Every finding on record at Golfview Nursing Center

Based on interviews and record reviews, the facility did not provide prompt efforts to resolve a grievance for one (Resident #1) of two residents reviewed. Findings include: An observation on 12/30/2025 at 12:28 P.M. of Resident #1's privacy curtain in her room revealed three ants moving on the curtain. An interview was conducted on 12/20/2025 at 12:31 P.M. with Resident #1. Resident #1 said that she had filed a formal grievance on 12/22/2025 regarding ants in her room. Resident #1 provided a photo of the grievance that was written by her on 12/22/2025. A review of the facility provided grievance log for December 2025 revealed the facility did not have a grievance listed for Resident #1. An interview was conducted on 12/30/2025 at 1:15 P.M. with Staff D, Social Services (SS). Staff D, SS said Resident #1 filed a formal grievance on 12/22/2025. Staff D said she gave the grievance form to the Nursing Home Administrator (NHA) for review. Staff D said the NHA stated she would handle it [the grievance]. Staff D said she had not followed up with the NHA and did not know the outcome of the grievance. An interview was conducted on 12/30/2025 at 2:01 P.M. with the NHA. The NHA said Resident #1 filed a grievance 12/22/2025. The NHA said the grievance was regarding ants in her room. The NHA said Staff C, Plant Director (PD) observed ants in Resident #1's room. The NHA said she did not know where the original formal grievance form was for Resident #1. An interview was conducted on 12/30/2025 at 2:10 P.M. with Staff C, PD. Staff C, PD said Resident #1 had ants in her room on the walls and the resident's privacy curtain. Staff C, PD said the NHA spoke to him last week about the grievance Resident #1 filed. An interview was conducted on 12/30/2025 at 3:40 P.M. with the NHA. The NHA said she did not have the original grievance Resident #1 had written. A review of facility provided policy revised in January 2025, titled, Resident and Family Grievances showed: It is the policy of this facility to support each resident's and family member's right to voice grievances with discrimination, reprisal or fear of discrimination or reprisal. The policy's explanation and compliance guidelines showed: 2. The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; coordinating any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances. 17. All grievances should be documented on the grievance log and maintained per retention policy.

Based on interviews and record reviews, the facility did not ensure alleged abuse were reported to the governing agency in accordance with the State law for one (Resident #1) of two residents sampled. Findings include: An interview was conducted on 12/30/2025 at 12:31 P.M with Resident #1. Resident #1 filed a grievance on 12/22/2025 and provided a photo. Resident #1 said Staff C, Plant Director (PD) was aggressive and yelling at her. Resident #1 had given the grievance form to Staff A, Activities Director (AD). Resident #1 did not know the outcome of the grievance. Resident #1 had not spoken to the Nursing Home Administrator (NHA). An interview was conducted on 12/30/2025 at 1:15 P.M. with Staff D, Social Services Director (SSD). Staff D, SSD had given the grievance to the NHA on 12/22/2025. Staff D, SSD said Staff C, PD spoke rudely to Resident #1. Staff D, SSD had received the grievance form from Staff A, AD. Staff D, SSD did not know the outcome of the grievance. Staff D, SSD said the NHA had the grievance form for Resident #1. An interview was conducted on 12/30/2025 at 2:01 P.M. with the NHA. The NHA said Resident #1 filed a grievance on 12/22/2025 regarding ants in the resident's room. The NHA said Resident #1 did not like the way Staff C, PD spoke to her. The NHA did not have the original grievance form that Resident #1 completed. An interview was conducted on 12/30/2025 at 2:10 P.M. with Staff C, PD. Staff C, PD said the NHA spoke to him about the grievance for Resident #1. Staff C, PD said Resident #1 alleged I spoke to her [Resident #1] aggressively and was yelling at her [Resident #1]. Staff C, PD said if I look back on it now, maybe I was speaking harshly to the resident. An interview was conducted on 12/30/2025 at 3:00 P.M. with Staff A, AD. Staff A, AD had reported Resident #1's allegation to the NHA on 12/22/2025. Staff A, AD had given the grievance form to Resident #1; after Resident #1 completed the grievance form, had given the form to Staff D, SSD. Staff A, AD had not spoken to the NHA since reporting the allegation. Review of the facility provided grievances revealed no grievances placed by the resident for the month of December. A review of the facility provided policy revised in January 2025, titled, Resident and Family Grievances showed: It is the policy of this facility to support each resident's and family member's right to voice grievances with discrimination, reprisal or fear of discrimination or reprisal. The policy's explanation and compliance guidelines showed: 10: Procedure g: For investigations regarding allegations of neglect, abuse, injuries of unknow source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State Law, within five working days of the incident. A review of the facility provided policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property showed: Mental and Verbal Abuse: .Verbal abuse includes the use of oral, written, or gestured communication. Examples of mental and verbal abuse included, but are not limited to, harassing the resident, mocking, insulting, ridiculing; yelling or hovering over a resident with the intent to intimated. Reporting/Documentation Requirements: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the center and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care centers) in accordance with State law.

Based on record review and interviews, the facility failed to permit a resident to return to the facility after a hospital stay for one resident (#1) of three sampled residents reviewed for discharge process. Resident #1 was eligible for discharge from the hospital on [DATE] and as of 06/27/2025, the facility notified the hospital Resident #1 was not accepted back at the facility. Findings included:A review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and was discharged on 05/17/2025 to an acute care hospital. His medical diagnoses included, but not limited to schizoaffective disorder, bipolar type; unspecified diastolic (congestive) heart failure and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and morbid obesity due to excessive calories.A review of a Brief Interview for Mental Status (BIMS), dated 03/26/2025, documented a score of 15, which meant the resident was cognitively intact.A review of Resident #1's care plan, initiated 04/20/2023, reflected a focus area: [Resident #1] wishes to Stay[sic] at this facility under long term care. The goal of the plan: The resident's discharge goals are LTC (Long Term Care). The interventions included: Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress, initiated on 04/20/2023.A review of Resident #1's progress notes revealed the following: 05/17/2025 at 6:00 p.m.: Nurse reported to this writer that resident had a change in condition. This writer went to resident room. Resident noted to have vitals as followed . HR [heart rate] 117, O2 [oxygen] Sats [saturation] Fluctuating between 74-76% on 3 liters Via N/C [nasal cannula]. Temp [temperature] 99.4 Tympanic. Patient presented with altered mental status, noted to be confused and unable to follow simple commands due to concerning vitals and neurological presentation, 911 activated .05/17/2025 at 6:42 p.m.: hospitalized [DATE] at 6:51 p.m.: Call place to [Hospital], Admitting DX [diagnosis] Acute Hypoxic Respiratory Failure.Review of the facility's Midnight Census Report dated 7/1/25 and 7/2/25 revealed Resident #1 was not admitted back to the facility.Review of Resident #1's medical record did not reveal a 30-day notice of discharge was provided to Resident #1.An interview was conducted on 06/18/2025 at 11:26 a.m., with Staff E, Director of Nursing (DON). Regarding Resident #1, she stated the reason the resident was transferred to the hospital was respiratory distress. She confirmed the resident had been at the facility for three to four years. She confirmed the Nursing Home Transfer and Discharge Notice, dated 05/17/25, was the notice provided on 05/17/25 for the transfer to the hospital. She stated the resident had not come back. When asked if Resident #1 could come back, Staff E, DON said, Yes. When asked if there was any reason the facility would not take him back, Staff E, DON said, There was a discussion about safety due to his size. His weight is (### pounds). It took over an hour to complete his transfer to the hospital. It took three different transports to be able to transfer the resident due to his size and the type of equipment necessary. Staff E, DON stated, I just received paperwork today, (06/18/2025), the hospital is requesting the resident to come back. She stated this was the first paperwork from the hospital asking for a return. When asked if anyone had received any phone calls requesting the return of the resident, she stated she would have to talk to the Nursing Home Administrator (NHA). Most of the time, the case managers will talk with the NHA about a returning resident. An interview was conducted on 06/18/2025 at 1:44 p.m. with the NHA and Staff E, DON regarding Resident #1. The NHA stated the hospital had not called him, but the hospital had called Representative A, Hospital/Facility Liaison. The NHA stated he did not know when Representative A, Hospital/Facility admission Liaison was called or what the discussion was. The NHA stated, probably one week after the resident was admitted to the hospital, we had a discussion that the resident should come back. The NHA said he had not decided whether or not to take the resident back at the time. He said he did not know if Resident #1 was ready to come back. The NHA said, if the resident wanted to come back, he could come back. Staff E, DON stated she had received clinical paperwork that morning (06/18/2025).On 06/18/2025 at 10:12 a.m., Representative B, Local Hospital Supervising Care Coordinator, was interviewed by phone. He stated when an attempt to return Resident #1 back to the facility was made, the admissions coordinator flat out refused to take the resident back. Representative B, Local Hospital Supervising Care Coordinator stated Resident #1 was still in the hospital, he is alert and oriented. The hospital has been having a difficult time placing the resident. When asked if the facility had requested any additional information from the hospital about the resident's condition to make their determination on whether or not to take the resident back, he said no. The resident had no additional conditions.On 06/18/2025 at 2:10 p.m. Representative B, Local Hospital Supervising Care Coordinator, was interviewed again by phone. He stated Resident #1 was eligible for discharge on [DATE]. He stated one of his discharge planners had reached out to Representative A, Facility/Hospital admission Liaison, who had reportedly given the discharge planner a hard time. So Representative B, Local Hospital Supervising Care Coordinator called Representative A, Facility/Hospital admission Liaison and he told him No. When asked what the situation was, currently, for Resident #1, if the facility had agreed to take the resident back, he stated, we have a system where we can see if a referral has been accepted, no one has accepted the resident as of yet. He stated, it looks as if the facility reached out this morning for clinical paperwork, but no acceptance yet. A phone interview was conducted on 7/1/25 at 2:41p.m with Representative A, Facility/Hospital admission Liaison. He said he handles the admissions from the hospital to the nursing home. He said Resident #1 was hospitalized and quite a while ago the hospital was just keeping him abreast about Resident #1's status through their communication program. He said the hospital did request Resident #1 to be readmitted to the facility. He did not know when they made the request. Representative A, Facility/Hospital admission Liaison, said he told the hospital they would have to talk to the facility's administration because he does not handle readmissions. He said the facility's administration discusses readmissions and he is not involved in the discussion. Representative A, Facility/Hospital admission Liaison said he told the hospital last week sometime the facility would not be accepting Resident #1 back. He said he does not know why the facility didn't accept the resident back. He said he did not know where Resident #1 was at this time. A phone interview was conducted on 7/2/25 at 9:35AM with the NHA. He said Representative A, Facility/Hospital admission Liaison, is a third party contracted personnel who handles the admissions and the readmission back to the facility, the facility does not have an in-house admissions coordinator. The NHA said when a hospital requests a readmission the interdisciplinary team at the facility reviews the hospital documentation to see if the resident is safe for admission. He said Representative A, Facility/Hospital admission Liaison, is the person who informs the hospital of the decisions and the NHA said he includes Representative A, Facility/Hospital admission Liaison, as part of the interdisciplinary team who reviews the information provided. The NHA confirmed Resident #1 has not been re-admitted back to the facility because he has concerns about Resident #1's weight, although the resident has lost some weight while he's been in the hospital. The NHA said he has talked to the social worker at the hospital, and they said he still weighs over 600 pounds. The NHA said the facility still has not made the decision to accept Resident #1 back or not because of his weight. The NHA said he does not know if Resident #1 is ready for discharge from the hospital. The NHA said he started as the NHA on the day Resident #1 was sent out to the hospital, so he does not know how the facility was providing care to Resident #1 leading up to his discharge to the hospital.A phone interview was conducted on 7/2/25 at 12:11 p.m. with Resident #1. He said he was still at the hospital, but he is feeling better. Resident #1 was asked if he wanted to go back to the facility and he said, I can't go back to the facility because they won't take me back. He said he doesn't know why they won't take him back but it makes me feel bad. He said he never received a discharge notice from the facility. He said he has been ready for discharge for about a month now, but the hospital is having a problem finding a place for him because of his weight. He said the hospital is now looking for facilities outside of Florida. He said most of his family is in Florida. He said the staff at the facility were bringing him food from outside the facility, chicken, shrimp, oxtails, ice cream with caramel sauce. They were feeding my addiction, so I was getting bigger and bigger. Resident #1 said he has lost 65 pounds at the hospital because they put him on a concentrated carbohydrate diet. A phone interview was conducted on 7/2/25 at 12:25 PM with Representative C, Local Hospital's Case Manager. She said she was working on Resident #1's discharge back in May of 2025. She said she spoke to Representative A, Facility/Hospital admission Liaison. He was nasty to me. She said when she asked him if the facility was going to readmit Resident #1, he told me Yea well we're not. She asked what that meant and he told her No. She said her supervisor, Representative B, Local Hospital Supervising Care Coordinator, called Representative A, Facility/Hospital admission Liaison on 5/26/25 and wrote a note on 5/26/25 at 12:15 p.m. which said Consult to escalate. Patient is long term care of [Facility] since April of 2022. [Representative A, Facility/Hospital admission Liaison] is refusing, adamantly refusing, to accept the patient back. He said the patient was confused when he left the facility, so they called the POA [Power of Attorney] who refused to sign the bed hold so they do not have to take the patient back. [Representative A, Facility/Hospital admission Liaison] continues stating patient is bariatric, over 700 pounds, eats/orders whatever he wants, difficult to turn, has bed sores and no longer able to meet his needs. Since the POA refused to sign the bed hold he is under no obligation to take the patient back. [Representative A, Facility/Hospital admission Liaison] informed me no 30-day notice was provided but he is well within his right to refuse the patient because the bed hold was never signed. Representative C, Local Hospital's Case Manager said Resident #1 has lost a lot of weight since he has been at the hospital and as of today, he weighs 656 pounds and the day after he came into hospital, he was 709.5 pounds. She said Resident #1's discharge case has been escalated up to the complex discharge social worker at the hospital. A phone interview was conducted on 7/2/25 at 12:46PM with Representative D, Local Hospital Complex Discharge Social Worker. She said her job is to coordinate a discharge location for patients who are difficult to find a facility for. She said Representative B, Local Hospital Supervising Care Coordinator, reached out to Representative A, Facility/Hospital admission Liaison, on 5/26/25 to see if the facility was going to accept Resident #1 back and he said they were not going to accept Resident #1 back. She said within the last two weeks she had been talking to the NHA, and he said he has been fighting with the owner of the facility to readmit Resident #1. She said she followed up with the NHA daily and he kept saying he was working on it. Then, she was informed through the communication tab of the referral system on 6/27/25 the owner of the facility is not taking the patient back. Representative D, Local Hospital Complex Discharge Social Worker said since then she has not had communications with the facility. She requested 474 providers to review the referral to accept Resident #1 into their facility's, and they have all denied him. She said she is looking outside of the state of Florida now and she has not had any confirmations yet and Resident #1 is still at the hospital waiting for placement. A phone interview was conducted on 7/2/24 at 1:14 PM with Resident #1's Family. She said she does not have official Power of Attorney paperwork written up. She said she is just his next of kin for the facility. She said the facility called her when Resident #1 was being transferred out and they said he was having trouble breathing, and she asked how they were going to transfer him, and they said the fire department was handling it. She said the facility told her they would hold his bed for 24 hours and she could pay an additional fee to hold it longer, but she said she does not have access to Resident #1's funds so she told the facility she could not do that. She said she did not understand why he had not returned to the facility. An interview was conducted with Staff F, DON on 7/2/25 at 1:48p.m. She said she started working at the facility on Monday 6/30/25. She said she receives the admission request documentation, reviews the documents, and makes a determination whether or not the facility can meet the resident's needs. She said she has not been involved in a readmission request for Resident #1. She said she was just informed Resident #1 had not come back after he was transferred to the hospital. She said Resident #1 transferred to the hospital prior to her becoming the DON. She said she was made aware Resident #1 was a patient of the facility and from her understanding he remains their resident, and he should be brought back to the facility. She said for someone who is around 650 pounds, for a new patient, they would probably not accept that resident but since Resident #1 was their resident before they should accept him back into the facility and from what she had been told he gained weight while he was admitted at the facility. Staff F, DON said the facility can have a bed available for Resident #1 and they just need to come up with a plan to get the dietitian and physical therapy involved to help him lose weight and come up with a plan with the paramedic company if he needs transfer out. Review of the facility's policy Admission, Transfer & Discharge -Permitting Resident to Return to Facility, undated, revealed the following:Intent: It is the policy of the facility to permit the resident to return to facility [sic] according to state and federal regulations. PROCEDURE:1. A facility will establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. 2. The policy will provide for the following: a. A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident: i. Requires the services provided by facility; and ii. Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.b. If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirement of paragraph (c) as they apply to discharges. When the facility to which a resident returns is a composite distinct part ., the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within the two-hour time frame requirement, for one resident (#1) of three residents reviewed for abuse. Findings included: Review of a Psych note for Resident #1 dated 03/03/25 showed Resident #1 disclosed the CNA [Certified Nursing Assistant] grabbed my arm (pointing to her left hand) and wouldn't let go. [Resident #1] then points at the dressing on her skin tears on her left hand. There is a third on her left forearm, and when asked her if that was related to the incident, she first says no and then quickly said yes. Review of a Change of Condition dated 03/01/25 showed Situation: 1. Sustained x 3 skin tears (left hand x 2 and left forearm x 1)- combative with CNA - hitting and calling her names. This started on: 03/01/25. Under A 2. Resident/Patient Evaluation on Behavior Evaluation, 7. Physical aggression was check marked. An interview was conducted on 03/17/25 at 10:20 a.m. with Staff D, Certified Nursing Assistant (CNA). Staff D, CNA stated she recalled the incident between herself and Resident #1 which occurred on 03/01/25. Staff D, CNA stated Resident #1 had her call light on, so she stopped in Resident #1's room, during which she asked for her wheelchair to be moved away from in front of her television. Staff D, CNA said, I informed Resident #1 that I would be in to assist her with her morning ADL (activities of daily living) care next, after I finished assisting another resident whose care was already in progress. Staff D, CNA stated when she went back to Resident #1 and started to assist with her morning ADL, Resident #1 reached out and grabbed a handful of my shirt with the left hand and was hitting me with her right hand. Staff D, CNA stated that she immediately began screaming for help and asked her to stop hitting me. Staff D, CNA stated, she grabbed her arm to block her from hitting her, as she tried to pull herself from her grasp. Staff D, CNA stated Staff B, CNA, was the first person who came in to help, but by that time she had gotten away and moved herself away from the resident's reach. Staff D, CNA said, the second person who came in to help was Staff F, Registered Nurse (RN) and observed Resident #1 who was calling me a [racial expletive] and shaking her fist at me stating, I am going to kill them. Staff D, CNA stated she got suspended during the investigation. Staff D, CNA stated when there is an allegation of abuse staff are required to report it immediately. Review of the Admission Record showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of small artery, cognitive communication deficit, dementia in other diseases classified elsewhere, adult failure to thrive and chronic pain syndrome. Review of Resident #1's care plan revised on 3/1/25, showed, Focus- The resident has self-neglect behaviors related to refusing care. Refusing ADL care. The goal showed, The resident will have no evidence of behavioral concerns (Racist Comments) by review date. Interventions included: Anticipate and meet the residents' needs, explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to change, If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Review of the reportable log with the Nursing Home Administrator (NHA) dated 03/01/25 showed the facility reported an allegation of abuse between Resident #1 and Staff D, CNA on 03/01/25 at 4:30 p.m. The reportable showed the date and time the staff became aware of the allegation of abuse was on 03/01/25 at 10:30 a.m. An interview was attempted with Resident #1 on 03/17/25 at 10:30 a.m. Resident #1 stated she could not recall any incidents that occurred on 03/01/25. An interview was conducted on 03/17/25 at 10:42 a.m. with Resident #1's roommate who stated there was an incident that occurred between Resident #1 and Staff D, CNA, but she did not see anything because the curtain was pulled. This resident stated she was in the room at the time of the incident, and heard Staff D, CNA yelling for help and telling Resident #1, don't hit me. During an interview on 03/17/25 at 10:26 a.m. Staff B, CNA confirmed she was present during the day of the incident and heard Staff D, CNA screaming out for help. Staff B, CNA stated she ran down the hall to find where the yelling was coming from. She stated by the time she discovered where the yelling was coming from, she opened Resident #1's door and saw Staff D, CNA, standing at the foot of Resident #1's bed. During an interview on 03/17/25 at 3:02 p.m. Staff F, Registered Nurse (RN) stated on 03/01/25, Staff D, CNA came to her about 10:30 a.m. and stated Resident #1 was combative and had grabbed her and hit her. Staff F, RN stated she went directly to Resident #1 and completed assessments, notified the doctor and the family immediately. Staff F, RN stated she advised Staff D, CNA to write out a witness statement. Staff F, RN stated she notified the weekend nurse supervisor, Staff H, LPN about the incident. During an interview on 03/17/25 at 3:20 p.m. Staff H, License Practical Nurse (LPN)/Weekend Nursing Supervisor (WNS) stated she was notified by Staff F, RN Resident #1 had received a skin tear during care the morning of 03/01/25. Staff H, LPN stated sometimes skin tears do happen with care and didn't think anything of it. Staff H, LPN, stated later in the afternoon she interviewed Resident #1 and staff about how Resident #1 got the skin tears. Staff H, LPN, stated Resident #1 stated Staff D, CNA had grabbed my hands tightly during care and caused the skin tears. Staff H, LPN stated Resident #1 had two skin tears on her hand and then third skin tear on her forearm. Staff H, LPN stated once Resident #1 alleged abuse, she started the abuse reporting process. Staff H, LPN stated the abuse allegation was not reported immediately because she was not told details of the abuse allegation and had not investigated herself. During an interview on 03/17/25 at 3:30 p.m. the Director of Nursing (DON) stated she received a call on 03/01/25 around 2:30 p.m. and was informed Resident #1 had skin tears on her hand and arm. The DON stated she immediately called Staff H, LPN and told her to go interview Resident #1 and get witness statements. The DON stated that she would have been expected to have been notified about the incident when it occurred around 10:30 a.m. on 03/01/25 and not four hours later. An interview was conducted on 03/17/25 at 1:30 p.m. with the NHA. The NHA stated the DON reported the incident to her around 2:30 p.m. on 03/01/25, stating Resident #1 had skin tears and that a CNA had reported Resident #1 was combative with the staff. The NHA stated Staff H, LPN assessed the resident and found Resident #1 had skin tears on her hand. She stated Staff D, CNA was suspended pending investigation and the police and DCF (Department of Children and Services) were notified. The NHA stated Staff D, CNA's witness statement showed Resident #1 had grabbed the CNA and was hitting her. The NHA stated her findings did not find where Staff D, CNA intentionally set out to hurt Resident #1 as she was trying to get away from Resident #1 who was hitting her. The NHA stated the incident occurred on 03/01/25 at 10:30 a.m. and was not reported until 03/01/25 at 4:30 p.m. because she was not informed of the abuse allegation until a little after 2:00 p.m. The NHA stated Staff should have notified the DON and her earlier when the incident occurred. The NHA confirmed the allegation of abuse was reported 4 hours after the incident. Review of the facility's abuse education and in-service training showed the following in-service dated 02/13/25, Presenter: The Director of Nursing (DON) , Topic: Abuse, Neglect and Exploitation/Theft - It is the policy of the center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation and misappropriation of property. In addition, each resident will also be protected from those practices and omissions, which left unchecked, could lead to abuse. Further, each resident will be always treated with respect and dignity. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care, Residents will not be subject to abuse by anyone, including but not limited to Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends and others. 1: Definitions of abuse 2: Types of Abuse 3: If abuse witnessed or expressed report to abuse coordinator immediately. 4: Facility has a 2 our window to report the allegation 5: If abuse is reported all staff must complete a witness statement 6: Resident to Resident altercation also falls under guidelines 7: Ensure that the affected and all surroundings' residents are safe 8: Theft- definition 9: Misappropriation- definition 10: For any risk, please contact DON. Review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated 08/22/22 showed Reporting/Documentation Requirements: If the event that causes the allegation involve abuse or results in serious bodily injury, the event must be reported immediately, but no later than 2 hours after the allegation is made. Upon suspecting abuse, neglect or exploitation of a resident, the following procedure is to be followed: 1. Immediately notify: a. Administrator b. Director of Nursing c. FL Only- Florida Abuse Hotline 1-800-96-ABUSE d. Center Risk Manager

Based on record review and interview, the facility failed to ensure a safe and orderly discharge from the facility for one resident (#2) of two residents reviewed for transfer and discharge rights. Findings included: Review of Resident #2's admission Care Plan dated 12/04/24 showed the following focus and intervention areas, Resident #2, wishes to return back into the community when medically cleared. The goal showed, The resident will be able to verbalize/communicate required assistance post-discharge and services required to meet the needs before discharge. Interventions included to establish a pre-discharge plan with the resident/resident's representative/caregivers and evaluate progress and revise the plan frequently, and to evaluate the resident's motivation to return to the community. Review of Resident #2's medical record revealed the resident's discharge plan was not evaluated and her wish to return to the community when medically cleared was not honored. Resident #2's involuntary hospital transfer was rescinded on 12/13/24 and the facility did not document any attempts to ensure a safe and orderly transfer. Resident #2 remained in the hospital awaiting an appropriate discharge location for an additional 17 days. Review of record showed Resident #2's bed hold agreement was not honored and there was no documentation related to the cause. Review of a social services progress note dated 12/10/2024 showed, Spoke with the patient's [family member] regarding discharge planning. The family member stated the patient will discharge home with [them]. The family member was also educated on safe discharges, all questions and concerns were answered. Review of Resident #2's admission Record showed an admission date of 12/04/2024 with diagnoses included but not limited to, Post Traumatic Stress Disorder (PTSD), Conversion disorder (a mental health condition where psychological distress manifests aa physical symptoms that cannot be explained by a medical condition) with seizures or convulsions, Depression, Schizophrenia, Anxiety, Bipolar disorder, Insomnia, Altered mental status unspecified, Contusion to left eyelid and periocular area and Encounter for general psychiatric examination requested by authority. Review of a Bed-Hold Agreement for Resident #2 dated 12/24/24 showed, I [family member name], the representative of [Resident #2] hereby request that the facility hold his/her bed space while he/she is absent from the facility. I understand that I will be responsible for payment of the basic per diem rate. I understand the basic per diem rate is $261 per day, for maximum number of 8 days. The agreement signed by Staff F, RN showed wants bed hold per [family member]. Further review of Resident #2's record did not show documentation rescinding the agreement. Review of the Nursing Home Transfer and Discharge Notice for Resident #2 dated 12/12/24 revealed an incomplete document without signatures from the resident, resident representative and physician. The only signature was for Staff F, RN, signing on behalf of the NHA/designee, revealing Your needs cannot be met at this facility. The brief explanation showed , [involuntary hospitalization]. Review of Resident #2's Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 12/03/2024 initiated at a local hospital showed Resident #2 had a psychiatric evaluation completed on 11/14/2024 after status post an involuntary hospitalization for worsening agitation and behavioral outbursts. The review showed on 12/03/2024, Resident was deemed not necessary for the need for acute inpatient psychiatric care and recommendations were made for rehabilitative services of a lesser intensity than specialized services added to the patient's Comprehensive Person-Centered Nursing Care Plan to include: psychiatric medication management, individual therapy if cognition permits and supportive counseling. Review of Resident #2's physician order review report dated 3/17/25 showed orders for psychiatry and psychology services as needed, effective 12/06/24. Review of a minimum data set (MDS) for Resident #2 dated 12/12/24 showed the resident was unable to complete a Brief Interview for Mental Status (BIMS) assessment. The mental assessment revealed the resident had a memory problem and was moderately impaired - decisions poor, cues and supervision required. Review of an Occupational Therapy evaluation and plan of treatment note, certified period 12/6/24 -1/3/25 showed, transition/discharge plan was for patient to return to ALF (Assisted Living Facility). Under reason for therapy, the assessment summary showed a goal to, . facilitate independence with ADLs (activities of daily living) in order to facilitate ability to live in an environment with least amount of supervision and assistance, be able to return to prior level of living, facilitate follow- through with techniques and strategies and facilitate safe transition to next level of care. Under complexities, barriers likely to impact discharge to next level showed, None noted. Review of Resident #2's psychiatric evaluation note dated 12/10/2024 showed the following: Patient is a [AGE] year-old female with history of schizoaffective disorder bipolar type, anxiety, borderline personality disorder, and PTSD being seen by psychiatry for initial psychiatric evaluation. She was recently admitted to the hospital for altered mental status with change in behavior, throwing herself on the floor and banging her head with aggressive behavior. She was placed under an involuntary hospitalization. She was treated for acute psychosis and once stabilized was admitted to [name of facility] nursing center on 12/04/2024 for continuance of care. During evaluation, patient was pleasant and cooperative throughout the interview.She denies any current suicidal or homicidal ideation, plan, or intent . Patient's nurse reports that she has been compliant with her medications this morning thus far and staff has not observed her with any psychotic features including hallucinations, delusions, self-dialogue, and paranoia. Review of Resident #2's Medication Administration Record (MAR) for the month of December 2024 showed the resident was compliant with her medication with no entries for the resident refusing her medications. On 3/17/2025 at 2:05 p.m., a telephone interview was conducted with Staff L, Case Manager at the local hospital where Resident #2 was admitted . Staff L stated Resident #2 was admitted on [DATE] through the emergency department secondary to an involuntary hospitalization initiated by the facility. Staff L read from the resident's medical record and stated, the resident was seen by the emergency department physician and noted with no behaviors. Staff L stated the resident was seen by psychiatry services via telehealth on 12/13/2024 at 9:46 a.m. and deemed okay to return to the facility. Staff L stated the involuntary hospitalization was rescinded. Staff L stated while in the emergency department, the resident was noted with no behavior issues. Staff L stated, according to the resident's hospital medical record, a call was placed to the facility's administrator on 12/13/2024 at 10:00 a.m. informing her the involuntary hospitalization was rescinded, and the resident was good to discharge back to her facility. Staff L reading the medical records stated, the NHA stated the resident was not welcomed back after assaulting her nurse and throwing furniture. Staff L stated there were numerous attempts to contact the facility but return calls were never received. Staff L stated Resident #2 was eventually discharged to another local long term nursing home facility on 12/30/2024. On 3/17/2025 at 5:20 p.m., an interview was conducted with Staff E, RN. Staff E, RN stated she had a resident currently with aggressive behaviors and was assigned 1:1 supervision. Staff E, RN stated this other resident was aggressive towards staff and would wander into other residents' rooms. Staff E confirmed the facility had other residents with aggressive behaviors, including refusing Haldol injections and were not placed under involuntary hospitalizations. Staff E stated residents with such behaviors are placed on 1:1 supervision and are followed closely by psych. Review of Resident #2's psychiatric evaluation note dated 12/11/2024 showed the following, [Resident #2 said I feel sad and anxious, I do not know why. I want to get out of here and live with my [family member] Under patients strengths, the assessment showed, can benefit from structured care. Review of Resident #2's psychiatric evaluation note dated 12/11/2024 signed at 8:48 a.m. by the psychiatric provider showed a treatment plan with recommendations as follows: 5. Nursing staff is to monitor patient for changes in mood and behavior and contact psychiatry if patient begins to exhibit any signs of depression, anxiety, or behaviors. Nursing staff was advised to continue to document behaviors appropriately. 6. Case was discussed today with nursing staff who will assist with implementing the plan of care. 7. Goals of treatment include: remission of psychiatry symptoms and behavioral disturbances using lowest effective dose of medication, minimizing SE (side effects) and promptly detecting and addressing any psychotropic medication complications. 8. Gradual dose reduction is not recommended at this time as patient's baseline behavior is still being determined and she is noted with agitation and breakthrough symptoms. Gradual dose reduction is likely to cause a decompensation in patient's mental status. 9. Follow -up in 1 to 2 weeks or sooner if needed. On 3/17/2025 at 1:28 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated in general the AHCA (Agency for Health Care Administration) transfer form is provided to a resident or the family/POA (power of attorney). She stated if they are not present, they obtain consent via phone. She stated if they were to discharge a resident, a 30 - day discharge notice is issued. The NHA stated, we have all parties sign discharge paperwork usually for those that are getting discharged , including transfer to hospital. The NHA stated if a bed was available they would return to whatever bed is available. She stated they try to pack up their belongings and try to keep in touch with the hospital and hopefully the resident can go back to the same bed upon returning. Review of an undated facility policy and procedure titled, Admission, Transfer and Discharge - Notice requirements before Transfer/Discharge showed an intent statement: It is the policy of the facility to notify the resident and or their legal guardian of the transfer and or discharge before the transfer or discharge occurs in accordance with state and Federal regulations. The procedure showed: 2. The facility will provide sufficient preparation and orientation to residents to ensure safe and orderly transfer and or discharge from the facility. 3. If the information in the notice changes prior to effecting the transfer or discharge, the facility will update the recipients of the notice as soon as practicable once the updated information becomes available.

Based on interview and record review, the facility failed to permit readmission from the hospital for one resident (#2) of two residents reviewed for transfer and discharge rights. Findings included: Review of the facility's policy and procedure titled, Admission, Transfer and Discharge- Transfer and Discharge Requirements showed an intent statement: It is the policy of the facility to ensure residents are treated equally regarding transfer, discharge, and the provision of services, regardless of their payment source in accordance with state and federal regulations. On 3/17/2025 at 2:05 p.m., a telephone interview was conducted with Staff L, Case Manager at the local hospital where Resident #2 was admitted . Staff L stated Resident #2 was admitted on [DATE] through the emergency department secondary to an involuntary hospitalization initiated by the facility. Staff L read from the resident's medical record and stated, the resident was seen by the emergency department physician and noted with no behaviors. Staff L stated the resident was seen by psychiatry services via telehealth on 12/13/2024 at 9:46 a.m. and deemed okay to return to the facility. Staff L stated the involuntary hospitalization was rescinded. Staff L stated while in the emergency department, the resident was noted with no behavior issues. Staff L stated, according to the resident's hospital medical record, a call was placed to the facility's administrator on 12/13/2024 at 10:00 a.m. informing her the involuntary hospitalization was rescinded, and the resident was good to discharge back to her facility. Staff L reading the medical records stated, the NHA stated the resident was not welcomed back after assaulting her nurse and throwing furniture. Staff L stated there were numerous attempts to contact the facility but return calls were never received. Staff L stated Resident #2 was eventually discharged to another local long term nursing home facility on 12/30/2024. Review of Resident #2's admission Record showed an admission date of 12/04/2024 with diagnoses included but not limited to, Post Traumatic Stress Disorder (PTSD), Conversion disorder (a mental health condition where psychological distress manifests as physical symptoms that cannot be explained by a medical condition) with seizures or convulsions, Depression, Schizophrenia, Anxiety, Bipolar disorder, Insomnia, Altered mental status unspecified, Contusion to left eyelid and periocular area and Encounter for general psychiatric examination requested by authority. Review of Resident #2's Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 12/03/2024 initiated at a local hospital showed Resident #2 had a psychiatric evaluation completed on 11/14/2024 after status post an involuntary hospitalization for worsening agitation and behavioral outbursts. The review showed on 12/03/2024, Resident was deemed not necessary for the need for acute inpatient psychiatric care and recommendations were made for rehabilitative services of a lesser intensity than specialized services added to the patient's Comprehensive Person-Centered Nursing Care Plan to include: psychiatric medication management, individual therapy if cognition permits and supportive counseling. Review of Resident #2's physician order review report dated 3/17/25 showed orders for psychiatry and psychology services as needed, effective 12/06/24. Review of a minimum data set (MDS) for Resident #2 dated 12/12/24 showed the resident was unable to complete a Brief Interview for Mental Status (BIMS) assessment. The mental assessment revealed the resident had a memory problem and was moderately impaired - decisions poor, cues and supervision required. Review of Resident #2's admission Care Plan dated 12/04/24 showed the following focus and intervention areas, Resident #2 is placed under an involuntary hospitalization. Interventions included allowing the resident to make decisions about treatment regime, to provide a sense of control, educate the resident to voice out feelings of harming self and others/suicidal ideation and encourage as much participation/interaction by the resident as possible during care activities. A second focus in the same care plan showed Resident #2, wishes to return back into the community when medically cleared. The goal showed, The resident will be able to verbalize/communicate required assistance post-discharge and services required to meet the needs before discharge. Interventions included to establish a pre-discharge plan with the resident/resident's representative/caregivers and evaluate progress and revise the plan frequently, and to evaluate the resident's motivation to return to the community. Review of Resident #2's psychiatric evaluation note dated 12/10/2024 showed the following: Patient is a [AGE] year-old female with history of schizoaffective disorder bipolar type, anxiety, borderline personality disorder, and PTSD being seen by psychiatry for initial psychiatric evaluation. She was recently admitted to the hospital for altered mental status with change in behavior, throwing herself on the floor and banging her head with aggressive behavior. She was placed under an involuntary hospitalization. She was treated for acute psychosis and once stabilized was admitted to [name of facility] nursing center on 12/04/2024 for continuance of care. During evaluation, patient was pleasant and cooperative throughout the interview.She denies any current suicidal or homicidal ideation, plan, or intent . Patient's nurse reports that she has been compliant with her medications this morning thus far and staff has not observed her with any psychotic features including hallucinations, delusions, self-dialogue, and paranoia. Review of Resident #2's Medication Administration Record (MAR) for the month of December 2024 showed the resident was compliant with her medication with no entries for the resident refusing her medications. Review of Resident #2's progress note dated 12/12/2024 at 12:47 p.m. by Staff F, Registered Nurse (RN) showed, Resident is physically aggressive towards nursing staff, hit nurse in the back despite giving as needed intramuscular Haldol, which was given at 11:45 a.m. due to resident yelling, I want to get out of here and being agitated and knocked over table on smoking patio, punching walls, and threw a remote control, was not redirectable and is likely to further injure staff and other residents. The involuntary hospitalization was initiated by the psychiatric provider after speaking with the resident on phone/video. Police and emergency medical transport were called, and the resident was taken to a local hospital. Family member agreed to hold bed. Review of the Nursing Home Transfer and Discharge Notice for Resident #2 dated 12/12/24 revealed an incomplete document without signatures from the resident, resident representative and physician. The only signature was for Staff F, RN, signing on behalf of the NHA/designee, revealing Your needs cannot be met in this facility. The brief expanation showed, [involuntary hospitalization]. Review of a Bed-Hold Agreement for Resident #2 dated 12/24/24 showed, I [family member name], the representative of [Resident #2] hereby request that the facility hold his/her bed space while he/she is absent from the facility. I understand that I will be responsible for payment of the basic per diem rate. I understand the basic per diem rate is $261 per day, for maximum number of 8 days. The agreement signed by Staff F, RN showed wants bed hold per [family member]. Further review of Resident #2's record did not show documentation rescinding the agreement. On 3/17/2025 at 5:20 p.m., an interview was conducted with Staff E, RN. Staff E, RN stated she had a resident currently with aggressive behaviors and was assigned 1:1 supervision. Staff E, RN stated this other resident was aggressive towards staff and would wander into other residents' rooms. Staff E confirmed the facility had other residents with aggressive behaviors, including refusing Haldol injections and were not placed under involuntary hospitalizations. Staff E stated residents with such behaviors are placed on 1:1 supervision and are followed closely by psych. On 3/17/2025 at 1:28 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated Resident #2 was placed under an involuntary hospitalization on 12/12/2024 for escalating behavior both physically and verbally towards the staff. The NHA stated she received a phone call on the morning of 12/13/2024 from the local hospital stating the resident's involuntary hospitalization had been rescinded and could return to their facility. The NHA stated she had tried to communicate her concern for the resident's short stay at the hospital and wondered how the resident could be better in less than twenty-four hours. The NHA stated she spoke to a case manager but could not recall who she spoke to but stated it was someone in the emergency department because the resident was still in the emergency department. The NHA stated she did not receive any further calls from the hospital, and she assumed Resident #2 went with her family member. The NHA stated she could not confirm if she had reached out to the resident's family member. The NHA stated she had asked the hospital for evidence to prove the resident was safe to return and as far as she could recall, the hospital never called her back.

Based on observations, interviews, and record reviews, the facility failed to preserve the quality of life related to therapy services for one (#6) out of 6 sampled residents. Findings included: Review of Resident #6's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of adjustment disorder with anxiety, chronic pain, spinal stenosis, lower back pain, edema, chronic pain syndrome, obesity, and bed confinement status. The resident also had a diagnosis of patient's noncompliance with other medical treatment and regimen due to unspecified reason with an onset date of 9/1/24. An interview was conducted on 11/19/24 at 4:45 PM with Resident #6. She said she wanted to have therapy so she could gain strength to be able to sit on the side of her bed and in her wheelchair again. She said she used to be able to sit in her wheelchair but now she just laid in bed all day, every day. She said it had been over a year since she had therapy and the last time she had therapy she was provided with therapy three times a week. She said she was able to have a Certified Nursing Assistant (CNA) help her roll over and sit up on the side of the bed and transfer into her wheelchair and she could move around her room in her wheelchair. She said the CNAs were supposed to keep working with her, but they had not helped, and she could not get anyone to help her with therapy. She said she told the Director of Nursing (DON) she wanted occupational therapy, and she said she would let them know to come look at her, but therapy never came. She said she had asked many times to have therapy again and they would not give her therapy, and she did not know why. Review of Resident #6's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/13/24, Section C - Cognitive Patterns, revealed a brief interview for mental status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. A phone interview was conducted on 11/19/24 at 4:50 PM with the Director of Therapy. She said they performed an occupational therapy screen on Resident #6 about a month ago and the resident wanted to have one person assist with perineal care, but she needed three-person maximum assistance for care. She said the resident would not use the full body mechanical lift machine because her back hurt her. The only way they could provide therapy services was if she used the full body mechanical lift to get into her wheelchair so they could assess her sitting tolerance in the wheelchair in the therapy gym. The Director of Therapy said since she would not use the full body lift, therapy could not work with her. She said Resident #6 was on therapy services about a year ago and she met her goals. She was discharged to the function maintenance program where the CNA's work on exercises to maintain her level of function. An interview was conducted with Resident #6 on 11/19/24 at 4:59 PM. She said all she wanted to do was exercise to get stronger so she could sit on the side of the bed and get into her wheelchair. She did confirm she could not use the full body mechanical lift because it hurt her back and the last time they used it on her she ended up at the hospital needing three shots of morphine. She said if she got therapy, the staff could assist in the transfer to the wheelchair without needing the full body mechanical lift. An interview was conducted with the Director of Nursing (DON and Staff A, Registered Nurse (RN) on 11/19/24 at 5:10 PM. Staff A, RN said she took care of Resident #6 and confirmed the resident had been asking for therapy services several times and she was not sure why she had not received therapy. The DON said she started working at the facility in August of 2024 and Resident #6 said she wanted to receive occupational therapy services, so she put in a therapy referral for them to screen the resident. The DON said when she gave therapy the screening consult the therapy department told the DON Resident #6 would not participate. The DON said she told the therapy department they still had to screen the resident because she could have a decline. The DON said she questioned therapy if they had screened the resident because the resident was still not on therapy services. The DON was told she was being argumentative about getting the resident therapy and the DON said she was just trying to help the resident. The DON also said the facility did not have a restorative program, it is called something else but the CNAs should be doing exercises with the resident when they go in to do care. An interview was conducted with the Nursing Home Administrator (NHA) on 11/19/24 at 5:51 PM. She said it looked like Resident #6 was screened several times but never picked up by therapy services because of lack of motivation. That's just what the therapist documented. The NHA said she was not sure how the resident was not motivated if she had not been picked up for therapy services. They said she has met her therapy potential. Review of Resident #6's physician orders revealed a physician order with a start date of 7/21/23 and an end date on 7/21/23 for Skilled PT (Physical Therapy) to evaluate and treat as indicated, a physician order with a start date of 7/21/23 and an end date of 11/24/23 for Skilled PT services POC [plan of care] to treat 12 times per 30 days with therapeutic exercises, therapeutic activity, gait training, and wheelchair management training, and a physician's order with a revision date of 8/17/23 and an end date of 11/24/23 for PT Clarification/recertification: To continue skilled PT services POC to treat 12 times per 30 days with therapeutic exercises, therapeutic activity, wheelchair management and gait training. Review of Resident #6's Physical Therapy PT Evaluation & Plan of Treatment dated 1/10/23 revealed the following under Patient Referral and History: Current Referral: Reason for Referral/Current Illness: pt.[patient] is a 74 yo [year old] female referred to skill PT secondary to recent hospitalization on [DATE] s/p [status post] hysterectomy and suspected decline in level of independence with functional mobility At PLOF [prior level of function], pt. required SBA [stand by assistance] for bed mobility and total assist/[sit to stand mechanical lift] for stand pivot transfers. Pt. reports she is in too much pain to participate with skilled PT at this time and does not wish to participate. Pt. will continue use of [sit to stand mechanical lift] with staff for transfers and use of manual w/c [wheelchair]. Prior Equipment: Equipment Prior to Onset: manual w/c, [sit to standing position mechanical lift] transfers. Prior Level(s) of Function: PLOF: Roll left and right = supervision or touching assistance; Sit to lying = supervision or touching assistance; Lying to sitting on side of bed = supervision or touching assistance; Sit to stand = dependent; Chair/bed to chair transfer = dependent; Toilet transfer = not applicable. Review of Resident #6's Physical Therapy PT Evaluation & Plan of Treatment also revealed the following under Functional Mobility Assessment: Bed mobility: Roll left and right = dependent; Sit to lying = dependent; Lying to sitting on side of bed = Dependent Transfers: Sit to stand = dependent; Chair/bed-to-chair transfer= Dependent Review of Resident #6's Physical Therapy Treatment Encounter Notes dated 1/10/23 revealed under the section Response to TX (Treatment), Response to Session interventions: unwilling to participate and requires total assist with functional mobility. Review of Resident #6's Occupational Therapy Evaluation & Plan of Treatment dated 10/15/24 revealed the following under Patient Referral and History: Current Referral: Reason for Referral/Current Illness: Patient is a [AGE] year-old female referred to Occupational Therapy Services from nursing secondary to noted motivation and improved rehab potential. At this time, patient demonstrates decreased motivation to perform consistency with OOB [out of bed] activities impacting rehab potential and progress with therapy services. Prior Level(s) of Functioning: PLOF: .Patient is Max x 2/Max A for functional mobility and uses [Full body mechanical lift] for functional transfers. Able to perform most UB [upper body] ADL [activities of daily living] tasks. Review of Resident #6's Occupational Therapy Evaluation & Plan of Treatment also revealed the following under Other System/Condition Assessment: Pain: Patient has pain that interferes/limits functional activity? = No. Review of Resident #6's Occupational Therapy Treatment Encounter Notes dated 10/15/24 revealed the following under Summary of Daily Skilled Services: Evaluation: Patient presents with impairments in balance, mobility and strength resulting in limitations and/or participation restrictions in the areas of self-care, mobility and general tasks and demands, however at this time, patient does not require OT services due to decreased motivation to perform OOB activities and maximize rehab potential. Review of Resident #6's care plan, undated, revealed The resident has limited physical mobility r/t [related to] Weakness. The goal revealed The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The interventions revealed Locomotion: The resident is totally dependent on (x 1) staff for locomotion using (wheelchair with leg rest). For locomotion on/off the unit. Locomotion: the resident uses (assistive device: wheelchair) for locomotion. Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Review of the facility policy titled Quality of Care - Specialized Rehabilitative and Restorative Services, undated, revealed under Intent: It is the intent of the facility to provide Specialized Rehabilitative and Restorative Services in accordance with State and Federal regulations. The policy also revealed the following under Procedure: 1. The facility will provide specialized rehabilitative services such as, but not limited to physical therapy, speech language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity ., are required in the resident's comprehensive plan of care. 2. The facility will: a. Provide the required services; or b. In accordance with 483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. 3. The facility will ensure that specialized rehabilitative services are provide under the written order of a physician by qualified personnel. 4. The facility will provide restorative services such as but not limited to walking, transfer training, bowel and or bladder training, bed mobility, Range of Motion (ROM), Splint and brace, eating and/or swallowing, amputation/prostheses care and communication. When necessary, as indicated by the assessment of the interdisciplinary team.

Based on interview, record review, and facility policy review, the facility failed to maintain complete medical records for 24 current residents out of a total resident census of 47. The findings included: On 5/14/24 at 3:00 PM, a beneficiary notice was requested for Resident # 21. On 5/15/24 at 10:07 AM, the Interim Nursing Home Administrator (NHA) stated the facility could not provide Resident #21's beneficiary notice because the facility did not have access to the resident's full medical record. The Interim NHA stated the facility did not have access to the previous electronic medical record system used by the facility, which is where this document would be held. On 5/15/24 at 5:27 PM, the Medical Records Director (MRD) stated the facility began using a new electronic medical record system in May 2023. The MRD stated the facility did not have access to any residents' medical records prior to 4/31/2023. A review of the current census revealed 24 of 47 current residents were admitted to the facility prior to 4/31/2023. A review of the facility's undated policy titled Administration-Record Retention revealed medical records will be retained for a period of 7 years from the date of discharge or period outlined by payer contracts, whichever is longer. A review of the facility's undated policy titled Administration-Medical Records revealed the facility will retain medical records in accordance with State and Federal regulations.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included: proper storage and labeling in the upright freezer, proper cleanliness and temperature of the walk-in cooler, and proper cleanliness and labeling of one (Station #2) of two nourishment refrigerators. This had the potential to affect 47 residents receiving food service from the kitchen. The findings included: On 05/14/24 at approximately 09:00 AM, an initial tour of the kitchen revealed the upright freezer had several open bags of vegetables in the freezer door with no date. One of the bags was observed to be punctured. Additional bags of frozen food items were also undated on the shelves. Interview at the time of observation with the Dietary Manager revealed it was difficult to place dates on packages because the stickers come off and marker does not adhere to cold wet bags. Observation of the walk-in cooler revealed a liquid puddle was present on the floor next to a crate containing bags of onions. When the crate was moved, liquid and food debris were observed under the crate and storage shelves Interview at the time of observation with the Dietary Manager revealed she was unaware of the area prior to the observation. She stated she would clean it and have maintenance check for the source. Observation on 05/14/24 at 5:32 PM revealed the walk in cooler still contained liquid and debris on the floor where the crate was observed approximately 8 hours earlier. The Dietary Manager confirmed she had not cleaned the area observed during the initial tour. Observation of the thermometer in the walk-in cooler revealed the temperature was 52 degrees Fahrenheit. On 05/15/24 at 10:40 AM, the walk-in cooler was observed with a thermometer reading of 36 degrees Fahrenheit. Interview with the contracted Registered Dietitian present during the observation revealed all food was inspected and thrown away if there was a potential safety issue to include all eggs and dairy products. Observation of the contents of the walk in cooler revealed the bulk of items was fresh produce. The food debris from the previous day had been removed. 05/16/24 at 09:00 AM, observation of Station #2's nourishment refrigerator revealed a take-out container dated 5/12/24 with a resident's last name. A covered bowl of mashed potatoes and gravy with no date or name. The freezer contained frost and an open frozen bottle of soda. Food debris in both the refrigerator and freezer was observed. On 05/16/24 at 09:50 AM, the Dietary Manager reported the nurses were responsible for cleaning of nourishment room refrigerators, and the Director of Nursing reported this was dietary's responsibility. On 05/16/24 at 10:12 AM , a telephone interview with the contracted Registered Dietician revealed there was no facility policy specific to cleaning of nourishment refrigerators. The Registered Dietitian reported this would fall under the Dietary/Kitchen Policy for maintenance and cleaning of dietary equipment. She stated a separate policy was not needed and this task would be added to the cleaning schedule. Photographic evidence was obtained.

Based on interviews, record review, and facility policy review, the facility failed to obtain copies of a portion of a medical record requested for one (#98) of nineteen sampled residents. The findings included: Review of a subpoena dated 1/29/2024, addressed to the facility with the Administrator's name revealed the facility was to deliver copies of medical treatment records, billing statements, and Power of Attorney documentation for Resident #98 for the time period of 8/1/2022 to current by 2/28/2024. On 5/15/24 at 5:27 PM, the Medical Records Director (MRD) reported that the facility changed to a new electronic medical record system in April of 2023. The MRD reported that the facility responded to the subpoena but was unable to provide documents prior to 4/31/2023. The MRD stated the party requesting the records was not informed that records from 2022 to 4/31/23 were not present in the medical records that were provided. The MRD reported that the Nursing Home Administrator (NHA) who was working when the request was received had sent an email to the corporate office about the inability to access medical records prior to 4/31/2023. The MRD confirmed that the facility was still without access to any residents electronic medical records prior to 4/31/23. A review of documentation revealed the NHA sent an email to several parties within the nursing home corporation on 2/9/24. The NHA stated the facility had changed to a different electronic medical record system on 5/1/2023, but they could no longer access any records from the old system due to lack of payment. The NHA informed the parties on the email that the facility had a medical record request for Resident #98, which could not be fulfilled due to the inability to access these records. On 3/14/24, the NHA inquired about any updates to allow for access to the old medical record system. A party from the corporation responded stating they had requested a look up agreement. No additional documentation related to access to the previous medical record system was provided. A review of facility policy Administration-Record Retention undated, showed it was the facility's policy to maintain medical records for a period of 7 years from the date of discharge or a period outlined by payer contracts, whichever is longer. A review of facility policy Administration-Medical Records, undated, showed the facility will retain medical records in accordance with State and Federal regulations.

Based on observation, record review and interviews, the facility failed to ensure two (Resident #1 and Resident #2) of eight sampled residents were free from non-consensual sexual contact. Findings include: On 10/19/2022 at 9:29 a.m., an observation was conducted of Resident #1. She was in her bed, covers up to her chest, watching television, and she agreed to an interview. When asked if she felt safe, she said, I do now. She reported the housekeeper touched her breasts and she patted her chest for emphasis. On 10/19/2022 at 9:41 a.m. an observation was conducted of Resident #2. She was observed in her room, in bed, eyes closed. On 10/19/2022 at 9:58 a.m., an interview was conducted with the Housekeeping Supervisor (HS). He confirmed the housekeepers were not supposed to touch the residents, and said he was aware of the incident with Staff B, Housekeeper. The HS stated Staff B had worked for the facility about 3 months, and confirmed he was no longer employed at the facility. The HS stated, He was caught touching a resident inappropriately. I do not know where. Just inappropriate. It was a resident that could not say stop or say no. The HS reported he was present on the day of the allegation and said he did not see the incident occur. The HS continued, saying [Staff C, Certified Nursing Assistant (CNA)], saw him do it. She is no longer here. I was told in the hall; she was coming out of [Resident #1's] room. The HS continued, stating, The first victim was Resident #2; she is the one that could not move or talk. Staff C, CNA, told me, 'I have to tell you something about your employee. I just saw him touching Resident #2 inappropriately. When he noticed me, he liked jumped, and turned back to sweeping.' The HS said she did not explain what inappropriate meant. He stated, I went to get [Staff B]. I got the Nursing Home Administrator and went to the employee breakroom with them both. When I questioned him, initially, he acknowledged the incident. On 10/19/2022 at 11:57 a.m., an interview was conducted with Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). Resident #1 and Resident #2's allegations was reviewed. The NHA stated on 10/03/2022, around or before 10:00 a.m., Resident #1 told Staff C, CNA, the Housekeeper, Staff B, inappropriately touched her breast area. The NHA provided Staff C's signed witness statement, dated 10/03/2022, which stated: When I arrived for my 7-3 shift during breakfast time a resident called me to their room, (Resident #1), and stated that Staff B, had been touching her inappropriate in her breast area. I then looked for his supervisor as well as the administrator. They were both in morning meeting, so I proceeded to doing my morning rounds. One of my residents had an appointment. I gathered my supplies and headed into (Resident #2's room). As I walked in, I saw him touching her buttocks area. As he realized I had entered the room, he started sweeping the floor and then asked if I wanted him to leave the room and I said yes. During the interview with the NHA, she reported Staff C, CNA, had been terminated for not following the procedures. The RNC added, Her actions were not up to our expectations with this event. We felt like she could have/should have reported more timely. When asked how long between the allegation of Resident #1 and when Staff C, CNA, saw the next the inappropriate contact with Resident #2, the RNC stated, Resident #1 told the police officers the incident happened with her about 9:00 a.m. The NHA stated, Staff C, CNA, said it was around breakfast tray time, right around 8:30 a.m., 8:45 a.m., I always see the carts when I go to the morning meeting. The NHA stated she was informed around 9:45 a.m. She said, I had passed the HS, I had just come out of the bathroom. He said, I have to talk with you. We had an incident with Staff B. At this time, Staff C, CNA, also said she needed me, stating I did not know that the HS was looking for me for the same thing. We were in the employee break room. Staff B was in the room at the time, when I first heard. Staff B was there when the HS told me about the allegation. He told me that Staff B had touched a resident inappropriately. I went to get the Director of Nursing (DON). HS stayed with Staff B. That was when Staff C, CNA was trying to tell me about Staff B. The NHA reported she called Law Enforcement at 10:02 a.m., saying they came and arrested the housekeeper. An attempt to contact Staff C, CNA, was conducted on 10/19/2022 at 2:07 p.m., with her phone stating it was not allowing calls at this time. A review of Resident #1's clinical chart, the face sheet, reflected an admission of 01/31/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Brief Interview for Mental Status (BIMS), dated 08/09/2022, reflected a score of 11, which suggests the patient is moderately impaired. A review of Section G, MDS, Functional Status, dated 08/09/2022, reflected for Bed Mobility, the resident was extensive assistance with one person support; for Transfer (how resident moves between surfaces), the resident assessment reflected the activity did not occur; and for bathing, the resident was total dependence. A review of Resident #1's Psychiatric progress notes, dated 10/03/2022 revealed: Small anxiety at times .Staff reports employee seen touching patient (pt) inappropriately, fondling pt's chest area. Pt communicated incident . Pt will make needs known. Will follow up next visit .Staff notified family. Discussed with pt and psychologist an additional [MEDICATION(S)] dose 0.5 mg everyday PRN (as needed) x 2 weeks, anxiety, may help possible c/o (complaints of) [CONDITION(S)]. No other psych c/o. Observations: Cognitive Functioning: Oriented/Alert x 3,4. A review of Resident #2's face sheet, documented an admission of 06/02/2022, readmission of 09/21/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's BIMS, dated 09/05/2022, reflected a score of 3, which meant severely cognitively impaired. A review of Resident #2's Minimum Data Set (MDS), Section G, Functional status, dated 09/05/2022, reflected, for transfer-the resident was total dependence, with one-person physical assist; for toilet use, the resident was extensive assist, with one-person physical assist; for bathing-the resident was total dependence, with one-person physical assist. A review of Resident #2's Psychiatric Progress notes, dated 10/03/2022 revealed: Pt comfortable. No Psych c/o. Staff reports employee seen touching pt inappropriately, fondling pt's chest area. Pt unable to communicate any information regarding episode due to dementia. Staff notified family. No med changes. Continue current med profile. Observations: Cognitive Functioning: Oriented/ Alert x 1. Affect: blunted Mood: Euthymic Interpersonal: Interactive at times. Functional status: Impaired. A review of the facility Abuse, Neglect and Misappropriation of Property policy and procedure, last revised 07/06/2022, reflected the policy statement: It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation protection and reporting to provide protection for the health, welfare and rights of each resident residing in the facility . Applicability: For purposes of this guidance, stakeholder includes employees, the medical director, consultants, contractors, and volunteers. Staff would also include caregivers who provide care and services to residents on behalf of the facility, . Definitions of Types of Abuse: Abuse: Is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Mental abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, withholding of goods or services, or any other statements or behavior that a reasonable person would consider to be humiliating, demeaning, or threatening to a resident . Sexual Abuse: Is defined as non-consensual sexual contact of any type with a resident . Other Definitions: Allegations of Abuse: Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred . Identification of Abuse: Identification of occurrences of abuse is an ongoing process and responsibility of all persons as defined within this policy. Routine evaluations such as skin evaluations and comprehensive evaluations are methods of identification of potential abuse . Immediately: All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made . Injury of Unknown Source: Means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one particular point in time; or the incidence of injuries over time. Such occurrences will be investigated by the Administrator, Director of Nursing, or designee as outlined below in the investigation guidelines . A. Screening . B. Training . C. Prevention: 1. Establishing a safe environment that supports, to the extent possible, a resident's safety. 2. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. 3. Ensuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. 4. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . D. Identification: 1. Residents will be monitored for possible signs of abuse. 2. Identification includes having procedures to assist stakeholders in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This would include identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. E. Investigation Guidelines: 1. The Facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this document. The Facility Administrator may delegate some or all of the investigation as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident . F. Protection 1. Every Stakeholder must intervene immediately, protect the alleged victim and integrity of the investigation. 2. If a Stakeholder observes any form of abuse, the Stakeholder will intervene immediately, remove and/or separate residents involved and move them to an environment where the residents' safety can be assured. 3. Every Stakeholder shall immediately report any allegation of abuse, injury of unknown source, or suspicion of crime, as those terms are defined above 4. If the suspected perpetrator is a Stakeholder, they will be immediately removed from resident care areas and suspended while the matter is investigated . 5. If a suspected perpetrator is anyone other than a Stakeholder, the Facility Administrator or designee, will immediately take all appropriate measures to secure the safety and well-being of the affected resident or residents. 6. The Facility Administrator will identify, intervene, and correct situations in which reported abuse, neglect, exploitation, or misappropriation of resident property may recure. G. Reporting/Response: 1. Every Stakeholder shall immediately report any allegations of abuse, injury of unknown origin, or suspicion of crime, as those terms are defined above, to the Facility Administrator or designee as assigned by the facility administrator in his/her absence .

Based on observations, interviews and record review, the facility failed to provide the supervision needed for one resident (#1) while outdoors in excessively hot weather of 15 residents sampled who were identified as cognitively impaired and able to self-propel in a wheelchair or ambulate freely around the facility. Resident #1 was outdoors in the facility's enclosed unshaded courtyard on Sunday, 07/24/22 between 2:00 p.m. and 4:15 p.m. when the maximum temperature was 95 degrees Fahrenheit (F), and the heat index was between 93- and 106-degrees F. Resident #1 was cognitively impaired with multiple medical diagnoses and known by facility staff to frequently wheel himself outside to the courtyard in his wheelchair but was unable to return inside independently. He was found unresponsive outdoors in the courtyard between 4:00 p.m. and 4:15 p.m. by facility staff. The nurse who assessed him called Emergency Medical Services (EMS) and recorded on transfer documents a body temperature of 106.6 degrees F. The EMS report documented redness and [CONDITION(S)] on both feet, redness to his chest and head, and skin red, hot, and dry. The resident was transferred to the hospital and assessed upon admission with diagnoses that included heat stroke and second degree [CONDITION(S)] to the top of his head. Assessment after readmission to the facility revealed the scalp wound was attributed to a second degree burn from sun exposure and had progressed to a third degree burn according to the wound care Advanced Registered Nurse Practitioner (ARNP) on 08/03/22. Due to the courtyard being freely accessible through unlocked and unmonitored doors 24 hours a day, other residents with cognitive impairment and ability to self-propel in a wheelchair or ambulate were at risk for illness, injury, or even death as a result of the facility failing to have a system in place to supervise and monitor residents at all times while outside in the courtyard. This failure created a situation that resulted in serious injury and harm to Resident # 1 and resulted in the determination of Immediate Jeopardy on 07/24/22. The findings of Immediate Jeopardy were determined to be removed on 08/4/22 at 4:50 p.m. and the severity and scope was reduced to a D. Findings included: A telephone interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 08/01/22 at 4:29 p.m. She confirmed she was working second shift at the facility on 07/24/22 and was the nurse assigned to Resident #1. She said on 07/24/22, I was down at my first room and [Staff B, Certified Nursing Assistant (CNA)] hollers down the hall from the patio for me to come . she had [Resident #1] in the wheelchair . he was hotter than hell . it was like about 10 to 4 . 4 o'clock . he (Resident #1) felt like hot from the sun hot. She said, He looked really pink. Staff A reported Resident #1 was transferred into his bed and said, We packed him down with ice . tried to get vitals, couldn't get any vitals, called 911 . I mean he was breathing, just weren't registering (the vitals) on my machines. She reported EMS arrived to the facility and said they worked on him for a while. She said, We did finally get a temp (temperature) on him, and it was like 106 [Fahrenheit]. Staff A said, I have absolutely no idea how long [Resident #1] was outside . when I did my checks, he wasn't in his room but he rolls himself all over the building, so we don't worry too much about that . that day, seeing him unresponsive was the first time I'd seen him that day. Regarding what Resident #1 was wearing that day she said, About all he has is shorts and short-sleeved shirts, but I really wasn't paying attention to what he was wearing . I wasn't there when the aide undressed him . he always wears shoes, but I don't think he had shoes on because of the way the toes looked . wasn't blisters but was like an abrasion on top of his first two toes close to the door which would make it his right foot so I'm not sure if he had just socks on . but it was fresh. Regarding Resident #1's habits, Staff A confirmed she had been working at the facility for six years and knew Resident #1 well. She said, He does like to sit on the patio . depend on the day whether he can take himself in and out . sometimes you have to help him in over that little bump at the sliding doors. She said, I know he likes the sun; he likes being outside, I don't watch them (the residents) that close out there because we have aides who are watching smoke breaks and stuff because you know they're (the residents) not supposed to be out there in between smoke breaks . the alert ones can go out . I don't know if [Resident #1] is supposed to be out there by himself. Staff A reported Resident #1 had cognitive impairments, was alert to self, but would not be able to know if he needed to come inside because of the heat. An interview was conducted with Staff B, CNA on 08/1/22 at 1:45 p.m. She stated she normally worked the 7 a.m. - 3 p.m. shift at the facility but on 07/24/22 she had picked up the 3 p.m. - 11 p.m. shift. She confirmed she knew Resident #1 well and stated he was typically on her assignment, and she had cared for him regularly. Staff B stated on 07/24/22 Resident #1 wasn't assigned to her. She said, That day he wasn't assigned to me . I came in like about 3:30 (p.m.) . I was late . when I came in some of the CNAs were not here yet, they were late or whatever, so I decided to see which of the residents were up not in bed to put people up back to bed . I went to his [Resident #1] room and he wasn't there . I went to go find out where he was so when I was going down the hallway, I saw him on the patio . I went to check on him . it was 4ish . he was not responding to me, so I went and got the nurse (Staff A) and we brought him inside, put him to bed, the nurse put a cold compress on. Staff B said, The nurse said being how he was in the sun not supposed to give him anything cold to drink . [that's] why she applied the cold towels. Staff B stated Resident #1 was wearing shorts, sneaker-type shoes, a short-sleeved polo shirt, and nothing on his head (head was uncovered). She confirmed his feet were covered. She said, Nobody else was outside when I found him outside, and stated she did not know how long he had been outside. Staff B said she did not note any marks or redness on him when we put him to bed . no blisters. Staff B stated it was normal for Resident #1 to go outside and stated he was able to get out and in by himself. She said, He loves the sun. She said, I've been working here 5 years . been taking care of [Resident #1] for 4 years . I know him and know what he's capable of doing. On 08/01/22 at 3:09 p.m. Staff B, CNA demonstrated in the facility courtyard where and how she found Resident #1 on 07/24/22. She stated the resident always preferred to sit in a certain area of the courtyard next to a table. She stated on 07/24/22 there was an open umbrella at the table where he was sitting. She stated it was the only umbrella in the courtyard at that time. Staff B stated the resident was seated in his wheelchair facing the table and with his back facing the sliding glass door opposite the table. She stated he was unresponsive when she found him, that she called his name and tapped his shoulder, and he did not respond. She stated he was not slumped over or leaning over, she again stated there were no blisters or redness on his skin, and stated Resident #1 did not regain responsiveness the entire duration of getting him into bed. She could not confirm whether Resident #1 was shaded or partially shaded by the umbrella. During a follow-up interview with Staff B, CNA on 08/3/22 at 1:50 p.m. she confirmed when EMS arrived at the facility Resident #1 was already put back in his bed. She said, When I found him in the courtyard he was in his wheelchair, he was not on the ground. Observation was conducted of the courtyard on 08/03/22 at 10:56 a.m. The courtyard was a rectangular space interior to the facility, bordered on 3 sides by facility rooms and offices and on one side by two sets of sliding glass doors through which the courtyard could be entered, and windows that faced into the hallway of Unit A. The entire courtyard ground surface was entirely cement there was no natural shade source thus the area was in full sun during daytime hours. At the time of the observation there were 3 small round metal tables, one on each end of the courtyard and one in the middle. Each table contained an umbrella. Placed against the wall opposite one set of sliding glass doors was a small cart that contained an orange plastic water cooler with a spout and next to it was a package of disposable cups. Interviews during the survey revealed on 07/24/22 there was only 1 umbrella and no hydration station (Provisions for fluids). Photographic Evidence Obtained. On 08/01/2022 at 12:30 p.m. Resident #1 was observed lying in bed wearing a hospital gown. His eyes were closed, and he was mouth breathing with a nasal cannula in his mouth. His forehead contained a 4 x 4 size dressing dated 8/1/2022. On 08/02/2022 at 10:00 a.m. Resident #1 was observed in his bed. His eyes were open, and he made eye contact when spoken to. He verbalized his name when asked but could not answer any simple questions. His speech was slurred, mumbled, and garbled. Review of Resident #1's medical record revealed he was an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses listed on his face sheet included [CONDITION(S)] (a disease of the heart characterized by irregular and often faster heartbeat, dementia, malignant neoplasm of right kidney, dysphagia, severe protein-calorie malnutrition, and generalized muscle weakness. Allergies were listed as no known allergies. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 which meant the resident had moderately impaired cognition. The MDS revealed Resident #1 was dependent for transfers, independent with wheelchair mobility on the unit, and required extensive assistance with dressing, toilet use, and personal hygiene. A document titled Weekly Skin Integrity Evaluation dated 07/20/22 revealed no skin conditions present. The last set of vital signs taken before Resident #1 was found unresponsive were documented by Staff D at 2:19 p.m.: temperature 97.2 F, pulse 68 beats per minute, respirations 18 per minute, blood pressure 122/74 mmHg, and oxygen saturation 98% with no oxygen use. The care plan revealed Resident #1 had impaired decision making related to dementia, and poor safety awareness. A document titled SBAR (Situation Background Assessment Recommendation) Communication Form in Resident #1's medical record was reviewed. It was dated 07/24/22 and completed by Staff A, LPN. The documentation revealed Resident #1 was found unresponsive on 07/24/22. Pertinent medical history was documented as Dementia, Malignant Neoplasm (cancer) of R (right) kidney and allergies were documented as NKA (no known allergies). The document revealed, Vital Signs (VS)BP (blood pressure) 99/77 EMS Pulse 84 EMS Temp (temperature) 106.6 EMS, Resident assisted to bed per staff. Cold compresses applied to resident. EMS arrived at facility at 1650 (4:50 pm). VS per EMS evaluation BP 99/7, HR (heart rate) 84. T 106.6 (temporal). Resident transported to (local hospital) at 1715 (5:15 pm). Review of a progress note written by Staff A, LPN dated 07/25/22 12:20 a.m. revealed 4:15 PM Noticed resident out in the patio Aide brought him in and then called me down. Resident was non responsive and hot to touch Took him and put him to bed and put ice packs in place He was still non responsive could not get vitals on him. Called 911 they arrived at 4:50 They left the building at 5:15 and took him to [name of hospital]. A progress note dated 07/31/22 revealed Resident #1 was readmitted to the facility from the hospital on 07/31/22 at 6:00 p.m. Review of the EMS ambulance run report received from the hospital on 08/05/22 revealed EMS received a call from the facility on 07/24/22 at 4:59 p.m., arrived at the facility at 5:18 p.m., and to Resident #1 at 5:21 p.m. The narrative report documented the following: Subjective: . According to staff who gave the FD report, the patient went outside earlier in the morning prior to noon, and was found hours later seated in the sun on his wheelchair with [CONDITION(S)] to his legs, feet, not alert, not oriented, and with a core body temperature of 106 degree (unknown how the temperature was obtained) Objective: On our arrival, patient is met resting semi fowlers. The patient is not alert and not oriented. The patient is breathing at an elevated rate with symmetrical chest rise and fall. The patient is pink/red, hot, and dry and appears to be in significant distress . Assessment: . The patient had reddening to his feet bilaterally that appeared to have been minor [CONDITION(S)]. Due to the heat exposure, all attempts were made to turn down the temperature in the vehicle and multiple ice packs were utilized in the junctional areas of the patient's body. On a body diagram annotation, the EMS noted Redness to the resident's feet, head and chest areas. The Treatment Summary included IV (intravenous line) started at 5:07 pm, 1000 ml of IV fluid was administered to the resident by EMS. At 5:40pm the resident's vital signs were recorded as BP 94/57, Pulse 132, Respirations 19, oxygen saturation 95%. Review of hospital medical records for Resident #1 revealed an Emergency Department (ED) note dated 07/24/22 which included: [AGE] year-old male brought in unresponsive after found on the floor outside of assisted living facility. Unknown how long patient had been outside on the ground for. Patient was found in the sun and heat. Unknown how patient ended up on the floor. Unknown if there was a fall or syncopal episode. Patient arrives unresponsive. He has increased work of breathing. He is hypoxic (below-normal level of oxygen in the blood) in the low 80s. He is on a non-rebreather. He does not withdraw to pain. He does not verbalize. At baseline he is reported to be ambulatory and verbal and pleasantly confused secondary to dementia. No other history is reported. The PE (Physical Exam) notes from the hospital admission history and physical dated 07/24/22 revealed: general appearance lethargic, somnolent, protecting airway, no acute distress on 15 L (liter) venti mask (oxygen mask). Head/eyes: multiple blisters on the top of the head. Neuro/CNS (neurological status): somnolent (sleepy), arousable to painful stimuli, unable to further assess. Skin: second degree [CONDITION(S)] on top of head, warm to touch, open blisters on bilateral toes. The diagnosis, assessment, and plan dated 07/24/22 revealed: Heat Stroke patient was left outside at his ALF (Assisted Living Facility) (sic), unknown down time, presented altered, presented with 103-degree fever, has blisters on the top of his head. Type 2 MI (heart attack) likely due to heat stroke AKI (Acute Kidney Injury) due to dehydration and heat stroke Lactic acidosis secondary to [CONDITION(S)] and heat stroke. Review of a document titled Wound Management Detail Report in Resident #1's medical record dated 08/01/22 after 10:00 p.m. revealed the resident was assessed to have the following wounds: Abrasion left bottom of foot, length 17 cm (centimeters), width 8cm, this is a large abrasion that affects Achilles heel, the ankle, lateral foot, and extends to plantar (relating to the sole of the foot) surface . area is dry, no odor, no depth. Blister right ankle, length 17.5 cm, width 13 cm, this in an enormously raised blood filled blister. This area extends from back of right foot, onto ankle, and alongside of foot. Abrasion right big toe, length 1 cm, width 1.5cm, clean dry abrasion Abrasion right second toe, length 3 cm, width 1.5cm, clean dry abrasion Clear fluid blister right pinky toe, length 2.5cm, width 3 cm, blister is raised and filled with clear fluid, intact at this time Pressure ulcer sacrum, length 0.2cm, width 0.2cm, depth 0.1cm, stage II Burst blister right forehead, length 9.5cm, width 5.5cm, depth <0.1cm, beefy red open wound, no drainage, no odor. Report created by Staff J, RN. A telephone interview was conducted with the wound care ARNP on 08/03/22 at 9:36 a.m. She stated she had read the ED report for Resident #1 and confirmed it indicated the resident had a second-degree burn. Wound observation of Resident #1 was conducted with the ARNP on 08/03/22 at 12:10 p.m. The observation was conducted in Resident #1's room and the DON (Director of Nurses) was present. The ARNP stated she was informed by the facility that Resident #1 was outside for twenty minutes. She was informed that the investigation revealed an approximate two-hour period outside and she said, Well that changes everything. The ARNP removed the dressing to the resident's forehead which revealed a large open area with dried black borders. Upon visualizing the wound to the forehead, the ARNP said, They said it was a second-degree burn (referring to the hospital report) I see it's a third-degree burn. (Photographic Evidence Obtained). Review of the ARNP's Wound Care Wound/Dermatology Services report dated 08/03/2022, revealed the following related to Resident #1's scalp: Body Location: Front Parietal, New-14 days old Acquired: In house Acquired. Dimensions: Area 40.62 centimeter (cm) Length: 8.65 cm Width: 7.4 cm. WOUND TYPE: RUPTURED BLISTER, WOUND LOCATION: Frontal Parietal Scalp WOUND MARGIN: attached, WOUND 11 Measurements, LENGTH: 8.65 cm, WIDTH: 7.4 cm, AREA: 64.0, Wound 11 Bed: ESCHAR (a collection of dry, dead tissue within a wound): 51-75%, GRANULATION: 26-50%, GRANULATION (the development of new tissue and blood vessels in a wound during the healing process) TEXTURE: Firm, GRANULATION COLOR: bright red New order: Silver sulfate cream twice daily leave open to air indication for scalp third degree burn dated 08/03/2022. An interview was conducted with Staff C, Receptionist on 08/02/22 at 10:24 a.m. The facility Administrator (NHA) and the Corporation Care Consultant (CCC) were present during the interview. Staff C stated she worked in the facility on the weekends and her scheduled shift was 10:00 a.m. to 3:30 p.m. She confirmed she was working on 07/24/22. She confirmed she knew Resident #1 and said, he's a roamer . he roams around in his wheelchair . he loves to go out in the courtyard . most times he can go out on his own but it's harder for him to go back in . he'll wait there by the door for someone. She said, [Resident #1] has to get someone to wheel him back in (from the courtyard) . if someone doesn't wheel him back in he'll just stay out there . he wouldn't know it was time to come in because of the heat . cognitively he's not aware. Staff C confirmed she witnessed Resident #1 outside in the courtyard on 07/24/22 and said, When I saw him I was on my way to the restroom about 3:15 [p.m.] because I was getting ready to leave . on my way back from the bathroom he was still out there . another aide (identified as Staff B, CNA) was with me and I said I think he's been out there a long time. Staff C stated about 20 minutes passed between her seeing Resident #1 outside on her way to the restroom and seeing him again outside on her way back to the front door of the facility from the restroom. Staff C stated she and Staff B went outside into the courtyard together. She said, He was asleep . we woke him up and told him we were taking him back inside and he asked why and said I like it out here . he said okay . this was about 3:45 [p.m.] . nobody else was out there. Staff C stated the resident had his face down and was sitting near the second set of sliding glass doors near the DON's office, had his back to the doors and said, Sun was on him at that time. Regarding what Resident #1 was wearing, Staff C stated he was wearing a short-sleeved shirt and said, I don't remember if shorts or long pants, was wearing socks, no shoes . typical for him . he will kick the shoes off and the socks sometimes . you have to put the socks back on. Staff C said after she and Staff B found the resident, We brought him in and alerted the nurse . got him back to bed . his complexion wasn't looking normal . he was a different shade . face was pink. Staff C stated Staff B transferred the resident into bed by herself, that she lifted him from the chair and put him in the bed and the resident was out of it. Staff C said, After we got him into the room he was flushed and just kept saying what are you doing what are you doing. Staff C stated the last time she had seen Resident #1 that day prior to seeing him in the courtyard had been when he was at her desk after lunch. She stated she watched Staff B put Resident #1 in bed and then left for the day somewhere after 4:00 p.m. Review of the facility time clock punch detail report revealed Staff C clocked out at 4:33 p.m. A follow up interview was conducted with Staff C, Receptionist on 08/3/22 at 1:58 p.m. She confirmed when she found Resident #1 in the courtyard on 07/24/22 he was in his wheelchair and stated at no point was he on the ground. She stated the resident was in his room when EMS arrived to the facility. An interview was conducted with Staff D, LPN on 08/01/22 at 12:50 p.m. She confirmed she was working at the facility on 07/24/22 and was the assigned nurse that day on the day shift (7:00 a.m. to 3:00 p.m.) for Resident #1. She stated she did not know about the events that occurred with the resident after her shift and stated the resident was his normal self that day. She stated once Resident #1 got out of bed for the day his routine was to propel himself in his wheelchair throughout the facility. Staff D denied observing Resident #1 outside on 07/24/22 and said the last time she saw him on her shift was around 1:00 p.m. because he receives a 1:00 p.m. medication. She estimated the last time she saw him on 07/24/22 was between 1:00 p.m. and 1:30 p.m. at the nurses' station on Unit A because he came to the desk at that time for his medication and a shake. Review of the July 2022 Medication Administration Record (MAR) for Resident #1 for 07/24/22 revealed the medication [MEDICATION(S)] 0.5mg (milligram) was scheduled at 1:00 p.m. and the documentation revealed a charted date and time of 07/24/22 at 2:19 p.m. Charted Late documented by Staff D. A follow-up interview was conducted with Staff D, LPN on 08/01/22 at 1:15 p.m. and she stated she did not see Resident #1 again after administering his scheduled 1:00 p.m. medication that day, she did not witness him going outside, and she did not know how long he was outside. An interview was conducted with Staff E, CNA on 08/01/22 at 2:11 p.m. She confirmed she was working in the facility on the day shift on 07/24/22 and Resident #1 was on her assignment that day. She stated 7:00 a.m. to 3:00 p.m. was her usual shift. She stated she knew Resident #1 well and it was typical for him to go outside in the courtyard, that he went there every day, and he could exit and enter the courtyard independently. Staff E said, That day I got him (Resident #1) up for noon for lunch . he likes to sleep in on the weekends. She said, He wasn't having any behaviors that day with me, he was actually singing that day. She stated the resident ate breakfast and lunch that day and she did not know what time he went outside. She said, most days [Quality of Life Director] has him with her by her for support . for emotional/behavioral support . she wasn't here that day. Regarding the timeline for Resident #1 on 07/24/22, Staff E said, When I got him dressed and everything that day everything was normal . I didn't notice anything off or anything . no marks or redness on his skin . nothing abnormal with his vitals that day. Staff E stated she saw Resident #1 outside in the courtyard at 2:00 p.m. and said, I checked on him before I checked on the roommate . he was still out in the courtyard . I went outside, and I said [Resident #1] are you ok, and he said yeah and then I went back inside to check on his roommate. She said, I didn't see him go outside but I want to say like 2:15, 2:30ish I was in the room with his roommate, and I saw him [through the window] outside rocking his chair back and forth . looked fine. Staff E stated the first time she saw him he was under the shade of the one umbrella that was at one of the tables and the second time he was near a planter of flowers, and she wasn't sure if that area was shaded. Regarding what Resident #1 was wearing she reported t-shirt, shorts, black closed-toe shoes, socks, and no hat. An interview was conducted with the Quality-of-Life Director on 08/1/22 at 2:39 p.m. She stated she had worked at the facility for two years and confirmed she was not at the facility on 07/24/22. She stated she knew Resident #1 very well and said, He was already here when I started. She confirmed Staff E, Receptionist's statement that Resident #1 typically spent a lot of time with her when she was at the facility. She stated a typical daily routine for Resident #1 on a day when she was there would be breakfast in the morning, then CNAs get him out of bed in wheelchair and he'll start hollering for me . he'll come into activities [room] for coffee and snacks . his general day, he just kind of goes in tow with me. She stated Resident #1 always went outside in the courtyard and said, He goes outside any day he's up in his chair. The Quality-of-Life Director stated she was responsible for being the smoking monitor for residents who smoked at designated times during the day in the courtyard, and stated Resident #1 often went outside with her when she was doing her smoking supervision assignment. She said, He does go out and stay out by himself . I don't believe he can get back in the door by himself . he can get out the door but not back in, I assist him over the humps . if he wants to come back in he approaches the door and opens it and will holler for help . to my knowledge he can't get over those tracks [in the sliding door frame]. An interview was conducted with Staff F, Receptionist on 8/1/22 at 3:22 p.m. She confirmed she was working at the facility on 07/24/22 and stated she comes in to assist the residents during their designated smoking times because they don't have anyone to go out with them on the weekends because the Quality-of-Life Director did not work on the weekends. Staff F said, I saw [Resident #1] on 07/24/22 at 1:30 p.m. sitting by the patio doors. He was looking out at the patio. He was not attempting to go outside at the time. Staff F stated she had a habit of always looking at the patio just to see who was out there and the last time she looked out on 07/24/22 was at 2:00 p.m. and she said, No one was outside at the time and [Resident #1] was no longer sitting by the doors. Staff F denied ever having seen Resident #1 wheel himself outside on his own and stated she had never heard him ask to go outside. Staff F stated she recalled on 07/24/22 during the 15-minute smoking period she had actually supervised it from inside because of it being very hot. Staff F reported there were only three residents in the facility currently who participated in smoking: Resident #9, Resident #17, and Resident #21. Review of the facility smoking schedule for residents revealed the following periods scheduled every day: 8:30 to 8:45 a.m.; 10:30 to 10:45 a.m.; 1:00 to 1:15 p.m.; 4:00 to 4:15 p.m.; 6:30 to 6:45 p.m.; 8:15 to 8:30 p.m.; 10:00 to 10:15 p.m.; 12:00 to 12:15 a.m. Observation of resident smoking was conducted in the facility courtyard on 08/01/22 at 4:05 p.m. There were three residents in attendance: Resident #9, Resident #17, and Resident #21. Resident #9 was interviewed and confirmed he had seen Resident #1 let himself into the patio area before and said he did not recall if Resident #1 was able to get back inside on his own and said, You need to have enough strength. Resident #21 was interviewed and stated he had witnessed Resident #1 entering the courtyard on his own and denied ever witnessing the resident able to get back inside without assistance. Resident #17 confirmed he knew Resident #1 but stated he doesn't pay attention to who is entering the patio. None of them could provide any witness for Resident #1's whereabouts on 07/24/22. Resident #17's MDS dated [DATE] revealed BIMS score of 15, Resident #9's MDS dated [DATE] revealed BIMS score of 15, Resident #21's MDS dated [DATE] revealed no short-term memory problems and independence with daily decision making. A written timeline of events from 07/24/22 was provided by the facility NHA and the CCC during an interview on 08/02/22 at 10:40 a.m. They provided names of staff identified in the timeline. They also provided witness statements gathered from their investigation for review. The written timeline revealed: Resident #1 witnessed having breakfast in bed 10:00 a.m. Resident #1 witnessed in hallway outside of his room by Staff G, Housekeeper 10:30 a.m. Staff F, Receptionist supervised 10:30 a.m. resident smoking in courtyard and did not see Resident #1 out there 11:45 a.m. Staff E, CNA got Resident #1 out of bed into his wheelchair for lunch and he ate lunch 1:00 p.m. resident smoke time in courtyard - Resident #17 reported Resident #1 was out there but Staff F, Receptionist said he was not 1:45 p.m. - Staff G, Housekeeper witnessed Resident #1 in his room 2:00 p.m. - Staff F, Receptionist witnessed Resident #1 in hallway by entrance to courtyard 2:00 p.m. - Resident #1 was observed outside in the courtyard by Staff E, CNA from the window of Resident #1's room 2:45-3:00 p.m. - Staff D, LPN said she saw Resident #1 inside at the nurse's station during shift change 3:00 p.m. - Resident #1 was observed by Staff H, CNA outside in courtyard wheeling around in no distress 4:00 p.m. - observed by Staff I, LPN who was supervising resident smoking time - observed Resident #1 in the courtyard in no distress 4:15 p.m. - Resident #1 was brought inside by Staff B, CNA and Staff C, Receptionist - resident was unresponsive. EMS called. 4:40 p.m. EMS arrived 5:15 p.m. EMS transported resident to hospital. An interview was conducted with Staff G, Housekeeper on 08/02/22 at 9:41 a.m. She confirmed she was working at the facility during the day on 07/24/22 and stated she was aware of the incident involving Resident #1 because she had been questioned about it by the DON. She stated she saw Resident #1 wheeling himself in the hallway in his wheelchair between 12:00 p.m. and 1:45 p.m. An interview was conducted with Staff I, LPN on 08/02/22 at 4:35 p.m. She said, I do one good thing and it blows up. She explained what she meant was that it was not her job to supervise resident smoking but the person that was supposed to do it on 07/24/22 wasn't there, so she had done it. She said, I was out there (in the courtyard) only 15 minutes like 4:00 to 4:15 [p.m.]. She stated Resident #1 was out there during the time she was outside and said he was acting like his normal self. She stated Resident #1 was talking to himself, was in his wheelchair and facing the sliding glass doors on A side (doors closest to the nurses' station on Unit A). Staff I said, He was wearing pajamas . long pajamas, I think he was wearing shoes . pretty sure shoes. Regarding whether Resident #1 was still outside when she returned inside, she said, I really did not pay attention to whether he was still there . was concerned with the smokers and had to get to my med pass. She said, If I had known he had been out there for a while I would have brought him in . if I had known the day shift had brought him out or something then I would have brought him in because that would have been a long time. She stated it was not unusual for Resident #1 to be outdoors and stated he was often outside by himself. Staff I said, He can get himself out (outside to the courtyard) so I imagine he can get hi [TRUNCATED]

Based on observation of Medication Administration, interview with facility staff, and review of the Plan of Correction, the facility failed to ensure the Plan of Correction provided an assessment of the deficient practice related to not following the facility policy for Medication Administration, and failed to provide adequate training to nurses to ensure residents were correctly administered medications following physicians orders for four (#4, 12, 33, 60) residents of five residents observed during Medication Administration on 09/13/2022. Findings included: During a Survey to revisit the facility's correction of their deficient practice cited during the Recertification Survey (conducted from 07/17/2022 - 07/20/2022), Medication Administration was observed: -On 9/13/22 at 9:22 a.m. the medication administration task was conducted with Staff I, Licensed Practical Nurse (LPN.) She prepared to give the following medications for Resident #60. [MEDICATION(S)] 10 mg (milligrams) 1 tab, [MEDICATION(S)] cap 200 mg, [MEDICATION(S)] DR 500 mg 1 capsule (cap), [MEDICATION(S)] HCL DR 60mg 1 cap, [MEDICATION(S)] 5mg tab, [MEDICATION(S)] 24-26 mg 1 tab, [MEDICATION(S)] 500mg 1 tab, Budesonide-[MEDICATION(S)] ([MEDICATION(S)]) 160-4.5 inhaler 2 puffs, and Tamsulosin cap 0.4mg 1 cap. The nurse was unable to find [MEDICATION(S)] in the medication cart. She stated, I know I can't share someone else's. She did not attempt to locate the residents [MEDICATION(S)] elsewhere. She proceed to administer the remaining medications. After the resident was given his [MEDICATION(S)] inhaler, the LPN did not have the resident rinse his mouth out as required. A medication reconciliation with current orders indicated the following order: -[MEDICATION(S)] 5mg 1 tablet twice a day at 9:00 a.m. and 5 p.m. The start date of the order was 8/30/22. A review of the electronic medication record did not reveal any progress notes to indicate a physician was contacted about Resident #60 not receiving the ordered dose of [MEDICATION(S)]. -On 9/13/22 at 10:05 a.m. Staff I, LPN prepared to give Resident #12 her ordered insulin. The [MEDICATION(S)] insulin was administered to the resident at 10:10 a.m. A reconciliation of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 9/12/22 at 10:55 a.m. Staff I, LPN prepared the following medications for Resident #4: [MEDICATION(S)] 100mg/ml (milliliters) 7.5ml, [MEDICATION(S)] cap 50mg 1 cap, [MEDICATION(S)] 400mg 1 tab, Omeprazole DR 40mg 1 cap, [MEDICATION(S)] 150mg 1 tab, [MEDICATION(S)] ER 3mg 1 tab, Senna plus 1 tab, [MEDICATION(S)]-acetaminophen 37.5-325mg 1 tab. The computer screen highlighted seven out of eight of the medications as late. Staff I was observed pouring the [MEDICATION(S)] 7.5 ml into a medication cup. The LPN poured out too much medication. She then proceeded to pour the medication back into the original medication bottle. A medication reconciliation with current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 100mg/ml 7.5ml twice a day at 9:00 a.m. and 9:00 p.m. [MEDICATION(S)] 50mg three times a day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION(S)] 400 mg every 12 hours at 9:00 a.m. and 9:00 p.m. Omeprazole DR 40mg at 9:00 a.m. [MEDICATION(S)] 150mg every 12 hours at 9:00 a.m. and 9:00 p.m. [MEDICATION(S)] Extended Release 24 hours 3 mg at 9:00 a.m. Senna 8.6 mg every 12 hours at 9:00 a.m. and 9:00 p.m. These seven medications were given 1 hour and 55 minutes past their ordered administration time. -At 12:27 p.m. Resident #4's electronic medical record was reviewed. The eMAR indicated the resident had already been administered their 1:00 p.m. does of [MEDICATION(S)]. Therefore, the resident was given [MEDICATION(S)] at 10:55 a.m. and prior to 12:27 p.m., less than 1 ½ hours separating the two doses instead of the ordered 4 hours. A review of progress notes did not indicate there had been any contact with the physician regarding the late medications. -On 9/13/22 at 10:55 a.m. Staff I, LPN properly prepared an insulin pen for administration to Resident #33. Staff I entered the resident's room, and the resident was sleeping. The LPN did not speak to the resident or attempt to wake her, she administered the insulin to the resident while she was sleeping. A medication reconciliation with current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An interview was conducted on 9/13/22 at 2:30 p.m. with Staff I, LPN. The LPN confirmed Resident #60 did not receive his 9:00 a.m. [MEDICATION(S)]. When asked if she could have gotten the medication somewhere else since it was not in the cart she stated, oh I guess I could have gotten from the E-kit. I didn't think of that (referring to the emergency drug kit.). Staff I confirmed medications are to be given up to one hour prior to the scheduled time or one hour after the scheduled time. She stated if the nurse is late, they should click administered late in the computer then depending on the medication the nurse should clarify with the doctor the timing of the next dose. She stated she did not call the doctor about the [MEDICATION(S)] or the late medications this morning. When discussing pouring out too much [MEDICATION(S)] into the medication cup, she stated she should have gotten a new cup and disposed of the extra medication. She said she should never pour it back in the original bottle. Review of the Facility's Policy entitled Quality Assurance/Performance Improvement (QAPI) Program revealed a Purpose Statement: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. The Policy Statement read: It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. Under the heading of Guidelines, point # 6 read: The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. Point #7 read: The QAPI committee will review, and coordinate audits and assessments based on the QAPI calendar. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: c. High risk - residents are at risk of serious consequences or deprived of substantial benefits if the care is not provided correctly and in a timely fashion or on proper indication. A review of the facility's Plan of Correction for the deficient practice observed during the Recertification Survey and cited at F759, revealed the immediate correction of the wrong dosing of medications to the resident was documented with a medication error report and education to the nurse. To address the larger concern, all nurses were educated with observations conducted of the nurses during medication administration and review of the observations at the monthly QAPI meetings. A review of the QAPI meeting held on 08/24/2022 revealed the Plan of Correction was reviewed at the meeting with no status documented. The Quality Assurance interview was conducted with the Administrator, the Director of Nurses and the Regional Nurse on 09/13/2022 beginning at 4:25 p.m. during which the quality assurance review and monitoring of the corrections to the deficient practice cited was discussed. It was reported by the facility team that on 08/24/2022 a QAPI meeting was held and the correction plans for the Annual Survey were not altered and continued as planned. In an interview conducted with the Director of Nurses (DON) on 09/13/2022 beginning at 2:55 p.m., when apprised of the errors observed during the Medication Administration observation conducted beginning at 9:22a.m., the DON confirmed that she had noted the nurse was a new nurse that needed some additional training. The DON stated, I knew when I saw you with [Staff I] it could be a problem. During the QAPI meeting that began at 4:25 p.m., the DON confirmed that she had noted the nurse needed additional training but had not developed an action plan for the nurse or had paired her to work with another nurse to help improve her skills. The DON confirmed she had not observed the nurse during Medication Administration.

Based on record review and interviews the facility failed to provide a written bed hold notice for a facility-initiated emergency transfer to a hospital for one (#52) of two sampled residents. Findings included: Review of the closed medical record for Resident #52 revealed he was admitted to the facility on [DATE] and discharged to a hospital on 5/12/22. The resident did not return to the facility. There was no written bed hold notice found in the record. During an interview with the facility Director of Nursing (DON) and the Corporate Care Consultant (CCC) on 07/20/22 at 9:53 a.m., The CCC confirmed the notice was not in the closed record and stated she did not know where they were kept but would find out. An interview was conducted with the facility Social Services Director (SSD) on 07/20/22 at 10:27 a.m. She confirmed she had been working in her position at the facility since February 2022. She consulted the closed Electronic Medical Record (EMR) Resident #52 and confirmed there was no written bed hold notice there. She confirmed she knew the notice was required to be provided for any discharge or transfer to a hospital and said, the form has to be done at that time, so nursing does it. She stated she would search for the notice for Resident #52. She confirmed Resident #52 had been his own responsible party. At 1:17 p.m. on 07/20/22 the CCC followed up and confirmed there was no written bed hold notice for Resident #52's transfer to a hospital on 5/12/22. She confirmed it had not been found and therefore had not been done. Regarding the facility process/expectation she said when a resident was transferred to a hospital, nursing is responsible to give a copy of bed hold form to resident & communicate that to family. She stated the facility process for ensuring notices were provided for hospital transfers broke for whatever reason .the DON [former] thought it was being handled by Social Services and off of nursing's plate . I've got education scheduled for tomorrow on this with the nursing staff. Review of facility policy titled, Facility Bedhold revised 11/12/18 revealed, The Facility will notify the resident/responsible party of the facility's bed hold and re-admission policies at admission and anytime a resident is transferred to the hospital .the facility will provide written notice of the bed hold and re-admission policies: . Before a resident's transfer to the hospital.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care including oxygen therapy and nebulizer treatment was provided in accordance with professional standards of practice including storage, dispensing, and maintaining infection control measures for three (Residents #2, #19, #43) of three sampled residents: 1. Resident #19 was receiving oxygen therapy at a setting not in accordance with physician order, 2. Resident #2 was receiving oxygen therapy without physician orders and her nebulizer delivery equipment was improperly stored, 3. Resident #43's nebulizer delivery equipment was improperly stored. Findings included: 1. Observation was conducted 07/18/22 at 8:20 a.m. in Resident #19's room. She was in bed and was connected by nasal cannula and tubing to an oxygen concentrator at the bedside. The concentrator was on and running and the setting was at 3 liters. Observation conducted on 7/18/22 at 11:45 a.m., revealed the resident was still connected to oxygen and the setting was at 3 liters. An observation was conducted on 7/19/22 at 7:50 a.m., Resident #19 was again observed receiving oxygen therapy via nasal cannula connected to a concentrator at the bedside and set at 3 liters. Photographic evidence obtained. Review of the physician orders in Resident #19's Electronic Medical Record (EMR) revealed a physician's order for Oxygen Therapy: Oxygen via NC (nasal cannula) @ (at) 2 Liters per minute Every Shift - PRN. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 07/19/22 at 7:55 a.m. She stated she was employed PRN (as needed) by the facility and usually worked there 2 days per week. She said, I don't know people (residents) on this unit very well. She stated information about whether a resident was receiving oxygen therapy was shared in nurse to nurse reporting and said, usually when we do report they tell me who's on oxygen. Regarding Resident #19, Staff A stated she had not been given a report that the resident was receiving oxygen therapy and did not know what setting was ordered. Staff A observed the concentrator in Resident #19's room during the interview and confirmed that it was set at 3 liters. Afterwards she consulted the physician orders for Resident #19 in the Electronic Medical Record (EMR) and revealed orders were for 2 liters PRN. Regarding why the concentrator was set at 3 liters, Staff A said, I can't say what happened and I wasn't there. Staff A confirmed based on facility procedure and practice standards only a nurse could set or adjust settings for oxygen delivery. She confirmed practice standards were to consult physician orders and follow them. She stated she did not know if oxygen delivery was documented by nursing staff on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #19's medical record revealed the MAR for July 2022 had an entry template for oxygen administration but there was no documentation entered that oxygen therapy had been administered for any dates in July. The care plan for Resident #19 revealed a focus area for .requires oxygen due to SOB (shortness of breath) with history of pulmonary hypertension making her at risk for respiratory complications. Care plan interventions included Oxygen as ordered. An interview was conducted with the facility Director of Nursing (DON) and the Corporate Care Consultant (CCC) on 07/19/22 at 4:12 p.m. They consulted the EMR for Resident #19 and confirmed the physician orders revealed 2 liters PRN. The DON confirmed oxygen delivery settings should match what was ordered by the physician. They both confirmed only a nurse could manage and change settings and it was the nurse who was responsible for ensuring proper settings in accordance with physician orders. The CCC stated her expectation would be for a nurse to round on every patient at the start of shift and confirm oxygen delivery and settings were correct. 2. During an interview with Staff A on 07/19/22 at 8:02 a.m., she said Resident #2 was supposed to be receiving oxygen therapy. During the interview, Resident #2 was observed being wheeled out of her room and past the nurse's station by a staff member. She was not connected to any oxygen and there was no portable oxygen delivery tank present. Staff A stated Resident #2 was noncompliant with her oxygen and always wanted to go smoke and stated the reason she did not have portable oxygen was because she was on her way to go smoke. An observation was made in Resident #2's room on 07/19/22 at 8:05 a.m. The resident was not present in the room. An oxygen concentrator was observed at bedside, on and running, and set at 3 liters. The oxygen tubing and nasal cannula were on the floor. A nebulizer mask and tubing was observed on a bedside table. They were not stored in a bag and the mask was on the floor. Photographic evidence obtained. On 07/19/22 at 8:10 a.m., Staff A observed Resident #2's room and confirmed observations of the concentrator set at 3 liters, oxygen tubing and cannula on the floor, and nebulizer tubing and mask improperly stored. She stated the nebulizer mask and tubing should be stored in a bag and dated. She stated she would get a new mask and a new nasal cannula and tubing since both were on the floor. An observation and interview were conducted with Resident #2 in her room on 07/19/22 at 10:37 a.m. She was observed in bed wearing a nasal cannula that was attached to the oxygen concentrator at bedside. The concentrator was set at 3 liters. During the interview a staff member entered the room and the resident asked to be transferred to her wheelchair so she could go outside and smoke. The resident stated she did not wear oxygen when out of her room to go smoke and said, I can be off it for an hour. Regarding portable tank option for out of room activities other than smoking she said, I wish I had one. A review of Resident #2's medical record was conducted. The resident's face sheet revealed an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which meant the resident was not cognitively impaired. Section O of the MDS did not reveal any documentation that the resident was receiving respiratory treatments. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .impaired oxygen gas exchange related to [CONDITION(S)] and has a continuous oxygen requirement. Care plan interventions included Oxygen as ordered. An interview was conducted with the DON and CCC on 07/19/22 at 4:01 p.m. The DON consulted Resident #2's EMR and confirmed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, the nurse told me she had missed some standing orders today .I thought she would have fixed it by now. Regarding portable oxygen delivery device for out of room activity other than smoking, both confirmed one should be provided due to the resident's need for continuous oxygen support. 3. An observation was conducted on 07/19/22 at 7:49 a.m. in Resident #43's room. The resident was in bed being assisted with breakfast by Staff B, Certified Nursing Assistant (CNA). A nebulizer mask and tubing were observed on a bedside table not stored in a bag. Photographic evidence obtained. Review of the MAR for Resident #43 revealed nebulizer treatment was ordered every 4 hours and was documented administered as ordered on 7/19/22 at 2:00 a.m. and 6:00 a.m. On 07/19/22 at 8:10 a.m. Staff A observed Resident #43's room and confirmed the nebulizer tubing and mask were not properly stored. She stated they should be dated and stored in a bag. An interview was conducted on 07/19/22 at 3:47 p.m. with the DON and CCC expectations for nebulizer tubing and mask storage. They confirmed both should be labeled and dated, changed weekly, and stored in a bag at the bedside when not in use. Review of facility policy titled Oxygen Administration - Nasal Cannula Clinical Practice Guideline reviewed 10/23/20 revealed: Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Check the resident's medical record to confirm the presence of a complete and appropriate physician's order. An interview was conducted with the CCC on 07/20/22 at 3:17 p.m. She confirmed the facility did not have a written policy for respiratory equipment storage at the bedside and said that labeling and storing equipment including tubing and masks in a bag was simply the facility's standard of practice.

Based on observation, interview, medical record review, and policy on Drug Diversion, the facility failed to ensure the disposition of controlled medications reflected accurate accounting and record keeping for one (Unit A) of two units as evidenced by making reasonable effort to reconcile and investigate reported discrepancies. Findings Included Review of the Controlled Drug Declining Inventory Sheet stated every dose of drug listed under the Controlled Substances Act. The information must be filled in at the time the drug is administered and not at some future date. Failure to do so is punishable under the law by fine or imprisonment or both. The form contains an area that read Administered BY (FULL SIGNATURE). 1. A review of Resident #17's physician orders revealed [MEDICATION(S)] -Schedule II tablet; 50 mg; amount: 2 mg; oral [ Diagnosis (DX): Pain in unspecified shoulder] Twice a day; 12:00, 9:00 p.m. (21:00) dated 06/09/2022-open ended. Review of the July 2022 Medication Administration Record (MAR) confirmed documentation of the administration two times a day. Review of Resident #17's Controlled Drug Declining Inventory Sheet for the [MEDICATION(S)] revealed on 7/12/2022 the medication was administered at 12:00 p.m., 5:00 p.m. and at 9:00 p.m. No Physician orders were located for the admission of three doses for that day. Further review of the inventory sheet on 7/13/2022 at 12:00 p.m. revealed one set of initials with the word wasted next to it which indicated a dose of [MEDICATION(S)] was disposed of by one nurse. 2. Review of Resident #14's physician orders revealed [MEDICATION(S)]-Acetaminophen -Schedule II tablet 10-325 mg; amt 1 tablet; oral three times a day at 6:00, 2:00 p.m. (1400) and 10:00 p.m. (2200) dated 05/26/2022- Open Ended. Review of Resident #14's Controlled Drug Declining Inventory Sheet on 7/12/2022 the [MEDICATION(S)]-Acetaminophen 10-325 mg was administered at 6:00 a.m., 2:00 p.m., 9:00 p.m. and at 10:00 p.m. Further record review revealed no Physician order for the additional dose to be administered that day. A review of the inventory sheet on 7/13/2022 at 12:00 p.m. revealed one set of initials with the word wasted next to it which indicated a dose of [MEDICATION(S)] was disposed of by one nurse On 07/19/22 11:55 a.m., a phone interview was conducted with a nurse that no longer worked at the facility. The nurse alleged during her employment she had identified a discrepancy on the controlled inventory sheet. She said it was a narcotic in liquid form for Resident #51. The nurse stated, I immediately called the Director of Nursing and reported it to him. She said the facility had claimed they were investigating it. But nothing happened. A review of Resident #51's physician orders revealed [MEDICATION(S)] scheduled II solution; 5 gm/5 ml; amt: 10 ml oral every 4 hours as needed (PRN) dated 02/04/2022. A review of Resident #51's medical record contained three Controlled Drug Declining Inventory Sheet forms for the ordered [MEDICATION(S)]. Review of the first form revealed on 2/15/2022 at 11:10 p.m. reflected Dose correction with one set of initials that were illegible. Followed by wasted product Total on hand 300 ml, amount given was 30 ml remaining 270 ml. Indicated 30 ml of [MEDICATION(S)] solution was wasted. A review of a second Controlled Drug Declining Inventory Sheet form dated in-between 3/1/2022 at 2:50 a.m. and 3/1/2022 8:20 a.m. revealed the documentation read correct to 55 ml that indicated a loss of 5 ml. No licensed staff members name nor initials were documented. A review of the third Controlled Drug Declining Inventory Sheet form dated between 3/4/2022 at 5:10 a.m. and 3/4/2022 at 9:23 a.m. revealed the documentation read corrected followed by two sets of initials, that were illegible. The correction indicated 30 ml of [MEDICATION(S)] solution was missing. On 07/18/22 at approximately 9:00 a.m. the facility was asked for a copy of their medication diversions for the past eight months. On 7/19/2022 an interview was conducted with the Corporate Nurse as she confirmed discrepancies were identified in the control drug inventory sheet. She confirmed it was her expectation the sheets were filled out accurately, and physician orders were followed. If a medication was wasted, two licensed nurse signatures should be present. On 07/20/22 at 11:39 a.m., a phone interview was conducted with the Pharmacist. She said she had provided service at the facility for over two years. She said her monthly process included performing audits of the controlled log inventory sheets including documentation. The Pharmacist confirmed there had been discussions with the facility over inaccurate record keeping. She said, It wasn't that long ago, I had provided education to the licensed staff members just on filling out the controlled drug inventory sheets. The Pharmacist confirmed controlled medication should not be administered without a physician order, and without supporting documentation. She stated For [Resident #51] [MEDICATION(S)] missing 5 ml of the out the bottle was okay. But two out of three bottles missing 30 ml [MEDICATION(S)] was a problem. She added missing 30 ml is not okay. The Pharmacist said this issue had been on the radar for a while now and discussed with the facility. She said, If there was a discrepancy with the controlled medications the Director of Nursing (DON) would notify me. The Pharmacist said she did not recall the last time she was notified from the former DON on any discrepancies. Review of the facility policy and procedure Controlled Medication and Drug Diversion Policy contained a revised date 7/7/22. Policy Statement Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping with the facility in accordance with federal, state and other applicable laws and regulations. 7. The consultant pharmacist or pharmacy designee during medication storage inspection routinely reviews controlled medication storage, records and expiration dates. 9. Controlled substances medications that have been prepared for administration but became contaminated or are unable to be administered will be considered as wasted medications. Two staff members will be required to witness and attest to the wasting of a controlled substance. The two staff members will sign on the Narcotic Administration Record the reason for wasting the medication will be documented on the back of the form. DRUG DIVERSION 1. Report any discrepancy in controlled substance medication counts to the Director of Nursing (DON) immediately. 2. Investigate and make every reasonable effort to reconcile reported discrepancies. Investigations include, but are not limited to a. Interviews, b. Record Review c. specific types and names of controlled substances missing or lost d. Are the controlled substances associated with access by specific individuals e. Are the losses random f. Any potential impact on patient care.

Based on observation, interview, and record review, the facility did not ensure the medication error rate was below 5 % for one (# 23) of three sampled residents who were administered medications. This resulted in 5 errors from 26 medication administration opportunities for a medication error rate of 19.23%. Findings Included: On 07/18/22 at 8:58 a.m., the medication administration task was conducted alongside Staff A, Licensed Practical Nurse. She prepared and administered the following medications to Resident #23: Acetaminophen 500 mg one tablet, [MEDICATION(S)] 10 mg two tablets, aspirin 81 mg delayed release one tablet, Vitamin D 25 mcg one tablet, [MEDICATION(S)] 25 mg one tablet, [MEDICATION(S)] 1000 mg one tablet, [MEDICATION(S)] 1.5 mg one tablet, [MEDICATION(S)] 100 mg one capsule, [MEDICATION(S)] 2 mg one tablet, [MEDICATION(S)] eye drops were administered to both eyes. Staff A was observed as she prepared a [MEDICATION(S)] U-100- insulin pen by wiping the top off with an alcohol wipe. A needle was attached to top of the pen, and the dosage selector was verified and set to 25 units. Medication reconciliation of current Physician orders revealed the following: Acetaminophen tablet; 500 mg; amount: 1000 mg every 12 hours dated 06/16/2021, [MEDICATION(S)] tablet; 10 mg; oral once a day, dated 05/16/2021, [MEDICATION(S)] (Vitamin D3) capsule; 125 mcg one a day dated 05/16/2021, and [MEDICATION(S)] eye drops suspension amt: I drop to left eye dated 06/23/2022. On 7/18/2022 at 1:21 p.m., an interview was conducted with Staff A. She confirmed she had administered one Acetaminophen 500 mg tablet, when two were ordered. The physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed after reviewing the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She additionally confirmed the eye drops were administered to both of eyes. The order was for the left eye. Staff A stated the only time you prime an insulin pen is when its first opened. I was never taught to prime the pen with insulin every time. On 07/18/22 1:36 p.m., an interview was conducted with the facility's Corporate Nurse. She said medications were to be administered as ordered. She confirmed insulin pens should be prepped prior to selecting the dosage. Review of the facility policy titled Medication Administration Subcutaneous Insulin dated 05/16. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: removing air bubbles. D. hold the pen with the needle pointing upwards E. Tap the insulin reservoir so that any air bubbles rise up towards the needle. F. Press the injection bottom all the way in. Check if insulin comes out of the needle tip. Review of the Medication Administration General Guidelines dated 09/18. Policy Medications are administered as prescribed in accordance with specifications good nursing, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: 9. Verify medication is correct three (3) times before administering the medication. a. when pulling medication from the cart b. When dose is prepared c. Before dose is administered.

Based on record review and interviews, the facility failed to provide a nursing home transfer and discharge notice for a facility-initiated emergency transfer to a hospital for one (#52) of two sampled residents. Findings included: Review of the closed medical record for Resident #52 revealed he was admitted to the facility on [DATE] and discharged to a hospital on 5/12/22. The resident did not return to the facility. There was no nursing home transfer and discharge notice found in the record. During an interview with the facility Director of Nursing (DON) and the Corporate Care Consultant (CCC) on 07/20/22 at 9:53 a.m., the CCC confirmed the notice was not in the closed record and stated she did not know where they were kept but would find out. An interview was conducted with the facility Social Services Director (SSD) on 07/20/22 at 10:27 a.m. She confirmed she had been working in her position at the facility since February 2022. She consulted the closed Electronic Medical Record (EMR) for Resident #52 and confirmed there was no discharge and transfer notice there. She confirmed she knew the notice was required to be provided for any discharge or transfer to a hospital and said, the form has to be done at that time, so nursing does it. She stated she would search for the notice for Resident #52. She confirmed Resident #52 had been his own responsible party. At 1:17 p.m. on 07/20/22, the CCC followed up and confirmed there was no transfer and discharge notice for Resident #52's transfer to a hospital on 5/12/22. She confirmed it had not been found and therefore had not been done. Regarding the facility process/expectation she said, when they go to hospital nurses should initiate those (the notice) and a copy should be sent to hospital .resident should sign if able but if not we speak with representative verbally and mail them a copy. She stated the facility process for ensuring transfer and discharge notices were provided for hospital transfers broke for whatever reason .the DON [former] thought it was being handled by Social Services and off of nursing's plate . I've got education scheduled for tomorrow on this with the nursing staff. Review of facility policy titled Transfer/Discharge Notice revised 09/05/18 revealed The appropriate notice will be provided if it is necessary to transfer or discharge a resident(s) from a facility .When a resident's urgent medical needs require more immediate transfer .the notice will be provided as soon as practicable before the discharge.

Based on observation of Medication Administration, interview with facility staff, and review of the Plan of Correction, the facility failed to ensure the Plan of Correction provided an assessment of the deficient practice related to not following the facility policy for Medication Administration, and failed to provide adequate training to nurses to ensure residents were correctly administered medications following physicians orders for four (#4, 12, 33, 60) residents of five residents observed during Medication Administration on 09/13/2022. Findings included: During a Survey to revisit the facility's correction of their deficient practice cited during the Recertification Survey (conducted from 07/17/2022 - 07/20/2022), Medication Administration was observed: -On 9/13/22 at 9:22 a.m. the medication administration task was conducted with Staff I, Licensed Practical Nurse (LPN.) She prepared to give the following medications for Resident #60. Buspirone HCL 10 mg (milligrams) 1 tab, Celecoxib cap 200 mg, Divalproex DR 500 mg 1 capsule (cap), Duloxetine HCL DR 60mg 1 cap, Eliquis 5mg tab, Entresto 24-26 mg 1 tab, Metformin 500mg 1 tab, Budesonide-Formoterol (Symbicort) 160-4.5 inhaler 2 puffs, and Tamsulosin cap 0.4mg 1 cap. The nurse was unable to find Eliquis in the medication cart. She stated, I know I can't share someone else's. She did not attempt to locate the residents Eliquis elsewhere. She proceed to administer the remaining medications. After the resident was given his Symbicort inhaler, the LPN did not have the resident rinse his mouth out as required. A medication reconciliation with current orders indicated the following order: -Eliquis 5mg 1 tablet twice a day at 9:00 a.m. and 5 p.m. The start date of the order was 8/30/22. A review of the electronic medication record did not reveal any progress notes to indicate a physician was contacted about Resident #60 not receiving the ordered dose of Eliquis. -On 9/13/22 at 10:05 a.m. Staff I, LPN prepared to give Resident #12 her ordered insulin. The Lantus insulin was administered to the resident at 10:10 a.m. A reconciliation of current physician orders indicated Lantus u-100 Insulin solution; 100 unit/milliliter(ml); 12 units subcutaneously was ordered to be administered at 9:00 a.m. -On 9/12/22 at 10:55 a.m. Staff I, LPN prepared the following medications for Resident #4: Keppra 100mg/ml (milliliters) 7.5ml, Pregabalin cap 50mg 1 cap, Magnesium Oxide 400mg 1 tab, Omeprazole DR 40mg 1 cap, Oxcarbazepine 150mg 1 tab, Paliperidone ER 3mg 1 tab, Senna plus 1 tab, Tramadol-acetaminophen 37.5-325mg 1 tab. The computer screen highlighted seven out of eight of the medications as late. Staff I was observed pouring the Keppra 7.5 ml into a medication cup. The LPN poured out too much medication. She then proceeded to pour the medication back into the original medication bottle. A medication reconciliation with current physician orders indicated the following orders: Keppra 100mg/ml 7.5ml twice a day at 9:00 a.m. and 9:00 p.m. Pregabalin 50mg three times a day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Magnesium Oxide 400 mg every 12 hours at 9:00 a.m. and 9:00 p.m. Omeprazole DR 40mg at 9:00 a.m. Oxcarbazepine 150mg every 12 hours at 9:00 a.m. and 9:00 p.m. Paliperidone Extended Release 24 hours 3 mg at 9:00 a.m. Senna 8.6 mg every 12 hours at 9:00 a.m. and 9:00 p.m. These seven medications were given 1 hour and 55 minutes past their ordered administration time. -At 12:27 p.m. Resident #4's electronic medical record was reviewed. The eMAR indicated the resident had already been administered their 1:00 p.m. does of Pregabalin. Therefore, the resident was given Pregabalin at 10:55 a.m. and prior to 12:27 p.m., less than 1 ½ hours separating the two doses instead of the ordered 4 hours. A review of progress notes did not indicate there had been any contact with the physician regarding the late medications. -On 9/13/22 at 10:55 a.m. Staff I, LPN properly prepared an insulin pen for administration to Resident #33. Staff I entered the resident's room, and the resident was sleeping. The LPN did not speak to the resident or attempt to wake her, she administered the insulin to the resident while she was sleeping. A medication reconciliation with current physician orders revealed an order for Levemir u-100 Insulin 100 unit/ml; 15 units once a day at 9:00 a.m. -An interview was conducted on 9/13/22 at 2:30 p.m. with Staff I, LPN. The LPN confirmed Resident #60 did not receive his 9:00 a.m. Eliquis. When asked if she could have gotten the medication somewhere else since it was not in the cart she stated, oh I guess I could have gotten from the E-kit. I didn't think of that (referring to the emergency drug kit.). Staff I confirmed medications are to be given up to one hour prior to the scheduled time or one hour after the scheduled time. She stated if the nurse is late, they should click administered late in the computer then depending on the medication the nurse should clarify with the doctor the timing of the next dose. She stated she did not call the doctor about the Eliquis or the late medications this morning. When discussing pouring out too much Keppra into the medication cup, she stated she should have gotten a new cup and disposed of the extra medication. She said she should never pour it back in the original bottle. Review of the Facility's Policy entitled Quality Assurance/Performance Improvement (QAPI) Program revealed a Purpose Statement: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. The Policy Statement read: It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. Under the heading of Guidelines, point # 6 read: The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. Point #7 read: The QAPI committee will review, and coordinate audits and assessments based on the QAPI calendar. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: c. High risk - residents are at risk of serious consequences or deprived of substantial benefits if the care is not provided correctly and in a timely fashion or on proper indication. A review of the facility's Plan of Correction for the deficient practice observed during the Recertification Survey and cited at F759, revealed the immediate correction of the wrong dosing of medications to the resident was documented with a medication error report and education to the nurse. To address the larger concern, all nurses were educated with observations conducted of the nurses during medication administration and review of the observations at the monthly QAPI meetings. A review of the QAPI meeting held on 08/24/2022 revealed the Plan of Correction was reviewed at the meeting with no status documented. The Quality Assurance interview was conducted with the Administrator, the Director of Nurses and the Regional Nurse on 09/13/2022 beginning at 4:25 p.m. during which the quality assurance review and monitoring of the corrections to the deficient practice cited was discussed. It was reported by the facility team that on 08/24/2022 a QAPI meeting was held and the correction plans for the Annual Survey were not altered and continued as planned. In an interview conducted with the Director of Nurses (DON) on 09/13/2022 beginning at 2:55 p.m., when apprised of the errors observed during the Medication Administration observation conducted beginning at 9:22a.m., the DON confirmed that she had noted the nurse was a new nurse that needed some additional training. The DON stated, I knew when I saw you with [Staff I] it could be a problem. During the QAPI meeting that began at 4:25 p.m., the DON confirmed that she had noted the nurse needed additional training but had not developed an action plan for the nurse or had paired her to work with another nurse to help improve her skills. The DON confirmed she had not observed the nurse during Medication Administration.

Based on interview and record review, the facility failed to implement pharmaceutical procedures that assure the accurate administering of drugs to meet the needs of two (Resident #14 and Resident #33) out of five residents. Findings: 1. On 3/23/2021, the document Medication Admin Times was reviewed. The document indicated: -Early a.m. - 0400-0700 -upon rising - 0715-1100 -HS (at bedtime) - 1900 (5:00 p.m.) - 2300 (11:00 p.m.) -BID (twice a day) - 0700-1100, 1900 (5:00 p.m.) - 2300 (11:00 p.m.) -TID (three times a day) - 0700 - 1100, 1115 - 1500 (3:00 p.m.), 1900 (5:00 p.m.) - 2300 (11:00 p.m.) -QID (four times a day) - 0800, 1200, 1600 (4:00 p.m.), 2000 (10:00 p.m.) 2. On 3/25/2021 at 9:33 a.m., Resident #14's record was reviewed. Resident #14 was admitted in the facility on 3/16/2018. Resident #14's current physician's orders [REDACTED]. - 3/16/2021 [MEDICATION NAME] U-100 Insulin; 100 unit/mL; amt 20 units; subcutaneous .(DX (diagnosis): Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]) Twice a day. The administration schedule indicated 06:00-11:00, 16:00 - 23:00 - 3/16/2021 [MEDICATION NAME] (an antacid) tablet; 20 mg; amt amount: 1 Tablet; oral .Twice a day The administration schedule indicated 07:00-15:00, 15:00 - 23:00 3. On 3/25/2021 at 9:40 a.m., Resident #33's record was reviewed. Resident #33 was admitted in the facility on 7/3/2019. Resident # 33's current physician's orders [REDACTED]. The administration schedule indicated 07:00-11:00, 11:15-15:00, 19:00-23:00 4. On 03/25/2021 at 10:30 a.m., the Assistant Director of Nursing (ADON) was interviewed. She stated with regular routine medications the exact time of administration did not get recorded. If the medication is administered within the scheduled time of administration, the MAR indicated [REDACTED]. The ADON stated if the medication was scheduled for 7:00 a.m.-11:00 a.m., the medication was administered within the four hour time window. 5. On 03/25/21 at 10:35 a.m., a telephone interview was conducted with the facility's Pharmacy Consultant. The consultant stated the administration schedules or the four hour window of administration time was a company wide policy. The consultant stated the four hour window of administration was Suppose to help medications from being given late. 6. On 03/25/2021 at 11:22 a.m., the facility policy and procedure, Medication Administration General Guidelines dated 9/18, was reviewed with the Director of Nursing (DON). Item #14 on the policy and procedure was discussed and clarified with the DON. Item #14 indicated, Medications are administered within 60 minutes of scheduled time, except before and after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to established medication administration schedule for the nursing care center . The DON stated the company policy was liberal med pass. The DON stated if the medication scheduled time is 7:00 to 11:00, per the policy, medications can be administered 60 minutes before 7 and 60 minutes after 11, which meant medications administered at 6:00 or 6:30 a.m. or 11:30 - 12:00 a.m. are acceptable if the scheduled administration time is 07:00-11:00. The policy extends the administration time to six hours. The DON stated there was no other company policy and procedure in effect at the time of the survey for medication administration 7. On 03/25/21 at 1:15 p.m., the attending physician for Resident #14 and Resident #33 was interviewed. The facility policy and procedure, Medication Administration General Guidelines dated 9/18, was reviewed with the physician. The physician's orders [REDACTED].#33 were also reviewed with him. He stated the medication administration time of four hours that is extended to six hours by the policy is Too long of a window. The MD stated, We need to look into that in QA (quality assurance). He stated, When I order twice a day, my expectation is morning and evening with at least 8-12 hours in between doses. The MD stated the administration times are now overlapping for the tiagabine three times a day for Resident #33. He stated, There is the potential for toxicity (because of the medication administration windows) especially with the residents here who have slower GFR (glomerular filtration rate - kidney filtration) and liver metabolism.

Based on facility and resident record review, interviews with the facility's nursing and administrative staff, the Durable Power of Attorney (DPOA), the Medical Director, and review of the facility policies, it was determined that the facility failed to protect the rights of resident's to refuse Cardio-Pulmonary Resuscitation (CPR) consistent with their end of life wishes for one of seventeen residents (#1) of 43 total residents, identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of all current resident records and Resident #1's closed record. The facility initiated CPR on Resident #1, who was [AGE] years old and was admitted the facility for long term care and services. Resident #1 had a Do Not Resuscitate Order (DNR), completed on [DATE] by her appointed Durable Power of Attorney (DPOA), who was also her Health Care Surrogate (HCS). The Do Not Resuscitate order, which was on goldenrod paper, was signed by Resident #1 and her Physician on [DATE]. On [DATE], Resident #1 was found unresponsive. The facility referred to another resident's chart and did not have the correct code status when she was found unresponsive. The facility failed to honor Resident #1's advanced directives and denied the resident the opportunity to refuse treatment. The facility initiated CPR for Resident #1 without checking to ensure they had the right chart. The facility violated Resident #1's wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at the last moments of her life. Failure of the facility staff to honor and carry out the expressed wishes of the resident to withhold the treatment and interventions of CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of Resident #1's closed medical record, to include the demographic/face sheet, indicated she was admitted to the facility from the Hospital on [DATE] for rehabilitation services and long term care. The resident was noted to be [AGE] years of age. During the time of admission, Resident #1 had advanced directives in place with a Health Care Surrogate as of [DATE] (prior to facility admission). The advanced directives also indicated the resident was a DNR status. A "yellow" Do Not Resuscitate (DNR) order was present with signatures from Resident #1 and the Physician with a date of [DATE]. The medical record included a cumulative [DIAGNOSES REDACTED]. The Advanced Directives section of the closed clinical record revealed the following relevant documents: a. A State of Florida Do Not Resuscitate Order form printed on yellow goldenrod paper and signed by Resident #1 and her Physician on [DATE]. b. A Living Will & Appointment of Healthcare Surrogate indicating Resident #1 did not want 1. Cardio-pulmonary resuscitation (CPR) if her heart or breathing stops, 2. did not want a breathing machine if she was unable to breath on her own, 3. did not want Nutrition and fluids through tubes in her veins, nose or stomach, 4. did not want kidney [MEDICAL TREATMENT], a pacemaker or defibrillator, or other such machines, 5. did not want surgery or admission to a hospital intensive care unit, 6. did not want medications that can prolong her dying, such as antibiotics and 7. did not want Hospice involved in her care. This form was signed and dated by resident #1, person appointed as HCS and two witnesses on [DATE]. This form was also verified and notarized by a public notary. c. A General Durable Power of Attorney (DPOA), which was signed and dated by Resident #1, the appointee, and a Notary Public of the State of Florida on [DATE]. d. An "Advance Directives / Informed Consent " form indicated Resident #1 had a Durable POA and Designation of Health Care Surrogate which indicated that Resident #1 had been informed of her rights and all rules and regulations regarding decisions concerning medical care, including: 1. The right to accept or refuse medical or surgical treatment, 2. The right to formulate and to issue Advanced Directives to be followed should I become incapacitated. This form was signed by Resident #1 and witnessed by the Physician on [DATE]. e. A review of the Advanced Directives Policy and Record, dated ,[DATE], and revised on [DATE] revealed: " It is the policy of the facility to recognize and support the use of Advanced Directives through family, staff and community education and to encourage the residents' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly executed Advanced Directive, the facility will implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. f. A review of the "Admission Packet Checklist," which was signed and dated by the Admissions Office, Business Office Manager and the Nursing Home Administrator on [DATE], indicated that the Advanced Directives Informed Consent was completed and signed by Resident #1 and POA. The Admission Packet Checklist further revealed a section that included "Consent to Treatment", stating, The resident and responsible party consent to the administration of such care, treatment services, and medical or nursing procedures to the resident, as the Facility and resident's attending physician or nurse practitioner deem appropriate. The resident has the right to change this consent or to refuse treatment. " A review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated [DATE] under the "Cognitive Patterns" section revealed the Brief Interview of Mental Status (BIMS) score was a 14. Review of the Quarterly MDS assessment, dated [DATE] (last full assessment), under the "Cognitive Patterns" section, revealed the BIMS score was 13. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact. ,[DATE]: Moderately impaired. ,[DATE]: Severe Impairment." Review of the Telephone Orders for Resident #1, dated [DATE], indicated she was a DNR. An interview on [DATE] at 9:00 a.m. with the Care Plan Coordinator/MDS Coordinator confirmed that Resident #1 ' s care plan, reflecting " Advanced Directives " with interventions: to Do Not Resuscitate (DNR), was accurate and current. She confirmed the care plans for " Advanced Directives " were initiated on [DATE] and good through [DATE]. She indicated that prior to Resident #1 expiring, there had not been any plans to change the DNR status either by the resident or Power Of Attorney (POA). A review of Resident #1's care plans initiated on [DATE] with next review date on [DATE], indicated that Resident #1 "Has Advanced Directives on record: Do Not Resuscitate (DNR), Living will on chart with interventions to include: 1. Chaplain services for emotional, psychosocial, physical and clinical needs of resident, 2. Discuss Advanced Directives with the resident and/or appointed Health Care representative, 3. Resident is capable of making informed consent regarding their health care decisions, 4. Staff to follow Advanced Directives for "Do Not Resuscitate." 5. Allow resident, if able to discuss feeling regarding their Advanced Directives, 6. Refer to Social Services as needed, and 7. DNR is signed and dated in record. Review of the "Daily Skilled Nurse Notes" dated [DATE] 10:00 a.m. revealed "A call has been placed to physician on call service to inform physician of Midline Infiltration to antebrachial area of Left arm. At this time a return call is being awaited for by on call physician." At 10:05 a.m. "Call was returned by physician and new order to obtain new IV for completion of IV antibiotics was received. Pharmacy was phoned for services and currently awaiting their arrival." Further review of notes at 10:50 a.m. revealed, "Staff came to inform writer of change in status with resident. On encounter writer found that resident was completely pale in appearance, had fixated pupils and exhibited cheyne stoke breathing/ shallow respirations. Her B/P was ,[DATE], pulse 66 and respirations 10. She soon expired thereafter and went quietly at the time of 11:45 a.m. The physician ' s office was notified, family was phoned and made aware and administrator contacted and notified. Review of the facility's Timeline Investigation related to the [DATE] event with Resident #1, as completed by the Nursing Home Administrator, revealed the following: 1. "11:00 a.m. call placed to the MD to replace midline on Resident #1, orders received." 2. "11:10 a.m., order written and chart left on nurse station. " 3. "11:10 a.m. the family of (another resident - name indicated) came to me (employee A) with a question, chart was placed on the nurse's station next to Resident #1's chart. " 4. "11:12 a.m. CNA (employee B) reported to nurse (employee A) that Resident #1 was unresponsive, nurse (employee A) ran to the room and observed Resident #1 to be very pale, unresponsive with a faint heart rate. " 5. "11:16 a.m. Nurse (employee A) ran back to the nurses ' station and attempted to place a call with the on call MD. While on hold she noticed multiple staff members running to the Resident #1's room. Assuming a change in status, nurse (employee A) grabbed the resident's chart from the nurse's station and ran to Resident #1's room." 6. "11:16 a.m. Resident #1's bed was lowered and the CPR board was placed under her at this time it was noted that she took a gasp of air and stopped breathing." 7. "11:16 a.m. Nurse (employee A) placed the wrong resident ' s chart on the dresser of the room and opened the chart directly to the advanced directives tab and stated to the staff in the room Resident #1 is a Full Code and we need to initiate CPR." 8. "11:17 a.m. Nurse (employee A) initiated CPR while simultaneously calling 911 from her cell phone. She then threw the phone to nurse (employee E) who answered questions about the resident from memory." 9. "11:17 a.m. Nurse (employee A), CNA (employee C), CNA (employee D) performed CPR per nurse (employee A's) request." 10. "11:21 a.m. EMS (Emergency Medical Service) arrived at the facility and took over CPR." 11. "11:21 a.m. Nurse (employee A) returned to the nurses station and opened the correct chart to the face sheet and a call was placed to Resident #1's family who stated resident had a DNR from the hospital. Nurse (employee A) ran back to the room and expressed this to EMS. EMS stated they could not stop CPR unless the DNR was in their hands." 12. "11:21 a.m. Nurse (employee E) removed the face sheet, medication list and labs from the chart in Resident #1's room and handed them to CNA (employee D) to make copies. While making copies the copier got jammed and copies were made on the fax machine on station 2. The copies were given back to nurse (employee E) and the nurse gave copies to EMS." 13. "11:30 a.m. Nurse (employee A) returned to the nurse station and also made copies (of the correct resident chart) for EMS and placed them on the desk." 14. "11:35 a.m. Resident #1's family faxed over the DNR and it was given to EMS. At this time CPR was stopped and the resident was pronounced deceased ." 15. "11:45 a.m. Nurse (employee A) placed a call to Resident #1's family to inform them of her passing. At this time EMS returned to the facility and stated to nurse (employee A) that they must have received the wrong resident's paper work at that time (employee A) gave EMS the correct paper work." On [DATE] the facility ' s Nursing Home Administrator provided an Emergency Medical Services (EMS) run report depicting the EMS/Paramedic visit on [DATE] related to Resident #1. The report indicated that EMS arrived at the facility on [DATE] at 11:23 a.m. and then at the patient (Resident #1) at 11:24 a.m. and was back at the base at 12:08 p.m. The report notes further indicated that: " [AGE] year old female found lying supine in bed, CO [MEDICAL CONDITION]. Witnessed [MEDICAL CONDITION] by staff at nursing home approx. ,[DATE] minutes PTA. Staff placed a hard board on bed under patient and began CPR. On our arrival, staff states patient (Resident #1) was a full code as there is no DNR paperwork on file. Staff say arrest was witnessed while she was in bed and staff were doing rounds. Staff state patient ' s health was rapidly declining over the last months. Pulse checked absent and PEA on monitor. FD (Fire Department) continued compressions and IO access began. Staff remained on airway until further FD help arrived. Unable to gain IO access initially and had to increase to a larger bore needle which was successful. Admin EPI every ,[DATE] minutes. Advanced airway in place which was confirmed via ETCO2, lungs sounds and absent epigastric sounds. Subsequent rhythm checks revealed PEA and asystole only. At approx. 17 minutes, staff came in the room and stated she (Employee A) was on the phone with family. Family stated they do not want us to perform CPR on patient as they have a DNR. Staff states they do not have a copy of the DNR and never got one. Family faxed over DNR during consult to cease efforts. Staff states they remember family talking about initiated paperwork for DNR orders due to her rapid decline in health recently but they never got the copy. Received a valid copy at approx. 24 minutes of total down time. Ceased efforts EOR. During an interview with the DON and the NHA and Social Service Director on [DATE] at approximately 2:00 p.m. both staff members indicated and confirmed that the yellow DNR was indeed in the chart the entire time. They indicated that the EMS staff were referring to the information because it was the wrong chart that the Nurse had. The NHA further indicated that had the nurse (Employee A) had the right chart, there would not be an error in code status and she would have seen the DNR in the advanced directives section. An interview with the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m. revealed as soon as she was called by nurse (employee A) on [DATE] regarding the expiration of Resident #1, she took note of it but did not know that she (employee A) had the wrong chart until later in the day. As soon as she figured it out that the employee reported to Resident #1's room with another resident's chart unknowingly, and performed CPR on Resident #1 when she was deemed as a DNR, she immediately started an investigation and interviewed the nurse (employee A) regarding what happened. The NHA further indicated that she put the nurse (employee A) on suspension until the investigation was completed and was ultimately terminated. A written statement from Licensed Practical Nurse (employee A) dated [DATE] revealed: "On Sunday [DATE]st at approximately 11:00 a.m., I had placed a call to the physician to report that the midline of Resident #1 had infiltrated. Orders were received for a midline to be replaced. At that time I (employee A) had Resident #1's and another resident's (name not noted) chart on the desk. Certified Nursing Aide (CNA) (employee B) stated that she needed me in the room of Resident #1. I ran to the room and noted that Resident #1 was very pale in color, I returned to nursing station and again called the physician's office, while I was on hold I noticed that staff was running by toward Resident #1's room and I ran to the room with a chart that I thought was Resident #1's. My initial evaluation was that she had stopped breathing but did still have a pulse. I turned to the advanced directives tab in the chart and saw the "full code" insert. I began CPR (Compressions), (employee D) (employee C) were holding the face mask and bagging together. I called 911 from my cell phone in the room and gave some information to EMS, then handed the phone to nurse (employee E) to finish giving the information as I performed CPR. EMS arrived approximately ,[DATE] minutes later and took over CPR. I placed a call to the Nursing Home Administrator and notified her of the CPR and resident involved. I always call the Nursing Home Administrator and not the Director of Nursing. I placed a call to the family to notify of the situation and was informed that Resident #1 was a DNR, at that time I still didn't know that I had the wrong record and requested that they fax it over. Once the living will was received and given to the EMS the CPR was stopped by EMS. The paperwork from the record in the room was copied by nurse (employee E) pulled the records and (employee D) copied the records and gave them to the EMS. At some point the EMS stated that the paperwork was not for the right patient and requested the correct paperwork. At that time I realized that Resident #1 was a DNR. I didn't notify anyone, because at that time she had passed and I didn't think that it mattered. My documentation in the record did not reflect CPR performed." This statement was signed by (employee A), Licensed Practical Nurse. Multiple telephone communication attempts by the State survey team from [DATE] through to [DATE] with employee A were unsuccessful. The Nursing Home Administrator provided a "Stakeholder Suspension Form" dated [DATE] for review. It indicated that employee A was suspended until the investigation was concluded. Employee A, her supervisor, the Nursing Home Administrator and a witness all signed and dated the form on [DATE]. Further interview with the Nursing Home Administrator indicated that employee A had been terminated as a result from their investigation. In review of the nurse (employee A ' s) employee file, it was noted upon her hire date on [DATE] (employed almost four years at the facility), she was given education, training and in-services related to but not limited to: " Death and Dying/End of Life, " " Documentation for Nursing Aides and Nurses, " " Advanced Directives, " " Customer Service, " and " Resident Rights. " Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. In review of the nurse (employee A ' s) employee file, it was noted upon her hire date on [DATE] (employed almost four years at the facility), she was given education, training and in-services related to but not limited to: " Death and Dying/End of Life, " " Documentation for Nursing Aides and Nurses, " " Advanced Directives, " " Customer Service, " and " Resident Rights. " Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. A written statement from Licensed Practical Nurse (employee E) dated [DATE] revealed: "I (employee E) was called to resident #1's room. Writer entered resident room and observed resident unresponsive. The nurse (employee A) and two CNAs were present (employee C and D). Writer left room to retrieve crash cart, there was a crash cart present when writer arrived back to room. CPR was in progress with employee A during compression and employee D holding Ambu bag to resident's mouth and nose and employee C administering breath via bag. A few paramedics entered the rooms and took over the CPR process. Nurse (employee A) asked writer to make necessary copies from the chart that was sitting on top of the dresser in the patient's room. Writer removed face sheet and labs and writer gave employee C the papers that was removed from chart and she made copies and brought copies back to patient's room." This statement was signed and dated by employee E on [DATE]. An interview with employee E on [DATE] at approximately 11:00 a.m. revealed she did remember the event that occurred on [DATE] that involved Resident #1 and employee A. She indicated that she (employee E) did not realize she was making the wrong copies from another resident's chart. She further confirmed that as the secondary nurse who reported to the room, she assumed employee A had the right chart and when asked to make copies, she just ran them to the copier without thinking to look at the name. Employee E indicated that she, along with all the other direct care staff, had training and in-services to include how to verify they have the right resident information when reporting to a "Code Blue" call. She further indicated she and all the other direct care staff have had training and in-services to include resident rights, advanced directives and accuracy of charting since the event which occurred on [DATE]. Employee E stated that she would verify all this information with the chart. Employee E verbally demonstrated that when a "Code Blue" is called she would get the chart for the room called and when she gets to the room she would look at name badge on door and also on resident's wrist. She would then verify with another nurse and look at EMAR (Electronic Medication Administration Record) picture if have time. The Crash cart would be called upon and brought in by other staff. She indicated that she would then look at advanced directives for "yellow" DNR and telephone order that was placed on other side of the DNR sheet. If there is a DNR in place, she would not perform CPR and will chart and call the physician and Family. If no DNR in chart or cannot find one, she would then perform CPR. Employee E also stated that verifying the chart and the resident is "a standard of practice and is common sense to make sure you have the right chart." A written statement from Certified Nursing Assistant (CNA) (employee B) dated [DATE] revealed: "Passing Resident #1's room, she noticed the resident did not look good. I ran out of the room and back for the nurse to come to the room. I also sent a CNA and asked her to help clean the resident up in case she was not going to be sent out to the Hospital. Left the room to do something and never went back until she was gone." This statement was signed and dated by employee B on [DATE]. An interview on [DATE] at approximately 1:00 p.m. with employee B confirmed she reported to the Resident #1's room and had another aide get a nurse. When the nurse reported she left the room and had to care for another resident. She indicated she did not know of anything else that happened. She did indicated that she, along with all other staff, were immediately trained and in serviced that day and the next day [DATE] related to how to ensure you have the right information for the right resident, advanced directives, "Code Blue" reporting and resident rights. Further interview with employee B indicated that CNAs are not normally asked to retrieve charts or make copies, and had never done so or had ever been asked in the past. A written statement from CNA (employee D) dated [DATE] revealed: "It was 11:05 a.m. when CNA called me to help her clean Resident #1 up because we thought she was deceased . Nurse said there was not a DNR form in place and she had to start CPR. The crash cart was brought in and CPR was started then 911 arrived and took over." This statement was signed and dated by employee D on [DATE]. An interview on [DATE] at approximately 1:30 p.m. with employee D, confirmed she reported to Resident #1's room to assist. She was not asked to do anything at the time and did not know the chart that the nurse (employee A) brought to the room was not Resident #1's chart. She indicated that she, along with all other staff, have received training's and in-services related to how to verify resident information, advanced directives, and resident rights. Employee D indicated that CNA's are not asked to go and retrieve charts or to make copies. She confirmed that she did not make any copies for the nurse (employee A) during the time of the event with Resident #1 on [DATE]. An interview on [DATE] at approximately 10:00 a.m. with the Social Service Director was conducted. She was interviewed regarding her duties and responsibilities related to resident advanced directives. The Social Service Director indicated as far as her responsibilities for obtaining advanced directives, she would meet with the resident or family or representative the day of admission or the next day and go over admissions to include advanced directives. She would assist them with explanation of advanced directives but will not make the decisions or point them either way of DNR or Full Code. She would let the resident or representative know that if the resident chooses DNR, they would have to also get an order from the Physician indicating DNR status. She further explained that, until that order is obtained, the facility had a responsibility to perform CPR if the resident became unresponsive. The Social Service Director indicated that even if it was verbalized at the time that the resident was to be a DNR, they still have to wait until they get the DNR sheet and telephone order. The Social Service Director confirmed she was responsible for training all new staff upon hire in relation to advanced directives and resident rights. The Social Service Director indicated she had been part of the training and in servicing staff after the [DATE] event with Resident #1. She has participated in "Code Blue" drills and also was involved with advanced directives training, resident rights, and resident information verification. The Social Service Director indicated that if a resident was admitted on a Saturday, since she only works Monday through Friday, information was to be taken down with the admission assessment and charting. Even if the resident requested DNR, it still had to be verified with a "Yellow" DNR sheet and physician's orders [REDACTED]. Until the advanced directives are ordered, it is policy that CPR is performed unless the DNR order and telephone order are in chart. An Interview was conducted with the Medical Director on [DATE], at 2:30 p.m., regarding the event that occurred with Resident #1 on [DATE]. The Medical Director stated that he was made aware of the event on [DATE] via telephone from the NHA. He indicated that, apparently, Resident #1 was given CPR when she was a DNR. He also said that he was told that the nurse (employee A) brought the wrong resident's chart to the room and when she opened the chart she found that the resident (thinking it was Resident #1's advanced directives), was a Full Code and provided CPR and called 911. He confirmed that he was told the nurse (employee A) should not have provided CPR and honored Resident #1's advanced directives as being a DNR. He further confirmed that is just something you cannot get wrong and cannot explain what was going through the nurse's (employee A's) head during the time of the event. The Medical Director also stated that it was human error and that everyone makes mistakes but everyone should use checks and balances to make sure the right information is clarified during "Code Status" situations. He indicated that he was present during the last QA meeting and listened to the situation and is in agreement on how the facility staff are going to move forward to ensure all resident advanced directives are honored. He indicated there are only so many checks and balances and having too many will only complicate things when verification is needed. He was aware of the arm bands, the advanced directives in the chart with yellow sheet, telephone order and electronic MAR with resident names and pictures and names on the doorway of the room. He did not have anything further to add other than he was satisfied on how the NHA was moving forward with her staff to ensure this did not happen again. He indicated that the nurse at the time should have taken the time to verify the name on the chart and the resident and that was totally error on her part, not the facility as a whole. He stated he was satisfied with the Quality Assurance program (QA) and NHA and DON were working on to ensure plans are in place to ensure all those who are CPR certified are kept current. An interview with the Director of Nursing (DON) in relation to the event on [DATE] with Resident #1 could not be obtained. The DON had to leave the facility during the time of the complaint investigation. Another interview with the NHA on [DATE] at approximately 9:00 a.m. indicated that as of [DATE] after the event, she and the administrative team to include the DON, Social Service Director and the Corporate Regional Nurse investigated the event and took the following measures: a. Training and in-services titled, "Your role in Code Blue and Advanced Directives" were conducted and completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] with signatures of all "Direct Care" staff to include Register Nurses, Licensed Practical Nurses and Certified Nursing Assistants (all those who would report and assist during a "Code Blue" call). However there were a couple of employees (non-direct care) who were on leave and were not given the training and in-service until they returned back to work on [DATE], and [DATE] (all of whom were either a therapist or therapist assistants). It was determined that 100% of all staff were trained and in-serviced by [DATE]. However, 100% of all "Direct Care" staff were fully trained and in-serviced by [DATE]. The in-services included information to staff to include, "Resident Identification" by: Verifying resident ' s identity by checking all identifiers such as 1. Chart Binder Label, 2. Wrist band, 3. Photograph in EZMar and 4. Door identifier. The information also included information to always make sure that you identify each resident prior to any life saving measure withholding of CPR, utilizing the correct record and identification process. Through interview it was determined that fifteen various staff members to include Certified Nursing Assistants, Registered Nurses, Licensed Practical Nurses, Activities staff and Social Services, and those who work or have worked the ,[DATE], ,[DATE] and ,[DATE] shift and also on weekends, revealed they have all had " Advance Directives, " " Resident Rights, " " Resident Chart Verification, " " Code Blue " training, and in-services on and around [DATE] through [DATE]. Further, the fifteen employees interviewed indicated that they have participated in more than three mock " Code Blue " drills during the month of ,[DATE]. This was verified through facility record review. The employees, upon interview all indicated that they had been trained from administration on or and around [DATE] through to [DATE] on how to properly verify resident records with the resident by looking at the door label with the residents name, to look at the residents wrist band with their name on it and then to look in the medical record face sheet and the outside spine of the physical chart. They were also trained on to look at the advanced directives section of the correct medical record to either find a " yellow " DNR order sheet and a telephone order attached. The employees indicated that if the " yellow " DNR and telephone orders were absent from the record, then the resident was deemed " Full Code " status. The employees also stated that prior to the [DATE] event with Resident #1, they were to do the same steps with resident verific

Based on facility policy review, review of clinical records, review of advance directive information included in the admission packet, and interviews with the Medical Director and facility staff, it was determined that the facility failed to implement the policies and procedures for advanced directives and failed to readily identify and carry out the end of life wishes regarding resuscitation for one of seventeen Residents (#1), of 43 total residents, identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of all current resident records and review of Resident #1's clinical record. The facility failed to implement their own policies for Code Status and Response and the execution of Advanced Directives in accordance with their Admission Agreement as the facility initiated CPR on Resident #1, a [AGE] year old female. The resident and her Power of Attorney (POA) had a Do Not Resuscitate order (DNR) dated [DATE], which was signed by Resident #1 and the Physician. This " yellow " goldenrod order, along with the telephone order from the Physician, were filed in the advanced directives section of the chart without any further review by facility staff. The facility's systems reflected that this was a valid DNR and failed to honor it during the event on [DATE] as a nurse brought another resident's chart to Resident #1's room when she was unresponsive. While looking in the wrong chart advanced directives, the nurse found that the chart had "Full Code" status and no DNR. Therefore, the nurse performed Cardio-Pulmonary Resuscitation (CPR), though Resident #1 was a DNR. The facility failed to follow their procedure for admission in accordance with their Code Status orders & Response Policy and Procedure. The facility failed to honor Resident #1's DNR order and allow the resident and the POA the opportunity to refuse treatment. The facility called 911 for the resident who was at the mercy of the staff and provided her with unwanted treatments of cardiac compressions and artificial ventilation to prolong life. The facility ' s failure to ensure facility staff correctly implemented advanced directives procedures resulted in findings of Immediate Jeopardy, which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: A review of the facility ' s " Advanced Directives " Policy and Procedure with an effective date ,[DATE] and last revised on [DATE] revealed: It is the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education and to encourage the residents ' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly executed Advanced Directive, the facility will implement the resident ' s choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident ' s wishes would be followed. The policy further indicated in order to understand the intent of Advance Directives, a glossary of important definitions is required, as follows (but not limited to): 1. " Advance directive " - Means a witnessed written document or oral statement in which instructions are given by a principal or in which the principal ' s desires are expressed concerning any aspect of the principal ' s health care, and includes, but is not limited to, the designation of a health care surrogate, a living will, or an anatomical gift made pursuant to Florida law, 5. " Health care decision " - Means (a) Informed consent, refusal of consent, or withdrawal of consent to any and all health care, including life-prolonging procedures, (b) The decision to apply for private, public, government, or veterans ' benefits to defray the cost of health care, (c) The right to access to all records of the principal reasonably necessary for a health care surrogate to make decisions involving health care and to apply for benefits, and (d) The decision to make an anatomical give pursuant to Florida law. 10. " Life-prolonged procedure " - Means any medical procedure, treatment, or intervention, including artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function. The term does not include the administration of medication or performance of medical procedure, when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain. The procedure section of this " Advance Directives " policy indicated that this facility complies with the applicable State and Federal law regarding Advance Directives and acknowledges a resident ' s right to refuse treatment to the extent that such right is recognized under applicable State and Federal laws. As such, the following (but not limited) procedures apply: (2) The Social Worker or designee will interview the resident and/or family upon admission to determine the need and knowledge relative to Advance Directives. If the resident has an Advance Directive, the Admission Director or designee or Social Worker will request a copy of the directive so that it may become part of the medical record, documentation of such directives will be placed in the Social Service progress notes, the resident ' s attending Physician will be made aware of the directive, and the appropriate orders will be incorporated into the resident ' s plan of care. (3) A signed copy of the Advance Directives will be placed in a separate section, tabbed "Advance Directives," in the resident ' s in-house chart. NOTE: The Advance Directives copy should always remain in the resident ' s record, protected in a plastic cover, even in the chart is thinned. The policy further indicated " Do Not Resuscitate " (DNR) - Regardless of whether the resident is in a persistent vegetative state or has a terminal condition, all facility ' s residents shall receive full resuscitative measures unless a DNR directive is written in the resident ' s medical record and is identified in the residents Advance Directive. The attending Physician or designated Physician, after consultation with the resident, surrogate or proxy, may order that emergency Cardio [MEDICAL CONDITION] Resuscitation (CPR) measures are provided under [MEDICAL CONDITION] or respiratory arrest conditions. The following procedures are to be enforced: (a) A physician's order [REDACTED]., must be obtained, (b) DNR is flagged appropriately on the resident ' s chart to alert staff as to status, (c) Documentation of the DNR must be present in the Physician ' s progress notes regarding the DNR status or on the designated " Advanced Directives " form, (d) The resident, surrogate or proxy must sign an informed consent indicating that the resident consents to a " DNR " or " no CPR " or no resuscitation in the event of [MEDICAL CONDITION] or [MEDICAL CONDITION]. NOTE: Should the resident be incapable of providing informed consent for a DNR order, the surrogate or proxy has the authority to sign the informed consent, (e) The DNR order is incorporated into the resident ' s care plan and is periodically reviewed, at least quarterly, including supportive care and comfort measures. These measure may include the use of oxygen and suctioning to help maintain normal and routine treatments and will not be withheld when a DNR order exits, (h) The Director of Nursing Services or designee will establish a system to inform all direct care staff of the resident ' s DNR status. Review of the admission agreement which is found in the admission packet under the "consent to treat section," revealed " The Resident and Responsible Party consent to the administration of such care, treatment services, and medical or nursing procedures to the Resident, as the Facility and resident ' s attending Physician or nurse practitioner deem appropriate. The Resident has the right to change this consent or to refuse treatment. " The admission agreement also contains " Advanced Directives/Informed Consent form that indicates " This is to acknowledge that I have been informed, in writing and in a language that I understand, of my rights and all rules and regulations regarding decisions concerning medical care, including: a. The right to accept or refuse medical surgical treatment and b. The right to formulate and issue Advanced Directives to be followed should I become incapacitated. " This form indicates the following areas to be checked or not checked: Living Will, Durable POA, Do Not Resuscitate, Do Not Hospitalize, Organ Donation, Autopsy Request and Designation of Health Care Surrogate. If one of these areas are checked, there is a section where the staff and resident have to document when it or they were issued. This form must be signed but the resident or Power of Attorney, the Physician and two witnesses. The admission agreement also contained admission information (page 10) related to "Health Care Advanced Directives." This section indicated "Information for residents and their families about advance directives for medical care " to include but not limited to: a. Make your wishes known - You alone have the right to make basic decisions about the medical and health care services you receive from you Physician or other health care providers. You have the right to accept, refuse or take away any treatment. You also have the right to be informed and give informed consent before [DIAGNOSES REDACTED]. b. Right to Natural Death - The Right to Natural Death Act recognizes your rights as a competent adult to make decisions about your medical care. This law says that every person has the basic and natural right to die with as much dignity as possible. It also says that every person can accept, refuse and stop treatment. A person can control decisions about the care he or she receives. Medical care means any procedure for [DIAGNOSES REDACTED]. The status does not permit the withholding of normal food or fluids. A review of the facility ' s "CPR - CODE BLUE" Policy and Procedure with an effective date of ,[DATE] revealed Guidelines to: It shall be the policy of this facility to administer Cardio [MEDICAL CONDITION] Resuscitation on any/all residents unless there is a consent of authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending Physician may make a DNR decision. The procedure of this policy indicated the following: a. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place, b. CPR will be initiated utilizing the American Heart Association/Red Cross guidelines, c. A call will be placed for Emergency Assistance and Transport, d. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR, and 5. Utilize the emergency code documentation form to document the event. A review of the facility ' s "Abuse, Neglect and Misappropriation" policy and procedure dated and revised ,[DATE] revealed the following information - (a) Verbal, sexual, physical, and mental abuse, corporate punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited, (b) All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines, (c) Individuals are not hired when a history of abuse is known, (d) Retribution against resident, staff or visitors who file reports of abuse is prohibited, (e) Each facility must designate an Abuse Prevention Coordinator. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Training/Identification/Prevention: Staff receives orientation and on-going training on: (a) Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, (b) How to report their knowledge related to allegations and reasonable suspicion of a crime, (c) Notification of their reporting obligations under the Elder Justice Act (EJA) to report a suspicion of a crime to the State survey agency, (d) What constitutes as a crime, (e) What constitutes abuse, neglect and misappropriation of resident property, (f) How to recognize signs of burnout, frustration and stress that may lead to abuse, (g) Signs & Symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal) to name a few, and (h) Reporting of abuse and to whom to report abuse. A written statement from Licensed Practical Nurse (employee A) was reviewed, dated [DATE], which revealed: "On Sunday [DATE]st at approximately 11:00 a.m., I had placed a call to the physician to report that the midline of Resident #1 had infiltrated. Orders were received for a midline to be replaced. At that time I (employee A) had Resident #1's and another resident's (name not noted) chart on the desk. Certified Nursing Aide (CNA) (employee B) stated that she needed me in the room of Resident #1. I ran to the room and noted that Resident #1 was very pale in color, I returned to nursing station, and, again called the physician's office, while I was on hold I noticed that staff was running by toward Resident #1's room and I ran to the room with a chart that I thought was Resident #1's. My initial evaluation was that she had stopped breathing but did still have a pulse. I turned to the advanced directives tab in the chart and saw the "full code" insert. I began CPR (Compressions), (employee D) (employee C) were holding the face mask and bagging together. I called 911 from my cell phone in the room and gave some information to EMS, then handed the phone to nurse (employee E) to finish giving the information as I performed CPR. EMS arrived approximately ,[DATE] minutes later and took over CPR. I placed a call to the Nursing Home Administrator and notified her of the CPR and resident involved. I always call the Nursing Home Administrator and not the Director of Nursing. I placed a call to the family to notify of the situation and was informed that Resident #1 was a DNR, at that time I still didn't know that I had the wrong record and requested that they fax it over. Once the living will was received and given to the EMS the CPR was stopped by EMS. The paperwork from the record in the room was copied by nurse (employee E) pulled the records and (employee D) copied the records and gave them to the EMS. At some point the EMS stated that the paperwork was not for the right patient and requested the correct paperwork. At that time I realized that Resident #1 was a DNR. I didn't notify anyone, because at that time she had passed and I didn't think that it mattered. My documentation in the record did not reflect CPR performed". This statement was signed by (employee A), Licensed Practical Nurse. Multiple telephone communication attempts by the State survey team from [DATE] through to [DATE], with employee A, were unsuccessful. The Nursing Home Administrator provided a "Stakeholder Suspension Form" dated [DATE] for review. It indicated that employee A was suspended until the investigation was concluded. Employee A, her supervisor, the Nursing Home Administrator and a witnessed all signed and dated the form on [DATE]. Further interview with the Nursing Home Administrator indicated that employee A had been terminated as a result from their investigation. In review of the nurse (employee A ' s) employee file, it was noted upon her hire date on [DATE] (employed almost four years at the facility), she was given education, training and in-services related to but not limited to: " Death and Dying/End of Life " , " Documentation for Nursing Aides and Nurses " , " Advanced Directives," "Customer Service," and "Resident Rights." Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. A written statement from Licensed Practical Nurse (employee E) dated [DATE] revealed: "I (employee E) was called to Resident #1's room. Writer entered resident room and observed resident unresponsive. The nurse (employee A) and two CNAs were present (employee C and D). Writer left room to retrieve crash cart, there was a crash cart present when writer arrived back to room. CPR was in progress with employee A during compression and employee D holding Ambu bag to resident's mouth and nose and employee C administering breath via bag. A few paramedics entered the rooms and took over the CPR process. Nurse (employee A) asked writer to make necessary copies from the chart that was sitting on top of the dresser in the patient's room. Writer removed face sheet and labs and writer gave employee C the papers that was removed from chart and she made copies and brought copies back to patient's room." This statement was signed and dated by employee E on [DATE]. An interview with employee E on [DATE] at approximately 11:00 a.m. revealed she did remember the event that occurred on [DATE] that involved Resident #1 and employee A. She indicated that she (employee E) did not realize she was making the wrong copies from another resident's chart. She further confirmed that, as the secondary nurse who reported to the room, she assumed employee A had the right chart and when asked to make copies, she just ran them to the copier without thinking to look at the name. Employee E indicated that she along with all the other direct care staff have had training and in-services to include how to verify they have the right resident information when reporting to a "Code Blue" call. She further indicated she and all the other direct care staff have had training and in-services to include resident rights, advanced directives and accuracy of charting since the event which occurred on [DATE]. Employee E stated that she would verify all this information with the chart. Employee E verbally demonstrated that when a "Code Blue" is called she would get the chart for the room called and when she gets to the room she will look at name badge on door and also on resident's wrist. She would then verify with another nurse and look at EMAR (Electronic Medication Administration Record) picture if have time. The Crash cart will be called upon and brought in by other staff. She indicated that she would then look at advanced directives for "yellow" DNR and telephone order that is placed on other side of the DNR sheet. If there was a DNR in place, she would not perform CPR and will chart and call the physician and Family. If no DNR in chart or cannot find one, she would then perform CPR. Employee E also stated that verifying the chart and the resident is "a standard of practice and is common sense to make sure you have the right chart." A written statement from Certified Nursing Assistant (CNA) (employee B) dated [DATE] revealed: "Passing Resident #1's room, I noticed the resident did not look good. I ran out of the room and back for the nurse to come to the room. I also sent a CNA and asked her to help clean the resident up in case she was not going to be sent out to the Hospital. Left the room to do something and never went back until she was gone." This statement was signed and dated by employee B on [DATE]. An interview on [DATE] at approximately 1:00 p.m. with employee B confirmed she reported to the Resident #1's room and had another aide go get a nurse. When the nurse reported she left the room and had to care for another resident. She indicated she did not know of anything else that happened. She did indicated that she along, with all other staff, were immediately trained and in serviced that day and the next day [DATE] related to how to ensure you have the right information for the right resident, advanced directives, "Code Blue" reporting and resident rights. Further interview with employee B indicated that CNAs are not normally asked to retrieve charts or make copies, and had never done so or had ever been asked in the past. A written statement from CNA (employee D) dated [DATE] revealed: "It was 11:05 a.m. when CNA called me to help her clean Resident #1 up because we thought she was deceased . Nurse said there was not a DNR form in place and she had to start CPR. The crash cart was brought in and CPR was started then 911 arrived and took over." This statement was signed and dated by employee D on [DATE]. An interview on [DATE] at approximately 1:30 p.m. with employee D, confirmed she reported to Resident #1's room to assist. She was not asked to do anything at the time and did not know the chart that the nurse (employee A) brought to the room was not Resident #1's chart. She indicated that she, along with all other staff, had received training's and in-services related to how to verify resident information, advanced directives, and resident rights. Employee D indicated that CNA's are not asked to go and retrieve charts or to make copies. She confirmed that she did not make any copies for the nurse (employee A) during the time of the event with Resident #1 on [DATE]. Review of the facility's timeline related to the [DATE] event with Resident #1, as completed by the Nursing Home Administrator, revealed the following: 1. "11:00 a.m. call placed to the MD to replace midline on Resident #1, orders received." 2. "11:10 a.m., order written and chart left on nurse station." 3. "11:10 a.m. the family of (another resident - name indicated) came to me (employee A) with a question, chart was placed on the nurse's station next to Resident #1's chart. 4. "11:12 a.m. CNA (employee B) reported to nurse (employee A) that Resident #1 was unresponsive, nurse (employee A) ran to the room and observed Resident #1 to be very pale, unresponsive with a faint heart rate." 5. "11:16 a.m. Nurse (employee A) ran back to the nurses station and attempted to place a call with the on call MD. While on hold she noticed multiple staff members running to the Resident #1's room. Assuming a change in status, nurse (employee A) grabbed the resident's chart from the nurse's station and ran to Resident #1's room." 6. "11:16 a.m. Resident #1's bed was lowered and the CPR board was placed under her at this time it was noted that she took a gasp of air and stopped breathing." 7. "11:16 a.m. Nurse (employee A) placed the wrong residents chart on the dresser of the room and opened the chart directly to the advanced directives tab and stated to the staff in the room Resident #1 is a Full Code and we need to initiate CPR." 8. "11:17 a.m. Nurse (employee A) initiated CPR while simultaneously calling 911 from her cell phone. She then threw the phone to nurse (employee E) who answered questions about the resident from memory." 9. "11:17 a.m. Nurse (employee A), CNA (employee C), CNA (employee D) performed CPR per nurse (employee A's) request." 10. "11:21 a.m. EMS (Emergency Medical Service) arrived at the facility and took over CPR." 11. "11:21 a.m. Nurse (employee A) returned to the nurses station and opened the correct chart to the face sheet and a call was placed to Resident #1's family who stated resident had a DNR from the hospital. Nurse (employee A) ran back to the room and expressed this to EMS. EMS stated they could not stop CPR unless the DNR was in their hands." 12. "11:21 a.m. Nurse (employee E) removed the face sheet, medication list and labs from the chart in Resident #1's room and handed them to CNA (employee D) to make copies. While making copies the copier got jammed and copies were made on the fax machine on station 2. The copies were given back to nurse (employee E) and the nurse gave copies to EMS." 13. "11:30 a.m. Nurse (employee A) returned to the nurse station and also made copies (of the correct resident chart) for EMS and placed them on the desk." 14. "11:35 a.m. Resident #1's family faxed over the DNR and it was given to EMS. At this time CPR was stopped and the resident was pronounced deceased ." 15. "11:45 a.m. Nurse (employee A) placed a call to Resident #1's family to inform them of her passing. At this time EMS returned to the facility and stated to nurse (employee A) that they must have received the wrong resident's paper work at that time (employee A) gave EMS the correct paper work." On [DATE] the facility ' s Nursing Home Administrator provided an Emergency Medical Services (EMS) run report depicting the EMS/Paramedic visit on [DATE] related to Resident #1. The report indicated that EMS arrived at the facility on [DATE] at 11:23 a.m. and then at the patient (Resident #1) at 11:24 a.m. and was back at the base at 12:08 p.m. The report notes further indicated that: " [AGE] year old female found lying supine in bed, CO [MEDICAL CONDITION]. Witnessed [MEDICAL CONDITION] by staff at nursing home approx. ,[DATE] minutes PTA. Staff placed a hard board on bed under patient and began CPR. On our arrival, staff states patient (Resident #1) was a full code as there is no DNR paperwork on file. Staff say arrest was witnessed while she was in bed and staff were doing rounds. Staff state patient ' s health was rapidly declining over the last months. Pulse checked absent and PEA on monitor. FD (Fire Department) continued compressions and IO access began. Staff remained on airway until further FD help arrived. Unable to gain IO access initially and had to increase to a larger bore needle which was successful. Admin EPI every ,[DATE] minutes. Advanced airway in place which was confirmed via ETCO2, lungs sounds and absent epigastric sounds. Subsequent rhythm checks revealed PEA and asystole only. At approx. 17 minutes, staff came in the room and stated she (Employee A) was on the phone with family. Family stated they do not want us to perform CPR on patient as they have a DNR. Staff states they do not have a copy of the DNR and never got one. Family faxed over DNR during consult to cease efforts. Staff states they remember family talking about initiated paperwork for DNR orders due to her rapid decline in health recently but they never got the copy. Received a valid copy at approx. 24 minutes of total down time. Ceased efforts EOR. Interview with the DON and the NHA and Social Service Director on [DATE] at approximately 2:00 p.m. all indicated and confirmed that the yellow DNR was indeed in the chart the entire time. They indicated that the EMS staff were referring to the information because it was the wrong chart that the Nurse had. The NHA further indicated that had the nurse (Employee A) had the right chart, there would not be an error in code status and she would have seen the DNR in the advanced directives section. An interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 p.m., revealed as soon as she was called by nurse (employee A) on [DATE] regarding the expiration of Resident #1, she took note of it but did not know that she (employee A) had the wrong chart until later in the day. As soon as she determined it out the employee reported to Resident #1's room with a different resident's chart unknowingly, and performed CPR on Resident #1 when she was deemed as a DNR. The Administrator immediately started an investigation and interviewed the nurse (employee A) regarding what happened. The NHA further indicated that she put the nurse (employee A) on suspension until the investigation was completed and was ultimately terminated. An interview on [DATE] at approximately 10:00 a.m. with the Social Service Director was conducted. She was interviewed regarding to her duties and responsibilities related to resident advanced directives. The Social Service Director indicated as far as her responsibilities for obtaining advanced directives she would meet with the resident or family or representative the day of admission or the next day and go over admissions to include advanced directives. She would assist them with explanation of advanced directives but would not make the decisions or point them either way of DNR or Full Code. She will let the resident or representative know that if the resident chooses DNR, they will have to also get an order from the Physician indicating DNR status. She further explains that until that order is obtained, the facility has a responsibility to perform CPR if the resident become unresponsive. The Social Service Director indicated that even if it is verbalized at the time that the resident is to be a DNR, they still have to wait until they get the DNR sheet and telephone order. The Social Service Director confirmed she is to assist the resident and family with explanation of advanced directives and not make the choice for the resident and or representative. She further revealed she was responsible for training all new staff upon hire in relation to advanced directives and resident rights. The Social Service Director indicated she has been part of the training and in servicing staff after the [DATE] event with Resident #1. She has participated in "Code Blue" drills and also was involved with advanced directives training, resident rights, resident information verification. The Social Service Director indicated that if a resident is admitted on a Saturday, since she only works Monday through Friday, information is taken down with the admission assessment and charting. Even if the resident requests DNR, it still has to be verified with a "Yellow" DNR sheet and physician's orders [REDACTED]. So, in short, until the advanced directives are ordered, it is the policy that CPR is performed unless the DNR order and telephone order are in chart. An Interview with the Medical Director on [DATE], at 2:30 p.m., about the event that occurred with Resident #1 on [DATE], revealed he was made aware of the event on [DATE] via telephone from the NHA. He indicated that, apparently, Resident #1 was given CPR when she was a DNR. He further indicated that he was told that the nurse (employee A) brought the wrong resident's chart to the room and when she opened the chart she found that the resident (thinking it was Resident #1's advanced directives), was a Full Code and provided CPR and called 911. He confirmed that he was told the nurse (employee A) should not have provided CPR and honored Resident #1's advanced directives as being a DNR. He further confirmed that this is just something you cannot get wrong and cannot explain what was going through the nurse's (employee A's) head during the time of the event. The Medical Director also stated that it was human error and that everyone makes mistakes but everyone should use checks and balances to make sure the right information is clarified during "Code Status" situations. He indicated that he was present during the last QA meeting and listened to the situation and is in agreement on how the facility staff are going to move forward to ensure all resident advanced directives are honored. He indicated there are only so many checks and balances and having to many will only complicate things when verification is needed. He is aware of the arm bands, the advanced directives in the chart with yellow sheet, telephone order and electronic MAR indicated [REDACTED]. He did not have anything further to add other than he is satisfied on how the NHA is moving forward with her staff to ensure this does not happen again. He indicated that the nurse at the time should have taken the time to verify the name on the chart and the resident and that was totally an error on her part, not the facility as a whole. He stated he was satisfied wit

Based on interview with staff, review of resident's medical records and policy and procedures, it was determined the facility failed to honor the advanced directives for one of seventeen residents (#1) identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of 43 total residents, all current resident records. The facility initiated Cardio - [MEDICAL CONDITION] Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility initiated CPR on Resident #1, who was a [AGE] year old female, without first verifying the correct chart and advanced directives per their policy and procedures. The staff did not fulfill a care taking obligation to provide goods or services necessary to avoid physical harm and mental anguish consistent with the Abuse Prevention Policy and Procedure effective April, 2013, the resident ' s signed State of Florida Do Not Resuscitate (DNR) dated [DATE] by the Resident and Physician and a DNR telephone order issued by the facility ' s attending primary care Physician dated [DATE]. This DNR order document, which was on goldenrod paper, was placed in the resident ' s medical record in the Advance Directives section without further review by the facility staff. The facility ' s systems reflected that this was a valid DNR and failed to honor it during the event. The facility failed to follow their procedure for admission in accordance with its CPR - Code Blue policy and procedure. The facility staff failed to correctly implement the response policy and procedure resulting in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of the facility's timeline related to a [DATE] event with Resident #1, as completed by the Nursing Home Administrator, revealed the following: 1. "11:00 a.m. call placed to the MD to replace midline on Resident #1, orders received." 2. "11:10 a.m., order written and chart left on nurse station." 3. "11:10 a.m. the family of (another resident - name indicated) came to me (employee A) with a question, chart was placed on the nurse's station next to Resident #1's chart. " 4. "11:12 a.m. CNA (employee B) reported to nurse (employee A) that Resident #1 was unresponsive, nurse (employee A) ran to the room and observed Resident #1 to be very pale, unresponsive with a faint heart rate." 5. "11:16 a.m. Nurse (employee A) ran back to the nurses station and attempted to place a call with the on call MD. While on hold she noticed multiple staff members running to the Resident #1's room. Assuming a change in status, nurse (employee A) grabbed the resident's chart from the nurse's station and ran to Resident #1's room." 6. "11:16 a.m. Resident #1's bed was lowered and the CPR board was placed under her at this time it was noted that she took a gasp of air and stopped breathing." 7. "11:16 a.m. Nurse (employee A) placed the wrong residents chart on the dresser of the room and opened the chart directly to the advanced directives tab and stated to the staff in the room Resident #1 is a Full Code and we need to initiate CPR." 8. "11:17 a.m. Nurse (employee A) initiated CPR while simultaneously calling 911 from her cell phone. She then threw the phone to nurse (employee E) who answered questions about the resident from memory." 9. "11:17 a.m. Nurse (employee A), CNA (employee C), CNA (employee D) performed CPR per nurse (employee A's) request." 10. "11:21 a.m. EMS (Emergency Medical Service) arrived at the facility and took over CPR." 11. "11:21 a.m. Nurse (employee A) returned to the nurses station and opened the correct chart to the face sheet and a call was placed to Resident #1's family who stated resident had a DNR from the hospital. Nurse (employee A) ran back to the room and expressed this to EMS. EMS stated they could not stop CPR unless the DNR was in their hands." 12. "11:21 a.m. Nurse (employee E) removed the face sheet, medication list and labs from the chart in Resident #1's room and handed them to CNA (employee D) to make copies. While making copies the copier got jammed and copies were made on the fax machine on station 2. The copies were given back to nurse (employee E) and the nurse gave copies to EMS." 13. "11:30 a.m. Nurse (employee A) returned to the nurse station and also made copies (of the correct resident chart) for EMS and placed them on the desk." 14. "11:35 a.m. Resident #1's family faxed over the DNR and it was given to EMS. At this time CPR was stopped and the resident was pronounced deceased ." 15. "11:45 a.m. Nurse (employee A) placed a call to Resident #1's family to inform them of her passing. At this time EMS returned to the facility and stated to nurse (employee A) that they must have received the wrong resident's paper work at that time (employee A) gave EMS the correct paper work." Review of Resident #1's closed medical record to include the demographic/face sheet indicated she was admitted to the facility from the Hospital on [DATE] for rehabilitation services and long term care. The resident was noted to be [AGE] years of age. During the time of admission, Resident #1 had advanced directives in place with a Health Care Surrogate as of [DATE] (prior to facility admission). The advanced directives further indicated the resident was a DNR status. A "yellow" Do Not Resuscitate (DNR) order with signatures from Resident #1 and the Physician revealed a date of [DATE]. The medical record included a cumulative [DIAGNOSES REDACTED]. The Advanced Directives section of the closed clinical record revealed the following relevant documents: a. A State of Florida Do Not Resuscitate Order form printed on yellow goldenrod paper and signed by Resident #1 and her Physician on [DATE]. b. A Living Will & Appointment of Healthcare Surrogate (HCS) indicating Resident #1 does not want 1. Cardio-pulmonary resuscitation (CPR) if her heart or breathing stops, 2. does not want a breathing machine if she is unable to breath on her own, 3. does not want Nutrition and fluids through tubes in her veins, nose or stomach, 4. does not want kidney [MEDICAL TREATMENT], a pacemaker or defibrillator, or other such machines, 5. does not want surgery or admission to a hospital intensive care unit, 6. does not want medications that can prolong her dying, such as antibiotics and 7. does not want Hospice involved in her care. This form was signed and dated by Resident #1, person appointed as HCS and two witness' on [DATE]. This form was also verified and notarized by a public notary. c. A General Durable Power of Attorney (DPOA), which was signed and dated by Resident #1, the appointee and a Notary Public of the State of Florida on [DATE]. d. An "Advance Directives/Informed Consent form indicating Resident #1 had a Durable POA and Designation of Health Care Surrogate indicated that Resident #1 had been informed of her rights and all rules and regulations regarding decisions concerning medical care, including: 1. The right to accept or refuse medical or surgical treatment, 2. The right to formulate and to issue Advanced Directives to be followed should I become incapacitated. This form was signed by Resident #1 and witnessed by the Physician on [DATE]. e. A review of the Advanced Directives Policy and Record, dated ,[DATE] and revised on [DATE], revealed: It is the policy of the facility to recognize and support the use of Advanced Directives through family, staff and community education and to encourage the residents' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly executed Advanced Directive, the facility will implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. f. A review of the "Admission Packet Checklist", which was signed and dated by the Admissions Office, Business Office Manager and the Nursing Home Administrator, on [DATE], indicated that the Advanced Directives Informed Consent was completed and signed by Resident #1 and POA. The Admission Packet Checklist further revealed a section that included "Consent to Treatment", stating, The resident and responsible party consent to the administration of such care, treatment services, and medical or nursing procedures to the resident, as the Facility and resident's attending physician or nurse practitioner deem appropriate. The resident has the right to change this consent or to refuse treatment. A review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], under the "Cognitive Patterns" section revealed the Brief Interview of Mental Status (BIMS) score was a 14. Review of the Quarterly MDS assessment dated [DATE] (last full assessment), under the "Cognitive Patterns" section, revealed the BIMS score was 13. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment." An interview on [DATE] at 9:00 a.m. with the Care Plan Coordinator/MDS Coordinator confirmed that Resident #1 ' s care plan, reflecting "Advanced Directives" with interventions: to Do Not Resuscitate (DNR), was accurate and current. She confirmed the care plans for "Advanced Directives" were initiated on [DATE] and good through [DATE]. She indicated that prior to Resident #1 expiring, there had not been any plans to change the DNR status either by the resident or Power Of Attorney (POA). A review of Resident #1's care plans initiated on [DATE] with next review date on [DATE], indicated that Resident #1 "Has Advanced Directives on record: Do Not Resuscitate (DNR), Living will on chart with interventions to include: 1. Chaplain services for emotional, psychosocial, physical and clinical needs of resident, 2. Discuss Advanced Directives with the resident and/or appointed Health Care representative, 3. Resident is capable of making informed consent regarding their health care decisions, 4. Staff to follow Advanced Directives for "Do Not Resuscitate". 5. Allow resident, if able to discuss feeling regarding their Advanced Directives, 6. Refer to Social Services as needed, and 7. DNR is signed and dated in record. Review of the Telephone Orders for Resident #1 dated [DATE] indicated she had a DNR. Review of the "Daily Skilled Nurse Notes" dated [DATE] 10:00 a.m. revealed "A call has been placed to physician on call service to inform physician of Midline Infiltration to antebrachial area of Left arm. At this time a return call is being awaited for by on call physician." At 10:05 a.m. "Call was returned by physician and new order to obtain new IV for completion of IV antibiotics was received. Pharmacy was phoned for services and currently awaiting their arrival." Further review of notes at 10:50 a.m. revealed, "Staff came to inform writer of change in status with resident. On encounter writer found that resident was completely pale in appearance, had fixated pupils and exhibited cheyne stoke breathing/ shallow respirations. Her B/P was ,[DATE], pulse 66 and respirations 10. She soon expired thereafter and went quietly at the time of 11:45 a.m. The physician ' s office was notified, family was phoned and made aware and administrator contacted and notified. An interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 p.m., revealed as soon as she was called by nurse (employee A) on [DATE] regarding the expiration of Resident #1, she took note of it but did not know that she (employee A) had the wrong chart until later in the day. As soon as she figured it out the employee reported to Resident #1's room with a different resident's chart, unknowingly, and performed CPR on Resident #1 when she was deemed as a DNR. The administrator immediately started an investigation and interviewed the nurse (employee A) regarding what happened. The NHA further indicated that she put the nurse (employee A) on suspension until the investigation was completed and was ultimately terminated. On [DATE] the facility ' s Nursing Home Administrator provided an Emergency Medical Services (EMS) run report depicting the EMS/Paramedic visit on [DATE] related to Resident #1. The report indicated that EMS arrived at the facility on [DATE] at 11:23 a.m. and then at the patient (Resident #1) at 11:24 a.m. and was back at the base at 12:08 p.m. The report notes further indicated that: "[AGE] year old female found lying supine in bed, CO [MEDICAL CONDITION]. Witnessed [MEDICAL CONDITION] by staff at nursing home approx. ,[DATE] minutes PTA. Staff placed a hard board on bed under patient and began CPR. On our arrival, staff states patient (Resident #1) was a full code as there is no DNR paperwork on file. Staff say arrest was witnessed while she was in bed and staff were doing rounds. Staff state patient's health was rapidly declining over the last months. Pulse checked absent and PEA on monitor. FD (Fire Department) continued compressions and IO access began. Staff remained on airway until further FD help arrived. Unable to gain IO access initially and had to increase to a larger bore needle which was successful. Admin EPI every ,[DATE] minutes. Advanced airway in place which was confirmed via ETCO2, lungs sounds and absent epigastric sounds. Subsequent rhythm checks revealed PEA and asystole only. At approx. 17 minutes, staff came in the room and stated she (Employee A) was on the phone with family. Family stated they do not want us to perform CPR on patient as they have a DNR. Staff states they do not have a copy of the DNR and never got one. Family faxed over DNR during consult to cease efforts. Staff states they remember family talking about initiated paperwork for DNR orders due to her rapid decline in health recently but they never got the copy. Received a valid copy at approx. 24 minutes of total down time. Ceased efforts EOR." An interview on [DATE] at approximately 10:00 a.m. with the Social Service Director was conducted. She was interviewed regarding to her duties and responsibilities related to resident advanced directives. The Social Service Director indicated as far as her responsibilities for obtaining advanced directives she would meet with the resident or family or representative the day of admission or the next day and go over admissions to include advanced directives. She would assist them with explanation of advanced directives but would not make the decisions or point them either way of DNR or Full Code. She will let the resident or representative know that if the resident chooses DNR, they will have to also get an order from the Physician indicating DNR status. She further explains that until that order is obtained, the facility has a responsibility to perform CPR if the resident become unresponsive. The Social Service Director indicated that even if it is verbalized at the time that the resident is to be a DNR, they still have to wait until they get the DNR sheet and telephone order. The Social Service Director confirmed she is to assist the resident and family with explanation of advanced directives and not make the choice for the resident and or representative. She further revealed she was responsible for training all new staff upon hire in relation to advanced directives and resident rights. The Social Service Director indicated she has been part of the training and in servicing staff after the [DATE] event with Resident #1. She has participated in "Code Blue" drills and also was involved with advanced directives training, resident rights, resident information verification. The Social Service Director indicated that if a resident is admitted on a Saturday, since she only works Monday through Friday, information is taken down with admission assessment and charting. Even if the resident requests DNR, it still has to be verified with a "Yellow" DNR sheet and physician's orders [REDACTED]. So, in short, until those advanced directives are ordered, it is the policy that CPR is performed unless the DNR order and telephone order are in chart. An Interview with the Medical Director on [DATE], at 2:30 p.m., in relation to the event that occurred with Resident #1 on [DATE], revealed he was made aware of the event on [DATE] via telephone from the NHA. He indicated that apparently Resident #1 was given CPR when she was a DNR. He further indicated that he was told that the nurse (employee A) brought the wrong resident's chart to the room and when she opened the chart she found that the resident (thinking it was Resident #1's advanced directives), was a Full Code and provided CPR and called 911. He confirmed that he was told the nurse (employee A) should not have provided CPR and honored Resident #1's advanced directives as being a DNR. He further confirmed that this is just something you cannot get wrong and cannot explain what was going through the nurse's (employee A's) head during the time of the event. The Medical Director also stated that it was human error and that everyone makes mistakes but everyone should use checks and balances to make sure the right information is clarified during "Code Status" situations. He indicated that he was present during the last QA meeting and listened to the situation and is in agreement on how the facility staff are going to move forward to ensure all resident advanced directives are honored. He indicated there are only so many checks and balances and having to many will only complicate things when verification is needed. He is aware of the arm bands, the advanced directives in the chart with yellow sheet, telephone order and electronic MAR indicated [REDACTED]. He did not have anything further to add other than he is satisfied on how the NHA is moving forward with her staff to ensure this does not happen again. He indicated that the nurse at the time should have taken the time to verify the name on the chart and the resident and that was totally an error on her part, not the facility as a whole. He stated he was also satisfied with the Quality Assurance program (QA) and NHA and DON were working on to ensure plans are in place to ensure all those who are CPR certified are kept current. An interview with the Director of Nursing (DON) in relation to the event on [DATE] with Resident #1 could not be obtained. The DON had to leave the facility during the time of the complaint investigation. A written statement from Licensed Practical Nurse (employee A) dated [DATE] revealed: "On Sunday [DATE]st at approximately 11:00 a.m., I had placed a call to the physician to report that the midline of Resident #1 had infiltrated. Orders were received for a midline to be replaced. At that time I (employee A) had Resident #1's and another resident's (name not noted) chart on the desk. Certified Nursing Aide (CNA) (employee B) stated that she needed me in the room of Resident #1. I ran to the room and noted that Resident #1 was very pale in color, I returned to nursing station and again called the physician's office, while I was no hold I noticed that staff was running by toward Resident #1's room and I ran to the room with a chart that I thought was Resident #1's. My initial evaluation was that she had stopped breathing but did still have a pulse. I turned to the advanced directives tab in the chart and saw the "full code" insert. I began CPR (Compressions), (employee D) (employee C) were holding the face mask and bagging together. I called 911 from my cell phone in the room and gave some information to EMS, then handed the phone to nurse (employee E) to finish giving the information as I performed CPR. EMS arrived approximately ,[DATE] minutes later and took over CPR. I placed a call to the Nursing Home Administrator and notified her of the CPR and resident involved. I always call the Nursing Home Administrator and not the Director of Nursing. I placed a call to the family to notify of the situation and was informed that Resident #1 was a DNR, at that time I still didn't know that I had the wrong record and requested that they fax it over. Once the living will was received and given to the EMS the CPR was stopped by EMS. The paperwork from the record in the room was copied by nurse (employee E) pulled the records and (employee D) copied the records and gave them to the EMS. At some point the EMS stated that the paperwork was not for the right patient and requested the correct paperwork. At that time I realized that Resident #1 was a DNR. I didn't notify anyone, because at that time she had passed and I didn't think that it mattered. My documentation in the record did not reflect CPR performed". This statement was signed by (employee A), Licensed Practical Nurse. Multiple telephone communication attempts by the State survey team from [DATE] through to [DATE], with employee A, were unsuccessful. The Nursing Home Administrator provided a "Stakeholder Suspension Form" dated [DATE] for review. It indicated that employee A was suspended until the investigation was concluded. Employee A, her supervisor, the Nursing Home Administrator and a witnessed all signed and dated the form on [DATE]. Further interview with the Nursing Home Administrator indicated that employee A had been terminated as a result from their investigation. In review of the nurse (employee A ' s) employee file, it was noted upon her hire date on [DATE] (employed almost four years at the facility), she was given education, training and in-services related to but not limited to: "Death and Dying/End of Life," "Documentation for Nursing Aides and Nurses," "Advanced Directives," "Customer Service," and "Resident Rights." Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. A written statement from Licensed Practical Nurse (employee E) dated [DATE] revealed: "I (employee E) was called to resident #1's room. Writer entered resident room and observed resident unresponsive. The nurse (employee A) and two CNAs were present (employee C and D). Writer left room to retrieve crash cart, there was a crash cart present when writer arrived back to room. CPR was in progress with employee A during compression and employee D holding Ambu bag to resident's mouth and nose and employee C administering breath via bag. A few paramedics entered the rooms and took over the CPR process. Nurse (employee A) asked writer to make necessary copies from the chart that was sitting on top of the dresser in the patient's room. Writer removed face sheet and labs and writer gave employee C the papers that was removed from chart and she made copies and brought copies back to patient's room". This statement was signed and dated by employee E on [DATE]. An interview with employee E on [DATE] at approximately 11:00 a.m. revealed she did remember the event that occurred on [DATE] that involved Resident #1 and employee A. She indicated that she (employee E) did not realize she was making the wrong copies from another resident's chart. She further confirmed that as the secondary nurse who reported to the room, she assumed employee A had the right chart and when asked to make copies, she just ran them to the copier without thinking to look at the name. Employee E indicated that she along with all the other direct care staff have had training and in-services to include how to verify they have the right resident information when reporting to a "Code Blue" call. She further indicated she and all the other direct care staff have had training and in-services to include resident rights, advanced directives and accuracy of charting since the event which occurred on [DATE]. Employee E stated that she will verify all this information with the chart. Employee E verbally demonstrated that when a "Code Blue" is called she will get the chart for the room called and when gets to the room she will look at name badge on door and also on resident's wrist. She will then verify with another nurse and look at EMAR (Electronic Medication Administration Record) picture if have time. The Crash cart will be called upon and brought in by other staff. She indicated that she will then look at advanced directives for "yellow" DNR and telephone order that is placed on other side of the DNR sheet. If there is a DNR in place, she will not perform CPR and will chart and call the physician and Family. If no DNR in chart or cannot find one, she will then perform CPR. Employee E also stated that verifying the chart and the resident is "a standard of practice and is common sense to make sure you have the right chart." A written statement from Certified Nursing Assistant (CNA) (employee B) dated [DATE] revealed: "Passing Resident #1's room, I noticed the resident did not look good. I ran out of the room and back for the nurse to come to the room. I also sent a CNA and asked her to help clean the resident up in case she was not going to be sent out to the Hospital. Left the room to do something and never went back until she was gone". This statement was signed and dated by employee B on [DATE]. An interview on [DATE] at approximately 1:00 p.m. with employee B confirmed she reported to the Resident #1's room and had another aide go get a nurse. When the nurse reported she left the room and had to care for another resident. She indicated she does not know of anything else that happened. She did indicated that she along with all other staff were immediately trained and in serviced that day and the next day [DATE] related to how to ensure you have the right information for the right resident, advanced directives, "Code Blue" reporting and resident rights. Further interview with employee B indicated that CNAs are not normally asked to retrieve charts or make copies, and has never done so or has ever been asked in the past. A written statement from CNA (employee D) dated [DATE] revealed: "It was 11:05 a.m. when CNA called me to help her clean Resident #1 up because we thought she was deceased . Nurse said there was not a DNR form in place and she had to start CPR. The crash cart was brought in and CPR was started then 911 arrived and took over". This statement was signed and dated by employee D on [DATE]. An interview on [DATE] at approximately 1:30 p.m. with employee D, confirmed she reported to Resident #1's room to assist. She was not asked to do anything at the time and did not know the chart that the nurse (employee A) brought to the room was not Resident #1's chart. She indicated that she along with all other staff have received training's and in-services related to how to verify resident information, advanced directives, and resident rights. Employee D indicated that CNA's are not asked to go and retrieve charts or to make copies. She confirmed that she did not make any copies for the nurse (employee A) during the time of the event with Resident #1 on [DATE]. Review of the admission agreement which is found in the admission packet under the "consent to treat section, " revealed " The Resident and Responsible Party consent to the administration of such care, treatment services, and medical or nursing procedures to the Resident, as the Facility and Resident ' s attending Physician or nurse practitioner deem appropriate. The Resident has the right to change this consent or to refuse treatment. " The admission agreement also contains " Advanced Directives/Informed Consent form that indicates " This is to acknowledge that I have been informed, in writing and in a language that I understand, of my rights and all rules and regulations regarding decisions concerning medical care, including: a. The right to accept or refuse medical surgical treatment and b. The right to formulate and issue Advanced Directives to be followed should I become incapacitated " . This form indicates the following areas to be checked or not checked: Living Will, Durable POA, Do Not Resuscitate, Do Not Hospitalize, Organ Donation, Autopsy Request and Designation of Health Care Surrogate. If one of these areas are checked, there is a section where the staff and resident have to document when it or they were issued. This form must be signed but the Resident or Power of Attorney, the Physician and two witnesses. The admission agreement also contained admission information (page 10) related to " Health Care Advanced Directives. " This section indicated " Information for residents and their families about advance directives for medical care " to include but not limited to: a. Make your wishes known - You alone have the right to make basic decisions about the medical and health care services you receive from you Physician or other health care providers. You have the right to accept, refuse or take away any treatment. You also have the right to be informed and give informed consent before [DIAGNOSES REDACTED]. b. Right to Natural Death - The Right to Natural Death Act recognizes your rights as a competent adult to make decisions about your medical care. This law says that every person has the basic and natural right to die with as much dignity as possible. It also says that every person can accept, refuse and stop treatment. A person can control decisions about the care he or she receives. Medical care means any procedure for [DIAGNOSES REDACTED]. The status does not permit the withholding of normal food or fluids. A review of the facility ' s " CPR - CODE BLUE " Policy and Procedure with an effective date of ,[DATE] revealed Guidelines to: It shall be the policy of this facility to administer Cardio [MEDICAL CONDITION] Resuscitation on any/all residents unless there is a consent of authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending Physician may make a DNR decision. The procedure of this policy indicated the following: a. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place, b. CPR will be initiated utilizing the American Heart Association/Red Cross guidelines, c. A call will be placed for Emergency Assistance and Transport, d. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR, and 5. Utilize the emergency code documentation form to document the event. A review of the facility ' s "Advanced Directives" Policy and Procedure with an effective date ,[DATE] and last revised on [DATE] revealed: It is the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education and to encourage the residents ' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly exec

Based on resident medical record review, interviews with staff, and the facility ' s policy and procedures, it was determined that the facility failed to implement the individualized care plan for advanced directives for one of seventeen residents (#1), of 43 total residents, identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit. The facility initiated Cardio - [MEDICAL CONDITION] Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility initiated CPR on Resident #1, who was a [AGE] year old female, without first verifying the correct chart and advanced directives per their policy and procedures. The staff did not ensure advanced directives, which were in effect for DNR, were carried out in accordance with the resident ' s plan of care. The facility personnel did not ensure that, in the event the resident ' s heart stopped and breathing ceased, that CPR would not be initiated to honor the resident ' s DNR wishes. In addition, the facility did not ensure that the wishes of the legally appointed Durable Power of Attorney (DPOA) who was also the resident ' s Health Care Surrogate (HCS), were honored for a DNR. The facility failed to follow their procedure for admission in accordance with their Code Status Orders & Response Policy and Procedure. The facility failed to honor Resident #1 ' s DNR order and allow the resident the opportunity to refuse treatment. The facility called 911 for the resident who was at the mercy of the staff and provided her with unwanted treatments of cardiac compressions and artificial ventilation to prolong life. Failure to protect the rights of residents to ensure facility staff correctly implemented advanced directives resulted in findings of Immediate Jeopardy, which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: A review of Resident #1's care plans, initiated on [DATE], with next review date due on [DATE], indicated that Resident #1 "Has Advanced Directives on record: Do Not Resuscitate (DNR), Living will on chart with interventions to include: 1. Chaplain services for emotional, psychosocial, physical and clinical needs of resident, 2. Discuss Advanced Directives with the resident and/or appointed Health Care representative, 3. Resident is capable of making informed consent regarding their health care decisions, 4. Staff to follow Advanced Directives for "Do Not Resuscitate". 5. Allow resident, if able to discuss feeling regarding their Advanced Directives, 6. Refer to Social Services as needed, and 7. DNR is signed and dated in record. An interview on [DATE] at 9:00 a.m. with the Care Plan Coordinator/MDS Coordinator confirmed that Resident #1 ' s care plans, reflecting " Advanced Directives " with interventions: to Do Not Resuscitate (DNR), was accurate and current. She confirmed the care plans for " Advanced Directives " were initiated on [DATE] and good through [DATE]. She indicated that prior to Resident #1 expiring, there had not been any plans to change the DNR status either by the resident or Power Of Attorney (POA). Review of Resident #1's closed medical record included the demographic/face sheet indicated she was admitted to the facility from the Hospital on [DATE] for rehabilitation services and long term care. The resident was noted to be [AGE] years of age. During the time of admission, Resident #1 had advanced directives in place with a Health Care Surrogate signed [DATE] (prior to facility admission). The advanced directives section of the chart further indicated the resident was a DNR status. The medical record included a cumulative [DIAGNOSES REDACTED]. The Advanced Directives section of the closed clinical record revealed the following relevant documents: a. A State of Florida Do Not Resuscitate Order form printed on yellow goldenrod paper and signed by Resident #1 and her Physician on [DATE]. b. A Living Will & Appointment of Healthcare Surrogate (HCS) indicating Resident #1 does not want 1. Cardio-pulmonary resuscitation (CPR) if her heart or breathing stops, 2. does not want a breathing machine if she is unable to breath on her own, 3. does not want Nutrition and fluids through tubes in her veins, nose or stomach, 4. does not want kidney [MEDICAL TREATMENT], a pacemaker or defibrillator, or other such machines, 5. does not want surgery or admission to a hospital intensive care unit, 6. does not want medications that can prolong her dying, such as antibiotics and 7. does not want Hospice involved in her care. This form was signed and dated by Resident #1, person appointed as HCS and two witness' on [DATE]. This form was also verified and notarized by a public notary. c. A General Durable Power of Attorney (DPOA), which was signed and dated by Resident #1, the appointee and a Notary Public of the State of Florida on [DATE]. d. An "Advance Directives / Informed Consent form indicating Resident #1 has a Durable POA and Designation of Health Care Surrogate indicated that Resident #1 has been informed of her rights and all rules and regulations regarding decisions concerning medical care, including: 1. The right to accept or refuse medical or surgical treatment, 2. The right to formulate and to issue Advanced Directives to be followed should I become incapacitated. This form was signed by Resident #1 and witnessed by the Physician on [DATE]. e. A review of the Advanced Directives Policy and Record dated ,[DATE] and revised on [DATE] revealed: It is the policy of the facility to recognize and support the use of Advanced Directives through family, staff and community education and to encourage the residents' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly executed Advanced Directive, the facility will implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. f. A review of the "Admission Packet Checklist", which was signed and dated by the Admissions Office, Business Office Manager and the Nursing Home Administrator, on [DATE], indicated that the Advanced Directives Informed Consent was completed and signed by Resident #1 and POA. The Admission Packet Checklist further revealed a section that included "Consent to Treatment," stating: " The resident and responsible party consent to the administration of such care, treatment services, and medical or nursing procedures to the resident, as the Facility and resident's attending physician or nurse practitioner deem appropriate. The resident has the right to change this consent or to refuse treatment. " A review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] under the "Cognitive Patterns" section revealed the Brief Interview of Mental Status (BIMS) score was a 14. Review of the Quarterly MDS assessment dated [DATE] (last full assessment), under the "Cognitive Patterns" section, revealed the BIMS score was 13. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment." Review of the Telephone Orders for Resident #1, dated [DATE], indicated she had a DNR order. Review of the "Daily Skilled Nurse Notes" dated [DATE] 10:00 a.m. revealed "A call has been placed to physician on call service to inform physician of Midline Infiltration to antebrachial area of Left arm. At this time a return call is being awaited for by on call physician." At 10:05 a.m. "Call was returned by physician and new order to obtain new IV for completion of IV antibiotics was received. Pharmacy was phoned for services and currently awaiting their arrival." Further review of notes at 10:50 a.m. revealed, "Staff came to inform writer of change in status with resident. On encounter writer found that resident was completely pale in appearance, had fixated pupils and exhibited cheyne stoke breathing/ shallow respirations. Her B/P was ,[DATE], pulse 66 and respirations 10. She soon expired thereafter and went quietly at the time of 11:45 a.m. The physician ' s office was notified, family was phoned and made aware and administrator contacted and notified. " Review of the facility's timeline related to the [DATE] event with Resident #1, as completed by the Nursing Home Administrator, revealed the following: 1. "11:00 a.m. call placed to the MD to replace midline on Resident #1, orders received." 2. "11:10 a.m., order written and chart left on nurse station." 3. "11:10 a.m. the family of (another resident - name indicated) came to me (employee A) with a question, chart was placed on the nurse's station next to Resident #1's chart. " 4. "11:12 a.m. CNA (employee B) reported to nurse (employee A) that Resident #1 was unresponsive, nurse (employee A) ran to the room and observed Resident #1 to be very pale, unresponsive with a faint heart rate." 5. "11:16 a.m. Nurse (employee A) ran back to the nurses station and attempted to place a call with the on call MD. While on hold she noticed multiple staff members running to the Resident #1's room. Assuming a change in status, nurse (employee A) grabbed the resident's chart from the nurse's station and ran to Resident #1's room." 6. "11:16 a.m. Resident #1's bed was lowered and the CPR board was placed under her at this time it was noted that she took a gasp of air and stopped breathing." 7. "11:16 a.m. Nurse (employee A) placed the wrong residents chart on the dresser of the room and opened the chart directly to the advanced directives tab and stated to the staff in the room Resident #1 is a Full Code and we need to initiate CPR." 8. "11:17 a.m. Nurse (employee A) initiated CPR while simultaneously calling 911 from her cell phone. She then threw the phone to nurse (employee E) who answered questions about the resident from memory." 9. "11:17 a.m. Nurse (employee A), CNA (employee C), CNA (employee D) performed CPR per nurse (employee A's) request." 10. "11:21 a.m. EMS (Emergency Medical Service) arrived at the facility and took over CPR." 11. "11:21 a.m. Nurse (employee A) returned to the nurses station and opened the correct chart to the face sheet and a call was placed to Resident #1's family who stated resident had a DNR from the hospital. Nurse (employee A) ran back to the room and expressed this to EMS. EMS stated they could not stop CPR unless the DNR was in their hands." 12. "11:21 a.m. Nurse (employee E) removed the face sheet, medication list and labs from the chart in Resident #1's room and handed them to CNA (employee D) to make copies. While making copies the copier got jammed and copies were made on the fax machine on station 2. The copies were given back to nurse (employee E) and the nurse gave copies to EMS." 13. "11:30 a.m. Nurse (employee A) returned to the nurse station and also made copies (of the correct resident chart) for EMS and placed them on the desk." 14. "11:35 a.m. Resident #1's family faxed over the DNR and it was given to EMS. At this time CPR was stopped and the resident was pronounced deceased ." 15. "11:45 a.m. Nurse (employee A) placed a call to Resident #1's family to inform them of her passing. At this time EMS returned to the facility and stated to nurse (employee A) that they must have received the wrong resident's paper work at that time (employee A) gave EMS the correct paper work." On [DATE] the facility ' s Nursing Home Administrator provided an Emergency Medical Services (EMS) run report depicting the EMS/Paramedic visit on [DATE] related to Resident #1. The report indicated that EMS arrived at the facility on [DATE] at 11:23 a.m. and then at the patient (Resident #1) at 11:24 a.m. and was back at the base at 12:08 p.m. The report notes further indicated that: [AGE] year old female found lying supine in bed, CO [MEDICAL CONDITION]. Witnessed [MEDICAL CONDITION] by staff at nursing home approx. ,[DATE] minutes PTA. Staff placed a hard board on bed under patient and began CPR. On our arrival, staff states patient (Resident #1) was a full code as there is no DNR paperwork on file. Staff say arrest was witnessed while she was in bed and staff were doing rounds. Staff state patient ' s health was rapidly declining over the last months. Pulse checked absent and PEA on monitor. FD (Fire Department) continued compressions and IO access began. Staff remained on airway until further FD help arrived. Unable to gain IO access initially and had to increase to a larger bore needle which was successful. Admin EPI every ,[DATE] minutes. Advanced airway in place which was confirmed via ETCO2, lungs sounds and absent epigastric sounds. Subsequent rhythm checks revealed PEA and asystole only. At approx. 17 minutes, staff came in the room and stated she (Staff Member A) was on the phone with family. Family stated they do not want us to perform CPR on patient as they have a DNR. Staff states they do not have a copy of the DNR and never got one. Family faxed over DNR during consult to cease efforts. Staff states they remember family talking about initiated paperwork for DNR orders due to her rapid decline in health recently but they never got the copy. Received a valid copy at approx. 24 minutes of total down time. Ceased efforts EOR. An interview with the DON and the NHA and Social Service Director on [DATE] at approximately 2:00 p.m. all indicated and confirmed that the yellow DNR was indeed in the chart the entire time. They indicated that the EMS staff were referring to the information because it was the wrong chart that the Nurse had. The NHA further indicated that had the nurse (Employee A) had the right chart, there would not be an error in code status and she would have seen the DNR in the advanced directives section. An interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 p.m., revealed as soon as she was called by nurse (employee A) on [DATE] regarding the expiration of Resident #1, she took note of it but did not know that she (employee A) had the wrong chart until later in the day. As soon as she figured it out the employee reported to Resident #1's room with a different resident's chart, unknowingly, and performed CPR on Resident #1 when she was deemed as a DNR. The administrator stated he immediately started an investigation and interviewed the nurse (employee A) regarding what happened. The NHA further indicated that she put the nurse (employee A) on suspension until the investigation was completed and was ultimately terminated. The Nursing Home Administrator further confirmed after review of Resident #1 ' s care plans dated from [DATE] through to [DATE], specifically the Advanced Directives area, the intervention to: Do Not Resuscitate was not followed by the nurse (employee A) on [DATE] when she was found unresponsive. A written statement from Licensed Practical Nurse (employee A) dated [DATE] revealed: "On Sunday [DATE]st at approximately 11:00 a.m., I had placed a call to the physician to report that the midline of Resident #1 had infiltrated. Orders were received for a midline to be replaced. At that time I (employee A) had Resident #1's and another resident's (name not noted) chart on the desk. Certified Nursing Aide (CNA) (employee B) stated that she needed me in the room of Resident #1. I ran to the room and noted that Resident #1 was very pale in color, I returned to nursing station and again called the physician's office, while I was on hold I noticed that staff were running by toward Resident #1's room and I ran to the room with a chart that I thought was Resident #1's. My initial evaluation was that she had stopped breathing but did still have a pulse. I turned to the advanced directives tab in the chart and saw the "full code" insert. I began CPR (Compressions), (employee D) (employee C) were holding the face mask and bagging together. I called 911 from my cell phone in the room and gave some information to EMS, then handed the phone to nurse (employee E) to finish giving the information as I performed CPR. EMS arrived approximately ,[DATE] minutes later and took over CPR. I placed a call to the Nursing Home Administrator and notified her of the CPR and resident involved. I always call the Nursing Home Administrator and not the Director of Nursing. I placed a call to the family to notify of the situation and was informed that Resident #1 was a DNR, at that time I still didn't know that I had the wrong record and requested that they fax it over. Once the living will was received and given to the EMS the CPR was stopped by EMS. The paperwork from the record in the room was copied by nurse (employee E) pulled the records and (employee D) copied the records and gave them to the EMS. At some point the EMS stated that the paperwork was not for the right patient and requested the correct paperwork. At that time I realized that Resident #1 was a DNR. I didn't notify anyone, because at that time she had passed and I didn't think that it mattered. My documentation in the record did not reflect CPR performed". This statement was signed by (employee A), Licensed Practical Nurse. Multiple telephone communication attempts by the State survey team from [DATE] through to [DATE], with employee A, were unsuccessful. The Nursing Home Administrator provided a "Stakeholder Suspension Form" dated [DATE] for review. It indicated that employee A was suspended until the investigation was concluded. Employee A, her supervisor, the Nursing Home Administrator and a witness all signed and dated the form on [DATE]. Further interview with the Nursing Home Administrator indicated that employee A had been terminated as a result of their investigation. In review of the nurse (employee A ' s) employee file, it was noted she was employed almost four years at the facility. Upon her hire date on [DATE], she was given education, training and in-services related to but not limited to: " Death and Dying/End of Life, " " Documentation for Nursing Aides and Nurses, " " Advanced Directives, " " Customer Service, " and " Resident Rights. " Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. A written statement from Licensed Practical Nurse (employee E), dated [DATE], revealed: "I (employee E) was called to Resident #1's room. Writer entered resident room and observed resident unresponsive. The nurse (employee A) and two CNAs were present (employee C and D). Writer left room to retrieve crash cart, there was a crash cart present when writer arrived back to room. CPR was in progress with employee A during compression and employee D holding Ambu bag to resident's mouth and nose and employee C administering breath via bag. A few paramedics entered the rooms and took over the CPR process. Nurse (employee A) asked writer to make necessary copies from the chart that was sitting on top of the dresser in the patient's room. Writer removed face sheet and labs and writer gave employee C the papers that were removed from chart and she made copies and brought copies back to patient's room". This statement was signed and dated by employee E on [DATE]. An interview with employee E on [DATE] at approximately 11:00 a.m. revealed she did remember the event that occurred on [DATE] that involved Resident #1 and employee A. She indicated that she (employee E) did not realize she was making the wrong copies from another resident's chart. She further confirmed that as the secondary nurse who reported to the room, she assumed employee A had the right chart and when asked to make copies, she just ran them to the copier without thinking to look at the name. Employee E indicated that she along with all the other direct care staff had training and in-services to include how to verify they have the right resident information when reporting to a "Code Blue" call. She further indicated she and all the other direct care staff have had training and in-services to include resident rights, advanced directives and accuracy of charting since the event which occurred on [DATE]. Employee E stated that she will verify all this information with the chart. Employee E verbally demonstrated that when a "Code Blue" is called she will get the chart for the room called and when she gets to the room she will look at the name badge on door and also on resident's wrist. She will then verify with another nurse and look at EMAR (Electronic Medication Administration Record) picture if she has time. The Crash cart will be called upon and brought in by other staff. She indicated that she will then look at advanced directives for "yellow" DNR and telephone order that is placed on other side of the DNR sheet. If there is a DNR in place, she will not perform CPR and will chart and call the physician and Family. If no DNR in chart or cannot find one, she will then perform CPR. Employee E also stated that verifying the chart and the resident is "a standard of practice and is common sense to make sure you have the right chart." A written statement from Certified Nursing Assistant (CNA) (employee B) dated [DATE] revealed: "Passing Resident #1's room, I noticed the resident did not look good. I ran out of the room and back for the nurse to come to the room. I also sent a CNA and asked her to help clean the resident up in case she was not going to be sent out to the Hospital. Left the room to do something and never went back until she was gone." This statement was signed and dated by employee B on [DATE]. An interview on [DATE] at approximately 1:00 p.m. with employee B confirmed she reported to the Resident #1's room and had another aide go get a nurse. When the nurse reported she left the room and had to care for another resident. She indicated she does not know of anything else that happened. She did indicated that she along with all other staff were immediately trained and in serviced that day and the next day [DATE] related to how to ensure you have the right information for the right resident, advanced directives, "Code Blue" reporting and resident rights. Further interview with employee B indicated that CNAs are not normally asked to retrieve charts or make copies, and has never done so or has ever been asked to do so in the past. A written statement from CNA (employee D) dated [DATE] revealed: "It was 11:05 a.m. when CNA called me to help her clean Resident #1 up because we thought she was deceased . Nurse said there was not a DNR form in place and she had to start CPR. The crash cart was brought in and CPR was started then 911 arrived and took over." This statement was signed and dated by employee D on [DATE]. An interview on [DATE] at approximately 1:30 p.m. with employee D, confirmed she reported to Resident #1's room to assist. She was not asked to do anything at the time and did not know the chart that the nurse (employee A) brought to the room was not Resident #1's chart. She indicated that she along with all other staff had received training's and in-services related to how to verify resident information, advanced directives, and resident rights. Employee D indicated that CNA's are not asked to go and retrieve charts or to make copies. She confirmed that she did not make any copies for the nurse (employee A) during the time of the event with Resident #1 on [DATE]. An interview on [DATE] at approximately 10:00 a.m. with the Social Service Director was conducted. She was interviewed regarding to her duties and responsibilities related to resident advanced directives. The Social Service Director indicated as far as her responsibilities for obtaining advanced directives she would meet with the resident or family or representative the day of admission or the next day and go over admissions to include advanced directives. She would assist them with explanation of advanced directives but would not make the decisions or point them either way of DNR or Full Code. She will let the resident or representative know that if the resident chooses DNR, they will have to also get an order from the Physician indicating DNR status. She further explained that until that order is obtained, the facility has a responsibility to perform CPR if the resident becomes unresponsive. The Social Service Director indicated that even if it is verbalized at the time that the resident is to be a DNR, they still have to wait until they get the DNR sheet and telephone order. The Social Service Director confirmed she is to assist the resident and family with explanation of advanced directives and not make the choice for the resident and or representative. She further revealed she is responsible for training all new staff upon hire in relation to advanced directives and resident rights. The Social Service Director indicated she has been part of the training and in servicing of staff after the [DATE] event with Resident #1. She has participated in "Code Blue" drills and also was involved with advanced directives training, resident rights, and resident information verification. The Social Service Director indicated that if a resident is admitted on a Saturday, since she only works Monday through Friday, information is taken down with admission assessment and charting. Even if the resident requests DNR, it still has to be verified with a "Yellow" DNR sheet and physician's order [REDACTED]. So, in short, until those advanced directives are ordered, it is the policy that CPR is performed unless the DNR order and telephone order are in chart. An Interview with the Medical Director on [DATE], at 2:30 p.m., in relation to the event that occurred with Resident #1 on [DATE], revealed he was made aware of the event on [DATE] via telephone from the NHA. He indicated that apparently Resident #1 was given CPR when she was a DNR. He further indicated that he was told that the nurse (employee A) brought the wrong resident's chart to the room and when she opened the chart she found that the resident (thinking it was Resident #1's advanced directives), was a Full Code and provided CPR and called 911. He confirmed that he was told the nurse (employee A) should not have provided CPR and honored Resident #1's advanced directives as being a DNR. He further confirmed that this is just something you cannot get wrong and cannot explain what was going through the nurse's (employee A's) head during the time of the event. The Medical Director also stated that it was human error and that everyone makes mistakes but everyone should use checks and balances to make sure the right information is clarified during "Code Status" situations. He indicated that he was present during the last QA meeting and listened to the situation and is in agreement on how the facility staff are going to move forward to ensure all resident advanced directives are honored. He indicated there are only so many checks and balances and having to many will only complicate things when verification is needed. He is aware of the arm bands, the advanced directives in the chart with yellow sheet, telephone order and electronic MAR with resident names and pictures and names on the doorway of the room. He did not have anything further to add other than he is satisfied on how the NHA is moving forward with her staff to ensure this does not happen again. He indicated that the nurse at the time should have taken the time to verify the name on the chart and the resident and that was totally an error on her part, not the facility as a whole. He stated he was satisfied with the Quality Assurance program (QA) and NHA and DON were working on to ensure plans are in place to ensure all those who are CPR certified are kept current. An interview with the Director of Nursing (DON) in relation to the event on [DATE] with Resident #1 could not be obtained. The DON had to leave the facility out of country and was not present on the days of the complaint investigation. Review of the Licensed Practical Nurse (LPN) employee A ' s record revealed she was hired on [DATE] and received Resident Rights, Advanced Directives, End of Life Care training on [DATE], prior to her first day providing care and services to residents. Further, review of employee A ' s " Healthcare Provider " and " American Heart Association " CPR card revealed an issue date of [DATE] with a " Recommended " renewal date of ,[DATE]. The CPR training was held at a Paramedics Plus Training Center with training provided by an instructor. On [DATE] at approximately 1:30 p.m. an interview with an instructor at this training center indicated per the American Heart Association and their office, they give a " Recommended renewal date for a month and year, but not a calendar day. She further explained that it is up to the Nursing home facility where the employee works, to notify employees that their CPR is expiring and can allow a couple more days after expiration to renew. In this case the nurse employee A ' s CPR had a " Recommended " renewal date of ,[DATE], which means the card is to expire on [DATE]. The event related to Resident #1 with nurse employee A. occurred on [DATE]. During the time of suspension, employee A. did bring in another CPR card with issue date ,[DATE] (no calendar day) and with a " Recommended " renewal date ,[DATE] (no calendar day) from the American Heart Association. Further review of employee A ' s record revealed she had no disciplinary actions since her hire date regarding Advanced Directives, Code Status or Resident Rights. This was verified with the Nursing Home Administrator. Review of all fifty-four Direct Care staff employee records revealed there were twenty-six employees that were CPR certified. All twenty-six employee CPR cards were reviewed and determined to be current within expiration month and year and current with American Heart Association training/certification. Another interview with the NHA on [DATE] at approximately 9:00 a.m. indicated that as of [DATE] after the event, she and the administrative team to include the DON, Social Service Director and the Corporate Regional Nurse investigated the event and took the following measures: a. Training and in-services titled "Your role in Code Blue and Advanced Directives" were conducted and completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] with signatures of all "Direct Care" staff to include Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants (all those who would report and assist during a "Code Blue" call). However there were a couple of employees (non-direct care) who were on leave and were not given the training and in-service until they returned back to work on [DATE], and [DATE] (all of whom were either a therapist or therapist assistants). It was determined that 100% of all staff were trained and in-serviced by [DATE]. However, 100% of all "Direct Care" staff were fully trained and in-serviced by [DATE]. The in-services included information to staff to include, "Resident Identification" by: Verifying resident ' s identity by checking all identifiers such as 1. Chart Binder Label, 2. Wrist band, 3. Photograph in EZMar and 4. Door identifier. The information als

Based on clinical record review, policy and procedure review for Advanced Directives, CPR-Code Blue, and Abuse Prevention Policy and Procedure, Nursing Home Administrator (NHA) job description review, and interviews with staff and the 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 of seventeen Residents (#1) identified as having do not resuscitate orders (DNR). The facility initiated CPR on Resident #1, who was a [AGE] year old female and was admitted the facility for long term care and services. Resident #1 had a Do Not Resuscitate Order (DNR) completed by her appointed Durable Power of Attorney (DPOA) on [DATE] and Health Care Surrogate (HCS) and was signed by a Physician on [DATE]. Administration did not ensure the direct functions and continued 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. Advanced Directives of DNR were not implemented and carried out as facility personnel administered Cardio-Pulmonary Resuscitation (CPR) 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 which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: A review of the Nursing Home Administrator ' s Job/Position Description, which was signed but not dated, was provided for review by the Nursing Home Administrator who acknowledged that it was her Position Description. The document provided the following relevant information: Summary of Position: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility ' s business objectives. Essential Duties and Responsibilities to include but not limited to: 1. Management duties including, but not limited to, hiring, training and developing, couching and counseling, and terminating department staff as deemed necessary, 2. Monitor each department ' s activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed, 3. Oversee regular rounds to monitor delivery of nursing are, operation of support departments, cleanliness and appearance of the facility; morale of staff; and ensure resident needs are being addressed, 4. Exhibit positive customer service - both to internal and external customers, 5. Responsible for the QA (Quality Assurance) program, 6. Maintain a working knowledge of and confirm compliance with all governmental regulations, 7. Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and /or improvement of services, and 8. Recognize Stakeholders (employees) for exceptional care and job performance on a regular basis and as part of their performance evaluations. An interview with the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m. revealed as soon as she was called by nurse (employee A) on [DATE] regarding the expiration of Resident #1, she took note of it but did not know that she (employee A) had the wrong chart until later in the day. As soon as she figured it out the employee reported to Resident #1's room with another resident's chart unknowingly, and performed CPR on Resident #1 when she was deemed as a DNR, she immediately started an investigation and interviewed the nurse (employee A) regarding what happened. The NHA further indicated that she put the nurse (employee A) on suspension until the investigation was completed and was ultimately terminated. A review of the timeline related to the [DATE] event with Resident #1, as completed by the Nursing Home Administrator, revealed the following: 1. "11:00 a.m. call placed to the MD to replace midline on Resident #1, orders received." 2. "11:10 a.m., order written and chart left on nurse station." 3. "11:10 a.m. the family of (another resident - name indicated) came to me (employee A)with a question, chart was placed on the nurse's station next to Resident #1's chart. " 4. "11:12 a.m. CNA (employee B) reported to nurse (employee A) that Resident #1 was unresponsive, nurse (employee A) ran to the room and observed Resident #1 to be very pale, unresponsive with a faint heart rate." 5. "11:16 a.m. Nurse (employee A) ran back to the nurses station and attempted to place a call with the on call MD. While on hold she noticed multiple staff members running to the Resident #1's room. Assuming a change in status, nurse (employee A) grabbed the resident's chart from the nurse's station and ran to Resident #1's room." 6. "11:16 a.m. Resident #1's bed was lowered and the CPR board was placed under her at this time it was noted that she took a gasp of air and stopped breathing." 7. "11:16 a.m. Nurse (employee A) placed the wrong residents chart on the dresser of the room and opened the chart directly to the advanced directives tab and stated to the staff in the room Resident #1 is a Full Code and we need to initiate CPR." 8. "11:17 a.m. Nurse (employee A) initiated CPR while simultaneously calling 911 from her cell phone. She then threw the phone to nurse (employee E) who answered questions about the resident from memory." 9. "11:17 a.m. Nurse (employee A), CNA (employee C), CNA (employee D) performed CPR per nurse (employee A's) request." 10. "11:21 a.m. EMS (Emergency Medical Service) arrived at the facility and took over CPR." 11. "11:21 a.m. Nurse (employee A) returned to the nurses station and opened the correct chart to the face sheet and a call was placed to Resident #1's family who stated resident had a DNR from the hospital. Nurse (employee A) ran back to the room and expressed this to EMS. EMS stated they could not stop CPR unless the DNR was in their hands." 12. "11:21 a.m. Nurse (employee E) removed the face sheet, medication list and labs from the chart in Resident #1's room and handed them to CNA (employee D) to make copies. While making copies the copier got jammed and copies were made on the fax machine on station 2. The copies were given back to nurse (employee E) and the nurse gave copies to EMS." 13. "11:30 a.m. Nurse (employee A) returned to the nurse station and also made copies (of the correct resident chart) for EMS and placed them on the desk." 14. "11:35 a.m. Resident #1's family faxed over the DNR and it was given to EMS. At this time CPR was stopped and the resident was pronounced deceased ." 15. "11:45 a.m. Nurse (employee A) placed a call to Resident #1's family to inform them of her passing. At this time EMS returned to the facility and stated to nurse (employee A) that they must have received the wrong resident's paper work at that time (employee A) gave EMS the correct paper work." On [DATE] the facility ' s Nursing Home Administrator also provided an Emergency Medical Services (EMS) run report depicting the EMS/Paramedic visit on [DATE] related to Resident #1. The report indicated that EMS arrived at the facility on [DATE] at 11:23 a.m. and then at the patient (Resident #1) at 11:24 a.m. and was back at the base at 12:08 p.m. The report notes further indicated that: [AGE] year old female found lying supine in bed, CO [MEDICAL CONDITION]. Witnessed [MEDICAL CONDITION] by staff at nursing home approx. ,[DATE] minutes PTA. Staff placed a hard board on bed under patient and began CPR. On our arrival, staff states patient (Resident #1) was a full code as there is no DNR paperwork on file. Staff say arrest was witnessed while she was in bed and staff were doing rounds. Staff state patient ' s health was rapidly declining over the last months. Pulse checked absent and PEA on monitor. FD (Fire Department) continued compressions and IO access began. Staff remained on airway until further FD help arrived. Unable to gain IO access initially and had to increase to a larger bore needle which was successful. Admin EPI every ,[DATE] minutes. Advanced airway in place which was confirmed via ETCO2, lungs sounds and absent epigastric sounds. Subsequent rhythm checks revealed PEA and asystole only. At approx. 17 minutes, staff came in the room and stated she (Employee A) was on the phone with family. Family stated they do not want us to perform CPR on patient as they have a DNR. Staff states they do not have a copy of the DNR and never got one. Family faxed over DNR during consult to cease efforts. Staff states they remember family talking about initiated paperwork for DNR orders due to her rapid decline in health recently but they never got the copy. Received a valid copy at approx. 24 minutes of total down time. Ceased efforts EOR. Interview with the DON and the NHA and Social Service Director on [DATE] at approximately 2:00 p.m. indicated and confirmed that the yellow DNR was indeed in the chart the entire time. They indicated that the EMS staff were referring to the information because it was the wrong chart that the Nurse had. The NHA further indicated that had the nurse (Employee A) had the right chart, there would not be an error in code status and she would have seen the DNR in the advanced directives section. Review of Licensed Practical Nurse (LPN) Employee A ' s Job/Position Description which was signed and dated on [DATE], revealed the following relevant information: Summary of Position: Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality care at all times. Environment duties to include but not limited to: Due to the nature of facility ' s business, worker may be exposed to occasional slippery floors, objects on floors, chemicals, sharp objects, hazardous materials and waste (including human), blood borne pathogens, and communicable diseases, as well as high-stress medical and/or life threatening situations. The Essential Duties and responsibilities include but not limited to: 1. Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment, 2. Confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility, 3. Verify the identity of the resident before administering medications/treatment, 4. Verify that prescribed medication for one resident is not administered to another, 5. Review the resident ' s chart for specific treatments, medication orders, diets, etc., as necessary, and 6. Review care plans daily to confirm that appropriate care is being rendered. The job requirements indicated that 1. Must have a current/active CPR certification, 2. Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity and 3. Strong analytical and problem solving skills. A written statement from Licensed Practical Nurse (employee A) dated [DATE] revealed: "On Sunday [DATE]st at approximately 11:00 a.m., I had placed a call to the physician to report that the midline of Resident #1 had infiltrated. Orders were received for a midline to be replaced. At that time I (employee A) had Resident #1's and another resident's (name not noted) chart on the desk. Certified Nursing Aide (CNA) (employee B) stated that she needed me in the room of Resident #1. I ran to the room and noted that Resident #1 was very pale in color, I returned to nursing station and again called the physician's office, while I was no hold I noticed that staff was running by toward Resident #1's room and I ran to the room with a chart that I thought was Resident #1's. My initial evaluation was that she had stopped breathing but did still have a pulse. I turned to the advanced directives tab in the chart and saw the "full code" insert. I began CPR (Compressions), (employee D) (employee C) were holding the face mask and bagging together. I called 911 from my cell phone in the room and gave some information to EMS, then handed the phone to nurse (employee E) to finish giving the information as I performed CPR. EMS arrived approximately ,[DATE] minutes later and took over CPR. I placed a call to the Nursing Home Administrator and notified her of the CPR and resident involved. I always call the Nursing Home Administrator and not the Director of Nursing. I placed a call to the family to notify of the situation and was informed that Resident #1 was a DNR, at that time I still didn't know that I had the wrong record and requested that they fax it over. Once the living will was received and given to the EMS the CPR was stopped by EMS. The paperwork from the record in the room was copied by nurse (employee E) pulled the records and (employee D) copied the records and gave them to the EMS. At some point the EMS stated that the paperwork was not for the right patient and requested the correct paperwork. At that time I realized that Resident #1 was a DNR. I didn't notify anyone, because at that time she had passed and I didn't think that it mattered. My documentation in the record did not reflect CPR performed". This statement was signed by (employee A), Licensed Practical Nurse. Multiple telephone communication attempts by the State survey team from [DATE] through to [DATE], with employee A, were unsuccessful. The Nursing Home Administrator provided a "Stakeholder Suspension Form" dated [DATE] for review. It indicated that employee A was suspended until the investigation was concluded. Employee A, her supervisor, the Nursing Home Administrator and a witnessed all signed and dated the form on [DATE]. Further interview with the Nursing Home Administrator indicated that employee A had been terminated as a result from their investigation. In review of the nurse (employee A ' s) employee file, it was noted upon her hire date on [DATE] (employed almost four years at the facility), she was given education, training and in-services related to but not limited to: " Death and Dying/End of Life " , " Documentation for Nursing Aides and Nurses " , " Advanced Directives " , " Customer Service " , and " Resident Rights " . Employee A did not have any disciplinary actions since her employment related to any of these areas. Further, it was reviewed and noted that employee A had a current CPR card indicating she was up-to-date with the American Heart Association provisions. The CPR training was held at a Paramedics Plus Training Center with training provided by an instructor. On [DATE] at approximately 1:30 p.m. an interview with an instructor at this training center indicated per the American Heart Association and their office, they give a "Recommended renewal date for a month and year, but not a calendar day. She further explained that it is up to the Nursing Home Facility where the employee works, to notify employees that their CPR is expiring and can allow a couple more days after expiration to renew. In this case the nurse employee A ' s CPR had a " Recommended " renewal date of ,[DATE], which means the card was to expire on [DATE]. Nurse A responded to Resident #1's emergency on [DATE], which is the day the resident died . During the time of suspension, employee A brought in another CPR card with issue date ,[DATE] (no calendar day) and with a "Recommended" renewal date ,[DATE] (no calendar day). It was determined that the nurse, employee A had a current CPR card with updated training from the American Heart Association. Further review of employee A's record revealed she had no disciplinary actions since her hire date regarding Advanced Directives, Code Status or Resident Rights. This was verified with the Nursing Home Administrator. Review of all fifty-four Direct Care staff employee records revealed there were twenty-six employees that were CPR certified. All twenty-six employee CPR cards were reviewed and determined to be current within expiration month and year and also current with American Heart Association training/certification Interview with the Nursing Home Administrator on [DATE] at 9:00 a.m. revealed that an investigation was started on [DATE] the same day that CPR was provided to Resident #1 by employee A, when she should have been treated as a DNR. She indicated employee A was immediately suspended and terminated as a result of the investigation. A written statement from Licensed Practical Nurse (employee E) dated [DATE] revealed: "I (employee E) was called to Resident #1's room. Writer entered resident room and observed resident unresponsive. The nurse (employee A) and two CNAs were present (employee C and D). Writer left room to retrieve crash cart, there was a crash cart present when writer arrived back to room. CPR was in progress with employee A during compression and employee D holding Ambu bag to resident's mouth and nose and employee C administering breath via bag. A few paramedics entered the rooms and took over the CPR process. Nurse (employee A) asked writer to make necessary copies from the chart that was sitting on top of the dresser in the patient's room. Writer removed face sheet and labs and writer gave employee C the papers that were removed from chart and she made copies and brought copies back to patient's room." This statement was signed and dated by employee E on [DATE]. An interview with employee E on [DATE] at approximately 11:00 a.m. revealed she did remember the event that occurred on [DATE] that involved Resident #1 and employee A. She indicated that she (employee E) did not realize she was making the wrong copies from another resident's chart. She further confirmed that as the secondary nurse who reported to the room, she assumed employee A had the right chart and when asked to make copies, she just ran them to the copier without thinking to look at the name. Employee E indicated that she along with all the other direct care staff have had training and in-services to include how to verify they have the right resident information when reporting to a "Code Blue" call. She further indicated she and all the other direct care staff have had training and in-services to include resident rights, advanced directives and accuracy of charting since the event which occurred on [DATE]. Employee E stated that she will verify all this information with the chart. Employee E verbally demonstrated that when a "Code Blue" is called she will get the chart for the room called and when gets to the room she will look at name badge on door and also on resident's wrist. She will then verify with another nurse and look at EMAR (Electronic Medication Administration Record) picture if have time. The Crash cart will be called upon and brought in by other staff. She indicated that she will then look at advanced directives for "yellow" DNR and telephone order that is placed on other side of the DNR sheet. If there is a DNR in place, she will not perform CPR and will chart and call the physician and Family. If no DNR in chart or cannot find one, she will then perform CPR. Employee E also stated that verifying the chart and the resident is "a standard of practice and is common sense to make sure you have the right chart." A written statement from Certified Nursing Assistant (CNA) (employee B) dated [DATE] revealed: "Passing Resident #1's room, I noticed the resident did not look good. I ran out of the room and back for the nurse to come to the room. I also sent a CNA and asked her to help clean the resident up in case she was not going to be sent out to the Hospital. Left the room to do something and never went back until she was gone." This statement was signed and dated by employee B on [DATE]. An interview on [DATE] at approximately 1:00 p.m. with employee B confirmed she reported to the Resident #1's room and had another aide go get a nurse. When the nurse reported she left the room and had to care for another resident. She indicated she does not know of anything else that happened. She did indicated that she along with all other staff were immediately trained and in serviced that day and the next day [DATE] related to how to ensure you have the right information for the right resident, advanced directives, "Code Blue" reporting and resident rights. Further interview with employee B indicated that CNAs are not normally asked to retrieve charts or make copies, and has never done so or has ever been asked in the past. A written statement from CNA (employee D) dated [DATE] revealed: "It was 11:05 a.m. when CNA called me to help her clean Resident #1 up because we thought she was deceased . Nurse said there was not a DNR form in place and she had to start CPR. The crash cart was brought in and CPR was started then 911 arrived and took over". This statement was signed and dated by employee D on [DATE]. An interview on [DATE] at approximately 1:30 p.m. with employee D, confirmed she reported to Resident #1's room to assist. She was not asked to do anything at the time and did not know the chart that the nurse (employee A) brought to the room was not Resident #1's chart. She indicated that she along with all other staff have received training's and in-services related to how to verify resident information, advanced directives, and resident rights. Employee D indicated that CNA's are not asked to go and retrieve charts or to make copies. She confirmed that she did not make any copies for the nurse (employee A) during the time of the event with Resident #1 on [DATE]. An Interview with the Medical Director on [DATE], at 2:30 p.m., in relation to the event that occurred with Resident #1 on [DATE], revealed he was made aware of the event on [DATE] via telephone from the NHA. He indicated that apparently Resident #1 was given CPR when she was a DNR. He further indicated that he was told that the nurse (employee A) brought the wrong resident's chart to the room and when she opened the chart she found that the resident (thinking it was Resident #1's advanced directives), was a Full Code and provided CPR and called 911. He confirmed that he was told the nurse (employee A) should not have provided CPR and honored Resident #1's advanced directives as being a DNR. He further confirmed that this is just something you cannot get wrong and cannot explain what was going through the nurse's (employee A's) head during the time of the event. The Medical Director also stated that it was human error and that everyone makes mistakes but everyone should use checks and balances to make sure the right information is clarified during "Code Status" situations. He indicated that he was present during the last QA meeting and listened to the situation and is in agreement on how the facility staff are going to move forward to ensure all resident advanced directives are honored. He indicated there are only so many checks and balances and having to many will only complicate things when verification is needed. He is aware of the arm bands, the advanced directives in the chart with yellow sheet, telephone order and electronic MAR indicated [REDACTED]. He did not have anything further to add other than he is satisfied on how the NHA is moving forward with her staff to ensure this does not happen again. He indicated that the nurse at the time should have taken the time to verify the name on the chart and the resident and that was totally an error on her part, not the facility as a whole. He stated he was satisfied with the Quality Assurance program (QA) and NHA and DON were working on to ensure plans are in place to ensure all those who are CPR certified are kept current. An interview with the Director of Nursing (DON) in relation to the event on [DATE] with Resident #1 could not be obtained. The DON had to leave the facility during the time of the complaint investigation. A review of Resident #1's closed medical record included the demographic/face sheet which indicated she was admitted to the facility from the Hospital on [DATE] for rehabilitation services and long term care. The resident was noted to be [AGE] years of age. During the time of admission, Resident #1 had advanced directives in place with a Health Care Surrogate as of [DATE] (prior to facility admission). The advanced directives further indicated the resident was a DNR status. A "yellow" Do Not Resuscitate (DNR) order with signatures from Resident #1 and the Physician revealed a date of [DATE]. The medical record included a cumulative [DIAGNOSES REDACTED]. The Advanced Directives section of the closed clinical record revealed the following relevant documents: a. A State of Florida Do Not Resuscitate Order form printed on yellow goldenrod paper and signed by Resident #1 and her Physician on [DATE]. b. A Living Will & Appointment of Healthcare Surrogate (HCS) indicating Resident #1 does not want 1. Cardio-pulmonary resuscitation (CPR) if her heart or breathing stops, 2. does not want a breathing machine if she is unable to breath on her own, 3. does not want Nutrition and fluids through tubes in her veins, nose or stomach, 4. does not want kidney [MEDICAL TREATMENT], a pacemaker or defibrillator, or other such machines, 5. does not want surgery or admission to a hospital intensive care unit, 6. does not want medications that can prolong her dying, such as antibiotics and 7. does not want Hospice involved in her care. This form was signed and dated by Resident #1, person appointed as HCS and two witness' on [DATE]. This form was also verified and notarized by a public notary. c. A General Durable Power of Attorney (DPOA), which was signed and dated by Resident #1, the appointee and a Notary Public of the State of Florida on [DATE]. d. An "Advance Directives / Informed Consent form indicating Resident #1 has a Durable POA and Designation of Health Care Surrogate indicated that Resident #1 has been informed of her rights and all rules and regulations regarding decisions concerning medical care, including: 1. The right to accept or refuse medical or surgical treatment, 2. The right to formulate and to issue Advanced Directives to be followed should I become incapacitated. This form was signed by Resident #1 and witnessed by the Physician on [DATE]. e. A review of the Advanced Directives Policy and Record dated ,[DATE] and revised on [DATE] revealed: It is the policy of the facility to recognize and support the use of Advanced Directives through family, staff and community education and to encourage the residents' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and sound medical judgement. If a resident has become incompetent, but has provided evidence of a properly executed Advanced Directive, the facility will implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. f. A review of the "Admission Packet Checklist", which was signed and dated by the Admissions Office, Business Office Manager and the Nursing Home Administrator, on [DATE], indicated that the Advanced Directives Informed Consent was completed and signed by Resident #1 and POA. The Admission Packet Checklist further revealed a section that included "Consent to Treatment," stating, The resident and responsible party consent to the administration of such care, treatment services, and medical or nursing procedures to the resident, as the Facility and resident's attending physician or nurse practitioner deem appropriate. The resident has the right to change this consent or to refuse treatment. A review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] under the "Cognitive Patterns" section revealed the Brief Interview of Mental Status (BIMS) score was a 14. Review of the Quarterly MDS assessment dated [DATE] (last full assessment), under the "Cognitive Patterns" section, revealed the BIMS score was 13. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental Status Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment." Review of the Telephone Orders for Resident #1 dated [DATE] indicated she had a DNR. A review of Resident #1's care plans initiated on [DATE] with the next review date due on [DATE], indicated that Resident #1 "Has Advanced Directives on record: Do Not Resuscitate (DNR), Living will on chart with interventions to include: 1. Chaplain services for emotional, psychosocial, physical and clinical needs of resident, 2. Discuss Advanced Directives with the resident and/or appointed Health Care representative, 3. Resident is capable of making informed consent regarding their health care decisions, 4. Staff to follow Advanced Directives for "Do Not Resuscitate". 5. Allow resident, if able to discuss feeling regarding their Advanced Directives, 6. Refer to Social Services as needed, and 7. DNR is signed and dated in record. An interview on [DATE] at 9:00 a.m. with the Care Plan Coordinator/MDS Coordinator confirmed that Resident #1 ' s care plan, reflecting "Advanced Directives" with interventions: to Do Not Resuscitate (DNR), was accurate and current. She confirmed the care plans for "Advanced Directives" were initiated on [DATE] and good through [DATE]. She indicated that prior to Resident #1 expiring, there had not been any plans to change the DNR status either by the resident or Power Of Attorney (POA). Review of the "Daily Skilled Nurse Notes" dated [DATE] 10:00 a.m., revealed "A call has been placed to physician on call service to inform physician of Midline Infiltration to antebrachial area of Left arm. At this time a return call is being awaited for by on call physician". At 10:05 a.m. "Call was returned by physician and new order to obtain new IV for completion of IV antibiotics was received. Pharmacy was phoned for services and currently awaiting their arrival." Further review of notes at 10:50 a.m. revealed, "Staff came to inform writer of change in status with resident. On encounter writer found that resident was completely pale in appearance, had fixated pupils and exhibited cheyne stoke breathing/ shallow respirations. Her B/P was ,[DATE], pulse 66 and respirations 10. She soon expired thereafter and went quietly at the time of 11:45 a.m. The physician ' s office was notified, family was phoned and made aware and administrator contacted and notified. A review of the facility ' s " Advanced Directives " Policy and Procedure with an effective date ,[DATE] and last revised on [DATE] revealed: It is the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education and to encourage the residents ' rights to self-determination through recognition and assistance with executing such directives. As long as the resident is competent to make decisions, his/her wishes will be followed to the maximum extent possible as dictated by State law and soun

Based on clinical record review and staff and family interviews, the facility failed to ensure that interventions were in place and appropriate supervision was provided to prevent an accident for one (Resident #53) of three residents investigated for falls out of the four Stage I sampled residents who presented with falls in the facility within the past 30 days. The facility discontinued an intervention of a chair alarm without evidence that the resident had improved in her functional capabilities and no longer presented a fall risk. In addition, the facility failed to implement other effective measures to ensure proper supervision was provided to prevent accidents. The resident sustained [REDACTED]. Following the fall, the resident was diagnosed with [REDACTED]. Findings include: During an interview with Staff F on 1/20/2015 at 11:50 a.m. he stated that Resident #53 fell on [DATE] and was sent out to the emergency room with a dislocated hip. A review of Resident #53's clinical medical record revealed that the resident was an eighty-nine year old female admitted to the facility on [DATE]. A review of the Accumulative [DIAGNOSES REDACTED]. On 12/31/2014 the [DIAGNOSES REDACTED]. In addition, a review of the Physician order [REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #53 was coded as requiring "Extensive Assistance (resident involved in activity, staff provide weight-bearing support)" for walking in her room with "One person physical assist". It further noted that she had a history of [REDACTED]. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #53 was coded as continuing to require "Extensive Assistance (resident involved in activity, staff provide weight-bearing support)" for walking in her room with "One person physical assist". A review of the Nursing Admission Information document dated 12/19/2014 revealed that a Fall Risk Evaluation was conducted for Resident #53. It noted that the Resident scored " 17 " (a resident who scored a 10 or higher is at risk). A review of Resident #53's x-ray results dated 12/26/2014 noted " There is no evidence of an acute fracture or dislocation seen. The patient is status [REDACTED]. " A review of the Interim Plan of Care dated 12/20/2014 revealed that Resident #53 was originally care planned to receive personal alarms as needed and a sensor pad. These interventions were highlighted and dated as being discontinued (personal alarms as needed discontinued on 1/2/2015; sensor pad discontinued on 12/21/2014). A review of the nursing notes revealed the following relevant information for Resident #53: On 12/31/2014, it was noted that the resident presented with "Unsteady Gait "on all three shifts. On 1/1/2015, it was noted that the resident presented with "Unsteady Gait" on all three shifts. On 1/2/2015, it was noted that the resident presented with "Unsteady Gait" on the evening and night shift. It further noted for the evening shift, "Alert with confusion. Encouraged to ask for (help) using call light when needing (assistance). " It was noted for the night shift, "2:50 a.m. Resident continues to get (out of bed) without assistance. Does not remember to turn light on." On 1/3/2015, it was noted that the resident presented with "Unsteady Gait" on all three shifts. It further noted for the night shift, "Confused at times." On 1/4/2015, it was noted that the resident presented with "Unsteady Gait" on day and night shifts. It further noted for the evening shift, "Resident alert with confusion, using the walker (with) unsteady gait, assisted to bathroom." On 1/5/2015, it was noted that the resident presented with "Unsteady Gait" on day and night shifts. It further noted for the night shift, "Alert with slight confusion." On 1/6/2015, it was noted that the resident presented with "Unsteady Gait" on day and night shifts. A review of a facility report dated 1/7/2015 revealed the following: " 1/7/2015 at 7:40 a.m. Resident sitting at bedside, having breakfast with call light in reach. fell . " A review of the Physicians Telephone order dated 1/7/2015 revealed an order for [REDACTED]. A review of Resident #53's x-ray results dated 1/7/2015 at 8:35 a.m. noted "There is posterior dislocation of femoral head with inward rotation of femur." A review of a SBAR (Situation, Background, Assessment, and Request) Communication Form and Progress Note dated 1/7/2015 revealed the resident sustained [REDACTED]. It further noted "Resident being transferred to (an acute care hospital)". During an interview with the MDS Coordinator on 1/22/2015 at 10:30 a.m. she stated that she assisted with creating the interim care plan for Resident #53. She confirmed that the resident was admitted as a fall risk into the facility, and that she had a bed and sensor alarm intervention implemented when she was admitted . After reviewing the Interim Plan of Care form dated 12/20/2014, she confirmed that on 1/2/2015 " someone " discontinued the alarms. She stated, "I don't know who did that. I don't know who would have done that. I would not have (discontinued) the alarms. " During an interview with Resident #53's family member on 1/22/2015 at 10:37 a.m. he stated that the facility did inform him when the resident first came into the facility that they were going to be using alarms for the resident because of her risk for falling. He stated that no one at the facility informed the family that they were discontinuing the use of alarms at any time. During an interview with Staff I via the telephone on 1/22/2015 at 10:42 a.m. she stated that on 1/7/2015 she was in the linen closet next to Resident #53's room. She stated that she heard Resident #53 holler for help. She stated that when she went to the resident's room, she saw the resident laying on her side on the floor near the bathroom. During an interview with Staff J, a Certified Nursing Assistant, on 1/22/2015 at 10:53 a.m. she stated that she has cared for Resident #53. She stated that the resident had both chair and bed alarms. Staff J stated she checked the resident frequently because she tried to get up by herself without asking for assistance. She confirmed that the alarms were used to alert staff that the resident was attempting to get up. During an interview with Staff M on 1/22/2015 at 3:35 p.m. she stated that she cared for Resident #53 when she was newly admitted to the facility. She confirmed that the resident had attempted to ambulate in her room without asking for assistance when she cared for her. She stated that the chair and bed alarms alert the staff when the resident is trying to get up so they can provide the resident with assistance. During an interview with the Nursing Home Administrator (NHA), on 1/22/2015 at 12:22 p.m. she stated that the facility's interdisciplinary team (IDT) got together to try and reduce the use of alarms in the facility. She stated that through interviews with the staff, the team decided to discontinue Resident #53's alarms on 1/2/2015. She stated that they did not review the resident's record when making this determination. She stated they just went off of the information received by the nursing staff. She stated nursing staff informed the IDT team that the resident was using the call light to request assistance and that the resident was ambulating with steady gait. She was asked about the nursing notes prior to the resident ' s fall noting unsteady gait and continued attempts to get out of bed without calling for assistance. The administrator stated that the staff must have given incorrect information during the interviews with the IDT. She confirmed that they have no documentation as to who was interviewed or what was stated during the interviews when they made the determination to discontinue the alarms. She further confirmed that no fall risk evaluation or documented assessment was conducted when they made the decision to discontinue the alarm interventions for Resident #53. She was asked if the family was notified that the alarms would be discontinued. She stated, "I don't know. I don't have an answer for that." During an interview with the Rehabilitation Director on 1/22/2015 at 12:45 p.m. she stated that Resident #53 was evaluated and that during the time period of 12/26/2015 to 1/1/2015 the resident continued to need assistance with transferring and was ambulating with contact guard assist. She stated one person needed to be with the resident during transferring. She stated that the resident's cognition and poor safety awareness had hindered her progress in therapy, as she did not consistently understand her limitations. An interview with the Director of Nursing (DON) and the NHA was conducted on 1/22/2015 at 12:55 p.m. The DON stated that the facility nursing staff used the fall risk evaluation to determine a residents risk upon admission, and they create an interim care plan for residents at risk for falls. She stated that on 12/19/2014, Resident #53 scored 17, and this meant that she was at risk for falls and the interventions of the alarms were put in place. The NHA stated that the assessment score does not indicate what interventions are used. The NHA stated, "It would be nursing judgment to put in the interventions. No evaluation would have been done prior to the discontinuation of the alarms. Alarms do not prevent falls." A subsequent interview with the NHA and the DON was conducted on 1/22/2015 at 2:34 p.m. The DON stated that, when a resident is admitted to the facility, the nursing staff completes the Nursing Admission Data Sheet and on this tool, a fall risk assessment is conducted. This assessment scores the resident ' s fall risk. She stated that the assessment helps to determine if interventions need to be put into place. The DON was asked if she expected the nursing staff to complete an assessment prior to discontinuing an intervention or prior to implementing an intervention. She stated, "Yes." The DON was asked if it was the expectation that the assessment was documented. She stated, "Yes." The NHA and the DON confirmed that there was no documentation related to the discontinuation of the intervention of an alarm for Resident #53.