that Resident #108 ' s whereabouts on 2/7/19 were unknown for a period of about 2.5 hours (11:15 a.m. to 1:45 p.m.) until a call was received from the local business. The facility had not identified that the resident was missing from the facility prior to this call. The NHA and Risk Manager indicated that they tried to question Resident #108 when he was brought back to the facility on [DATE]. They indicated that the resident told them he had taken off his electronic wander device, but did not remember how. They asked the resident how he got out of the building, and how he got to the business. The Risk Manager and NHA indicated that the resident started to get agitated and said, I don ' t know. They asked the resident if he had eaten lunch, and he stated he had a hamburger and milk. When asked where he got the food from, the resident continued to get agitated and told them he was not going to tell them. Follow-up interviews with the NHA, Risk Manager and the DON on the morning of 2/8/19 revealed they were still in the early stages of their investigation and it was unclear how Resident #108 got to the local business. A medical record review for Resident #108 revealed an Admission Record that noted he was admitted to the facility for long term care services on 10/30/18. Review of the electronic cumulative [DIAGNOSES REDACTED]. A review of a Hospital Consultation and History and Physical form dated 10/27/18, 3 days prior to admission, revealed Resident #108 was found walking into traffic, confused, was unaware of where he was or current events, and was hospitalized involuntarily due to this dangerous behavior. Review of the nursing facility ' s Admission Data Collection assessment dated [DATE], revealed Resident #108 exhibited elopement risk factors to include wandering, utilized an electronic wander device and had an interim care plan with a focus area to include elopement risk. The goal of the care plan initiated 10/31/18 was: Resident will not exit the facility without staff knowledge and staff will monitor whereabouts on an ongoing basis. Review of the current physician's order [REDACTED]. a. Electronic Bracelet for safety – check placement every shift and located on person on left ankle, every shift for prevention. Initial order date was 12/7/18. b. Resident requires an electronic bracelet for safety due to poor safety awareness and wandering behavior. Initial order date was 11/1/18. c. Electronic bracelet for safety – check functioning daily on 11-7 shift every night shift replace if not working correctly. Initial order date was 11/1/18. Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The assessment documented no behaviors to include wandering, and the resident was coded as supervision only with all ADLs. Review of the nurse progress notes dated 10/30/18 to 2/14/19 revealed the following: - 12/2/18 16:22 (4:22 p.m.) – Resident noted to continue to pace from room . to nurse station. - 2/1/19 06:16 (6:16 a.m.) – Resident is at risk for wandering, electronic bracelet on for safety. - 2/7/19 13:45 (1:45 p.m.) – Resident was identified to be at a local business and assisted back to the facility by staff. Resident is independently ambulatory and stated he went to the business via taxi. Resident returned without any complaints of pain or no signs and symptoms of distress. Physician and family notified same. Review of the Certified Nursing Assistant (CNA) ADL flow sheet for the month of (MONTH) 2019 revealed Resident #108 was independent with eating. The flow sheet documented on 2/7/19 at 11:30 a.m., resident did not have a lunch tray and resident was not available. Review of Resident #108 ' s active care plans with next review date of 4/25/19 revealed the following problem areas to include, but not limited to: · Elopement (initiated 10/31/18) - Resident is an elopement risk/wanderer as evidenced by resident presents with cognitive impairments and is independently mobile, resident wanders aimlessly, impaired safety awareness with interventions (implemented 10/31/18) to include: 1. Use audible alarm system to alert staff to exit seeking behaviors every shift qs (every shift), 2. Educate resident/responsible party regarding the sign out procedure, 3. Identify pattern of wandering, 4. Psych services as needed, 5. Family available to be called if distressed or exit seeking, 6. Electronic Bracelet, 7. Verify placement Q shift and Verify functioning with transponder q24h (every 24 hours), 8. Assess for fall risk, and 9. Monitor for fatigue and weight loss. · Fall (Initiated on 10/31/18) - Resident is at Risk for falls or fall related injury because of: Psychoactive drug use, Unaware of safety needs, with interventions to include, but not limited to: Remind resident and reinforce safety awareness. · Incontinence (Initiated on 11/16/18): The resident is Incontinent of Bladder and is not a candidate for a toileting program related to: Involuntary or unpredictable bladder elimination, with interventions to include, but not limited to: Check for incontinence with routine care, upon arising, before and after mealtime, at bedtime and as needed. · Cognition (initiated 11/16/18) - Resident has impaired cognitive function, impaired thought process r/t (related to) severely impaired: Dementia with interventions to include, but not limited to: Cue, reorient and supervise as needed. · ADLs (initiated 11/6/18) - Self-care performance deficit cannot complete ADL tasks independently and requires individualized interventions to improve function with interventions in place. On 2/8/19 at approximately 2:00 p.m., a telephone interview was conducted with the manager of the local business where Resident #108 was found. The manager indicated that her staff noticed Resident #108 walking and rounding their building a couple of times before coming inside. She indicated that she knew Resident #108 as he had been a customer for over forty years, but she had not seen him for a while. She stated, the resident conducted a financial transaction at the business and appeared confused. The manager revealed that she spoke with the resident for a few minutes and realized he had paperwork in his hand with an address. She asked to look at the papers and noted that the address and name were that of the nursing facility. She knew at that point that Resident #108 was a resident at the facility and she began asking him questions. He told her that he just ate a hamburger, had a glass of milk and came to the business, but he did not know how he got there. The manager then called the nursing facility and spoke to staff to let them know Resident #108 was there, he appeared confused, and he didn ' t know how he had gotten there. Interview with the Risk Manager on 2/14/19 at around 10:00 a.m., revealed she had spoken with the business manager and was able to verify through their property cameras that Resident #108 got out of a white colored vehicle. However, it was still unclear when and where Resident #108 got into that vehicle. It was also unclear who the driver of that vehicle was. The Risk Manager verified that Resident #108 ' s family member did not drive a white colored vehicle. A review of an Internet Map Program showed the business was 6.1 miles east of the facility. On route to the business, from the facility, the roads varied from a two lane residential neighborhood to a six lane major thoroughfare leading in and out of downtown Saint Petersburg. At least seven major intersections of four lanes or greater were present along the route to the local business where the resident was located. Traffic at the time of day for which the resident was unaccounted for would be moderate to heavy in some areas. Internet Map Program indicated this was a two hour and forty-seven minute walk from the nursing facility to the business. By automobile, it was approximately 20 minutes or greater depending on the flow of traffic and traffic lights. By public transportation (bus), it was approximately a one hour trip. General observations of Resident #108 from 2/7/19 to 2/14/19 revealed the resident walked without assistance at a very slow pace with very little stride. An attempt was made to interview Resident #108 on 2/8/19 at approximately 11:00 a.m. When asked if he had gone out the day before to do some business, Resident # 108 stated that he did not want to answer any questions. The resident was guarded and did not wish to speak any further. On 2/13/19 at approximately 10:00 a.m., another attempt to talk to Resident #108 about the events of 2/7/19 was made. Again, he stated he didn ' t want to talk about it. The resident was found to exchange pleasantries and small talk with the Survey Agency but when the topic of him leaving the facility was mentioned, he became agitated and did not want to speak further. Two telephone attempts were made to interview Resident #108 ' s attending physician on 2/12/19 at approximately 11:00 a.m. and 2/13/19 at about 9:45 a.m. A message was left on both occasions and no return call was received. On 2/12/19 at 8:15 a.m., a telephone interview was obtained with the facility ' s regular weekday receptionist, Staff AA, who was currently at home on suspension. Staff AA confirmed she had worked at the facility as the front desk receptionist starting 11/14/18 and her normal working hours were 8:00 a.m. – 5:00 p.m. She also confirmed that she worked the front desk on 2/7/19. Staff AA revealed that she was aware of Resident #108 ' s elopement risk and that he wore an electronic wander device. She indicated that Resident #108 routinely sat in the front lobby area, but in an area near her desk, and not the front doors. She indicated that he was not allowed to go outside but if he had the chance, he would. She revealed that he was easily re-directed when going up to the front entrance doors. Staff AA revealed she felt that Resident #108 would quietly watch the front doors looking for opportunities to get out, but he would not do it often. She indicated that she never reported the few opportunities of the resident scoping out the front doors and looking to exit the facility. She indicated that she did not tell staff because he was so easily re-directed. Staff AA revealed that on 2/7/19, she was manning the reception desk and when staff and visitors wanted to enter or exit the building, she had to physically press a button at the desk to open the doors. She indicated she worked on 2/7/19 until just before 12:00 p.m. Staff AA revealed Resident #108 was seated in a chair in the front lobby for most of the morning and at an unknown time, he walked back towards the main hallway. She assumed he was going to his room for lunch. She too left the desk to go to lunch and Staff CC took over for her. Staff AA indicated she returned back from lunch around 12:45 p.m. and sat at the front desk with Staff CC. She stated, they sat their together for a while going over business related tasks and at about 1:45 p.m. the phone at the desk rang. Staff CC answered the call from the local business. It was at that time that they both realized that Resident #108 was not at the facility and that he eloped to the business miles away. She indicated that Staff CC immediately reported the call to the NHA and a short time after that she was interviewed by the NHA who then suspended her pending an investigation. Staff AA was asked about her training related to elopement, missing persons, and resident signing out for Leave of Absence (LOA). Staff AA expressed that during her orientation she did not receive any formal training related to elopement, but only received the definition on elopement. She stated, she had not received any training on missing persons either during orientation. Staff AA stated, I took it upon myself to review the elopement book at the front desk and that is how I learned about elopement, missing person protocol and who the elopement risks were. Staff AA did say she received training on 1/23/19 after another resident left LOA that did not sign out and never returned. She confirmed that was the only training she had. A review of Staff AA ' s personnel file, revealed an orientation checklist dated 11/20/18. Staff AA initialed and it was checked that she received training on: LOA, Elopement, Missing Residents, search protocols, and reporting. However, an interview with the DON, and NHA, revealed no documentation or evidence of the curriculum and knowledge check related to these trainings could be provided. The DON provided documentation of the last in-service training on the Elopement policy and procedure to all staff dated 9/13/18, prior to the 2/7/19 event. Additional documentation dated 1/25/19 revealed in-service training was conducted on the facility LOA books for the three receptionists only, which included Staff AA. A review of the Receptionist job description (no date documented), revealed: Summary of position: The Receptionist is responsible for providing secretarial support services to Administrator and other managers as designated; responsible for handling incoming telephone calls and greeting visitors. Essential duties to include, but not limited to: - Monitors residents as they arrive and leave to ensure that they are not leaving the facility without the proper permission or supervision. - Report and document any incidents or accidents of residents, staff or visitors to the appropriate facility personnel. Based on the information provided by facility administration related to Resident #108 ' s elopement, Resident #108 ' s record review, interview with the receptionist (Staff AA), and a review of Staff AA ' s personnel record, facility administration failed to provide supervision either directly or indirectly to Staff AA to include training and education programs related to elopement prior to the 2/7/19 event. Interview with Staff Q, Registered Nurse (RN) on 2/12/19 at 7:30 a.m. indicated she worked the 11:00 p.m. to 7:00 a.m. shift on 2/6/19 to 2/7/19. She indicated that Resident #108 was wearing his electronic wander device during that shift when she checked for placement of the device, but she did not check the function of the battery with a transponder. She indicated, she never received training on how to check the function of the electronic wander devices and therefore did not check to see if it was working or not. She revealed that Resident #108 would routinely pace up and down the hallways and would go to the front lobby and sit in a chair. She did not recall if he presented with any exit seeking behaviors during her shifts. A review of the Treatment Administration Record (TAR) for (MONTH) and (MONTH) of 2019 revealed she had initialed off on the functioning and placement of the electronic monitoring device on 2/6, 1/28, 1/23, and 1/14. Based on the information provided by facility administration related to Resident #108 ' s elopement, Resident #108 ' s record review, and interview with Staff Q, RN assigned to Resident #108, the facility administration failed to implement and enforce the facility policies regarding the operation of the facility (following physician orders), failed to provide supervision either directly or indirectly to Staff Q to include training and education programs, failed to identify needs or issues that require monitoring, failed to provide patient rounds to ensure nursing personnel were performing their work assignments in accordance with acceptable standards, failed to ensure accountability for adherence by staff to policies, procedures, and failed to establish and implement monitoring methods to avoid, eliminate, and/or reduce risk associated with the provision of patient care and services related to testing the function of an electronic monitoring device for a known elopement risk resident. On 2/11/19 at approximately 8:30 a.m., an interview was conducted with Staff FF, Certified Nursing Assistant (CNA), who had been employed by the facility since 6/24/03. Staff FF revealed she routinely cared for Resident #108 on her 7:00 a.m. – 3:00 p.m. shift assignment, and she did have him on her assignment on 2/7/19. She indicated, he ate breakfast that morning, and he usually went and sits sat in the front lobby the rest of the morning. She did see him in the front lobby around 8:30 a.m./9:00 a.m. Staff FF indicated she spoke with him a few times and he did not need anything. Staff FF indicated that on 2/7/19 around 11:00 a.m. - 11:15 a.m., she went to the main dining room as assigned to help with the lunch meal service. Staff FF revealed that she stayed in the dining room until sometime after 12:00 p.m. and then went right to her lunch break. Staff FF revealed she did not return from lunch on 2/7/19 until just before 1:00 p.m. Staff FF explained that the staff on the floor who pass meal trays and assist with lunch in resident rooms were usually responsible to check on her residents. She did not know if anyone saw Resident #108 during the lunch service on 2/7/19. She did find out that a staff member (name unknown) had placed Resident #108's lunch meal tray in his room and did not check to see where he was. Staff FF indicated that the floor staff likely knew Resident #108 did not need assistance with his meal, and that may be the reason they placed the tray in the room and left. She indicated she had Elopement and Missing Person training on orientation and routinely over the years that she has been employed at the facility. Staff FF revealed that during her shifts, Resident #108 had not presented with eloping or exit seeking behaviors. She further explained that he usually just sat in the front lobby next to the reception desk. Based on the information provided by facility administration related to Resident #108 ' s elopement, Resident #108 ' s record review, and interview with Staff FF, C.N.A. assigned to Resident #108, the facility administration failed to implement and enforce the facility policies regarding the operation of the facility, failed to identify needs or issues that require monitoring, failed to provide patient rounds to ensure nursing personnel were performing their work assignments in accordance with acceptable standards, failed to ensure accountability for adherence by staff to policies and procedures, and failed to establish and implement monitoring methods to avoid, eliminate, and/or reduce risk associated with the provision of patient care and services related to the failure to ensure Staff FF was monitoring Resident #108 ' s whereabouts in accordance with industry standards and failed to ensure Staff FF or other personnel provided regular rounds for elopement risk residents in accordance with the facility elopement policy and procedure. On 2/20/19 at 3:52 p.m., a telephone interview was conducted with Resident #108 ' s sister, who was listed as the emergency contact on the Admission Record contained in the clinical record. Resident #108 ' s sister indicated she did not live too far from the facility, but she did not visit often. Resident #108 ' s sister stated that he stayed at the nursing facility because he has dementia. She further indicated, she mostly had phone conversations with Resident #108 and was not involved with his care and services at this time due to other family responsibilities she was tending to. She confirmed that staff called her on 2/7/19 to let her know that he eloped from the facility and was brought back safely. She was upset to hear that he got out of the facility, but happy he was back. 3. A review of Resident #460 ' s closed electronic medical record revealed he was admitted to the facility on [DATE]. The resident did not have any advanced directives and was his own decision maker. The admission record indicated Resident #460 did have a family member who was listed as emergency contact only. Review of the cumulative [DIAGNOSES REDACTED].#460 was admitted with [DIAGNOSES REDACTED]. Review of nurse progress notes and department notes dated from admission date of [DATE] to 1/24/19 revealed the following: a. 1/23/19 20:38 (8:38 p.m.) – Pinellas County law enforcement agency arrived to facility after it was reported that resident left facility this a.m. and has not returned at this time. All inform

Based on interviews with the facility's nursing and administrative staff, a family member, and the facility Medical Director as well as review of clinical records and facility policies and procedures, it was determined that the facility failed to promote the rights of residents to have their advance directives honored as were formulated for one (#1) of out of seventeen residents identified as having previously expressed their wishes to NOT receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Of one hundred thirteen residents, fourteen were identified by the facility to have current DNR orders. The facility failed to honor a State of Florida Do Not Resuscitate order executed by Resident # 1. The facility failed to follow its facility's policy and procedures regarding identification of the end-of-life wishes prior to conducting CPR for Resident #1 who was identified as having current DNR orders and not ensuring that his rights were protected and DNR wishes honored. On [DATE], Resident #1, an [AGE] year old male, was found unresponsive, without a pulse or respirations, however, the facility conducted CPR. The facility failed to honor Resident#1's expressed wishes and violated his right to refuse treatment. The facility failed to protect the resident from unwanted, potentially violent interventions in his last moments of life. The facility's failure to follow their policies and procedures represented a system wide failure. Failure of the facility staff to correctly implement advance directives resulted in findings of Immediate Jeopardy past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings included: 1. Resident #1 was admitted to the facility on [DATE], with a re-admission date of [DATE], from a local hospital with multiple diagnoses, including, but not limited to: dietary folate deficiency [MEDICAL CONDITIONS], Type II diabetes mellitus with diabetic [MEDICAL CONDITION], and [MEDICAL CONDITIONS], per the Admission Record. The General Progress Note of [DATE] at 16:40 reflected the events surrounding Resident #1's hospital transfer as: Resident was on LOA with his son. His son brought him back to the facility and reported that when the resident was getting out of the car he began to collapse with the son holding him up. The son immediately returned the resident to the seat and chose to bring him back to be evaluated. The resident was helped to his bed and evaluated. Vitals were T: 97.2, P: 68, BP: ,[DATE] R: 32 and 99% on 2L. The resident was lethargic but rousable. He stated he had pain to his right arm and the skin tear was beginning to bleed through the dressing .the ARNP stated he wanted the resident sent to the ER for full evaluation, blood work, and treatment .due to his DNR status, the paperwork went with the patient. His son was notified. 2. A record review of the Minimum Data Set (MDS), dated [DATE], reflected a Brief Interview for Mental Status score of 09 (moderate impairment). The resident had not formulated advance directives as indicated on his admission documents. The resident did not have a Power of Attorney, Health Care Surrogate, or Living Will as documented in the medical record. The resident did sign a Do Not Resuscitate Order, dated [DATE]. The DNR was signed by the resident and the physician. The physician order [REDACTED]. The 3008 form, dated [DATE], indicated that Resident #1 was a DNR. The Psychosocial History and Assessment, completed at the facility on [DATE], also indicated that the Resident had a code status of DNR. Review of Progress Notes in the record of Resident #1provided the following notations of his condition on [DATE], prior to being found unresponsive on [DATE]: On [DATE] at 07:45, Resident has runny nose/cold symptoms .reported to AM nurse to monitor, and for orders. On [DATE] at 10:30, Resident observed at bedside in walker c/o feeling bad. Slight non-productive dry cough is present, along with what resident describes as a heavy headache .ARNP was present in facility and assessed resident. Orders for antibiotics were sent to the pharmacy and orders for labs were also faxed. Scheduled nebulizer as well as all other medications per order. Resident was resting comfortably in bed, in lowered position, call light within reach. Resident is able to verbalize needs and currently is showing no symptoms of distress. Later that evening, on [DATE] at 20:15, Resident was sitting on seat to rolling walker, and stated, I am uncomfortable but I do not want to move. The nurse and C.N.A encouraged resident to transfer from seat on rolling walker into the bed, and a 2 person assist was utilized. During transfer, he became slightly combative, however, he was easily redirected by this nurse. Resident showed +1 [MEDICAL CONDITION] to RT lower extremity due to [MEDICAL CONDITION], resident's legs were elevated for comfort and to reduce [MEDICAL CONDITION]. Bed was placed in lowered position, with call bell in reach. The nurse as well as the C.N.A. on duty make frequent checks on patient to ensure he was not attempting to get out of bed, as he is a fall risk. At no point, did resident attempt to get up/ambulate with rolling walker. Throughout the evening, he was resting comfortably in bed, with no obvious signs of distress or pain noted. Record review of the Nursing Progress notes portrayed the following: Dated [DATE] at 14:36, CNA (certified nursing assistant) checked on this patient at 14:15, found him unresponsive, and not breathing. This patient had an active DNR order in the chart, and paramedics were called to verify his passing. His time of death was listed as 14:15. An attempt has been made to reach his son. Will continue to follow up until family is notified. 2. The most common cardiac resuscitation-related injuries are fractures of the ribs and sternum in ,[DATE]% of cases. Above all, elderly patients are prone to such injuries. Forensic Pathology Reviews, book series, pp ,[DATE], (FPR, volume 1). 3. On [DATE], at 11:10 AM, during an interview with the NHA (nursing home administrator) the following was confirmed: Unit Manager, Staff member (S), and staff member (R), LPN, were terminated for not following policy protocol for Code Status Orders and Response. They performed 5 (five) chest compressions on Resident #1 then stopped. At this time, the NHA was asked if she had more specifics and she stated that she would bring all the documentation that she had on the event. At 11:35 AM, the NHA and the Risk Consultant provided the following information: The NHA reported that she was made aware Resident #1 had passed. She heard a code blue over the intercom; I assisted in getting the chart from the nursing station, saw he was a DNR, handed the chart to staff member (A) to take the chart back to the resident's room. I was then informed that the Director of Nursing had stopped the code. The NHA interviewed staff member (E), LPN, who stated staff member (Q) said to stop CPR after she was made aware that the patient was a DNR. The NHA stated that, At this time I took over the investigation and suspended staff members (Q, R, and S). All were given the option to resign the following day, after the event had occurred, and I completed my investigation for not following facility policy and ending the code. The NHA provided a time line of the events as follows: On [DATE] a code blue process was initiated and EMS activated. The resident's condition prior to the incident, based on documentation and/ or staff interviews: displaying signs of a cold (cough/runny nose) and increased confusion. Evaluated by ARNP a day prior and antibiotics were initiated. The resident, identified by staff member (C), did not appear to be breathing and a code blue was paged overhead. The CNA had addressed the resident's needs prior to lunch and upon completion of lunch, approximately 40 minutes prior to the event. The resident displayed no signs/symptoms of distress at the time. Upon identification of unresponsiveness a code blue was paged, staff members (A, C, E, F, Q, R, and S) responded, initial compressions approximately (5) five were administered, and 911 activated. The chart arrived, the DON confirmed that the resident was a DNR and advised to cease activity. Paramedics arrived and pronounced, son and physician were notified. 4. During an interview on [DATE], at 1:00PM, with staff member (E) she reported the following: I heard them call code blue and I went into Resident #1's room. The DON, staff members (R and S), were in the room, I said, did anyone check his chart to see if he was a DNR or full code? I observed staff member (S) doing chest comprehensions, the DON then sent someone to go check the chart. Staff member (A) came back and replied he is a DNR. The DON said Stop CPR because he is a DNR. I came out of the room and the NHA said do not stop, continue doing CPR never stop CPR when you start. 5. During an interview on [DATE], at 2:14PM, with staff member (F) she provided the following details of the event: I was on the North Station and responded to the code. All nurses are required to respond to a code, the DON and staff members (R and S) were trying to resuscitate Resident #1. Staff member (R) was giving the chest compressions and the DON was at the foot of the bed. Staff member (R) was giving chest compressions when I walked in. Staff member (R) was on the right side of the bed and staff member (S) was on the left side of the bed. The DON was at the foot of the bed. I remember one of the nurses saying, Where is the chart, what is the code status? The DON shouted out to go get the chart, in the meantime staff members (R and S) switched off and staff member (A) returned with the chart. The chart was handed to the DON. The DON opened the chart and said the patient was a DNR; again, she stated the patient is a DNR stop the compressions. staff members (R and S) immediately stopped. I went to make sure a call was being placed to 911 (EMS). 6. During an interview with staff member (G) on [DATE], at 2:40 PM, she provided the following details: When I responded to the code, I really did not know who it was. We are supposed to respond with the crash cart, I saw a CNA with the backboard, which is part of the crash cart. When I walked in, I saw staff members (R and S) on either side of the bed doing chest compressions on the resident, it appeared that they were doing it without the backboard. Staff member (E) assisted in placing the backboard. At this point, staff member (D) shouted, Where is the chart? I was surprised because it is our protocol to check the chart before you call the code, and they are expected to have pulled the chart. Why would a code be called on a patient if they were a DNR? Staff member (A) handed the chart to the DON and as soon as she opened it up, she said, Stop compressions. Someone in the room questioned her and she did not respond and said, Stop doing the compressions. 7. An interview was completed on [DATE] at 10:25 AM with staff member (C), the staff member who found Resident #1 unresponsive on [DATE]. She reported the following information in regards to the event: When I came in that morning, on [DATE] around 6:45 AM, the resident did not look good, he looked tired, and he looked sick, so I notified staff member (R) to look at Resident #1. I was told that his vital signs were good. Around mid-morning, I was providing care to him but it was more care than usual, it was like total care, usually he was independent. I told staff members (R and S) to take another look at him. They came and looked at him and said his vitals were good. He had his oxygen on. After lunch, I came back and checked on Resident #1, he had his mouth open, eyes open and I knew he was not breathing. I ran out of the room and shouted, code blue, code blue (name of resident and room number), everyone started moving fast, they went into the room they started working on him, when I walked into the room I saw staff member (R) doing compressions, I saw staff member (S) at the bedside and then I walked out of the room. At this time, everyone was crowding around. I think staff member (A) grabbed the chart. I heard people talking . he was a DNR and they started compressions, the DON said, stop. They should not have stopped because once you start you should not stop. 8. During an interview on [DATE], at 3:55 PM, with staff member (D), who was present during the event, reported the following: I heard the code and ran inside from the patio; I went down the hallway and went to the patient's room. Staff member (S) was doing chest compressions; staff member (R) was standing on other side of the bed. The DON was standing at the foot of the bed. I said, Where is the chart, everyone was just looking and the DON ordered the CAN to get the chart. Staff member (A) retrieved the chart. Staff member (B) called 911 EMS (emergency medical services), everyone started shouting, the back board was brought in, the resident was rolled over, placed on the backboard, unknown who slid the backboard, it happened so quick. The DON said, Everyone stop he is a DNR, so we all looked, hands off he is DNR, and everyone started packing the crash cart. I do not think anyone wanted to question the DON, because she was the type of person who would embarrass you in front of other people. I did not want to be belittled by her. Everyone looked at her because she said to stop the compressions. Staff member (S) came to the nurse's station and said there was no CPR done, no chest compressions done, everyone hold off on your statements. The DON asked me if I saw anybody do CPR, and I said yes, staff members (R & S). I was interviewed by the NHA and told her the same thing I am telling you. 9. During a telephone interview with staff member (S) on [DATE], at 1:53 PM, she provided the following details of the event: Staff member (C) called a code blue, everyone went running down to Resident #1's room. I grabbed the crash cart and brought it into the room. The chart came down later; the first nurse that arrived was staff member (R), she started giving chest compressions maybe five without looking at the chart for a code status. I do not think she was thinking and started right away with the chest compressions. When she was made aware that the resident was a DNR she immediately stopped, the DON said, hands off, he is a DNR. The resident was not on the backboard, no 02. I had come in and just gotten to bedside. I, along with the DON, spoke with the son and his response was that obviously everyone on the unit had a good will towards my father. I believe it was the DON that documented that the son was informed of the chest compressions. The way that I was trained in Illinois, you start and you can stop a CPR if the resident is a DNR. Therefore, when it was stopped I was not surprised. We received education the day of the incident from the new Risk Manager and the Administrator along with the corporate Risk Manager provided training. Drills were put in place for all shifts. 10. During a telephone interview with staff member (Q) on [DATE], at 2:26 PM, the following information was reported: I remember hearing someone calling a code blue, I left my office, I grabbed the crash cart, I saw multiple employees in the room and I grabbed the clip board to transcribe. I noticed two nurses (staff members R and S) turning him over, I did not observe any chest compressions. When staff member (A) brought in the chart, I noticed the State of Florida DNR order yellow form goldenrod and stated, He is a DNR. I never said stop doing chest compressions, because I did not observe any being done. She confirmed that the code blue worksheet was completed by her and was accurate. The Surveyor read the Code Blue Worksheet back to her where she indicated that CPR was initiated at 2:17 PM. At this time, she stated that she had not written that information on the Code Blue Worksheet. She confirmed that staff member (R) and herself had spoken with the resident's son and notified him of the possibility that his father had ,[DATE] chest compressions. The son was fine with this information and thanked her for taking such good care of his father. She stated that she did not document this conversation and believed that staff member (R) would have documented. A review of the job description for the Director of Nursing indicated that the DON is responsible for developing, organizing, evaluating and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for all overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Additionally, the DON signed a Commitment to Honoring Advance Directives, dated [DATE], which is attached to her clinical job description. 11. An additional interview with the NHA on [DATE] at 4:25 PM revealed the following information: On [DATE] at 2:15 PM, I heard a code called over the intercom. I went to the nursing station and looked at Resident #1 medical record. I verified the resident had State of Florida DNR orders yellow forms. I passed the chart to staff member (A) and she took it down the hall. I believe that she made the statement that they had already started and I said, Well it is too late now, you have to keep going. That was the extent of my involvement until I took the investigation over from the DON. When I realized that she had stopped the code, I spoke to her and asked why she had stopped the code, and she told me she had not. At that point, I told her that she would no longer collect any statements and she had to go home. She was suspended until the investigation was finished. Per the statements that we collected, it became apparent that she was the one to stop the CPR. She was terminated on [DATE]. I did not report her to the board, the company chose not too, since there was no harm done to the resident or family we chose not to go against her license at this point. The other two nurses were terminated; we did not report them to the board. The NHA was asked to provide documentation that the family had been notified that the staff had not followed facility policy in regards to the end-of-life wishes prior to conducting CPR for Resident #1. She reported that she could not locate in the resident's medical record where we documented that we notified the son about the compressions and he had said he was fine with it. The DON had spoken with the son on [DATE], I believe. I cannot answer as to why the medical record does not reflect what had occurred. Staff members (Q, R, or S) would have conducted chart documentation. My expectations would be that all three would have charted. 12. During a telephone interview with staff member (R) that was conducted on [DATE], at 10 :49 AM, revealed the following details of the event: Someone called we have a code, Staff member (S) was almost down by the resident's room, I was at my medication cart. I went to the room and everyone was following me. Staff member (S) was at bedside and placed the patient down in a lying position, getting ready for CPR, checking for a pulse, no respirations. I was on the other side of the bed; my back was to the door. I was handed the backboard, staff member (S) and I were trying to position the backboard under the resident and we had him positioned on the backboard. My hand was on his chest, then somebody called out from behind me, He is a DNR. I cannot remember how many chest compressions I had done, I may have done one compression, I really don't remember. We stepped away from the bed as soon as we were told he was a DNR. Someone from behind me said, He was a DNR. I do not recall who said the resident was a DNR. Someone had called 911 (emergency medical services). 13. During a telephone interview on [DATE], at 11:45 AM, with the son of Resident #1, he stated his father would make his own decisions in regards to his health and was able to make all of his needs known. He reported that his father had a DNR in place, he noticed a decline in health over the past weeks. The facility had contacted him the day before his father's passing to inform him that the he had a urinary tract infection [MEDICAL CONDITION]. His father was given an antibiotic drip. This was not unusual because he had a history of [REDACTED]. They tried to reach me and left a voicemail for me to call them back. I called back at 2:45 PM on [DATE] and I spoke staff member (S) who informed me that my father had passed. I was informed by staff member (S) that when my father had stopped breathing, there might have been a few chest compressions done. 14. A telephone interview was conducted with the Resident's Physician/Medical Director on [DATE], at 10:12 AM. He reports that he did remember Resident #1 and recalled the event. I was called and informed that CPR had been done by mistake on Resident #1. He also stated there was very little amount of compressions done, then they stopped. If he had a DNR they must stop the compressions immediately and respect the DNR status. He was asked if the facility followed proper protocol in stopping the compressions after having had ,[DATE] chest compressions, he replied absolutely. When asked if he had given orders to cease the CPR he confirmed that he had not provided any orders to cease CPR. The medical director confirmed that he attended the Emergency Quality Assurance Meeting. 15. Review of the facility's Clinical Programs Manual, ADM 11.1 Page 3 of 5, Procedure for Initiating CPR (Effective October, (YEAR)), &, current on [DATE], at the time Resident #1 was found unresponsive, found: Once CPR is started, CPR will continue until: 1. Relieved by EMS; 2. Relieved by another staff member who will take over CPR; 3. Physician orders [REDACTED].>4. Resident pulse and respirations are palpable /observable. 16. On [DATE], at 8:00 AM, it was verified that all fourteen current residents and/or family members of residents, who had expressed a wish to have CPR withheld, had current physician DNR orders in place on their clinical record. Verification was made for residents who had State of Florida DNR orders yellow forms, those forms were also were in place in the clinical record. Verification was made on [DATE] that residents who had expired at the facility from (MONTH) (YEAR) to the present had their Advance Directives honored. A review of the Advance Directives for expired residents #2, #3, #4, #5 and #6 revealed no concerns with having their end of life wished honored. A full review of in-services regarding honoring advance directives and the process for verifying code status of a resident by checking the clinical record for a DNR order as the definitive method of verification of code status was completed. Sign in sheets for Code Status Orders and Response were reviewed which revealed signatures for all licensed staff. Staff are to check the medical record for the code status, in absence of Advance Directives or physicians order, the resident will be considered a Full Code Status. According to the 4-Point Plan provided by the NHA, licensed staff were re-educated on the fact that we follow physician orders [REDACTED]. Mock code drills and critiques were conducted by lead staff beginning on [DATE] for all shifts, randomly and ongoing, with a last documented code drill date of [DATE]. Interviews were conducted on [DATE] and [DATE] to assess knowledge of facility policy for Advance Directives and Response to a Code. Interviews with licensed staff revealed consistency with the current policy, Advanced Directive-Nursing and recent trainings. On [DATE] and [DATE], seventy-five percent of the nursing staff were interviewed and able to voice the Advanced Directive Policy. Review of facility documentation revealed that 100% of all licensed nurses received Advance Directive in-service training in response to the incident. An audit was completed of licensed staff personnel to verify the presence of a valid CPR certification. An interview with the NHA on [DATE], at 4:00 PM, stated that the facility currently has 14 LPNs and 1 RNs. She provided a copy of the current CPR certification for each licensed staff member. A review and verification of the facility's corrective action plan revealed the following: The Quality Assessment & Performance Improvement Plan, started on [DATE], with an actual completion date of [DATE] included: 1) Notify family and Medical Director of resident's expiration. Charge Nurse Start - [DATE], Estimated Completion Date: [DATE], Actual Completion date: [DATE]. 2) Advanced directive audit of resident's charts validated for accuracy. SSD - Start Date: [DATE], completion date: [DATE]. 3) Validated licensed staff's CPR licensure. NHA/Designee-Start: [DATE], Actual Completion date: [DATE]; 100% nurses & 100% CNA training. 4) Educated nurses related to advanced Directives, DNR orders, & Code Blue process. -ADON/SDC/Clinical Designee: [DATE] currently at 88% nurses & 100% CNA training. Completion date: [DATE]. 5) Code drills q shift with use of code drill minutes to critique & re-educate areas identified as in need of improvement as applicable. -DON/SDC/Clinical Designee: Start: [DATE]; [DATE] & ongoing. 6) Audit Advanced Directive orders weekly X 4 weeks. - DON/SSD-Start: [DATE], Actual Completion date: [DATE]. 7) Review resident advanced directives upon admission, quarterly and with significant changes. -SSD-Start: [DATE] Actual Completion Date: [DATE] and ongoing. Policies Reviewed Code Status Orders & Response-Standard & Procedure-Florida (Effective March, (YEAR)) The facility provides Basic Life Support (BLS) CPR only. The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. Do Not Resuscitate (DNR) ORDER-Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status. Code status orders will be reviewed on admission, quarterly, PRN, and with any significant change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/resident representative or legally authorized party will have their elected code status documented in the medical record. Code status physician's orders [REDACTED]. The resident/resident representative or legally authorized party may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. The facility does not provide Advanced Life Support. ON ADMISSION Staff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/resident representative wishes to change their decision. 1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible. 2. Discuss code status preference with the resident /resident representative. 3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders [REDACTED]. 4. Notify physician if the resident/resident representative preference is changed, obtain order. In the event that the physician is not available the medical director may be contacted for the order. 5. While awaiting the physician's orders [REDACTED]. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request, the conversation of the request will be printed and placed as the first document of the medical record. a. While the physician's orders [REDACTED]. QUARTERLY/PRN 1. Review and discuss code status with the resident/resident representative; confirm code status is unchanged. Document wishes are unchanged in the medical record. 2. If the resident or resident representative wishes to change status, document in the record and notify the physician to obtain order. 3. In the event that the physician is not available the medical director may be contacted for the order. 4. While awaiting the physician's orders [REDACTED]. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request. a. While the physician's orders [REDACTED]. 5. Documentation of resident /resident representative's wishes will be printed and placed in the front of the medical record. 6. Social Services and/or Nursing should discuss Advance Directives decisions with the resident/resident representative to ascertain that the resident/resident representative understands their decision. 7. Notify attending MD of the resident/resident representative request for DNR or Full Code Status. Resident's wishes will be honored. 8. Obtain a written MD order for the Resident medical record. This can be written on a telephone order if the order is obtained in the presence of two nurses. The order may signed by the physician at the next visit. a. Transcribe order via paper or into the electronic medical record system. If transcribed into the electronic medical record, print a copy of the DNR or Full Code order and place in front of the medical record for transport/transfer purposes. 9. Update the care plan. 10. Notify staff members of the code status; Review in Clinical Meeting/Stand Down meeting with the IDT. 11. Provide psycho-social support for the resident/resident representative as indicated. Changing code status/while awaiting physician's orders [REDACTED].>The resident and or/resident representative may change the code status at any time. The staff must notify the MD, describe the requested change and request an order for [REDACTED]. The resident wishes will be communicated verbally shift to shift, both witnesses must document conversation in the medical record, print and placed as the first document of the medical record. Staffing Staff members trained &/or certified to perform CPR for Health Care Providers will be present to provide CPR for those residents electing a full code status. These certified team members shall provide CPR until ordered to cease by an authorized, licensed physician, EMS arrives to assume care, or the resident's pulse & respirations are assessed as present. CPR certification staffing needs will be reviewed as indicated. Procedure for initiating CPR 1. Upon identification that resident is unresponsive the person making the identification will check for pulse and respirations, and immediately call for help; loudly calling Code Blue Room (#). 2. Staff will respond to room with medical record and emergency cart. 3. Chart will be checked for code status and, if resident is a full code CPR will be initiated. Once CPR is started, CPR will continue until: Relieved b (TRUNCATED)

Based on review of resident medical and admission records, review of facility policies and procedures and interview with facility staff, a resident's family member, the attending physician, and the Medical Director, it was determined the facility failed to honor the advance directives & end of life wishes of one (Resident #1) of fourteen residents, identified as having Do Not Resuscitate Orders, according, to the State of Florida Do Not Resuscitate Order, initiated by Resident #1, on [DATE]. The staff did not fulfill a care taking obligation of providing goods and services necessary to avoid physical harm or mental anguish consistent with their Abuse, Neglect and Exploitation policy and procedure ([DATE], Revision (MONTH) (YEAR)). On [DATE], Resident #1, an [AGE] year old, was found unresponsive, without pulse or respirations. The resident had a current physician order [REDACTED]. The facility failed to honor Resident #1's wishes regarding his advance directives not to be resuscitated. The facility failed to follow their policy and procedure, in regards to, its Code Status Orders & Response (Effective (MONTH) (YEAR)) and Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Failure of the facility staff to honor and fulfill the expressed wishes of the resident not to receive CPR, resulted in findings of Past Non-Compliance of Immediate Jeopardy, corrected on [DATE] prior to the survey. Findings include: 1. The most common cardiac resuscitation-related injuries are fractures of the ribs and sternum in ,[DATE]% of cases. Above all, elderly patients are prone to such injuries. Forensic Pathology Reviews, book series, pp ,[DATE], (FPR, volume 1). 2. A telephone interview was completed on [DATE] at 11:45 AM, with Resident # 1' son, regarding his parent's end of life wishes. He stated his father would make his own decisions in regards to his health and was able to make all of his needs known. He reports that his father had a DNR in place, he noticed a decline in health over the past weeks. The facility had contacted him the day before his father's passing to inform him that the he had a urinary tract infection [MEDICAL CONDITION]. His father was given an antibiotic drip. This was not unusual because he had a history of [REDACTED]. They tried to reach me and left a voicemail for me to call them back. I called back at 2:45 PM on [DATE] and I spoke to staff member (S) who informed me that my father had passed. I was informed by staff member (S) that when my father had stopped breathing, there might have been a few chest compressions done. 3. Review of Progress Notes in the record of Resident #1provided the following information of his condition on [DATE], prior to being found unresponsive on [DATE]: On [DATE] at 07:45, Resident has runny nose/cold symptoms .reported to AM nurse to monitor, and for orders. On [DATE] at 10:30, Resident observed at bedside in walker c/o feeling bad. Slight non-productive dry cough is present, along with what resident describes as a heavy headache .ARNP was present in facility and assessed resident. Orders for antibiotics were sent to the pharmacy and orders for labs were also faxed. Scheduled nebulizer as well as all other medications per order. Resident was resting comfortably in bed, in lowered position, call light within reach. Resident is able to verbalize needs and currently is showing no symptoms of distress. Later that evening, on [DATE] at 20:15, Resident was sitting on seat to rolling walker, and stated, I am uncomfortable but I do not want to move. The nurse and C.N.A encouraged resident to transfer from seat on rolling walker into the bed, and a 2 person assist was utilized. During transfer, he became slightly combative, however, he was easily redirected by this nurse. Resident showed +1 [MEDICAL CONDITION] to RT lower extremity due to [MEDICAL CONDITION], resident's legs were elevated for comfort and to reduce [MEDICAL CONDITION]. Bed was placed in lowered position, with call bell in reach. The nurse as well as the C.N.A. on duty make frequent checks on patient to ensure he was not attempting to get out of bed, as he is a fall risk. At no point, did resident attempt to get up/ambulate with rolling walker. Throughout the evening, he was resting comfortably in bed, with no obvious signs of distress or pain noted. Continued reviewed of Resident#1's electronic record found Nursing Progress notes indicating the following: Date [DATE] at 14:36 electronically signed by Staff Member (S) Registered Nurse (RN): CNA (certified nursing assistant) checked on this patient at 14:15 and found him unresponsive, and not breathing. This patient had an active DNR order in the chart, and paramedics were called to verify his passing. His time of death was listed as 14:15. An attempt has been made to reach his son. Will continue to follow up until family is notified. Resident # 1 was admitted to the facility on [DATE] with a re-admission date of [DATE] from a local hospital with multiple diagnose but not limited to dietary folate deficiency [MEDICAL CONDITIONS], Type II diabetes mellitus with diabetic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. The General Progress Note of [DATE] at 16:40 reflected the events surrounding Resident #1's hospital transfer as: Resident was on LOA with his son. His son brought him back to the facility and reported that when the resident was getting out of the car he began to collapse with the son holding him up. The son immediately returned the resident to the seat and chose to bring him back to be evaluated. The resident was helped to his bed and evaluated. Vitals were T: 97.2, P: 68, BP: ,[DATE] R: 32 and 99% on 2L. The resident was lethargic but rousable. He stated he had pain to his right arm and the skin tear was beginning to bleed through the dressing .the ARNP stated he wanted the resident sent to the ER for full evaluation, blood work, and treatment .due to his DNR status, the paperwork went with the patient. His son was notified. Record review of the Minimum Data Set ((MDS) dated [DATE], found a Brief Interview for Mental Status score of 09 (moderate impairment).The Resident had not formulated advance directives which was indicated on his admission documents. The resident did not have a Power of Attorney, Health Care Surrogate or Living Will as documented in the medical record. The Resident did sign a Do Not Resuscitate Order dated [DATE]. The DNR was signed by the resident and the physician, the physician order [REDACTED]. 4. A telephone interview was conducted with the Residents Physician/Medical Director on [DATE] at 10:12 AM. He reports that he did remember Resident#1 and recalled the event. I was called and informed that CPR had been done by mistake on Residentt#1. He also stated there was very little amount of compressions done, then they stopped. If he has a DNR they must stop the compressions immediately and respect the DNR status. He was asked if the facility followed proper protocol in stopping the compressions after having had ,[DATE] chest compressions, he replied absolutely. When asked if he had given orders to cease the CPR he confirmed that he had not provided any orders to cease CPR. The medical director confirmed that he attended the Emergency Quality Assurance Meeting. 5. During an interview on [DATE] at 10:25 AM with staff member (C) staff member who found Resident#1 unresponsive on [DATE]. She reported the following information in regards to the event: When I came in that morning on [DATE] around 6:45 AM the resident did not look good, he looked tired, he looked sick, so I notified staff member ( R) to look at Resident#1. I was told that his vital signs were good. Around mid-morning, I was providing care to him but it was more care than usual, it was like total care, usually he was independent. I told staff members (R and S) to take another look at him. They came and looked at him and said his vitals were good. He had his oxygen on. After lunch, I came back and checked on Resident#1. He had his mouth open, eyes open and I knew he was not breathing. I ran out of the room and shouted, Code blue, code blue (name of resident and room number), everyone started moving fast, they went into the room they started working on him. When I walked into the room I saw staff member (R) doing compressions, I saw staff member (S) at the bedside and then I walked out of the room. At this time, everyone was crowding around. I think staff member (A) grabbed the chart. I heard people talking .he was a DNR and they started compressions. The DON said, stop. They should not have stopped because once you start you should not stop. During an interview on [DATE] at 2:14PM with Staff Member (F), she provided the following details of the event: I was on the North Station and responded to the code. All nurses are required to respond to a code. The DON and staff members (R & S) were trying to resuscitate Resident#1, staff member (R) was giving the chest compressions, the DON was at the foot of the bed. Staff member (R) was giving chest compressions when I walked in. Staff member (R) was on the right side of the bed and staff member (S) was on the left side of the bed. The DON was at the foot of the bed. I remember one of the nurses saying, Where is the chart, what is the code status? The DON shouted out to go get the chart, in the meantime staff members (R and S) switched off and staff member (A) returned with the chart. The chart was handed to the DON. The DON opened the chart and said the patient is a DNR; again, she stated, the patient is a DNR, stop the compressions. Staff members (R & S) immediately stopped. I went to make sure a call was being placed to 911 (Emergency Medical Services). During an interview with Staff Member (B), LPN, 0n [DATE] at 12:06PM, she provided the following details of the event: I had just come in early that day to do some charting, I must not even have been in the building three minutes when I heard a CNA say I have a code blue over the pager system. I went to the medical chart for Residnet#1 and saw that the patient was a DNR. While at the same time, I was on the phone calling 911. It was so chaotic I gave the chart to a CNA Staff Member (A) and while on the phone, I told 911 to please cancel the code the patient is DNR status. The 911 operator stated that they were on their way and would come and check anyway. EMS came and left. Afterwards the DON stated to me, We did not do CPR, compressions never started. I was never in the room to observe anything; I was busy on the phone calling 911. I did not meet with EMS afterwards. During an interview on [DATE] at 1:00PM with staff member (E) she reported the following: I heard them call code blue and I went into Resident#1's room. The DON, staff members (R and S), were in the room, I said, did anyone check his chart to see if he was a DNR or full code? I observed the staff member (S) doing chest compressions, the DON then sent someone to go check the chart. Staff member (A) came back and replied he is a DNR. The DON said, Stop CPR because he is a DNR. I came out of the room and the NHA said do not stop, continue doing CPR never stop CPR when you start. During an interview with staff member (G), the former Director of Nurses, on [DATE] at 2:40 PM she provided the following details: When I responded to the code, I really did not know who it was. We are supposed to respond with the crash cart, I saw a CNA with the backboard which is part of the crash cart. When I walked in, I saw staff members (R & S) on either side of the bed doing chest compressions on the resident, it appeared that they were doing it without the backboard. Staff member (E) assisted in placing the backboard. At this point, staff member (D) shouted, Where is the chart? I was surprised because it is our protocol to check the chart before you call the code, and they are expected to have pulled the chart. Why a code would be called on a patient if they are a DNR? Staff member (A) handed the chart to the DON and as soon as she opened it up, she said, Stop compressions. Someone in the room questioned her and she did not respond and said, Stop doing the compressions. During a telephone interview with staff member (S) on [DATE] at 1:53 PM, she provided the following details of the event: Staff member (C) called a code blue, everyone went running down to Resident#1's room. I grabbed the crash cart and brought into the room. The chart came down later; the first nurse that arrived was staff member (R) she started giving chest compressions, maybe five, without looking at the chart for a code status. I do not think she was thinking and started right away with the chest compressions. When she was made aware that the resident was a DNR she immediately stopped, the DON said hands off, he is a DNR. The resident was not on the backboard, no 02. I had come in and just gotten to bedside. I along with the DON spoke with the son and his response was that obviously everyone on the unit had a good will towards my father. I believe it was the DON that documented that the son was informed of the chest compressions. The way that I was trained in Illinois, you start and you can stop a CPR if the resident is a DNR. Therefore, when it was stopped I was not surprised. We received education the day of the incident from the new Risk Manager and the Administrator along with the corporate Risk Manager provided training. Drills were put in place for all shifts. During a telephone interview with Staff Member (Q), the former Director of Nurses, on [DATE] at 2:26 PM the following information was reported: I remember hearing someone calling a code blue, I left my office, I grabbed the crash cart, I saw multiple employees in the room and I grabbed the clipped board to transcribe. I notice two nurses (staff members R & S) turning him over, I did not observe any chest compressions. When staff member (A) brought in the chart, I noticed the State of Florida DNR order yellow form goldenrod and stated, He is a DNR. I never said stop doing chest compressions, because I did not observe any being done. She confirmed that the code blue worksheet was completed by her and was accurate. The Surveyor read the Code Blue Worksheet back to her where she indicated that CPR was initiated at 2:17 PM. At this time, she stated that she had not written that information on the Code Blue Worksheet. She confirmed that staff member (R) and herself had spoken with the resident's son and notified him of the possibility that his father had ,[DATE] chest compressions. The son was fine with this information and thanked her for taking such good care of his father. She stated that she did not document this conversation and believed that staff member (R) would have documented. A review of the job description for the Director of Nursing indicated that the DON was responsible for developing, organizing, evaluating and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for all overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Additionally, the DON signed a Commitment to Honoring Advance Directives, dated [DATE], which was attached to her clinical job description. 6. On [DATE] at 11:10 AM- During an interview with the NHA (nursing home administrator) the following was confirmed; Unit Manager Staff member (S) and staff member (R) LPN were terminated for not following policy protocol for Code Status Orders and Response. They performed 5 (five) chest compressions on Resident#1 then stopped. At this time the NHA was asked if she had more specifics and she stated that she would bring all the documentation that she had on the event. At 11:35 AM the NHA and the Risk Consultant provided the following information: NHA reports that she was made aware Resident#1 had passed. She heard a code blue over the intercom; I assisted in getting the chart from the nursing station, saw he was a DNR, handed the chart to staff member (A) to take the chart back to the resident's room. I was then informed that the Director of Nursing had stopped the code. The NHA interviewed staff member (E) LPN who stated staff member (Q) said to stop CPR after she was made aware that the patient was a DNR. NHA stated, At this time I took over the investigation and suspended staff members (Q, R and S.) All were given the option to resign the following day after the event had occurred and I completed my investigation for not following facility policy and ending the code. The NHA provided a time line of the events as follows: On [DATE] a code blue process was initiated, EMS activated. The residents' condition, prior to the incident based on documentation and or/ staff interviews: displaying signs of a cold (cough/runny nose) and increased confusion. Evaluated by ARNP a day prior and antibiotics were initiated. Resident identified by staff member (C), did not appear to be breathing, code blue paged overhead. CNA had addressed the resident's needs prior to lunch and upon completion of lunch, approximately 40 minutes prior to the event. Resident displayed no signs/symptoms of distress at the time. Upon identification of unresponsiveness, code blue paged, staff members (A,C,E,F,Q,R,S) responded, initial compressions, approximately (5) five were administered, and 911 activated. Chart arrived, DON confirmed that the resident was a DNR and advised to cease activity. Paramedics arrived and pronounced, son and physician were notified. The facility policy: Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. The facility has designated and implementing processes, which drive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification and of staff burn out, or resident behavior, which may increase the likelihood of such events. Abuse includes Verbal, Physical, Sexual and Mental/Emotional Abuse- Willful infliction of injury. Unreasonable confinement/involuntary seclusion, intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Corporal punishment and any physical or chemical restraint not required to treat the residents' symptoms. Instances of abuse of residents, irrespective of any mental or physical condition that causes physical harm, pain or mental anguish to include verbal, sexual, physical, and mental abuse. Abuse includes that which is facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal- oral, written, or gestured language that includes disparaging and derogatory terms to the residents or the families to describe the resident within their hearing distance, regardless of the age and or ability to comprehend or disability. Physical-Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. It also includes controlling behaviors of corporal punishment. Neglect Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Procedure The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. 1. The Administrator is responsible for designating an abuse coordinator. 2. The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. 3. The Administrator, Director of Nursing and Risk Manager are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. 4. The Administrator, the Director of Nursing, Risk Manager are also ultimately responsible for the following: Implementation, Ongoing monitoring, reporting, investigation, tracking and trending, fear of retribution, Staff is instructed to report concerned incidents and grievances. Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation maybe more likely to occur such as resident with needs/ behaviors which might lead to conflict or abuse/neglect. Staff burnout. Analyze the occurrences to determine what changes are needed if any policies and procedures to prevent further occurrences. Prevention Post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, noncompliance with the advance directives requirements and request for information regarding returning to the community. Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. Residents and families are encouraged to report concerns, incidents and grievances without reprisal. The NHA and DON will be informed of investigation process and findings. A review and verification of the facility's corrective action plan revealed the following: A Quality Assessment & Performance Improvement Plan, started on [DATE] with an actual completion date of [DATE], included the following: 1) Notify family and medical director of resident's expiration. Charge Nurse Start-[DATE], Estimated Completion Date: [DATE], Actual Completion date [DATE]. 2) Advanced directive audit of resident's charts validated for accuracy. SSD- Start Date-[DATE], completion date: [DATE]. 3) Validated licensed staff's CPR licensure. NHA/Designee-Start-[DATE], Actual Completion date; [DATE]; 100% nurses & 100% CNA training. 4) Educated nurses related to advanced Directives, DNR orders, & Code Blue process. -ADON/SDC/Clinical Designee-[DATE]-Currently at 88% nurses & 100% CNA training. Completed [DATE]. 5) Code drills q shift with use of code drill minutes to critique & re-educate areas identified as in need of improvement as applicable. -DON/SDC/Clinical Designee: Start-[DATE]; [DATE] & ongoing, 6) Audit Advanced Directive orders weekly X 4 weeks. - DON/SSD-Start-[DATE], Actual Completion date [DATE]. 7) Review resident advanced directives upon admission, quarterly and with significant changes. -SSD-Start-[DATE]- Actual Completion Date [DATE] and ongoing. On [DATE] at 8:00 AM, it was verified that all fourteen current residents and or family members of residents who had expressed a wish to have CPR withheld had current physician DNR orders in place on their clinical record. Verification was determined for residents who had State of Florida DNR orders yellow forms. These forms were also were in place in the clinical record. Verification was made on [DATE] for residents who had expired at the facility form (MONTH) (YEAR) to the present had their Advance Directives honored. A review of the Advance Directives for expired Residents #2, #3, #4, #5 and #6 revealed no concerns with having their end of life wished honored. A full review was completed of in-services regarding honoring advance directives, and the process for verifying code status of a resident by checking the clinical record for a DNR order as the definitive methods of verification of code status. Sign in sheets for Code Status Orders and Response were reviewed which revealed signatures for all licensed staff. Staff are to check the medical record for the code status. In the absence of Advance Directives or physicians order, the resident will be considered a Full Code Status. According to the 4-Point Plan provided by the NHA, licensed staff were re-educated on the fact that we follow physician orders [REDACTED]. Mock code drills and critiques were conducted by lead staff beginning on [DATE] for all shifts, randomly and ongoing, with a last documented code drill date of [DATE]. Interviews conducted on [DATE] and [DATE] to assess knowledge of facility policy for Advance Directives and response to a code. Interviews with licensed staff revealed consistency with the current policy, Advanced Directive-Nursing and recent trainings. On [DATE] and [DATE], 75 percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. Review of facility documentation revealed that 100% of all licensed nurses received Advance Directive in-service training in response to the incident. An audit was completed of licensed staff personnel to verify the presence of a valid CPR certification. On [DATE] an interview with the NHA on [DATE] at 4:00 PM stated that the facility currently had 14 LPN's and 1 RN's. She provided a copy of the current CPR certification for each licensed staff member. Policies Reviewed * Policy for Code Status Orders & Response prior to [DATE] (Effective (MONTH) (YEAR)) The following CPR policy provided by the NHA on [DATE] at 1:42 PM Procedure for initiating CPR Effective Date (MONTH) (YEAR) Once CPR is started, CPR will continue until: Relieved by EMS; Relieved by another staff member who will take over CPR; Physician orders [REDACTED].>Resident pulse & respirations are palpable/observable. Personnel 1st person on scene-Confirmed cardiac and/or respiratory arrest. (2) Call for HELP. (3.) Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. (4) Check medical record for code status. Point of emphasis: CODE status must be confirmed by checking the medical record. (5.) Begins CPR and continue CPR while AED is being set up for shock if AED is assessable and utilized by the facility- ensure resident is on firm surface. 2nd person- The role of the 2nd responder is to assist the first responder as necessary and be the coordinator of the event. The 2nd responder with assure that someone: (1) Brings emergency cart and medical record to the patient's location. (2) Calls a code blue and the location over the PA system. (3) ** Assures that assignments are made for: (a) Notifying 911 (b)Notifying family and MD (c) Completing paperwork for impending transfer to the hospital (d) Waiting for EMS personnel and escort to code site (e)Designate a scribe to record activity related to the code blue, (MONTH) use the code blue worksheet Number 3 is critical element. This prevents each participant from believing someone else completed the tasks. Code Status Orders & Response-Standard & Procedure-Florida (Effective (MONTH) (YEAR)) The facility provides Basic Life Support (BLS) CPR only. The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. Do Not Resuscitate (DNR) ORDER-Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status. Code status orders will be reviewed on admission, quarterly, PRN and with any significant change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/resident representative or legally authorized party will have their elected code status documented in the medical record. Code status physician's orders [REDACTED]. The resident/resident representative or legally authorized party may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. The facility does not provide Advanced Life Support. ON ADMISSION Staff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/resident representative wishes to change their decision. 1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible. 2. Discuss code status preference with the resident /resident representative. 3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders [REDACTED]. 4. Notify physician if the resident/resident representative preference is changed, obtain order. In the event that the physician is not available the medical director may be contacted for the order. 5. While awaiting the physician's orders [REDACTED]. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request, the conversation of the request will be printed and placed as the first document of the medical record. a. While the physician's orders [REDACTED]. QUARTERLY/PRN 1. Review and discuss code status with the resident/resident representative; confirm code status is unchanged. Document wishes are unchanged in the medical record. 2. If the resident or resident representative wishes to change status, document in the record and notify the physician to obtain order. 3. In the event that the physician is not available the Medical Director may be contacted for the order. 4. While awaiting the physician's orders [REDACTED]. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request. a. While the physician's orders [REDACTED]. 5. Documentation of resident /resident representative's wishes will be printed and placed in the front of the medical record. 6. Social Services and/or Nursing should discuss Advance Directives decisions w (TRUNCATED)

Based on resident record review, observation, staff interview, family interview and review of policies and procedures, it was determined that the facility failed to implement the facility's Abuse, Neglect, Exploitation, Mistreatment of [REDACTED].#1). The facility failed to honor Resident # 1's signed Do Not Resuscitate order. The facility failed to honor Resident # 1's express and written end of life wishes to have cardiopulmonary resuscitation withheld in the event his heart failed. Facility staff initiated CPR on Resident#1, an [AGE] year-old alert, resident who was admitted to the facility with a signed DNR order. The facility failed to follow its own policies and procedures for Advance Directives, Determination of Code status, Code Blue and failed to ensure that nursing staff followed their facility policy in assuring validation of Resident#1's code status prior to initiating CPR. The Facility neglected Resident # 1 by initiating CPR in violation of his written and expressed wishes to not be resuscitated. The facility's failure to prevent neglect of Resident # 1 represented a system wide failure. This failure resulted in findings of Immediate Jeopardy Past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings Included: 1. A review of the facility policy: Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. The facility has designated and implementing processes, which drive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification and of staff burn out, or resident behavior, which may increase the likelihood of such events. Abuse includes Verbal, Physical, Sexual and Mental/Emotional Abuse- Willful infliction of injury. Unreasonable confinement/involuntary seclusion, intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Corporal punishment and any physical or chemical restraint not required to treat the resident's symptoms. Instances of abuse of residents, irrespective of any mental or physical condition that causes physical harm, pain or mental anguish to include verbal, sexual, physical, and mental abuse. Abuse it includes that which is facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal- oral, written, or gestured language that includes disparaging and derogatory terms to the residents or the families to describe the resident within their hearing distance, regardless of the age and or ability to comprehend or disability. Physical-Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. It also includes controlling behaviors of corporal punishment. Neglect Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Procedure The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. 1. The Administrator is responsible for designating an abuse coordinator. 2. The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. 3. The Administrator, Director of Nursing and Risk Manager are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. 4. The Administrator, the Director of Nursing, Risk Manager are also ultimately responsible for the following: Implementation, Ongoing monitoring, reporting, investigation, tracking and trending, fear of retribution, Staff is instructed to report concerned incidents and grievances. Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation maybe more likely to occur such as resident with needs/ behaviors which might lead to conflict or abuse/neglect. Staff burnout. Analyze the occurrences to determine what changes are needed if any policies and procedures to prevent further occurrences. Prevention Post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, noncompliance with the advance directives requirements and request for information regarding returning to the community. Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. Residents and families are encouraged to report concerns, incidents and grievances without reprisal. The NHA and DON will be informed of investigation process and findings. * Policy for Code Status Orders & Response prior to [DATE] (Effective (MONTH) (YEAR)) The following CPR policy provided by the NHA on [DATE] at 1:42 PM Procedure for initiating CPR Effective Date (MONTH) (YEAR) Once CPR is started, CPR will continue until: Relieved by EMS; Relieved by another staff member who will take over CPR; Physician orders to discontinue CPR; or Resident pulse & respirations are palpable/observable. Personnel 1st person on scene-Confirmed cardiac and/or respiratory arrest. (2) Call for HELP. (3.) Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. (4) Check medical record for code status. Point of emphasis: CODE status must be confirmed by checking the medical record. (5.) Begins CPR and continue CPR while AED is being set up for shock if AED is assessable and utilized by the facility- ensure resident is on firm surface. 2nd person- The role of the 2nd responder is to assist the first responder as necessary and be the coordinator of the event. The 2nd responder with assure that someone: (1) Brings emergency cart and medical record to the patient's location. (2) Calls a code blue and the location over the PA system. (3) ** Assures that assignments are made for: (a) Notifying 911 (b)Notifying family and MD (c) Completing paperwork for impending transfer to the hospital (d) Waiting for EMS personnel and escort to code site (e)Designate a scribe to record activity related to the code blue, (MONTH) use the code blue worksheet Number 3 is critical element. This prevents each participant from believing someone else completed the tasks. 2. Review of Progress Notes in the record of Resident #1 found the following notations of his condition on [DATE], prior to being found unresponsive on [DATE]: On [DATE] at 07:45, Resident has runny nose/cold symptoms .reported to AM nurse to monitor, and for orders. On [DATE] at 10:30, Resident observed at bedside in walker c/o feeling bad. Slight non-productive dry cough is present, along with what resident describes as a heavy headache .ARNP was present in facility and assessed resident. Orders for antibiotics were sent to the pharmacy and orders for labs were also faxed. Scheduled nebulizer as well as all other medications per order. Resident was resting comfortably in bed, in lowered position, call light within reach. Resident is able to verbalize needs and currently is showing no symptoms of distress. Later that evening, on [DATE] at 20:15, Resident was sitting on seat to rolling walker, and stated, I am uncomfortable but I do not want to move. The nurse and C.N.A encouraged resident to transfer from seat on rolling walker into the bed, and a 2 person assist was utilized. During transfer, he became slightly combative, however, he was easily redirected by this nurse. Resident showed +1 [MEDICAL CONDITION] to RT lower extremity due to [MEDICAL CONDITION], resident's legs were elevated for comfort and to reduce [MEDICAL CONDITION]. Bed was placed in lowered position, with call bell in reach. The nurse as well as the C.N.A. on duty make frequent checks on patient to ensure he was not attempting to get out of bed, as he is a fall risk. At no point, did resident attempt to get up/ambulate with rolling walker. Throughout the evening, he was resting comfortably in bed, with no obvious signs of distress or pain noted. Resident # 1 was admitted to the facility on [DATE] with a re-admission date of [DATE] from a local hospital with multiple diagnoses, including, but not limited to, dietary folate deficiency [MEDICAL CONDITIONS], Type II diabetes mellitus with diabetic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. The General Progress Note of [DATE] at 16:40 reflected the events surrounding Resident #1's hospital transfer as: Resident was on LOA with his son. His son brought him back to the facility and reported that when the resident was getting out of the car he began to collapse with the son holding him up. The son immediately returned the resident to the seat and chose to bring him back to be evaluated. The resident was helped to his bed and evaluated. Vitals were T: 97.2, P: 68, BP: ,[DATE] R: 32 and 99% on 2L. The resident was lethargic but rousable. He stated he had pain to his right arm and the skin tear was beginning to bleed through the dressing .the ARNP stated he wanted the resident sent to the ER for full evaluation, blood work, and treatment .due to his DNR status, the paperwork went with the patient. His son was notified. Record review of the Minimum Data Set (MDS), dated [DATE], following this readmission, reflected a Brief Interview for Mental Status score of 09 (moderate impairment).The Resident had not formulated advance directives as indicated on his admission documents. The resident did not have a Power of Attorney, Health Care Surrogate or Living Will as documented in the medical record. The Resident did sign a Do Not Resuscitate Order, dated [DATE]. The DNR was signed by the resident and the physician. The physician order was dated [DATE]. The 3008 form, dated [DATE], indicated that the resident was a DNR. The Psychosocial History and Assessment, completed at the facility on [DATE], indicated that the Resident has a code status of DNR. Resident#1 had an active plan of care for Advance Directives, which was initiated upon admission to the facility on [DATE] indicating that the resident's Advance Directives were as follows: Resident/authorized party responsible party request DNR wish to be honored. Residents Advance Directives will be honored as indicated through next review with a target date of [DATE]. Record review of the Nursing Progress notes showed the following: Dated [DATE] at 14:36-CNA (certified nursing assistant) checked on this patient at 14:15, found him unresponsive, and not breathing. This patient had an active DNR order in the chart, and paramedics were called to verify his passing. His time of death was listed as 14:15. An attempt has been made to reach his son. Will continue to follow up until family is notified. 3. During a telephone interview on [DATE] at 11:45 AM, with the son of for Resident #1 he stated his father would make his own decisions in regards to his health and was able to make all of his needs known. He reports that his father had a DNR in place, he noticed a decline in health over the past weeks. The facility had contacted him the day before his father's passing to inform him that the he had a urinary tract infection [MEDICAL CONDITION]. His father was given an antibiotic drip. This was not unusual because he had a history of [REDACTED]. They tried to reach me and left a voicemail for me to call them back. I called back at 2:45 PM on [DATE] and I spoke staff member (S) who informed me that my father had passed. I was informed by staff member (S) that when my father had stopped breathing, there might have been a few chest compressions done. 4. A telephone interview was conducted with the Resident's Physician/Medical Director on [DATE] at 10:12 AM. He reports that he did remember Resident#1 and recalled the event. I was called and informed that CPR had been done by mistake on Residnet#1. He also stated there was very little amount of compressions done, then they stopped. If he has a DNR they must stop the compressions immediately and respect the DNR status. He was asked if the facility followed proper protocol in stopping the compressions after having had ,[DATE] chest compressions, he replied absolutely. When asked if he had given orders to cease the CPR he confirmed that he had not provided any orders to cease CPR. The medical director confirmed that he attended the Emergency Quality Assurance Meeting. 5. On [DATE] at 11:10 AM- During an interview with the NHA (nursing home administrator) the following was confirmed; Unit Manager Staff member (S) and staff member (R) LPN were terminated for not following policy protocol for Code Status Orders and Response. They performed 5 (five) chest compressions on Resident#1 then stopped. At this time the NHA was asked if she had more specifics and she stated that she would bring all the documentation that she had on the event. At 11:35 AM the NHA and the Risk Consultant from Consulting Support Services provided the following information: NHA reports that she was made aware Resident#1 had passed. She heard a code blue over the intercom; I assisted in getting the chart from the nursing station, saw he was a DNR, handed the chart to staff member (A) to take the chart back to the resident's room. I was then informed that the Director of Nursing had stopped the code. The NHA interviewed staff member (E) LPN who stated staff member (Q) said to stop CPR after she was made aware that the patient was a DNR. NHA stated that At this time I took over the investigation and suspended staff members (Q, R and S.) All were given the option to resign the following day after the event had occurred and I completed my investigation for not following facility policy and ending the code. The NHA provided a time line of the events as follows: On [DATE] a code blue process was initiated, EMS activated. The residents' condition prior to the incident based on documentation and or/ staff interviews: displaying signs of a cold (cough/runny nose) and increased confusion. Evaluated by ARNP a day prior and antibiotics were initiated. Resident identified by staff member (C), did not appear to be breathing, code blue paged overhead. CNA had addressed the residents' needs prior to lunch and upon completion of lunch, approximately 40 minutes prior to the event. Resident displayed no signs/symptoms of distress at the time. Upon identification of unresponsiveness, code blue paged, staff members (A,C,E,F,Q,R,S) responded, initial compressions approximately (5) five were administered and 911 activated. Chart arrived, DON confirmed that the resident was a DNR and advised to cease activity. Paramedics arrived and pronounced, son and physician were notified. 6. During an interview on [DATE] at 10:25 AM with staff member (C) staff member who found Resident#1 unresponsive on [DATE]. She reported the following information in regards to the event: When I came in that morning on [DATE] around 6:45 AM the resident did not look good, he looked tired, he looked sick, so I notified staff member ( R) to look at Resident#1. I was told that his vital signs were good. Around mid-morning, I was providing care to him but it was more care than usual, it was like total care, usually he was independent. I told staff members (R and S) to take another look at him. They came and looked at him and said his vitals were good. He had his oxygen on. After lunch, I came back and checked on Resident#1, he had his mouth open, eyes open and I knew he was not breathing. I ran out of the room and shouted code blue, code blue (name of resident and room number), everyone started moving fast, they went into the room they started working on him, when I walked into the room I saw staff member (R) doing compressions, I saw staff member (S) at the bedside and then I walked out of the room. At this time, everyone was crowding around. I think staff member (A) grabbed the chart. I heard people talking .he was a DNR and they started compressions, the DON said, stop. They should not have stopped because once you start you should not stop. During an interview on [DATE] at 2:14PM with Staff Member (F), she provided the following details of the event: I was on the North Station and responded to the code. All nurses are required to respond to a code, the DON and staff members (R & S) were trying to resuscitate Resident#1, staff member (R) was giving the chest compressions, the DON was at the foot of the bed. Staff member (R) was giving chest compressions when I walked in. Staff member (R) was on the right side of the bed and staff member (S) was on the left side of the bed. The DON was at the foot of the bed. I remember one of the nurses saying, Where is the chart, what is the code status? The DON shouted out to go get the chart, in the meantime staff members (R and S) switched off and staff member (A) returned with the chart. The chart was handed to the DON. The DON opened the chart and said the patient is a DNR; again, she stated, the patient is a DNR stop the compressions staff members (R & S) immediately stopped. I went to make sure a call was being placed to 911 (Emergency Medical Services). During an interview with Staff Member (B) LPN 0n [DATE] at 12:06PM she provided the following details of the event: I had just come in early that day to do some charting, I must not even have been in the building three minutes when I heard a CNA I have a code blue over the pager system. I went to the medical chart for Resident#1 and saw that the patient was a DNR. While at the same time, I was on the phone calling 911. It was so chaotic I gave the chart to a CNA Staff Member (A) and while on the phone, I told 911 to please cancel the code the patient is DNR status. The 911 operator stated that they were on their way and would come and check anyway. EMS came and left. Afterwards the DON stated to me We did not do CPR, compressions never started. I was never in the room to observe anything; I was busy on the phone calling 911. I did not meet with EMS afterwards. During an interview on [DATE] at 1:00PM with staff member (E) she reported the following :I heard them call code blue and I went into Resident#1's room the DON, staff members (R and S), were in the room, I said, did anyone check his chart to see if he was a DNR or full code? I observed the staff member (S) doing chest compressions, the DON then sent someone to go check the chart. Staff member (A) came back and replied he is a DNR, the DON said Stop CPR because he is a DNR. I came out of the room and the NHA said do not stop, continue doing CPR never stop CPR when you start. During an interview with staff member (G) on [DATE] at 2:40 PM she provided the following details: When I responded to the code, I really did not know who it was. We are supposed to respond with the crash cart, I saw a CNA with the backboard which is part of the crash cart. When I walked in, I saw staff members (R & S) on either side of the bed doing chest compressions on the resident, it appeared that they were doing it without the backboard. Staff member (E) assisted in placing the backboard. At this point, staff member (D) shouted, Where is the chart? I was surprised because it is our protocol to check the chart before you call the code, and they are expected to have pulled the chart. Why a code would be called on a patient if they are a DNR? Staff member (A) handed the chart to the DON and as soon as she opened it up, she said, Stop compressions. Someone in the room questioned her and she did not respond and said, Stop doing the compressions. During a telephone interview with staff member (S) on [DATE] at 1:53 PM she provided the following details of the event: Staff member (C) called a code blue, everyone went running down to Resident#1 room. I grabbed the crash cart and brought into the room. The chart came down later; the first nurse that arrived was staff member (R) she started giving chest compressions maybe five without looking at the chart for a code status. I do not think she was thinking and started right away with the chest compressions. When she was made aware that the resident was a DNR she immediately stopped, the DON said hands off, he is a DNR. The resident was not on the backboard, no 02. I had come in and just gotten to bedside. I along with the DON spoke with the son and his response was that obviously everyone on the unit had a good will towards my father. I believe it was the DON that documented that the son was informed of the chest compressions. The way that I was trained in Illinois, you start and you can stop a CPR if the resident is a DNR. Therefore, when it was stopped I was not surprised. We received education the day of the incident from the new Risk Manager and the Administrator along with the corporate Risk Manager provided training. Drills were put in place for all shifts. During a telephone interview with Staff Member (Q), the former Director of Nurses, on [DATE] at 2:26 PM the following information was reported: I remember hearing someone calling a code blue, I left my office, I grabbed the crash cart, I saw multiple employees in the room and I grabbed the clipped board to transcribe. I notice two nurses (staff members R & S) turning him over, I did not observe any chest compressions. When staff member (A) brought in the chart, I noticed the State of Florida DNR order yellow form goldenrod and stated, He is a DNR. I never said stop doing chest compressions, because I did not observe any being done. She confirmed that the code blue worksheet was completed by her and was accurate. The Surveyor read the Code Blue Worksheet back to her where she indicated that CPR was initiated at 2:17 PM. At this time, she stated that she had not written that information on the Code Blue Worksheet. She confirmed that staff member (R) and herself had spoken with the resident's son and notified him of the possibility that his father had ,[DATE] chest compressions. The son was fine with this information and thanked her for taking such good care of his father. She stated that she did not document this conversation and believed that staff member (R) would have documented. A review of the job description for the Director of Nursing indicated that the DON was responsible for developing, organizing, evaluating and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for all overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Additionally, the DON signed a Commitment to Honoring Advance Directives, dated [DATE], which was attached to her clinical job description. On [DATE] at 11:10 AM- During an interview with the NHA (Nursing Home Administrator) the following was confirmed; Unit Manager Staff member (S) and staff member (R) LPN were terminated for not following policy protocol for Code Status Orders and Response. They performed 5 (five) chest compressions on Resident#1 then stopped. At this time the NHA was asked if she had more specifics and she stated that she would bring all the documentation that she had on the event. At 11:35 AM the NHA and the Risk Consultant provided the following information: NHA reports that she was made aware Resident#1 had passed. She heard a code blue over the intercom; I assisted in getting the chart from the nursing station, saw he was a DNR, handed the chart to staff member (A) to take the chart back to the resident's room. I was then informed that the Director of Nursing had stopped the code. The NHA interviewed staff member (E) LPN who stated staff member (Q) said to stop CPR after she was made aware that the patient was a DNR. NHA stated, At this time I took over the investigation and suspended staff members (Q, R and S.) All were given the option to resign the following day after the event had occurred and I completed my investigation for not following facility policy and ending the code. The NHA provided a time line of the events as follows: On [DATE] a code blue process was initiated, EMS activated. The residents' condition prior to the incident based on documentation and or/ staff interviews: displaying signs of a cold (cough/runny nose) and increased confusion. Evaluated by ARNP a day prior and antibiotics were initiated. Resident identified by staff member (C), did not appear to be breathing, code blue paged overhead. CNA had addressed the resident's needs prior to lunch and upon completion of lunch, approximately 40 minutes prior to the event. Resident displayed no signs/symptoms of distress at the time. Upon identification of unresponsiveness, code blue paged, staff members (A,C,E,F,Q,R,S) responded, initial compressions, approximately (5) five, were administered and 911 activated. Chart arrived, DON confirmed that the resident was a DNR and advised to cease activity. Paramedics arrived and pronounced, son and physician were notified. A review and verification of the facility's corrective action plan revealed the following: Quality Assessment & Performance Improvement Plan started on [DATE] with an actual completion date of [DATE]. 1) Notify family and medical director of resident's expiration. Charge Nurse Start-[DATE], Estimated Completion Date: [DATE], Actual Completion date [DATE]. 2) Advanced directive audit of resident's charts validated for accuracy. SSD- Start Date-[DATE], completion date: [DATE]. 3) Validated licensed staff's CPR licensure. NHA/Designee-Start-[DATE], Actual Completion date; [DATE]; 100% nurses & 100% CNA training. 4) Educated nurses related to advanced Directives, DNR orders, & Code Blue process. -ADON/SDC/Clinical Designee-[DATE]-Currently at 88% nurses & 100% CNA training. Completed [DATE]. 5) Code drills q shift with use of code drill minutes to critique & re-educate areas identified as in need of improvement as applicable. -DON/SDC/Clinical Designee: Start-[DATE]; [DATE] & ongoing. 6) Audit Advanced Directive orders weekly X 4 weeks. - DON/SSD-Start-[DATE], Actual Completion date [DATE]. 7) Review resident advanced directives upon admission, quarterly and with significant changes. -SSD-Start-[DATE]- Actual Completion Date [DATE] and ongoing. On [DATE] at 8:00 AM, it was verified that all fourteen current residents and or family members of residents who had expressed a wish to have CPR withheld had current physician DNR orders in place on their clinical record. Verification was made for residents who had State of Florida DNR orders yellow forms, those forms were also were in place in the clinical record. Verification was made on [DATE] for residents who had expired at the facility form (MONTH) (YEAR) to the present had their Advance Directives honored. A review of the Advance Directives for expired Residents #2, #3, #4, #5 and #6 revealed no concerns with having their end of life wished honored. A full review of in-services regarding honoring advance directives, and the process for verifying code status of a resident by checking the clinical record for a DNR order as the definitive methods of verification of code status. Sign in sheets for Code Status Orders and Response were reviewed which revealed signatures for all licensed staff. Staff are to check the medical record for the code status, in absence of Advance Directives or physicians order, the resident will be considered a Full Code Status. According to the 4-Point Plan provided NHA licensed staff were re-educated on the fact that we follow physician orders when determining whether to provide or withhold CPR. Mock code drills and critiques were conducted by lead staff beginning on [DATE] for all shifts, randomly and ongoing, with a last documented code drill date of [DATE]. Interviews conducted on [DATE] and [DATE] to assess knowledge of facility policy for Advance Directives and response to a code. Interviews with licensed staff revealed consistency with the current policy, Advanced Directive-Nursing and recent trainings. On [DATE] and [DATE], 75 percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. Review of facility documentation revealed that 100% of all licensed nurses received Advance Directive in-service training in response to the incident. An audit was completed of licensed staff personnel to verify the presence of a valid CPR certification. On [DATE] an interview with the NHA on [DATE] at 4:00 PM stated that the facility currently has 14 LPN's and 1 RN's. She provided a copy of the current CPR certification for each licensed staff member. Policies Reviewed Code Status Orders & Response-Standard & Procedure-Florida (Effective (MONTH) (YEAR)) The facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative or legally authorized party. Advanced Directives will be honored during the code process. Do Not Resuscitate (DNR) ORDER-Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status. Code status orders will be reviewed on admission, quarterly, PRN and with any significant change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/resident representative or legally authorized party will have their elected code status documented in the medical record. Code status physician's order (DNR or Full Code) will be filed as the first document within the medical record. The resident/resident representative or legally authorized party may change the code status at any time. The staff must notify the MD and request an order for [REDACTED]. The facility does not provide Advanced Life Support. ON ADMISSION Staff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/resident representative wishes to change their decision. 1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible. 2. Discuss code status preference with the resident /resident representative. 3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders [REDACTED]

Based on clinical record review, policy and procedure review for Code Status and Process and Abuse Prevention Policy and Procedure, Nursing Home Administrator (NHA) job description review, and interviews with the facility's nursing and administrative staff, & the attending physician/Medical Director, it was determined that administration failed to provide resource management to ensure the right to refuse treatment and exercise advanced directives for end of life decisions were protected for one (#1) of 14 residents identified as having a DO NOT RESUSCITATE order (DNR). Administration did not ensure the direct functions and operations of the facility, including the right to be free from neglect, were in accordance with current regulations governing long term care facilities related to implementing policies and procedures for code arrest and abuse prevention. The facility failed to verify the Advance Directives for Resident#1 prior to initiating Cardio- [MEDICAL CONDITION] Resuscitation (CPR) on [DATE]. The facility failed to ensure that Resident #1's Advance Directives of DNR were properly carried out as facility personnel administered Cardio- [MEDICAL CONDITION] Resuscitation when the resident was found to be without pulse or respirations. The administration's failure to ensure that the resident's expressed wishes related to advanced directives and the right to refuse treatment were honored and protected led to the findings of Immediate Jeopardy Past non-compliance, which was corrected on [DATE] prior to the survey. Findings Included: 1. Review of the job description for the Nursing Home Administrator (undated) included the following relevant information: Position: Nursing Home Administrator Reports To: Regional Vice President Summary of Position: The Nursing Home Administrator is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents. Essential Duties and Responsibilities: Plans, develops, organizes, implements, and directs the facility's programs and activities; Ensures that each resident's right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced; Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations are available and followed; Conducts Residents Council Meetings regularly; Ensures that an adequate number of personnel are employed to meet the needs of the residents and State requirements; maintains her license on a status as required by law and maintains a copy of such license on the premise; Ensures that all facility personnel, residents, visitors, etc., follow established safety regulations to include fire protection/prevention, smoking regulations, accident prevention, sanitation/infection control, etc.; Monitors and ensures compliance with all state and federal regulations including wage and hour laws, affirmative action, Americans with Disabilities Act, OSHA and other related programs. Attends and participates in training classes, performance improvement committees, and other meetings as needed; Responsible for the financial, administrative and personnel management of the facility Responsible for Survey Management, Responsible for Census Development Responsible for Account Receivables Outcomes. Supervisory Responsibilities: Supervises staff whether directly or indirectly in accordance with company policies and procedures; Responsible for the hiring, selection, training and coaching of employees. Knowledge: Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods and coordination of people and resources. Skills- effective verbal and communication skills, using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. Considering the relative costs and benefits of potential actions to choose the most appropriate one. Abilities: the ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. The ability to communicate information and ideas in writing so others will understand. The ability to relate positively, effectively, and appropriately with residents families, community members, volunteers, and other facility staff. Possess special interest in working with long-term care residents and the elderly. 2. The Job Description for the Director of Nursing included: Commitment to Honoring Advance Directives was included as an attachment to the clinical job description of the Director of Nursing, signed on [DATE]. It is the right of every resident to execute an advance directive. I acknowledge that I understand the risk and benefits of a patient forming an advance directive. I acknowledge my responsibility as a nurse and employee of the facility to provide care under an advance directive for the patient when they are unable to direct their care; I have the ability to react to an emergency situation (where decision making is critical to the outcome of a patient), to assure that the patients previously expressed desires regarding their care (i.e. full code, DNR) under the guidance of physician orders [REDACTED]. I have been provided education on the procedures for executing an advance directive in this facility, I have been given an opportunity to ask questions and be fully informed of my responsibilities in providing care under an advance directive. I understand my responsibility in obtaining CPR certification and maintaining that certification while employed at this facility. I do not have ethical, moral or religious philosophies that would inhibit my ability to provide patient care under an advance directive. Position: Director of Nursing Reports To: Nursing Home Administrator Summary of Position: The Director of Nursing is responsible for developing, organizing, evaluating and administering patient care programs and services of the Center. Has twenty-four (24) hour responsibility for the overall delivery of nursing services and insures that the implementation of all-clinical policies and procedures. Essential Duties and Responsibilities: Leads, organizes, evaluates, and manages nursing and clinical personnel through sound management practices and delegation. Makes daily patient rounds with the appropriate manager/supervisor to note patient/resident conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Ensures that each resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint are strictly enforced. Ensures compliance with applicable local, state, federal and other regulatory agencies and quality assurance standards, certifications and licensure requirements. Participates in the clinical admission process Attends regularly conducted staff meetings and participates regularly in continuing education trainings programs. Handles on call responsibilities as required. Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. Leads manages the General and Restorative Nursing Services on a 24-hour basis to ensure delivery of high quality comprehensive patient care. Assures directly or through delegation, the current licensure status and employee records of all RN's and LPN's and other licensed clinical personnel reporting to this position. Survey Management Performs duties as defined by the State Nurse Practice Act and other regulatory agencies. Other duties as assigned Supervisory Responsibilities: Supervise nursing staff whether directly or indirectly in accordance with company policies and procedures. Responsible for hiring, selection, training and coaching employees. Knowledge: Knowledge of the information and techniques needed to diagnose and treat human resources, diseases and deformities. This includes symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures. Knowledge of principles and processes for providing customer and personal services. This included customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. Skills- effective verbal and communication skills, using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. Considering the relative costs and benefits of potential actions to choose the most appropriate one. Abilities: the ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. The ability to communicate information and ideas in writing so others will understand. The ability to relate positively, effectively, and appropriately with residents families, community members, volunteers, and other facility staff. Possess special interest in working with long-term care residents and the elderly. 3. On [DATE] at 11:10 AM- During an interview with the NHA (nursing home administrator) the following was confirmed; Staff member (S) Unit Manager and staff member (R) LPN were terminated for not following policy protocol for Code Status Orders and Response. They performed 5 (five) chest compressions on Resident#1 then stopped. At this time the NHA was asked if she had more specifics and she stated that she would bring all the documentation that she had on the event. At 11:35 AM the NHA and the Risk Consultant provided the following information: The NHA reports that she was made aware Resident#1 had passed. She heard a code blue over the intercom; I assisted in getting the chart from the nursing station, saw he was a DNR, handed the chart to staff member (A) to take the chart back to the resident's room. I was then informed that the Director of Nursing had stopped the code. The NHA interviewed staff member (E) LPN who stated staff member (Q) said to stop CPR after she was made aware that the patient was a DNR. The NHA stated that, At this time I took over the investigation and suspended staff members (Q, R, and S.) All were given the option to resign the following day after the event had occurred and I completed my investigation for not following facility policy and ending the code. The NHA provided a time line of the events as follows: On [DATE] a code blue process was initiated, EMS activated. The resident's condition prior to the incident based on documentation and or/ staff interviews: displaying signs of a cold (cough/runny nose) and increased confusion. Evaluated by ARNP a day prior and antibiotics were initiated. Resident identified by staff member (C), did not appear to be breathing, code blue paged overhead. CNA had addressed the resident's needs prior to lunch and upon completion of lunch, approximately 40 minutes prior to the event. Resident displayed no signs/symptoms of distress at the time. Upon identification of unresponsiveness, code blue paged, staff members (A,C,E,F,Q,R,S) responded, initial compressions, approximately (5) five were administered, and 911 activated. Chart arrived, DON confirmed that the resident was a DNR and advised to cease activity. Paramedics arrived and pronounced, son and physician were notified. 4. The Admission Record for Resident # 1 revealed that he was admitted to the facility on [DATE] with a re-admission date of [DATE] from a local hospital with multiple diagnoses, including, but not limited to, dietary folate deficiency [MEDICAL CONDITIONS], Type II diabetes mellitus with diabetic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. The General Progress Note of [DATE] at 16:40 reflected the events surrounding Resident #1's hospital transfer as: Resident was on LOA with his son. His son brought him back to the facility and reported that when the resident was getting out of the car he began to collapse with the son holding him up. The son immediately returned the resident to the seat and chose to bring him back to be evaluated. The resident was helped to his bed and evaluated. Vitals were T: 97.2, P: 68, BP: ,[DATE] R: 32 and 99% on 2L. The resident was lethargic but rousable. He stated he had pain to his right arm and the skin tear was beginning to bleed through the dressing .the ARNP stated he wanted the resident sent to the ER for full evaluation, blood work, and treatment .due to his DNR status, the paperwork went with the patient. His son was notified. Record review of the Minimum Data Set (MDS), dated [DATE], reflected a Brief Interview for Mental Status score of 09 (moderate impairment).The Resident had not formulated advance directives as indicated on his admission documents. The resident did not have a Power of Attorney, Health Care Surrogate or Living Will as documented in the medical record. The Resident did sign a Do Not Resuscitate Order, dated [DATE]. The DNR was signed by the resident and the physician. The physician order [REDACTED]. The 3008 form, dated [DATE], indicated that the resident was a DNR. The Psychosocial History and Assessment, completed at the facility on [DATE], indicated that the Resident had a code status of DNR. Record review of the Nursing Progress notes showed the following: Dated [DATE] at 14:36-CNA (certified nursing assistant) checked on this patient at 14:15, found him unresponsive, and not breathing. This patient had an active DNR order in the chart, and paramedics were called to verify his passing. His time of death was listed as 14:15. An attempt has been made to reach his son. Will continue to follow up until family is notified. Review of Progress Notes in the record of Resident #1provided the following notations of his condition on [DATE], prior to being found unresponsive on [DATE]: On [DATE] at 07:45, Resident has runny nose/cold symptoms .reported to AM nurse to monitor, and for orders. On [DATE] at 10:30, Resident observed at bedside in walker c/o feeling bad. Slight non-productive dry cough is present, along with what resident describes as a heavy headache .ARNP was present in facility and assessed resident. Orders for antibiotics were sent to the pharmacy and orders for labs were also faxed. Scheduled nebulizer as well as all other medications per order. Resident was resting comfortably in bed, in lowered position, call light within reach. Resident is able to verbalize needs and currently is showing no symptoms of distress. Later that evening, on [DATE] at 20:15, Resident was sitting on seat to rolling walker, and stated, I am uncomfortable but I do not want to move. The nurse and C.N.A encouraged resident to transfer from seat on rolling walker into the bed, and a 2 person assist was utilized. During transfer, he became slightly combative, however, he was easily redirected by this nurse. Resident showed +1 [MEDICAL CONDITION] to RT lower extremity due to [MEDICAL CONDITION], resident's legs were elevated for comfort and to reduce [MEDICAL CONDITION]. Bed was placed in lowered position, with call bell in reach. The nurse as well as the C.N.A. on duty make frequent checks on patient to ensure he was not attempting to get out of bed, as he is a fall risk. At no point, did resident attempt to get up/ambulate with rolling walker. Throughout the evening, he was resting comfortably in bed, with no obvious signs of distress or pain noted. 5. During a telephone interview with Staff Member (Q), the former Director of Nurses, on [DATE] at 2:26 PM the following information was reported: I remember hearing someone calling a code blue, I left my office, I grabbed the crash cart, I saw multiple employees in the room and I grabbed the clipped board to transcribe. I noticed two nurses (staff members R & S) turning him over, I did not observe any chest compressions. When staff member (A) brought in the chart, I noticed the State of Florida DNR order yellow form goldenrod and stated, He is a DNR. I never said stop doing chest compressions, because I did not observe any being done. She confirmed that the code blue worksheet was completed by her and was accurate. The Surveyor read the Code Blue Worksheet back to her where she indicated that CPR was initiated at 2:17 PM. At this time, she stated that she had not written that information on the Code Blue Worksheet. She confirmed that staff member (R) and herself had spoken with the resident's son and notified him of the possibility that his father had ,[DATE] chest compressions. The son was fine with this information and thanked her for taking such good care of his father. She stated that she did not document this conversation and believed that staff member (R) would have documented. 6. Interviews were conducted with staff who also responded to Resident #1's Code: During an interview with Staff Member (B) LPN 0n [DATE] at 12:06PM she provided the following details of the event: I had just come in early that day to do some charting, I must not even have been in the building three minutes when I heard a CNA I have a code blue over the pager system. I went to the medical chart for Resident#1 and saw that the patient was a DNR. While at the same time, I was on the phone calling 911. It was so chaotic I gave the chart to a CNA Staff Member (A) and while on the phone, I told 911 to please cancel the code the patient is DNR status. The 911 operator stated that they were on their way and would come and check anyway. EMS came and left. Afterwards the DON stated to me We did not do CPR, compressions never started. I was never in the room to observe anything; I was busy on the phone calling 911. I did not meet with EMS afterwards. During an interview on [DATE] at 10:25 AM with staff member (C) staff member who found Resident#1 unresponsive on [DATE]. She reported the following information in regards to the event: When I came in that morning on [DATE] around 6:45 AM the resident did not look good, he looked tired, he looked sick, so I notified staff member ( R) to look at Resident#1. I was told that his vital signs were good. Around mid-morning, I was providing care to him but it was more care than usual, it was like total care, usually he was independent. I told staff members (R and S) to take another look at him. They came and looked at him and said his vitals were good. He had his oxygen on. After lunch, I came back and checked on Resident#1, he had his mouth open, eyes open and I knew he was not breathing. I ran out of the room and shouted code blue, code blue (name of resident and room number), everyone started moving fast, they went into the room they started working on him, when I walked into the room I saw staff member (R) doing compressions, I saw staff member (S) at the bedside and then I walked out of the room. At this time, everyone was crowding around. I think staff member (A) grabbed the chart. I heard people talking .he was a DNR and they started compressions, the DON said, stop. They should not have stopped because once you start you should not stop. During an interview on [DATE] at 1:00PM with staff member (E) she reported the following :I heard them call code blue and I went into Resident#1's room the DON, staff members (R and S), were in the room, I said, did anyone check his chart to see if he was a DNR or full code? I observed the staff member (S) doing chest compressions, the DON then sent someone to go check the chart. Staff member (A) came back and replied he is a DNR, the DON said Stop CPR because he is a DNR. I came out of the room and the NHA said do not stop, continue doing CPR never stop CPR when you start. During an interview on [DATE] at 2:14PM with Staff Member (F), she provided the following details of the event: I was on the North Station and responded to the code. All nurses are required to respond to a code. The DON and staff members (R & S) were trying to resuscitate Resident#1. Staff member (R) was giving the chest compressions. The DON was at the foot of the bed. Staff member (R) was giving chest compressions when I walked in. Staff member (R) was on the right side of the bed and staff member (S) was on the left side of the bed. The DON was at the foot of the bed. I remember one of the nurses saying, Where is the chart, what is the code status? The DON shouted out to go get the chart. In the meantime, staff members (R and S) switched off and staff member (A) returned with the chart. The chart was handed to the DON. The DON opened the chart and said the patient is a DNR. Again, she stated, the patient is a DNR, stop the compressions. Staff members (R & S) immediately stopped. I went to make sure a call was being placed to 911 (Emergency Medical Services). During an interview with staff member (G) on [DATE] at 2:40 PM, she provided the following details: When I responded to the code, I really did not know who it was. We are supposed to respond with the crash cart. I saw a CNA with the backboard which is part of the crash cart. When I walked in, I saw staff members (R & S) on either side of the bed doing chest compressions on the resident. It appeared that they were doing it without the backboard. Staff member (E) assisted in placing the backboard. At this point, staff member (D) shouted, Where is the chart? I was surprised because it is our protocol to check the chart before you call the code, and they are expected to have pulled the chart. Why a code would be called on a patient if they are a DNR? Staff member (A) handed the chart to the DON and, as soon as she opened it up, she said, Stop compressions. Someone in the room questioned her and she did not respond and said, Stop doing the compressions. During a telephone interview with staff member (S) on [DATE] at 1:53 PM she provided the following details of the event: Staff member (C) called a code blue, everyone went running down to Resident#1's room. I grabbed the crash cart and brought into the room. The chart came down later. The first nurse that arrived was staff member (R). She started giving chest compressions, maybe five, without looking at the chart for a code status. I do not think she was thinking and started right away with the chest compressions. When she was made aware that the resident was a DNR, she immediately stopped. The DON said, hands off, he is a DNR. The resident was not on the backboard, no 02. I had come in and just gotten to bedside. I, along with the DON, spoke with the son and his response was that, obviously, everyone on the unit had a good will towards my father. I believe it was the DON that documented that the son was informed of the chest compressions. The way that I was trained in Illinois, you start and you can stop a CPR if the resident is a DNR. Therefore, when it was stopped I was not surprised. We received education the day of the incident from the new Risk Manager and the Administrator along with the corporate Risk Manager provided training. Drills were put in place for all shifts. A telephone interview was conducted with the Resident's Physician/Medical Director on [DATE] at 10:12 AM. He reported that he did remember Resident#1 and recalled the event. I was called and informed that CPR had been done by mistake on Resident#1. He also stated, there was very little amount of compressions done, then they stopped. If he has a DNR they must stop the compressions immediately and respect the DNR status. He was asked if the facility followed proper protocol in stopping the compressions after having had ,[DATE] chest compressions, he replied absolutely. When asked if he had given orders to cease the CPR he confirmed that he had not provided any orders to cease CPR. The Medical Director confirmed that he attended the Emergency Quality Assurance Meeting. Review, however, of the facility's Clinical Programs Manual, ADM 11.1 Page 3 of 5, Procedure for Initiating CPR (Effective October, (YEAR)), &, current on [DATE], at the time Resident #1 was found unresponsive, found: Once CPR is started, CPR will continue until: 1. Relieved by EMS; 2. Relieved by another staff member who will take over CPR; 3. Physician orders [REDACTED].>4. Resident pulse and respirations are palpable /observable. During a telephone interview on [DATE], at 11:45 AM, with the son of Resident #1, he stated his father would make his own decisions in regards to his health and was able to make all of his needs known. He reported that his father had a DNR in place, he noticed a decline in health over the past weeks. The facility had contacted him the day before his father's passing to inform him that the he had a urinary tract infection [MEDICAL CONDITION]. His father was given an antibiotic drip. This was not unusual because he had a history of [REDACTED]. They tried to reach me and left a voicemail for me to call them back. I called back at 2:45 PM on [DATE] and I spoke staff member (S) who informed me that my father had passed. I was informed by staff member (S) that when my father had stopped breathing, there might have been a few chest compressions done. Procedure The facility implemented the following processes in an effort to provide residents, visitors, and staff with a safe and comfortable environment. 1. The Administrator is responsible for designation an abuse coordinator. 2. The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. 3. The Administrator, Director of Nursing, and Risk Manager are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, exploration, and misappropriation. 4. The Administrator, the Director of Nursing, and the Risk Manager are also ultimately responsible for the following: implementation, ongoing monitoring, reporting, investigation, tracking and trending, fear of retribution, staff is instructed to report concerned incidents and grievances. Facility leadership will identity situations in which abuse, neglect, mistreatment, exploitation, or misappropriation may be more likely to occur, such as: resident with needs/behaviors which might lead to conflict or abuse/neglect and staff burnout. Analyze the occurrences to determine what changes are needed of any policies and procedures to prevent further occurrences. Prevention - Post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including, but not limited to: resident abuse, neglect, exploration, misappropriation of resident property in the facility, noncompliance with the advance directives requirements, and request for information regarding returning to the community. - Post information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing home regulations, including, but not limited to: resident abuse, neglect, exploration, misappropriation of resident property in the facility, noncompliance with the advance directives requirements, and request for information regarding returning to the community. - Residents and families are encouraged to report concerns, incidents, and grievances without reprisal. - The NHA and DON will be informed of investigation process and findings. A review and verification of the facility's corrective action plan revealed the following: Quality Assessment & Performance Improvement Plan started on [DATE] with an actual completion date of [DATE]. 1) Notify family and medical director of resident's expiration. Charge Nurse Start-[DATE], Estimated Completion Date: [DATE], Actual Completion date [DATE]. 2) Advanced directive audit of resident's charts validated for accuracy. SSD- Start Date-[DATE], completion date: [DATE]. 3) Validated licensed staff's CPR licensure. NHA/Designee-Start-[DATE], Actual Completion date; [DATE]; 100% nurses & 100% CNA training. 4) Educated nurses related to advanced Directives, DNR orders, & Code Blue process. -ADON/SDC/Clinical Designee-[DATE]-Currently at 88% nurses & 100% CNA training. 5) Code drills q shift with use of code drill minutes to critique & re-educate areas identified as in need of improvement as applicable. -DON/SDC/Clinical Designee: Start-[DATE]; [DATE] & ongoing, 6) Audit Advanced Directive orders weekly X 4 weeks. - DON/SSD-Start-[DATE], Actual Completion date [DATE]. 7) Review resident advanced directives upon admission, quarterly and with significant changes. -SSD-Start-[DATE]- Actual Completion Date [DATE] and ongoing. On [DATE] at 8:00 AM, staff verified that all fourteen current residents and or family members of residents who had expressed a wish to have CPR withheld had current physician DNR orders in place on their clinical record. Verification was made for residents who had State of Florida DNR orders yellow forms & those forms were also were in place in the clinical record. Verification was made on [DATE] for residents who had expired at the facility form (MONTH) (YEAR) to the present had their Advance Directives honored. A review of the Advance Directives for expired residents #2, #3, #4, #5 and #6 revealed no concerns with having their end of life wished honored. A full review was completed of in-services regarding honoring advance directives, and the process for verifying code status of a resident by checking the clinical record for a DNR order as the definitive methods of verification of code status. Sign in sheets for Code Status Orders and Response were reviewed which revealed signatures for all licensed staff. Staff are to check the medical record for the code status, in absence of Advance Directives or physicians order, the resident will be considered a Full Code Status. According to the 4-Point Plan provided NHA licensed staff were re-educated on the fact that we follow physician orders [REDACTED]. Mock code drills and critiques were conducted by lead staff beginning on [DATE] for all shifts, randomly and ongoing, with a last documented code drill date of [DATE]. Interviews were conducted on [DATE] and [DATE] to assess knowledge of facility policy for Advance Directives and response to a code. Interviews with licensed staff revealed consistency with the current policy, Advanced Directive-Nursing and recent trainings. On [DATE] and [DATE], 75 percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. Review of facility documentation revealed that 100% of all licensed nurses received Advance Directive in-service training in response to the incident. An audit was completed of licensed staff personnel to verify the presence of a valid CPR certification. On [DATE] an interview with the NHA on [DATE] at 4:00 PM stated that the facility currently had 14 LPN's and 1 RN's. She provided a copy of the current CPR certification for each licensed staff member. Policies Reviewed * Policy for Code Status Orders & Response prior to [DATE] (Effective (MONTH) (YEAR)) The following CPR policy provided by the NHA on [DATE] at 1:42 PM Procedure for initiating CPR Effective Date (MONTH) (YEAR) Once CPR is started, CPR will continue until: Relieved by EMS; Relieved by another staff member who will take over CPR; Physician orders [REDACTED].>Resident pulse & respirations are palpable/observable. Personnel 1st person on scene-Confirmed cardiac and/or respiratory arrest. (2) Call for HELP. (3.) Checks airway and pulse and connect to oxygen if available while awaiting the emergency cart. (4) Check medical record for code status. Point of emphasis: CODE status must be confirmed by checking the medical record. (5.) Begins CPR and continue CPR while A (TRUNCATED)