Every finding on record at Gulf Coast Village

Based on observation, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to investigate a fall and implement individualized interventions to minimize the risk of further falls and fall related injuries for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility's policy and procedure titled, Fall Management Program with an effective date of 8/2018 and revision date of 10/24/2022 revealed, 1) All residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. 2) Preventative measures shall be taken to decrease the number of falls whenever possible. document fall as incident . following risk management/incident policy. The post Fall incident/Assessment form will be completed after each fall and any changes in interventions will be noted on the form, on the resident's care plan and Kardex (Provides instructions for care) and in the nurse's notes . A post fall huddle will be completed at the time of a resident fall . Use the huddle information to perform root cause analysis. Staff will work together to determine the underlying cause(s) and contributing factors . The interdisciplinary Team will meet daily and PRN (as needed) to review accident/incidents and determine if investigation of incident is needed and will assist with assessing for further intervention(s) . The interdisciplinary Team will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise.Review of the clinical record for Resident #1 revealed an admission date of 2/18/26. Diagnoses included ataxia (uncoordinated movements), vascular parkinsonism (condition causing movement issues like stiffness, slowness and walking problems), dysphagia (difficulty swallowing), pneumonia, moderate protein-calorie malnutrition, unspecified dementia, adjustment disorder with mixed anxiety and depressed mood, disorder of thyroid.Review of the End of (Prospective Payment System) PPS Medicare Part A Minimum Data Set (MDS) with an assessment date of 3/26/26 revealed that Resident #1 required supervision/touching assistance with bed mobility, sit to lying, sit to stand and transfers; substantial/maximal assistance with toileting hygiene and showering. The MDS documented that the resident's cognitive status was severely impaired.Review of the Post Incident Review form dated 5/19/26 revealed that on 5/19/26 at 11:35 a.m., Resident #1 was lying on the bed in her room when the family walked in. The family walked to the nurse and told the nurse to check the resident's eye. Upon the nurse's assessment, Resident #1 presented with bruises on the right eye area of the face. Resident #1 denied any discomfort, denied having pain. Resident #1 also presented with a minor right leg abrasion.Review of facility provided staff statements revealed that Occupational Therapy (OT) Staff B documented that on the morning of 5/19/26 she was going to attend to another resident when the resident pointed to Resident #1's room across the hall. OT Staff B said that Resident #1's legs were outside of the bed and both knees were resting on the floor mat next to the bed. She said the resident was assisted back to bed.Review of the care plan for falls initiated on 2/18/26 revealed the resident has a history of weakness and ataxia. The goal was to receive no injury due to falling. The interventions included to review information on past falls and attempt to determine cause of falls, record possible root causes; after, remove any potential causes if possible, educate as to causes. The fall care plan was not updated after the resident's fall on 5/19/26.Further review of the clinical record revealed that on 5/21/26, a Fall Incident Report documented that Resident #1 was found on the floor on provided floor mats. Resident #1 was confused and unable to express how the incident occurred. Resident #1 was assisted back to bed.On 5/26/26, the fall care plan was updated to include a perimeter defining mattress (raised borders to prevent rolling or climbing out of bed).On 5/26/26 at 9:07 a.m., Resident #1's room was observed. A perimeter mattress was in place on the bed with bilateral floor mats. In an interview, Resident #1 said that she fell and hit her eye. Resident #1 said she could not remember any other fall. A reddish purple discoloration was observed under the resident's right eye. On 5/26/26 at 1:00 p.m., in an interview OT Staff B said that on 5/19/26 around 11:00 a.m. she was walking in the hallway across from Resident #1's room. She said a resident alerted her to look at the resident across the hall. OT Staff B said that she observed Resident #1's legs out of bed with her knees on the floor mat. She notified RN Staff A. OT Staff B said that RN Staff A came in and assisted Resident #1 back to bed. OT Staff B said she observed the bruising around Resident #1's right eye.On 5/26/26 at 2:00 p.m., in an interview, the Director of Nursing (DON) said that a fall is any change in plane. She said someone being lowered to the ground, sliding out of a wheelchair, or two knees on the floor next to the bed is a fall. The DON said that she did not know that Resident #1 was found with her knees on the floor on 5/19/26 and must have missed the OT statement that Resident #1's knees were on the fall mats. She said the nurse should have done an incident report because it was a fall. She verified that no new fall interventions were put into place on 5/19/26 and verified that on 5/21/26 Resident #1 was found on the floor on the fall mats.On 5/26/26 at 2:40 p.m., in an interview, RN Staff A said he found out about the bruise to Resident #1's right eye on 5/19/26 around 11:30 a.m., when the family came in. He said that on 5/19/26 around 11:00 a.m., Resident #1 was slipping off the bed. He said Resident #1's legs were off the bed. RN Staff A, RN said OT staff B was in the room when he put Resident #1 back to bed. RN Staff A said that he did a full assessment and observed an abrasion to Resident #1's right lower leg. RN Staff A said that a fall is when a resident is lying on the ground. RN Staff A said he did not complete an incident report on 5/19/26 when Resident #1 was found with her knees on the floor mat next to the bed.On 5/26/26 at 4:14 p.m., during an interview, the Nursing Home Administrator (NHA) and the DON, said they were not aware of Resident #1's fall on 5/19/26 until today. The DON said that no one told her about the fall or the abrasion to Resident #1's right lower leg. The DON said they completed an investigation for the bruise to the resident's right eye but she did not read OT Staff B's statement during the investigation. The DON said that since they did not know about the fall, no interventions were put into place on 5/19/26. She said that RN Staff A did not mention the fall to her, the facility, or the police. The DON said that it was possible that the resident's fall on 5/21/26 could have been prevented if new interventions were put into place when Resident #1 fell on 5/19/26 but there was no way of knowing.

Based on record review, residents and staff interviews, the facility failed to ensure that the arbitration agreement signed by 3 (Residents #111, #115 and #107) of 3 residents reviewed provided the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that is convenient to both parties when there is a dispute. This has the potential to affect all residents residing in the facility.The findings included:Review of the Facility provided Arbitration Agreement, attachment J of contract revealed, Disputes . By signing this agreement Resident and Facility agree that the arbitration shall be administered by [name of lawyers association] in accordance with its Rules of Procedure . Location of Arbitration. The Arbitration will be conducted at a site selected by Facility which shall be either at Facility or somewhere within a reasonable distance of Facility that is convenient for both Facility and Resident . Time Limitation for Arbitration . In the event [name of lawyers association] is unable or unwilling to serve . Facility shall select an alternative neutral arbitration service within thirty (30) days after receiving the [name of lawyers association]'s notice and the selected arbitration service's procedural rules shall apply to the arbitration proceeding. Review of the clinical record for Resident #111 revealed an admission date of 4/29/26 and a signed Arbitration Agreement dated 5/1/26. On 5/5/26 at 11:34 a.m., during an interview, Resident #111 verified her signature on the Arbitration Agreement dated 5/1/26 but said she did not remember signing the contract and did not remember anyone discussing the Arbitration Agreement with her. Resident #111 asked if the Arbitration Agreement was for if she thought they were discharging her before she thought she was ready.Review of the clinical record for Resident #115 revealed an admission date of 4/30/26 and a signed Arbitration Agreement dated 5/1/26. On 5/5/26 at 11:40 a.m., during an interview, Resident #115 reviewed and verified his signature on the Arbitration Agreement dated 5/1/26. Resident #115 said he did not remember anyone discussing arbitration with him, did not know what it was and did not remember signing the contract.Review of the clinical record for Resident #107 revealed an admission date of 4/29/26 and a signed Arbitration Agreement dated 5/1/26. On 5/6/26 at 11:50 a.m., during an interview, Resident #107 verified her signature on the Arbitration Agreement dated 5/1/26 but said she did not know if she signed a contract. Resident #107 said that she did not know what an Arbitration Agreement was and no one had explained it to her. Resident #107 asked if it was where you know you go to the hospital and then have to go to rehab.On 5/6/26 at 12:30p.m., in an interview, the Admissions Director said she and her assistant handle the contract signing which includes the Arbitration Agreement (Attachment J). She said they let the residents know the arbitration agreement is optional and they have the option to decline and they explain to them what it means. The Admissions Director said she did not know what would happen if a resident declined to use the arbitration company listed in the Arbitration Agreement for representation. She would have to look into that. The Admissions Director said she would have to look into what would happen if a location within a reasonable distance from facility was not convenient for the Resident. On 5/6/26 at 12:40 p.m., in an interview, the Administrator said she saw where the arbitration agreement was specific to using the Lawyers Association listed in the arbitration agreement as the Arbitrator. She said she was not sure what would happen if the resident was not agreeable to that choice and would have to look into that. She reviewed the section indicating if the lawyers association listed in the arbitration agreement was unable or unwilling to serve as the arbitrator, then the facility chose the alternative. The Administrator said it offered the resident no choice. She said she would also have to look into what would happen if a location within a reasonable distance of the facility wasn't convenient for the resident.

Based on record review, review of facility policy and procedure, and staff interviews, the facility failed to develop and implement an individualized care plan to meet the needs of 1 (Resident #104) of 5 residents reviewed for care plan.The findings included:Review of the facility policy, Comprehensive Care Plans dated 4/11/2025 revealed, the facilities will develop and implement a comprehensive, person-centered care plan for each resident that reflects their unique needs, goals, and preferences, and ensures that all services are delivered in accordance with regulatory requirements and professional standards.Review of the clinical record for Resident #104 revealed an initial admission date of 4/16/2026. Diagnoses included but were not limited to, primary osteoarthritis left knee, aftercare following joint replacement surgery, unspecified psychophysiologic insomnia, unsteadiness on feet, muscle weakness (generalized), anemia in other chronic diseases, adjustment disorder with mixed anxiety and depressed mood.Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 scored 15 of 15 in the Brief Interview for Mental Status (BIMS), which indicates intact cognition. The MDS noted that Resident #104 was prescribed an anticoagulant (high-risk drug class).Review of Resident #104's Medication Administration Record revealed a physician's order dated 4/17/2026 for Eliquis (anticoagulant) 2.5 milligrams by mouth two times a day for 30 days for anticoagulant.Resident #104's care plan initiated on 4/18/26 failed to reflect the use of the anticoagulant.On 5/6/2026 at 2:00 p.m., in an interview, Registered Nurse Staff A verified that the use of anticoagulants was not included in Resident #104's care plan. She said that it should be listed in the care plan if a resident was on anticoagulants.On 5/7/2026 at 9:40 a.m., in an interview, the Director of Nursing said that when residents are on anticoagulation therapy, it should be reflected on the care plan.

Based on observation, record review and interviews, the facility failed to ensure the safe transfer with a mechanical lift of 1 (Resident #14) of 3 residents by failing to ensure the sling was properly placed and secured, resulting in a bruise to the resident's left upper extremity. The findings included:Review of the facility's Policy and Procedure titled, Free of Accident Hazards/Supervision/Devices policy (last revised 10/2021) noted, All resident environments will remain free of accident hazards as is possible and each resident will receive adequate supervision and assistive devices to prevent accidents.The policy further noted Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . The facility must provide an environment that is free from accident hazards over which the facility has control.Review of the facility's Policy and Procedure titled, Mechanical Lifts (last revised 8/14/2023) noted all staff receive orientation and annual training for mechanical lifts. This training includes safety considerations and how to operate the mechanical lift based on manufacture specifications. The training also includes sling selection, inspection and maintenance.Record review for Resident #14 showed an admission date of 2/26/23 with a diagnosis of ataxic gait (unsteady, uncoordinated ambulation) and repeated falls. Resident #14's Brief Interview for Mental Status (BIMS) score was 13 indicating intact cognition.Resident #14's Care Plan revealed, I may need two assist and a lift to transfer to the toilet or bath (dated 5/12/2025). Resident #14's Care Plan also noted to use padding between patient and lift sling during transfers as/if needed to prevent friction of skin/underarms (dated 6/23/2025).Review of the Nursing Weekly Skin Checks revealed on 10/16/25 Resident #14 had no skin issues.Review of a Incident-Post Incident Review dated10/22/2025 revealed Resident #14 had a 11.5 x 4 cm bruise dark with slight fading edges above the left antecubital (left elbow).On 11/20/25 at 7:28 a.m., in an interview Resident #14 said a Certified Nursing Assistant (CNA) used the mechanical lift to help her stand. She said while using the mechanical lift, the battery went out. She said the CNA left her hanging in the sling for 5 to 10 minutes while she left the room to go get a new battery. Resident #14 said she was very uncomfortable, was in pain and got a bruise on her left arm from the sling.Observation during the interview revealed a black and yellow discoloration measuring approximately 6 centimeters in length by 2 centimeters on the resident's upper left outer arm. Resident #14 said she did not know the CNA's name but said she had black and red hair. The resident said she told the CNA how to do the transfer, but she continued to do it wrong 2 days in a row.Review of facility provided undated investigation revealed:The resident was unsure this was the same incident previously reported on 10/9/2025.The CNA with red and black hair was CNA Staff G.On 10/9/25 Resident #14 said staff left her in a (brand name) full body mechanical lift. CNA Staff H and 3 Student CNAs were present during the transfer. The 3 student CNAs reported The [brand name full body mechanical lift] stopped functioning due to a depleted battery. CNA Staff H immediately retrieved and replaced the battery.The facility's investigation included an undated interview with CNA Staff H who stated that Resident #14 was upset because the battery of the full body mechanical lift had to be replaced and she was unable to explain to the resident.The incident investigation noted that on 10/22/25 at 9:30 a.m., the Assistant Director of Nursing (ADON) observed CNA Staff K and CNA Staff L conduct a sit to stand transfer with Resident #14. The observation noted, The resident was abruptly shifted sideways in the bed without any prewarning. The resident yelled ouch during the transfer. The resident was then pulled up into the sitting position by each CNA holding an arm and abruptly sitting her up and slid to the side of the bed. Her feet were placed onto the foot of the lift but were not properly placed until prompted by this nurse. The lift was locked with 1 lock only.The ADON documented, The CNAs then placed the sling under the resident's arms with her shirt wrinkled and bunched up. The sling was not properly placed on the resident. The sling was directly placed under the axilla area. The waist stabilizing belt was not connected around the resident to prevent the sling from slipping up into the axilla. The resident was lifted in the sling and taken to the bathroom and lowered onto the toilet.On 11/20/25 at 9:29 a.m., in an interview the Director of Rehab said Resident #14 refuses to use the mechanical lift because it is too painful. The Director of Rehab said Resident #14 reported that sometimes staff do not use the Sit-to-Stand lift correctly and it pinches her skin.On 11/20/25 at 12:04 p.m., in an interview the ADON said Resident #14 sustained the bruise because the resident refused to use the support belt on the Sit-to-Stand mechanical lift. The ADON said there was never a battery issue.When asked about intervening when she observed the 2 CNAs improperly place the sling to transfer the resident, she said, When they lifted her up, I needed to see how they were transferring. The ADON said she did not realize the safety belt was not on until after Resident #14 was in the air. The ADON said it would have been too dangerous to stop at the time.On 11/20/25 at 9:27 a.m., in an interview CNA Staff G said she did not work with Resident #14 in October 2025 and has never helped CNA Staff H with a resident transfer.On 11/20/25 at 1:59 p.m., in an interview CNA Staff H said Resident #14 has always used a Sit-to- Stand mechanical lift and has never used a full body mechanical lift. CNA Staff H said on 10/9/25 the lift stalled out during the transfer with 3 CNA students. She said CNA Staff G was not present during the transfer. CNA Staff H said they lowered the resident using the safety lever, retrieved a new battery and came back to complete the transfer. CNA Staff H said Resident #14 never complained of pain or bruising to her left arm. CNA Staff H said she was suspended and when she came back, she was told Resident #14 got a bruise from her which she said was not true.Review of the Incident-IDT Team Initial Post Investigative Review dated 10/23/25 noted The specific CNA the resident accused had not worked for a period of time and the bruise was new.On 11/20/25 at 12:33 p.m., in an interview the Nursing Home Administrator said they think the incident happened on 10/9/25 but was not reported until 10/21/25. The Nursing Home Administrator said CNA Staff H left Resident #14 with 3 student CNAs when the battery went out mid transfer to go get a different battery. She said the CNA got the battery, came back and lowered her. She said when it was reported on 10/21/25, the resident was unclear when it happened. She said she made suggestions on when it may have happened and narrowed it down to the two CNAs (CNA Staff G and CNA Staff H). The Nursing Home Administrator said the ADON reported the bruises to be fresh and could not be more than 1 to 2 days old. The Nursing Home Administrator said she believes Resident #14 sustained the bruise during transfer with the Sit-to-Stand mechanical lift because the resident refused to use the safety belt. The Administrator said there was no documentation Resident #14 refused to use the safety belt before 10/21/25.

Based on observation, review of facility policy and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.The findings included:Review of the facility policy Food Storage documented Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food will be stored a minimum of 6 inches above the floor 18 inches from the ceiling and two inches from the wall with adequate space on all sides of the stored items to permit ventilation.Refrigerated food storage, All foods should be covered, labeled, and dated. Frozen foods- All freezer units will be kept clean and in good working condition at all times. All foods will be stored off of the floor.On 11/17/2025 at 7:30 a.m., during the Initial Kitchen Tour with the Certified Dietary Manager (CDM), the following observations were made.Dietary Staff were not wearing hair restraints during meal preparation. The CDM explained the kitchen was shared with the Independent Living Facility and verified the Independent Living Facility dietary staff were crossing over to the nursing home side during meal preparation without hair restraint. On 11/17/25 at 7:40 a.m., an opened plastic container of a three bean salad and an opened plastic container of pudding were stored undated in the reach-in refrigerator. Photographic evidence obtained.On 11/17/25 at 7:40 a.m., the yellow emergency eye wash sink was dusty and had several small, deceased bugs in the basin. Photographic evidence obtained.On 11/17/25 at 7:55 a.m., the floor of the walk-in freezer was dirty with a large accumulation of black and brown dirt. A large amount of frozen white chunky substance was observed on the floor underneath the shelf to the right of the walk-in freezer.A clear plastic bin of fish was stored uncovered on the floor of the dirty walk-in freezer. Photographic evidence obtained.In the Bistro pantry food storage, there were two boxes of children's shoes containing child's pajamas in one box, the other was empty. The CDM said she did not know what the boxes were doing in the Bistro pantry. Photographic evidence obtained.Observation of the Bistro dining area revealed the cabinet under the coffee maker that was heavily soiled with brown and black dirt. Photographic evidence obtained.On 11/17/25 at 12:00 p.m., during an observation of the lunch meal in the memory care unit, multiple, small, flying insects were observed in the dining area. Family members were observed swatting at the flying insects.On 11/17/25 at 12:15 p.m., observation of the lunch meal in the Bistro dining area revealed multiple small flying insects.On 11/18/25 at 9:45 a.m., observation of the Transitional Care Unit (TCU) revealed the ice machine spout was rusty and coated with white residue. The inner aspect of the dispensing spout was rusty. The ice tray was rusty, and dusty. Photographic evidence obtained.On 11/20/25 at 7:15 p.m., in an interview the Administrator said they were working on addressing the fruit flies in the dining areas and the Certified Dietary Manager was doing weekly audits of the kitchen and dining areas.

Based on observation, review of facility policy and staff interview, the facility failed to maintain an effective pest control program to ensure a sanitary environment free from pests for residents. The findings included: Review of the facility's policy Pest Control documented The facility maintains an affective pest control program to remain free of pests and rodents. On-going measures are taken to prevent, contain, and eradicate common household pests.On 11/17/25 at 12:00 p.m., observation of the lunch meal in the memory care unit revealed multiple small flying insects in the dining area. Family members were observed swatting at the flying insects.On 11/17/25 at 12:30 p.m., observation of the lunch meal in the Bistro dining area revealed multiple small flying insects.Review of the facility control company summary of service reports revealed:On 10/17/25, 10/22/25, 10/29/25, 11/5/25 and 11/12/25 in the memory care unit the log documented Be sure to keep garbage can clean. Drain trap is dry allowing pest entry. Please add water to the drain to block pest entry. Recommend fly light.On 11/19/25 at 11:00 a.m., in an interview the Director of Nursing (DON) said this was the first time she was hearing about the fruit flies. She said she was new to the facility but would check with the Maintenance Director.On 11/19/25 at 11:15 a.m., flying insects were observed on an uncovered tray of Danishes provided by the kitchen and placed in the conference room table. The DON observed the flying insects on the Danishes and said, Don't eat them. The DON said they had a meeting with family members of residents in the Memory Care Unit the previous evening. She said 5 family members mentioned the flying insects on the unit.

Based on record review, review of policy and procedure and staff interviews the facility failed to develop and implement systemic appropriate corrective actions related to identified quality of care deficiencies related to falls and failed to identify and address unresolved quality deficiency related to food safety and sanitation in the kitchen.The findings included:Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) dated 4/22/25 revealed the objective of QAPI was to, Ensure care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available.Prevent deviation from care processes to the extent possible;Identify issues and concerns with facility systems, as well as identify opportunities for improvement; andDevelop and implement plans to correct and/or improve identified areas.Program Systemic Analysis and Systemic Action:(a) The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained .1. Review of the facility's survey history revealed:During a recertification survey conducted on 11/4/24 the facility failed to store and prepare food in a sanitary manner. A flying insect was observed on a bucket of chicken bouillon in the dry food storage area. Food items were stored on the floor of the dry food storage area. Black bio growth was observed on the walk-in refrigerator and walk-in freezer.The identified deficiencies were found corrected as of 12/5/24.During a recertification survey conducted on 5/1/25 the facility failed to maintain sanitary conditions in the kitchen, including a visibly soiled ice machine, and improper storage of a scoop in the ice machine. The three-compartment sink had an inadequate sanitizer level. Dietary staff were not wearing proper hair restraint, posing a risk of food contamination.The identified deficiencies were found corrected as of 5/30/25.During the recertification survey conducted on 11/20/25 the facility failed to maintain ongoing compliance related to sanitary condition in the kitchen, dining areas, storage and preparation of food. Flying insects were observed during meals in 2 of 3 dining areas observed. Dietary staff were not wearing hair restraints during meal preparation. Unlabeled and undated food was stored in the refrigerator. Uncovered fish was observed stored on the heavily soiled floor of the walk-in freezer. The outer aspect of the spout of the ice machine in the Transitional Care Unit was coated with white residue. The inner aspect of the spout was rusty. The ice tray was soiled and rusty.On 11/20/25 at 7:15 p.m., a meeting was held with the Administrator and the Director of Nursing (DON) related to the ongoing noncompliance related to unsanitary condition in the kitchen, and dining areas of the food serving institution.The Administrator said that they were working on addressing the fruit flies but had no documentation of interventions implemented or progress towards resolution. When asked about ensuring that improvements were sustained in the kitchen, she said, As far as the kitchen, the CDM (Certified Dietary Manager) is doing weekly audits.She said, If the audits are coming back good, then it's not an issue. If it is coming back with an issue, then it needs to be addressed.Review of the Plan of Correction Audit forms provided by the Administrator revealed the last audit was dated 11/7/25. A check mark was placed in the box under Hairnet Check, Ice Machine Check, Ice Scoop Check.The Administrator said she and the Regional go in the kitchen and audit. She said she went to the kitchen last week and saw hair nets, labeling and dating. The Administrator said she had no documentation of the audits she completed.The Administrator offered no explanation for the unsanitary condition observed in the kitchen and dining areas. She said some of the departments were effective, and some were not. They were moving in another direction in dietary. When asked to explain, she said the CDM resigned on Monday.2. On 11/20/25 at 7:30 p.m., during a review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, the facility provided a list of fall incidents from June 1, 2025, through November 20, 2025.Review of the facility provided fall incidents revealed:June 2025: 2 falls.July 2025: 7 falls.August 2025: 9 falls.September 2025: 14 falls.October 2025: 13 falls.On 11/20/25 at 7:35 p.m., in an interview the DON said as of 11/20/25 the facility has had 16 falls. One resident sustained 3 falls.Review of the QAPI minutes for September 25, 2025, revealed the number of falls reported during the QAPI meeting for August 2025 differed from the number of falls listed on the facility incident report list.The facility documented a total of 19 falls for August 2025 as follows:9 falls on the night shift (11:00 p.m., to 7:00 a.m.),5 falls on the evening shift (3:00 p.m., to 11:00 p.m.), and5 falls on the day shift (7:00 a.m., to 3:00 p.m.).The QAPI meeting minutes noted under Performance Improvement Plan (PIP) review: Falls 24%. Root cause: Saturday. Location: B wing.On 11/20/25 at 7:40 p.m., the Administrator said B wing was the Long Term Care wing of the facility. She said there was nothing documented in clinical leadership to show what they were doing to address the increase in falls.The DON said the number of falls reported to QAPI for August 2025 was inaccurate.Review of the meeting minutes for October 23, 2025, revealed the number of falls reported to QAPI for September 2025 differed from the number of falls listed on the facility's incident list for September 2025.The QAPI minutes documented a total of 25 falls with 7 repeat falls. 9 residents sustained minor injuries, and 2 residents were transferred to the Emergency Room. The meeting minutes noted 22 of the 25 falls occurred in residents' rooms.The QAPI minutes documented, QAPI to review fall locations and develop targeted prevention strategies.On 11/20/25 at 7:54 p.m., in an interview the Administrator said she did not have documentation of the QAPI targeted prevention strategies.The Administrator verified that the increased number of falls at the facility was a problem area that needed to be addressed. She verified that falls were discussed in QAPI but she had no documentation that the facility trended the falls to determine the root cause in order to implement appropriate systemic interventions to reduce the number of falls at the facility.

Based on record review, review of facility's Policy and Procedure, and staff interview the facility failed to ensure the clinical records were completely and accurately documented for 3 (Residents #115, #34 and #109) of 3 residents reviewed. The findings included:Review of the facility's Policy and Procedure titled, Change in Condition (CIC) Policy and Procedure revealed the purpose was to ensure timely identification, assessment, communication, documentation, and intervention when a resident experiences a change in physical, mental, or functional condition, in order to promote resident safety, meet regulatory requirements, and prevent avoidable transfers or adverse outcomes. A licensed nurse will assess the resident, notify the provider and family/responsible party as appropriate, initiate interventions, and document all actions . Change in Conditions Definitions: Any worsening, or sudden change in resident's: vital signs, cardiovascular status, respiratory status, pain level, skin integrity, mobility/functional ability signs of infection, bowel or bladder function or behavioral/emotional status. Responsibilities: Licensed Nursing Staff: Perform immediate assessment upon notification of change. Document finding in electronic health record. Notify the following as appropriate: Attending physician/Nurse Practitioner, resident and/or legal representative, and Director of Nursing (DON) or nursing supervisor. Monitor and re-assess the resident. Document follow-up actions and resident response.Review of the clinical record for Resident #115 revealed an admission date of 1/12/24. Diagnoses included diverticulosis of large intestine, gastrointestinal hemorrhage, pressure ulcer of sacral region, dementia, and bipolar disorder.Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/19/24 documented that the residents' cognitive status was moderately impaired.Review of the Advance Practice Registered Nurse (APRN) progress note dated 8/29/24 revealed Resident #115 was seen today at the request of staff after having 1 episode of emesis (vomiting) this a.m. Upon examination resident appears stable heart rate 98, blood pressure 145/72, respirations 18, oxygen saturation on 2 liters oxygen 98% and with no fever at this time. CBC (complete blood count) and CMP (comprehensive metabolic panel) in the a.m. to rule out acute infection or electrolyte imbalances.On 8/29/24 at 1030 a.m., the APRN ordered Zofran 4 milligrams 1 tablet to be administered every 4 hours as needed for nausea and Zofran 4 milligrams 1 tablet to be administered 4 times a day for 4 days for nausea/vomiting. Review of nursing progress notes revealed no documentation of the change of condition, and no follow up assessments.On 8/30/24 at 4:45 a.m., an alert note documented Resident #115 was a DNR (Do Not Resuscitate). No vital signs were noted. The Director of Nursing was notified. A message was left for the family to call the facility. They needed to be notified of the resident's passing.Review of the CBC and CMP collected on 8/30/24 at 1:35 a.m., showed the facility was notified of the lab results on 8/30/24 at 1:17 p.m. Resident #115 white blood cell count was 37.3 (normal 4.0-11.0).On 11/20/25 at 1:30 p.m., an interview was held with the Director of Nursing (DON) related to documentation of change in condition and follow up assessments. The DON verified the lack of change in condition documentation and follow up assessments. She said there was no nursing documentation about what happened to the resident. A Change in Condition form should have been completed. The family should have been notified. She said the laboratory results showed the resident had a massive infections somewhere.Review of the Facility Policy Activities of Daily Living (ADL's) dated 5/1/25 revealed, A resident who is unable to carry out ADLs will be provided the necessary care and services to maintain good nutrition, grooming, and personal and oral care. (b) The facility will provide care and services for the following ADLs: (1) Hygiene-bathing, dressing, and oral care.Review of the clinical record revealed Resident #34 was admitted to the facility 12/20/17. Diagnoses included cerebral palsy (neurological disorder affecting movement, balance and posture), congenital hydrocephalus (excess cerebrospinal fluid in the brain) and osteoporosis (weakened bones).Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 8/21/25 documented that the resident was dependent on staff all ADLs. The MDS noted Resident #34 scored 03 on the Brief Interview for Mental Status (BIMS), indicative of severe cognitive impairment.Review of the Care Plan initiated on 4/4/25 revealed Resident #34 was dependent on the staff for bathing. The resident preferred a bath/shower 2-3 times per week in the morning.Review of Certified Nursing Assistant (CNA) Documentation Survey Report for October 2025 and November 2025 revealed, ADL-Bathing: Friday & Tuesday night only . Must wash hair.There was no documentation Resident #34 received a bath/shower on 10/1/25 through 10/6/25, 10/8/25 through 10/30/25. There was no bathing or shower documented for November 2025.Review of clinical record revealed Resident #109 was admitted the facility 11/3/25. Diagnoses included pubis fracture (Break in one of the pelvic bones).Review of the admission MDS with an assessment date of 11/9/25 revealed the resident required substantial/maximal assistance with showering/bathing.Review of the Care Plan initiated on 10/2/25 revealed the resident triggered in ADLs. The interventions listed included no weight bearing restrictions, physical help to transfer into bath/shower and one person assist for bathing.The CNA Documentation Survey Report for November 2025 documented ADL-Bathing: Monday and Thursday 7pm-7a, full body shower done by staff. The Survey Report documentation showed Resident #109 refused a bath/shower on 11/3/25,11/13/25, and 11/17/25. Code 97 not applicable was documented for bath/shower on 11/6/25 and 11/13/25. There was no nursing documentation indicating the resident had refused a bath or shower on 11/6/25 and 11/13/25.On 11/20/25 at 2:55 p.m., in an interview the Director of Nursing (DON) said the expectation was for residents to get bath/showers on their scheduled days. The DON said if a resident refuses a bath/shower, the CNA should notify the nurse. She said the nurse should speak to the resident and document in the clinical record the reason for refusal. The DON verified there was no documentation that Resident #34 received a bath/shower 10/3/25, 10/10/25, 10/14/25, 10/17/25, 10/21/25, 10/24/25 and 10/28/25. The DON said CNA documentation did not exist for November for Resident #34. She said there was a glitch in the system and they were investigating. The DON said she could not explain why bath/shower was documented as not applicable for Resident #109.

Based on record review, review of facility's policy and procedure and staff interview the facility failed implement their policy and procedure and notify the office of the Long-Term Care Ombudsman of residents' discharges. The notification to the Ombudsman's office is to protect residents' rights to prevent unwarranted or unnecessary transfers or discharges and to prevent facilities from refusing to allow the residents return to the facility.The findings included:Review of the facility's Policy and Procedure Admission, Transfer, Discharge with a created date of 12/2019 documented, . Procedure. Provide notification to local ombudsman of all involuntary discharges, facility initiated discharges, including hospital transfers. Social Service or designee should provide the information to the ombudsman according to the format and frequency the specific ombudsman has requested (monthly, weekly notification via email/fax/scan/etc.Review of the facility's Admission/Discharge log from 7/8/25 through 11/20/25 revealed the facility had 244 discharges including:65 residents were transferred to an acute care hospital.20 residents were discharged to an Assisted Living Facility.120 residents were discharged home.5 residents were transferred to a skilled nursing facility.Review of a sample of discharged residents revealed: Resident #112 was admitted to the facility on [DATE] and discharged home on [DATE].Resident #24 was admitted to the facility on [DATE] and discharged to an Assisted Living Facility on 11/17/25.On 11/20/25 at 11:18 a.m., in an interview the Director of Nursing (DON) said she was not able to locate documentation that the office of the Long-Term Care Ombudsman was notified of the discharges.On 11/20/25 at 12:01 p.m., a representative of the State Long Term Care Ombudsman's office reported in an email that the facility has not notified the Ombudsman's office of any discharges or transfers to the hospital since 7/7/25.On 11/20/25 at 12:30 p.m., in an interview the DON said the Administrator contacted the office of the Long-Term Care Ombudsman and verified that the facility had not sent any resident discharge or transfer notification to the Ombudsman's office since 7/7/25.

Based on observations and interviews, the facility failed to properly store medications in a safe manner. Throughout the survey, medications were observed unattended at bedside, unsupervised on medication carts and medication carts left unlocked leaving these medications to be easily accessible to residents.The findings include:Review of facility Storage and Expiration Dating of Medications and Biologicals (last revised 6/30/3035) states the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The policy further states facility should ensure all controlled substances are stored in a manner that maintains their integrity and security. The policy also notes the facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration.On 11/17/2025 at 8:16 a.m. 2 medication cups containing pills were observed on Resident #66's tray table. Photographic evidence obtained. Resident #66 said the nurse left them there this morning.Review of Resident #66's Self-Administration of Medications form said the resident does not wish to self-administer medications or keep them at bedside.On 11/17/2025 at 8:30 a.m. B-Wing treatment cart was observed unlocked. Photographic evidence obtained. RN Staff J verified that the cart should be locked but was not.On 11/17/2025 at 8:35 a.m. treatment cart in the Cove Unit had 4 tubes of medicated cream on top of the care. Medication cart also had a loose pill on top of the cart. Photographic evidence obtained. RN Staff E verified the observations.On 11/17/2025 at 8:39 a.m. medicated creams were observed on Resident #94's nightstand. Photographic evidence obtained. RN Staff E verified the medicated cream was in the room and should not have been there.On 11/18/2025 at 8:25 a.m. the Cove Unit medication cart was observed unattended and unlocked. When RN Staff F was showed the unlocked medication cart and said oh that's horrible. She said the cart should have been locked. She said she went to give a resident medication and did not lock the medication cart.On 11/18/2025 at 2:22 p.m. the Cove Unit medication storage cart check was conducted with RN Staff F. Lorazepam 0.5 mg tablet (a controlled substance) seal was observed broken for pill #27. The pill was observed behind the broken foil and easily accessible. Photographic evidence obtained. RN Staff F said she questioned it during the narcotic count that morning but was told it was fine.During an interview on 11/18/2025 at 2:32 p.m. the Director of Nursing was informed of the Lorazepam storage on the Cove Unit medication cart. The Director of Nursing said it should not be stored like that and it should have been wasted.During an interview on 11/20/2025 at 2:54 p.m. the Director of Nursing said medications should not be at bedside. She said if a resident wants to have their medications at bedside, they need to complete the self-medication administration form. She said medication carts should not be left unlocked. She said medication creams and loose pills should not be stored on top of medication carts.

Based on clinical record review, review of facility's Policy and Procedure, resident representative and staff interview the facility failed to notify the resident's representative of a change in condition requiring treatment with a new medication for 1 (Resident # 115) of 3 residents reviewed for change in condition.The findings included:Review of the facility's undated facility's Policy and Procedure titled, Change in Condition (CIC) Policy and Procedure revealed the purpose was to ensure timely identification, assessment, communication, documentation, and intervention when a resident experiences a change in physical, mental, or functional condition, in order to promote resident safety, meet regulatory requirements, and prevent avoidable transfers or adverse outcomes. Change in Conditions Definitions: Any worsening, or sudden change in resident's: vital signs, cardiovascular status, respiratory status, pain level, skin integrity, mobility/functional ability signs of infection, bowel or bladder function or behavioral/emotional status. Notification Requirements. The nurse must notify the family/responsible party for significant changes, new orders, or transfer. Document notification attempts and conversations.Review of the clinical record revealed Resident #115 was admitted to the facility on [DATE]. Diagnoses included dementia, bipolar disorder, and recurrent major depressive disorder.Review of the care plan revealed that Resident #115 was at risk for complications related to dementia (Date initiated 1/17/24).Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/19/24 revealed Resident #115 scored 09 on the Brief Interview for Mental Status, indicative of moderately impaired cognition.Review of the resident's profile revealed Resident #115's Emergency Contact #1 was the Responsible Party and Power of Attorney for Care.Review of the progress notes revealed on 8/29/24 the Advanced Practice Registered Nurse (APRN)documented the resident was seen at the request of staff after having an episode of emesis (vomiting) that morning. The APRN documented, Upon exam patient appears stable heart rate 98 blood pressure 145/72 respirations 18, O2 sats (oxygen saturation) on 2L (oxygen) 98% and with no noted fever at this time. The APRN noted the patient had a suprapubic procedure the day before and during which episode did have hypoxemia (low blood oxygen) requiring BIPAP (machine that helps with breathing difficulties) but then did recover and was transferred back to facility on amoxicillin (antibiotic) which could be causative factor for patient's nausea this morning.The practitioner ordered a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel) to be done in the morning to rule out acute infection or electrolyte imbalance. The APRN also ordered Zofran 4 milligrams (medication that prevents nausea and vomiting) every 8 hours along with 4 milligrams by mouth every 4 hours as needed for breakthrough nausea.Review of the clinical record, including nursing progress notes and assessment failed to reveal documentation Resident #115's emergency contact was notified of the change in condition (vomiting), the laboratory test order, or the need to start a new medication (Zofran) for the nausea and vomiting.On 8/30/24 at 4:45 a.m., an alert note documented that Resident #115 was a DNR (Do Not Resuscitate). No vital signs noted (Pulse, respirations, blood pressure). A message was left for the resident's family to call the facility to notify them of the resident's passing. On 11/17/25 at 3:35 p.m., in a telephone interview Resident #115's responsible party said the facility never notified her of the resident's declining condition, the vomiting, the need to start a new medication and the laboratory test ordered.On 11/20/25 at 1:30 p.m., in an interview the Director of Nursing (DON) said there was documentation from any nurse about what happened to the resident. The DON said a Change in Condition note should have been completed and the resident's family should have been notified.

Based on observation, clinical record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide activities that meets the interests and accommodate the needs of 1 (Resident #7) of 3 residents reviewed for involvement in activities.The findings included:Review of the facility policy Activities Programs, effective 3/2005 (revised 8/2/23) revealed, Varied activities will be planned and routinely scheduled. Activities will focus on the following:1. To stimulate socialization and encourage fellowship.2. To help maintain muscle tone and coordination.3. To encourage and provide opportunities for mental functioning.4. To provide sensory stimulation.5. To reduce isolation, build self-esteem, and strengthen capabilities and identity.6. To provide entertainment.7. To strengthen existing spiritual tenets, and to provide an opportunity to express individual beliefs.Review of the clinical record for Resident #7 revealed an admission date of 6/14/24. Diagnoses included legal blindness, schizoaffective disorder with delusions, and major depressive disorder. The resident resided on the secured memory care unit.Review of the Annual Minimum Data Set (MDS) assessment submitted on 7/10/25 revealed Resident #7 scored 12 on the Brief Interview for Mental Status, indicating moderately impaired cognition.The MDS noted the resident's vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects) and did not wear corrective lenses.The resident interview for Activity Preferences noted it was very important to her to listen to music she likes, somewhat important to do things with groups of people and to do her favorite activities. Resident #7 required moderate assistance with ambulation.The care plan initiated on 6/15/24 noted Resident #7 would receive three one to one room visits and/or attend group activities per week for socialization and stimulation. The interventions as of 6/20/25 noted the resident's favorite thing to do was listening to music, she enjoyed live music, small social groups, hand and nail care. Staff was to offer reminders for activities and transport her to activities.Review of the Therapeutic Recreation Data Collection form dated 9/22/25 revealed to continue the resident care plan, Resident #7 had no changes in leisure interest. The form noted the resident enjoyed and observed live entertainment groups, listening to musicals, social groups, nail care and hand massages. She enjoyed listening to music, listening to the television and had visitors regularly. The resident also received one on one visit for social, emotional and stimulation needs.On 11/17/25 at 10:12 a.m., Resident #7 was observed in bed, in her room. She did not answer to her name. There was no activities going on at the time of the observation. The television set was not on. No radio was observed in the resident's room.On 11/17/25 at 10:30 a.m., Resident #7 remained in her room in bed. The television was not on. In an interview the resident said she was blind but was able to feed herself.On 11/17/25 at 12:24 p.m., Resident #7 remined in her room in bed.On 11/18/2025 at 11:42 a.m., Resident #7 was observed in her room in bed. The television was not on. There was no music playing.On 11/18/25 at 2:10 p.m., live music entertainment was observed in progress in the dining area of the secured unit. Resident #7 remained in her room. She was sitting on the edge of the bed.On 11/18/25 at 2:15 p.m., in an interview, Resident #7 said she enjoyed listening to all kind of music. When asked about participating in the live music entertainment in progress, she said she would have loved to go but she was blind and could not leave her room. She said she did not attend activities because no one assisted her to the activities. No staff was observed inviting and assisting Resident #7 to the live music entertainment from 2:10 p.m., to 2:40 p.m.On 11/19/2025 at 9:09 a.m., Resident #7 was observed in bed. The television was off. No radio was playing.On 11/19/25 at 9:13 a.m., in an interview about activities participation for Resident #7, Activity Assistant Staff C said, I do room visits and I talk to her. Staff C said she spent no more than 10 minutes with the resident several times a week. She said Resident #7 attended activities every day this week. Staff C said Resident #7 loved music. She attended the music activity the day before and enjoyed it.When asked about the observation of Resident #7 in her room during the music activity the day before, Activity Assistant Staff C did not explain and said Resident #7 also loved to have her fingernails painted. She always made sure the staff brought the resident to get her nails done. She said she kept a log of the activity attendance for each resident.Review of the activity calendar for the Memory Care Unit for November 2025 revealed Nail Care was listed for November 11 at 10:30 a.m. Hand and nail care was listed for November 18 at 9:30 a.m.Review of the individual recreation participation record for Resident #7 for November 2025 failed to show documentation Resident #7 attended the music activity on 11/18/25.On 11/11/25, U (unable) was entered for hand massage. Nail care was left blank.On 11/17/25, U was entered for nail care.There was no documentation Resident #7 participated in the hand and nail care listed in the activity calendar for 11/18/25.11 Room visits one to one were documented from 11/1/25 through 11/17/25.For Hymn sing, U was entered on 11/5/25 and 11/13/25.For Sing-a-longs, U was entered on 11/2/25, 11/8/25, 11/10/25, 11/15/25 and 11/16/25.On 11/19/25 at 10:00 a.m., in an interview, Resident #7 said she did not attend the music program the previous day because no one came to pick her up. The resident's fingernails were observed extending approximately 1/2 inch past the tip of the nail and had an accumulation of brown substance under the nails. The resident's fingernails were not painted.On 11/19/25 at 10:20 a.m., Activity Assistant Staff C was observed entering Resident #7's room. The resident was in bed. The television was not on and there was no radio in the room. In an interview, Activity Assistant Staff C verified Resident #7 did not have a radio. She said, I check on her all the time. I try to get her up. She likes music. She said she did not know if they put the music channel on the television for the resident. She said Resident #7 had a language barrier. She spoke creole and there were some staff who could communicate with her. Staff C did not reply when told Resident #7 was able to answer all interview questions in English. She said, I just do the basics, maybe she would like a book in [NAME]. Staff C said she did not know if the facility had books on tape but she had not seen any. On 11/19/25 at 10:30 a.m., in an interview the Activity Director said Resident #7 was blind but really loved music. She said, I do sensory, nail care for her, she comes out here and there. I spend 20 - 30 minutes with her several times a week.The Individual Recreation Participation Record for Resident #7 for November 2025 did not document the sensory care, nail care or the 20 - 30 minutes the Activity Director said she spent with Resident #7 several times a week.

Based on clinical record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #66 and #92) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability.The findings included:Clinical record review revealed Resident #66 was admitted to the facility on [DATE]. The Medicare Part A Skilled Services episode start date was 5/2/25.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC), and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (Form CMS-10055) issued to Resident #66 contained conflicting information.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC) noted that the effective date coverage of the current skilled services would end on 6/7/25.Resident #66 signed the form on 6/5/25.The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form noted, Medicare does not pay for everything, even some care that you or your health care provider think you need. The form specified that beginning on 5/2/25, Resident #66 may have to pay out of pocket for Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care received at the facility if he did not have other insurance that may cover these costs.The form did not include the estimate cost the resident would have to pay per day/item or service.The form contained instructions to check the box for one of the 3 options listed to choose whether the resident wanted to continue the care listed, bill Medicare for an official decision on payment, assume financial responsibility or that they did not want to continue the care.Resident #66 signed the form on 6/5/25 but no option was checked.As of 11/20/25, Resident #66 remained in facility as a private payor.Clinical record review revealed that Resident #92 was admitted to the facility on [DATE].On 9/22/25 Resident #92 signed the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage that beginning on 9/25/25 Resident #92 may have to pay $470.00 per day for room and board and $75.00 per unit/per discipline for therapy. The form noted the care receiving during the Inpatient Skilled Nursing Facility included Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care.The section where the resident is to indicate whether he wished to discontinue care, continue care and have Medicare billed, or continue care and pay privately was left blank.As of 11/20/25, Resident #92 remained in facility with a private payor source. On 11/20/25 at 4:50 p.m., in an interview, the Administrator said the Advance Beneficiary Notice of Non-coverage for Residents #66 and #92 were not filled out correctly. She said Residents #66 and #92 should have checked a box indicating whether they wished to continue care and whether they want Medicare to be billed if they choose to receive care after coverage ends.

Based on observation, record review, review of facility's policies and procedures, resident and staff interviews the facility failed to protect the residents' right to be free from verbal and mental abuse resulting in feeling of humiliation for 1 (Resident #35) of 3 residents reviewed. The findings included: Review of the facility's policy and procedure titled, Freedom from Abuse, Neglect and Misappropriation revealed, Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The facility policy also stated, Emotional or psychological abuse is the verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering which includes demeaning statements, harassment, threats, insults, humiliation and intimidation. Review of facility a posttest for the education for Freedom from Abuse, Neglect and Exploitation dated 1/20/2025 noted, A caregiver reportedly uses derogatory and humiliating language when talking to, and about a patient on the unit. What type of abuse is this behavior?. Record review revealed Resident #35 had a date of admission of 1/8/25. Diagnoses included difficulty in walking, unsteadiness on feet, need for assistance with personal care. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/17/25 revealed Resident #35's cognition was moderately impaired with a Brief Interview for Mental Status score of 11. Resident #35 was frequently incontinent of bowel and bladder and required partial/moderate assistance with toileting hygiene. Review of the progress notes revealed on 4/28/25 at 4:50 a.m., Licensed Practical Nurse (LPN) Staff G documented, Resident observed crying and when approached by writer and asked what was wrong, she replied, just leave me alone. Writer offered PRN (as needed) medications for pain and anxiety to which she replied she wanted, and positive effect noted thus far. On 4/28/2025 at 3:11 p.m., in an interview Resident #35 said last night she was having diarrhea. Certified Nursing Assistant (CNA) Staff H was upset at her for having incontinent episodes of diarrhea. Resident #35 said that when she reported having diarrhea to CNA Staff H, she yelled, Again at her. She said they gave her dirty looks while providing incontinent care. Resident #35 said, It made me feel humiliated. Resident #35 was observed crying. On 4/28/2025 at 3:42 p.m., in an interview Registered Nurse (RN) Staff F said Resident #35 was total care for incontinent care and needed help with everything. RN Staff F said she was unsure if Resident #35 had diarrhea last night. On 4/29/25 at 1:27 p.m., in a telephone interview Licensed Practical Nurse (LPN) Staff G said Resident #35, can get tearful from time to time but this was a little different. When asked about Resident #35 cognitive status, LPN Staff G said Resident #35 is one hundred percent with it. LPN Staff G said Resident #35 has baseline loose stool. When asked about the note written on 4/28/2025 at 4:50 a.m., LPN Staff G said Resident #35 did not come out and say why she was crying. LPN Staff G said Resident #35 was very dismissive and said to leave her alone. LPN Staff G said, It just felt like something was a little bit different about this situation. On 4/28/2025 at 2:25 p.m., in a follow up interview, Resident #35 said she could not stop crying after the incident. The resident said, It made me feel mortified. Resident #35 said she told CNA Staff H she was going to report her. CNA Staff H replied, Go ahead, I don't work here. On 4/30/25 at 8:00 a.m., in a telephone interview, CNA Staff H verified she was from a staffing agency and took care of Resident #35 that night. CNA Staff H said the resident, kept calling me over and over for a bowel movement in the bed. CNA Staff H said when she went in the room Resident #35 was crying. She told the resident, you don't have to cry. CNA Staff H said she told Resident #35 to give her a minute because she was with another resident, and I'll be with you. CNA Staff H denied yelling at Resident #35. On 5/1/2025 at 9:14 a.m., in an interview the Director of Nursing (DON) said, If abuse is suspected we should be notified right away. We separate the staff member and resident. We get statements and suspend the staff member involved. We then do a full investigation and report it to the state. On 5/1/2025 at 10:05 a.m., in a follow up interview the DON said they interviewed Resident #35. The resident said she felt the CNA was rude but not abusive. The DON said they have removed CNA Staff H from the schedule, launched an investigation and reported the incident. On 5/1/2025 at 11:04 a.m., in an interview the Administrator said Resident #35 didn't think she was abused but, we are going to file a report out of caution.

Based on observations, facility policy, and staff interviews, the facility failed to maintain sanitary conditions during food service, including a visibly soiled ice machine, inadequate sanitizer levels in the three-compartment sink, and kitchen staff without proper hair restraints, posing a risk of food contamination and potential foodborne illness. The findings included: On 4/28/2025 at 9:30 a.m., during the initial kitchen tour with the Certified Dietary Manager (CDM), the ice scooper was observed lying unholstered on the ice machine. Photographic evidence obtained. On 4/29/2025 at 11:35 a.m., during a follow up observation of the kitchen, the ice machine scooper was again observed lying unholstered on the edge of a table next to the ice machine. Photographic evidence obtained. On 4/30/2025 at 11:15 a.m., black biofilm buildup and crust-like debris were observed on the interior and exterior of the ice machine. Photographic evidence obtained. The CDM verified the observation. In an interview the CDM said the kitchen's policy was to clean and sanitize the ice machine monthly. Review of the cleaning log for the ice machine provided by the facility were for February 2024, and March 2024. The logs had no documentation the ice machine was cleaned and sanitized. On 4/30/2025 at 2:54 p.m., in an interview Lead Chef, Staff C, said the exterior cleaning expectation is daily. Staff C verified the logs were for January and February of 2024 and said the logs were for January and February of 2025 but staff forgot to change the year. Staff C said that the new kitchen staff, probably forgot to sign off. When asked about the missing documentation verifying the ice machine was cleaned and sanitized in the last two months, the CDM stated, I do not have an answer for that. Review of the Ice Machine installation, operation, and maintenance manual revealed, You are responsible for maintaining the ice machine in accordance with the instructions in this manual, and Exterior cleaning: Clean area around the ice machine as often as necessary to maintain cleanliness and efficient operation. On 4/30/2025 at 11:15 a.m. to 12:00 p.m., during tray line prep and observation, three individuals were observed walking through the kitchen without hairnets. One staff member was starting her shift and was redirected by CDM to put on a hairnet after the observation.

Based on observation, interviews and records review, the facility failed to provide the necessary service to maintain grooming for 1 (Resident 12) of 3 sampled residents dependent on staff for Activities of Daily Living. The findings included: Review of the facility's Activities of Daily Living Policy updated 4/29/25 noted, A resident who is unable to carry out ADLs will be provided the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The policy also noted, The resident's or representative's decision to refuse care and treatments will be documented in the resident's medical record. Record review for Resident #12 revealed an admitted [DATE]. Diagnoses included unspecified dementia. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/13/25 revealed Resident #12's cognition was severely impaired with a Brief Interview for Mental Status score of 03. Resident #12 required partial/moderate assistance for personal hygiene. On 4/28/2025 at 11:09 a.m. Resident #12 was observed in bed. The resident's left hand fingernails were tightly curled inward. The fingernails extended approximately 3/4 of an inch from the fingertips with a brown substance under the nails. Photographic evidence obtained. Review of the Certified Nursing Assistant (CNA) Kardex (a medical-patient information system) revealed Resident #12's bathing preference was on Monday, Wednesday and Friday during the 7:00 a.m., to 3:00 p.m. shift. The CNAs were to clean and trim the resident's nails on shower days. Review of the CNA documentation for bathing from 3/31/25 through 4/28/25 revealed Resident #12 received assistance with bathing on 3/31/25, 4/2/25, 4/4/25, 4/9/25, 4/12/25, 4/13/25, 4/14/25, 4/25/25, and 4/28/25. Review of the CNA documentation for the task of Nails cleaned and trimmed by nursing assistant on shower days for a look back period of 30 days failed to reveal documentation Resident #12's nails were cleaned or trimmed on shower days. The documentation for the question, Did you complete the task? showed, No data found. On 4/29/2025 at 1:24 p.m., Resident #12's left hand fingernails remained long, extending approximately 3/4 of an inch from the fingertip with a brown substance under the nails. In an interview, Resident #12 said no one had come around to cut her nails. She said she would like to have them cut. When asked, Resident #12 was not able to say the last time her fingernails were trimmed. On 4/30/25 at 10:10 a.m., in an interview CNA Staff I said someone comes around to cut residents' toenails. CNA Staff I said she was not sure are who cuts the residents' fingernails. Resident #12's fingernails were observed with CNA Staff I. She said they shouldn't be that long. CNA Staff I verified the lack of documentation in the CNA task that Resident #12's fingernails were cleaned and trimmed in the last 30 days. She said someone should have documented something. On 4/30/25 at 10:21 a.m., Resident #12's fingernails were observed with Registered Nurse (RN) Staff J. RN Staff J said, They are too long. Staff J said the Activities Director does nails but she wasn't sure if they trim the residents' nails. On 4/30/25 at 10:35 a.m., in an interview the Activities Director said they do not trim nails, they only paint them. On 5/1/2025 at 11:04 a.m., in an interview the Administrator said she did not want to misspeak for the nursing team on who is responsible for trimming nails. She said, if the Kardex noted, nails cleaned and trimmed by nursing assistant on shower days, then it should have been done.

Based on record review and interview, the facility failed to ensure physician's orders received via text for 1 (Resident #92) of 3 residents reviewed for change in condition were immediately documented, signed, dated, and implemented, creating the potential for a negative outcome. The findings included: On 4/28/25 at 12:32 p.m., in a telephone interview Resident #92's son said he visited his father on 12/23/24. He said his father had not been feeling right, had been cold and shaky. The son said he explained to the nurse that his father had problems in the past with potassium levels and asked if they could get the doctor to check his potassium levels. Record Review of Resident #92's chart revealed no progress notes were documented on 12/23/24, no documentation of notification to the physician was found for 12/23/24, no orders were found to be entered on 12/23/24 and no lab work was taken on 12/23/24. Further review of Resident #92's chart revealed a change of condition note dated 12/24/24 at 4:34 a.m., indicating the resident was exhibiting Altered mental status and Diarrhea. A progress note dated 12/24/24 at 5:16 a.m., documented the Resident was observed with acute change in condition at 4:15., a.m. EMS (Emergency Medical Services) was called, Resident #92 was emergently transferred to stretcher via EMS at 4:30 a.m. EMS noted Resident #92 was without pulse and breath as transferring to ambulance and began chest compressions. EMS observed coding patient while in ambulance in parking lot for approximately 20-25 minutes prior to departure for hospital and writer was told resident in cardiac arrest when departing parking lot at 5:05 a.m. Resident transferred to hospital. On 4/30/25 at 11:00 a.m., the Advanced Practice Registered Nurse (APRN) reviewed Resident #92's medical record. In an interview, she said she found nothing in the nursing log with a request from the family. She said his last lab draw was on 12/14/24, the potassium level was normal. The last time she saw Resident #92 on12/6/24, he was at baseline with no complaints. She said in the progress notes it looked like Resident #92's diarrhea started around December 20 or 21st. She said, normally they would order lab work with persistent diarrhea. On 4/30/25 at 11:57 a.m., the APRN returned and explained she found a text message in her phone dated 12/23/24 at 3:32 p.m. from the facility. The text message said Resident #92, is trembling and complaining of being cold, his son believes something isn't right since he recently was admitted to hospital for hypokalemia, vital signs within normal limits, alert and oriented times 3, blood sugar 148. Son is requesting lab work. Last labs was 12/14. The APRN responded to the text on 12/23/24 at 3:41 p.m. and ordered a Stat (Immediately) Complete Blood Count (CBC) with differential and a Comprehensive Metabolic Panel (CMP). ( A CBC with differential measures the number and types of blood cells, including white blood cell subtypes. A CMP assesses various substances in the blood related to metabolism, liver, and kidney function - including potassium). The APRN said she couldn't say which nurse sent the text. The APRN said the order was never documented or carried out. On 4/30/25 at 12:26 p.m., in an interview the Interim Director of Nursing (DON) explained each unit has their own telephone to contact the provider via text. She said when the provider responds, staff are supposed to follow up with what the provider ordered and the order should be entered into the electronic health record. The DON reviewed the phone for Resident #92's unit. She found the same text to the APRN dated 12/23/24. Photographic evidence obtained. The DON verified the text message included an order for Stat lab work. The DON reviewed the Electronic Health Record and did not find an order for stat lab work for 12/23/24. She did not find any progress notes or documentation of Resident #92's condition or contact with the APRN for 12/23/24. DON said a Stat order should be documented and acted on immediately. She said the nurse assigned to the patient that day had been an agency nurse and hadn't worked at the facility since January. The DON said there is a double check of orders when entered into the electronic health record, but she was not sure if there was any double check of the phone to ensure texted orders were not missed. The DON said they had been discussing moving away from the text system for orders. On 5/1/25 10:05 a.m., in an interview the interim DON said at this time there was no policy and procedure for medication orders as far as written, verbal, telephone or text. She said this was something they will need to look into.

Based on observation, record review and staff interviews, the facility failed to ensure dietary staff operating the low temperature dishwasher had the necessary training and competency to test the sanitizing solution to ensure the sanitation of dishes to prevent food borne illnesses of residents consuming an oral diet. The facility also failed to store food in a sanitary manner. The findings included: The facility policy Cleaning Dishes/Dish Machine stated, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The facility policy Dish Machine Temperature Log stated, Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. The facility policy for Food Storage #9 Stated, Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall with adequate space on all sides of stored items to permit ventilation. Racks and other storage surfaces will be clean and protected from splashes, overhead pipes, or other contamination. On 11/4/2024 at 9:30 a.m., during the initial tour of the kitchen with the Certified Dietary Manager (CDM), she explained the high temp dishwasher had not been working correctly and approximately two months ago had been converted to a low temp dishwasher requiring the use of a sanitizer. Dietary Aide Staff C was observed operating the dishwasher. In an interview Dietary Aide Staff A said he had been employed at the facility for approximately five or six months. He said he had never tested the sanitizer in the dishwasher. He did not know where the test strips were kept or that a sanitizer test was required. The CDM said the Head Chef was in charge of training the employees so she didn't know what training the staff had received. Review of the dishwasher logs for the month of October 2024 and November 2024 revealed the water temperature was entered on the log. The log did not contain documentation the sanitizer was checked to ensure it was at the manufacturer's recommended concentration to ensure the sanitizing of the dishes. Photographic evidence obtained. On 11/4/24 at approximately 9:45 a.m., the CDM said the dietary staff operating the dishwasher were checking the sanitizer before using the machine but not documenting it on the log. The CDM retrieved a bottle of test strips which she said were used to test the sanitizer in the dishwasher. The expiration date of the test strips was August 2024. On 11/4/24 at approximately 9:50 a.m., observation of the dry storage area showed a small flying insect on a bucket of chicken bouillon. Food items were observed stored on the floor. The CDM verified the observation of the flying insect on the bucket of chicken bouillon and the storage of food items on the floor. She said the facility had not had pest issues. Photographic evidence obtained. Observation of the walk-in refrigerator and freezer revealed black bio growth around the bottom of the freezer entry door and the refrigerator ceiling. Photographic evidence obtained On 11/5/2024 at 9:20 a.m., in an Interview the Director of Dining and Culinary said the dishwasher had been waiting on a booster (heater) from the contracted company for months now. He said that the Executive Chef was the person responsible to hire and train the kitchen staff. On 11/5/2024 at 9:40 a.m., in an Interview the Executive Chef said she has been employed at facility for seven years and has been the head chef for the past year. She said the booster needed for the high temp dishwasher has been on back order for seven months. They added the layer of sanitizer to the dishwashing process to ensure the sanitization of the dishes. The Executive Chef said she did not know that the dishwasher required daily monitoring/testing of the sanitizer. She said the contracted company came out and occasionally checked the machine to make sure it was working properly. She said the dietary staff who use the dishwasher were never trained to test the sanitizer, including herself. On 11/6/2024 at 11:00 a.m., in an interview the Administrator said the CDM informed her the sanitizer in the dishwasher was not being monitored but the facility had not had any incident of food borne illness in the past seven months. On 11/6/2024 at 12:30 p.m., in a follow up interview the Executive Chef she had not started training the kitchen staff since she was never taught how to test the sanitizer level. The Executive Chef said they had ordered replacement test strips. She said at this time there was no way to ensure the dishes were sanitized. On 11/6/2024 at 2:00 p.m., in an interview the executive chef said they started sanitizing the dishes in the three compartment sink since they had the appropriate strips for the three compartment sink. Review of the contracted company Regular Service Call report dated 11/4/2024 at 4:28 p.m. noted, The machine is currently in chemical sanitation mode until the back ordered parts for the booster heater arrive. The chemical line from the pump to the injector inlet was severed and sanitizer was being pumped on to floor. The line from the pump to the inlet has been replaced and the machine is properly sanitizing again. The previous visit report was dated 9/12/2024 noted the sanitizer was checked at that time and was working. No other monitoring for appropriate sanitizer level documentation was provided. On 11/6/2024 at 2:45 p.m. in a telephone interview the contracted company representative said that he tests the dishwashing machine monthly when he comes out for service. He said everyone in the kitchen should know how to test the dishwasher. He said he was informed the dishwasher had not been tested since the booster went out in April because no one knew it was required. The facility contacted him for test strips and to provide training to the kitchen staff on testing the sanitizer of the dishwasher.

Based on record review, residents and staff interviews, the facility failed to act promptly upon grievances expressed during resident council meetings. The findings included: The facility policy Grievance/Concern Policy created on 2/2010, last revised on 10/21, read, . Grievances can be filed verbally or in writing using the Grievance/Concern Form . The facility will make prompt efforts to resolve grievances . Grievances will be routed and tracked by the Grievance Officer/social services/Residence Director . Grievance Official in long term care is the social service director . Grievances will be responded to with 7 days for nonemergency concerns. The facility will notify the complainant to provide updates on resolution of the complaint . The manager responsible for investigating and resolving the grievance will complete the Grievance/ Concern Form, including the plan of resolution . Grievance Official/Resident Director will utilize a tracking system of all complaints to ensure proper follow-up. Review of the Resident Council Minutes dated 7/30/24 showed residents attending the meeting complained about not having enough staff to assist them back to their rooms from the bistro after their meals in a timely manner. The Resident Council Minutes dated 8/27/24 showed residents complained of lack of assistance from staff to and from meals on the weekends. Residents also complained of staff on the evening shift not answering call lights promptly. The Resident Council Minutes dated 9/24/24 and 10/30/24 showed residents at the meeting complained about call lights not being answered promptly on the night shift. The Resident Council Minutes do not list the names of the residents who attended the meeting or the names of the residents making the complaints. The Resident Council Minutes did not list resolutions to the complaints voiced at the meetings. Review of the Grievance Log for July, August, September and October 2024 showed no documentation of the grievances voiced during the resident council minutes. On 11/4/24 at 10:54 a.m., in an interview Resident #201's spouse complained staff at times did not answer the call light in a timely manner. On 11/5/24 at 9:12 a.m., in an interview Resident #148 said, At night I wait an hour or two hours for the aide to respond. I have got to where I just get up and go by myself. Resident#148 stated she had a history of falls with fracture. On 11/5/24 at 12:59 p.m., in an interview Resident #202's son said the facility was short staffed on the weekend. He said his mother sat in feces for over an hour. She is incontinent and has dementia and not able to use the call light. He said on Saturday she was soiled. They turned on the call light and it was an hour before someone came to change her. They said they were short staffed. On 11/7/24 at 12:56 p.m., in an interview the Social Worker said grievances voiced at resident council were not being logged on the Grievance Log. The Social Worker said he was not sure of the process for tracking and resolving grievances voiced during resident council meetings. On 11/7/24 at 1:17 p.m., in a follow up interview the Social Worker said the Activity Director reports the grievances voiced during the resident council meetings about call light response time and staffing issues to the Nurse Manager. He said there was no current process to document and track resolution of resident council grievances. On 11/7/24 at 1:56 p.m. in an interview the Administrator said she could not provide documentation of how the facility tracked and documented the resolution of grievances voiced during the resident council meetings.

Based on observation, record review, review of facility policy and procedure, resident and staff interviews, the facility failed to implement an ongoing resident centered activities to meet the needs of 2 (Residents #250 and #251) of 3 residents of the Transitional Care Unit (TCU) reviewed for activities. The findings included: Review of the facility policy for Activity and Lifestyle Program revised October 2022 noted the facility will provide an ongoing program to support residents in the choice of activities. The facility will plan and conduct daily activities and events. The facility will encourage residents and families to participate. The facility will provide activities off campus. The facility will engage residents in various levels of physical, intellectual, social and spiritual involvement, both active and passive individually and in groups. Review of the November 2024 TCU Life Enrichment Calendar: 11/4/24 2:00 room visits; 2:30 coffee and trivia (volunteer). 11/5/24 Puzzle books, card games, books, adult coloring books, newspaper are available in the TV room. 11/6/24 10:00 a.m. Pet Therapy with Rocky; 2:00 Room Visits; 2:30 Big Pin Bowling (Volunteer). 11/7/24 Puzzle books, card games, books, adult coloring books, newspaper are available in the TV room. 11/8/24 2:00 p.m. Room Visits; 2:30 p.m. Coffee and Trivia (Volunteer). Review of the clinical record for Resident #250 revealed an admitted [DATE]. The Admission Minimum Data Set (MDS) assessment with a target date of 11/1/24 noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The MDS noted it was very important to the resident to do things with groups of people, do her favorite activities, go outside to get fresh air when the weather is good, have books, newspapers and magazines to read, participate in religious activities. The resident's activity preferences were also noted on the Therapeutic and Recreation Data assessment completed on 10/30/24. On 11/4/24 at 2:45 p.m., Resident #250 was observed lying in bed. In an interview, the resident said there were no activities in the TCU. She said participated in Physical and Occupational therapy for one in the morning. She said, The rest of the day, there is nothing to do. Resident #250 said she loves to play Bridge but they did not offer any card games. She said she did not know the facility had staff to provide activities. On 11/4/24 at 3:00 p.m., observation of the TCU unit revealed a long dining room table with word search and coloring books and pencils, a bookcase with reading materials, and a cabinet with an assortment of puzzles and games. A small wall mounted television in a small room next to the dining room was on with the volume muted . There was no afternoon activity staff or activity in progress. On 11/5/24 between breakfast, lunch, and dinner, no organized activities or activity staff were observed in the TCU. Several residents were sitting around the dining room table looking at each other making small talk. There were 3-4 word search and coloring books in the center of the dining room table. On 11/5/24 at 3:35 p.m., in an interview a family member said she visited her loved one every day and there were no activities for the residents in the TCU. She asked the Unit Manager (UM) about BINGO for the TCU residents. The UM told her BINGO was in the main building. She asked the UM to bring the BINGO over to the TCU, she would call the numbers and residents could play. The UM never brought the BINGO game over. On 11/6/24 at 3:06 p.m., in an interview the Life Enrichment Volunteer Coordinator Staff X, said she fills in for activity staff when they are on leave. Staff X said the TCU has its own separate activity calendar, and it is posted on the wall in the resident's room. Staff X said the facility offers live entertainment, BINGO, chair exercise, crafts, baking cookies next week, trivia, and sing-a longs. On 11/6/24 at 4:46 p.m., during an interview in the room, Resident #250 said therapy is finished around 9:30 a.m., and there is nothing to do after that except eat lunch and dinner. The resident said no one comes to say anything about activities. The activity calendar was taped on the wall in the room. The resident said, I can't read that. The Resident said they don't offer transport to the main building for activities. The resident said she did not know there was a cabinet with games and puzzles. The resident said she pushed her wheelchair over to the area near the cabinet one time and staff gave her an evil look. The resident said she thought residents were not allowed to go over there. On 11/5/24 9:40 a.m. Resident #251 pushed the wheelchair outside for an interview. Resident #251 said there are no activities that suit her interest and there was no staff offering activities. Resident #251 said, All we do is sit around the dining room table with a few word search and coloring books. There is no activity director that she knows of and never an outdoor activity. She said she likes to play cards, and didn't know another resident liked card games. The resident said she missed her husband who passed away a while ago and she thinks about him every day. The resident said an activity would keep my mind off my sorrow about losing him. The resident's eyes began to fill with tears. On 11/7/24 at 12:36 p.m., in an interview Resident #251 said a dog visited the TCU once. The resident said, Maybe trivia once in the TCU, but it was like nothing. The resident said no one announces, invites, or coordinates activities in the TCU, so how would you know there is anything going on? The resident said someone's husband brought in the word searches and coloring books at the dining room table because there was nothing to do. She said, For activities over here, there is basically nothing. On 11/7/24 at 3:37 p.m., in an interview Activity Assistant Staff Y said the TCU is a rehabilitation-focused unit. The activities for those residents is the rehabilitation therapy.

Based on record review, facility's policies and procedures review and staff interviews, the facility failed to ensure staff followed established policies and procedures to honor the advance directives for full code status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, without a pulse or respiration. Clinical staff failed to ensure timely confirmation of code status and immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who had a full code status. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced dead by EMS. The failure to honor the residents' right to receive life saving measures, to include CPR, intubation, and defibrillation placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate Jeopardy (IJ). On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F678, F726, and F835. The facility's policy and procedure titled, Resident's [NAME] of Rights and Dignity Policy with a revision date of [DATE] noted, The resident's bill of rights reflects current federal and state standards governing patient's rights. These rights identify specific prerogatives according to the individual while he/she is a resident at this health care facility. The facility must enforce and ensure resident rights are enforced, including the resident has the right to . self-determination . and access to persons and services inside and outside the facility . The facility must promote and protect the rights of the resident . The facility's policy and procedure titled, Advance Directive. CPR-Cardiopulmonary Resuscitation Policy. Determining Code Status with a date revised of ,d+[DATE] noted, It is the policy of this facility to honor resident advance directives and provide basic life support, including CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives . Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) or other approved association unless: A valid Do Not Resuscitate order in place . Every competent adult has the fundamental right of self-determination regarding decisions pertaining to his or her own health, including the right to choose or refuse medical treatment . All competent residents have the right to choose or refuse medical treatment during their stay in the facility . Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation. The baseline care plan initiated on [DATE] did not include Advance Directives. The Social Service Admission data collection in the electronic clinical record with an effective date of [DATE] (three days after admission) and did not include advance directives. On [DATE] a physician's progress note noted, Advanced Directives: Full code. On [DATE] at 8:37 a.m., Registered Nurse (RN) Staff A documented in a progress note, This nurse went in to check blood sugar and noted that resident was not responding, at this time I checked for a pulse and respirations. Resident was noted to be with out [sic] pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form when I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I called the Daughter, then the on call nurse who directed me to call the DON (Director of Nursing). When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR for Resident #1. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find the yellow DNR (Do Not Resuscitate) paper. She was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs (Certified Nursing Assistants) respond right away. They check the code status by looking in the front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. On [DATE] at 3:01 p.m., the Administrator stated she started an investigation and so far she found out Resident #1 was found unresponsive on [DATE] at 5:19 a.m., and CPR not initiated until [DATE] at 6:10 a.m. The Administrator provided an investigation into Resident #1's delay in receiving lifesaving measures, including CPR which included staff statements, and a timeline of the event which she said she obtained from watching the facility's surveillance video. The investigation noted, At 5:19 a.m. (Staff A) RN (Registered Nurse) went into (Resident #1's room) to check the resident's blood sugar via fingerstick method. She found (Resident #1) unresponsive. She checked for a pulse, no pulse present, sent (Staff D) C.N.A (Certified Nursing Assistant) to get the B (Staff B) and D (Staff C) wing nurses to assist. They checked her code status in EMR (Electronic Medical Record), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR or DNR binder. (Staff B) went to get the crash cart and CPR was initiated at approximately 06:10am. EMS was called and arrived at 06:24 a.m. and pronounced resident deceased . Delay in the initiation of CPR . Licensed nurses involved suspended pending investigation . A review of Registered Nurse Staff A's statement dated [DATE] noted, I went to check the blood sugar for resident in (Resident #1's room). When I entered the room, I noted the resident was not responding to her name, then rubbed her arm to which did not respond. I then checked for respirations and a pulse which there was none. Resident was noted without pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form. When I did not find one I called the PCP to inform that resident had passed. Next I call the daughter, then the on call nurse who directed me to call the DON. When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. A review of Licensed Practical Nurse (LPN) Staff B undated statement noted, At 0530 (5:30 a.m.) or 0540 (5:40 a.m.), A wing nurse came to me for help regarding (Resident #1's room). Walked back to A wing then we checked there was no pulse. We checked code status looked in the chart, there was no code form. Looked in computer, I went to get crash cart. CPR was started when I came to the room. A review of RN Staff C's statement dated [DATE] noted, A wing nurse (RN Staff A) asked me for help around 0520 ish (approximately 5:20 a.m.) stating the patient in (Resident #1's room) was not breathing and had no pulse. I went to Unit and looked for DNR in chart and computer told her to start CPR because she's a full code. I then told her to ask (LPN Staff B) to double check with B wing nurse because he had recently had a death, and he might be able to tell her better. She then went to B wing to ask B wing nurse for help. B wing nurse came to Unit started looking for DNR told him there was no DNR. I then went and checked the patient myself and noted there was no BP (Blood pressure) or pulse. At this point A wing nurse called the DON. DON said to initiate CPR and call 911 and therefore she did. On [DATE] at 2:18 p.m., RN Staff A said in a telephone interview she started employment at the facility on [DATE]. She said on [DATE] at approximately 5:30 a.m., she went in Resident #1's room to do a blood sugar. When she found Resident #1 unresponsive, she went to D wing to get help from RN Staff C. They both started to look for a DNR. They looked in the computer and chart to see if she was a DNR or not. They were not able to find anything. They then went to B wing since that nurse had more experience. LPN Staff B told her not to worry about it, go into the computer or the chart to find out if the resident was hospice. She looked again and couldn't find a DNR. She then drew her own conclusion. She called the resident's daughter, the Unit Manager who was on call and told her to call the DON. She then called the DON who asked if Resident #1 had a DNR. The DON told her if they do not have a yellow DNR form, the resident is a full code. She then told Staff B and Staff C they needed to do CPR. RN Staff A said there was approximately a 15 minutes delay in initiating CPR. Review of the Emergency Medical Services Patient Care Record dated [DATE] noted the call to EMS was received on [DATE] at 6:14 a.m. The EMS Patient Care record documented, Primary impression: Cardiac arrest; Secondary impression: Respiratory arrest. The narrative read, Patient is in cardiac arrest. Nursing home facility staff state that patient was last seen normal around 4:15 this morning. Facility staff stated that when they went to check on her at 5:45 she was found in cardiac arrest. According to facility staff, CPR was delayed until shortly before contacting 911 . Oral tracheal intubation was elected and attempted. While attempting to intubate patient, it was noted patient had rigor mortis (post-mortem stiffening of muscles) to her jaw. Attempt was abandoned and time of death called shortly after. deceased patient was left with NH (Nursing Home) facility RN that was on scene. No further treatment was provided. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of a resident on his unit when RN Staff A came to the door and asked him to come and help her. RN Staff A said it was the first time she had someone die. He went in the room and was not able to find a pulse. He went to get the crash cart. He called RN Staff C from another unit. They started CPR and called 911. He said he checked for the code status on the computer and the file. He could not find a DNR. Resident #1 was a full code. He ran to the cart to start CPR. The nurse on duty RN Staff A did not know what to do but he knew what to do. RN Staff C and him did CPR until 911 came. Staff B did not know how long the initiation of CPR was delayed. On [DATE] at 2:48 p.m., in a telephone interview the DON said upon hire, staff receive training on advance directives. She said she has not looked at the training and could not speak to the content. She said the Social Service department was responsible to provide the information to new staff. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was busy taking care of one of his residents when RN Staff A came to ask for help. He said the resident he was taking care of was not in distress. He kept going back and forth between the two residents (his resident and Resident #1). He helped with CPR. He has been employed at the facility for five months, received training related to advance directives and was comfortable with the process. Review of the computer based training for Advance Directives noted a DNRO (Do Not Resuscitate Order) protocol and process that read, Upon admission, the resident and/or resident representative will receive information in regards to advance directives . All valid DNRO Forms . will be kept in front of the resident's chart. If no form in front of the chart resident is a Full code. Review of the personnel file for RN Staff A, LPN Staff B, and RN Staff C revealed they completed one hour on-line training for Do Not Resuscitate Orders-Florida respectively on [DATE], [DATE], and [DATE]. On [DATE] at 10:22 a.m., in an interview the Staff Social Worker said the Social Service Department was responsible to obtain advance directives upon admission. She said Resident #1 was admitted on a Friday. Since there's no one on the premises from the Social Service department on weekends, she did not meet with Resident #1 until Monday [DATE], three days after her admission. The SSD provided a paper document of section C of the Minimum Data Set which she said was in her office. The words Full and No AD were handwritten on the form. Full was circled. The SSD explained full meant full code and no Ad meant no advance directives. She verified the baseline care plan did not include Resident #1's advance directives and expressed wishes to receive CPR in the event of cardiac or respiratory arrest. She verified the resident's wishes were not documented in the baseline care plan and not available to staff to quickly make the determination to start CPR. The SSD said she did not enter care plans for advance directives until the care plan meeting. On [DATE] at 9:30 a.m., the Administrator verified the clinical staff on duty on [DATE] failed to honor Resident #1's advance directives by failing to immediately initiate lifesaving measures, including CPR in the absence of a DNR per the facility's established policy and procedure. The immediate actions implemented by the facility and verified by the surveyors included: The facility reviewed policies and procedures: [DATE] related to resident rights, Advanced Directives, CPR, DNRO form. On [DATE] and [DATE] the surveyor verified through review of items discussed during QAPI on [DATE] to include a review of the policies and procedures related to Advanced Directives, DNRO and CPR, Code policy procedure. A facility wide assessment was completed on all residents advanced directives. [DATE]. On [DATE] the surveyor verified through review of the facility wide assessment. The facility provided a resident census list with the residents with DNR status highlighted. Three random residents were reviewed for accuracy of code status. The code status was accurate on the audit list for Resident #2, Resident #3, and Resident #4. The facility immediately initiated education on the advanced directives/DNRO process to all staff [DATE]. There are 10 employees that will receive education prior to their next shift. On [DATE] the surveyor verified through review of the in-service education provided to staff. On [DATE] at 4:25 p.m., the Staff educator said the scheduler is to notify them when the staff returns to work. The Unit Manager on that shift will be responsible to ensure the education is done. Ad hoc QAPI conducted on [DATE] at 10:30 a.m. on advanced directives, DNRO, CPR. Attended: Administrator, DON, Medical Director, Infection Preventionist, Staff Education, Rehab Director, Social Services Director, Social Services Coordinator, Nurse managers (3) Life enrichment Coordinator. Systemic revision made to include Code Drills quarterly with debrief, feedback and plan, introduced a CPR checklist in clinical orientation. Staff notification to supervisor, off hours administration staff is located on the PCC dashboard and the unit information binder. On [DATE] the surveyor verified through observation of the binder located at the nurse's station of the Cove. On [DATE] the surveyor verified through review of the Ad hoc QAPI meeting and review of code drills with debrief form conducted on [DATE], [DATE] and [DATE].

Based on record review, facility's policies and procedure reviews and staff interviews the facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in the absence of a Do Not Resuscitate (DNR) Order for 1 (Resident #1) of 4 residents reviewed who was found without a pulse or respirations. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, had no pulse, and no respirations. Clinical staff delayed calling Emergency Medical Services (EMS) and did not initiate CPR for 51 minutes while attempting to locate a non-existent DNR order. CPR is a crucial life-saving technique that aims to sustain blood circulation and oxygenation in individuals experiencing cardiac arrest. Resident #1 was pronounced dead by EMS. The facility's failure to implement their policies and procedures and immediately administer CPR to residents who requires such emergency care placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate Jeopardy (IJ). On [DATE] at 11:28 a.m., the facility Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F726 and F835. The facility's policy and procedure titled, CPR-Cardiopulmonary Resuscitation Policy with a reviewed date of ,d+[DATE] noted, . Prompt initiation of CPR (cardiopulmonary resuscitation) is essential as brain death begins four to six minutes following cardiac arrest if CPR is not initiated within that time . Purpose. The facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders . Procedure . Identify code status/advance directive preferences by checking for a signed DNRO (Do Not Resuscitate Order) form in front of the chart . If no DNR order/advance directive exists or if advance directive does not indicate Do Not Resuscitate, begin resuscitation efforts . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation, and generalized muscle weakness. The physician's orders dated [DATE] did not include a code status. The care plan initiated on [DATE] did not include a code status. On [DATE] the physician documented in a progress note, Advanced Directives: Full code. Full code means if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. On [DATE] at 8:37 a.m., Registered Nurse (RN) Staff A documented in a progress note, This nurse went in to check blood sugar and noted that resident was not responding, at this time I checked for a pulse and respirations. Resident was noted to be with out [sic] pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form when I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I called the Daughter, then the on call nurse who directed me to call the DON (Director of Nursing). When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. Review of the facility's incidents investigations revealed on [DATE] the facility initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . Registered Nurse Staff A documented in a statement dated [DATE], I went to check the blood sugar for resident in (Resident #1's room). When I entered the room, I noted the resident was not responding to her name, then rubbed her arm to which did not respond. I then checked for respirations and a pulse which there was none. Resident was noted without pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form. When I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I call the daughter, then the on call nurse who directed me to call the DON. When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR paper. She said, she (RN Staff A) was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs respond right away. They check the code status by looking in front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. The Nurse Educator said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping, and maintenance. She said the first thing you see is the yellow DNR form in front of the chart. If there is no yellow DNR, the resident is full code and staff initiates CPR. On [DATE] at 2:18 p.m., in a telephone interview RN Staff A said on [DATE] at approximately 5:30 a.m., she went in Resident #1's room to do a blood sugar. When she found Resident #1 unresponsive, she went to D wing to get help from RN Staff C. They both started to look for a DNR. They looked in the computer and chart to see if she was a DNR or not. They were not able to find anything. They then went to B wing since that nurse had more experience. LPN Staff B told her not to worry about it, go into the computer or the chart to find out if the resident was hospice. She looked again and couldn't find a DNR. She then drew her own conclusion. She called the resident's daughter, the Unit Manager who was on call and told her to call the DON. She then called the DON who asked if Resident #1 had a DNR. The DON told her if they do not have a yellow DNR form, the resident is a full code. She then told Staff B and Staff C they needed to do CPR. RN Staff A said there was approximately a 15 minutes delay in initiating CPR. LPN Staff B documented in an undated statement, At 0530 (5:30 a.m.) or 0540 (5:40 a.m.), A wing nurse (RN Staff A) came to me for help regarding (Resident #1's room). Walked back to A wing then we checked there was no pulse. We checked code status looked in the chart, there was no code form. Looked in computer, I went to get crash cart. CPR was started when I came to the room. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of a resident on his unit when RN Staff A came to the door and asked him to come and help her. RN Staff A said it was the first time she had someone die. He went in the room and was not able to find a pulse. He went to get the crash cart. He called RN Staff C from another unit. They started CPR and called 911. He said he checked for the code status on the computer and the file. He could not find a DNR. Resident #1 was a full code. He ran to the cart to start CPR. The nurse on duty RN Staff A did not know what to do but he (LPN Staff B) knew what to do. RN Staff C and him did CPR until 911 came. Staff B did not know how long it took to initiate CPR. On [DATE] at 3:01 p.m., in an interview the Administrator stated based on her investigative findings, Resident #1 was found unresponsive on [DATE] at 5:19 a.m., and CPR was not initiated until [DATE] at 6:10 a.m. She said the findings were based on staff statements and watching the facility's surveillance video. RN Staff C documented in a statement dated [DATE], A wing nurse (RN Staff A) asked me for help around 0520 ish (approximately 5:20 a.m.) stating the patient in (Resident #1's room) was not breathing and had no pulse. I went to Unit and looked for DNR in chart and computer told her to start CPR because she's a full code. I then told her to ask (LPN Staff B) to double check with B wing nurse (LPN Staff B) because he had recently had a death, and he might be able to tell her better. She then went to B wing to ask B wing nurse for help. B wing nurse came to Unit started looking for DNR told him there was no DNR. I then went and checked the patient myself and noted there was no BP (Blood pressure) or pulse. At this point A wing nurse called the DON. DON said to initiate CPR and call 911 and therefore she did. On [DATE] at 3:09 p.m., in an interview CNA Staff E said he has been employed at the facility for less than three months and received orientation. He said the process when a resident is found unresponsive, without a pulse or respiration is to call the nurse. If he couldn't find the nurse, he would go and get the nurse from a different unit. If he couldn't find a nurse he would start CPR by himself. He said he would start CPR no matter what. He said he did not receive training at the facility but knew what to do from previous employment. On [DATE] at 3:15 p.m., CNA Staff F said if she found a resident without a pulse or respiration she would call the nurse. If she cannot find a nurse, she would call 911 first and then tell the nurse manager and they would call the resident's family. She said she would get the nurse manager's number from a book at the nurse's station of the unit. Staff F said they also have a book on the unit with all the yellow DNR forms. On [DATE] at 3:30 p.m., RN Staff G said if a resident is found unresponsive she would call for help, check the code status, and start CPR. When asked about the process to call for help to get assistance, she pulled her personal cellular phone and said she would use it to call someone. There's always someone around on the unit. She said she did not know about the facility's process to dial an established code from the phone to get assistance. She said, To be honest, I don't know. On [DATE] at 3:43 p.m., a mock code drill was observed. The Staff Educator dialed (four digit code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying, what is the code status? Someone please check the code status after the Staff Educator went back to nursing station, RN Staff G yelled Full code from outside room [ROOM NUMBER]. When asked how she determined the code status, she did not answer. On [DATE] at 4:15 p.m., the Staff Educator provided an evaluation of the code drill which noted, Stop once heard EMS (Emergency Medical Services) arrived. She said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was busy taking care of one of his residents when RN Staff A came to ask for help. RN Staff C said his assigned resident was not in distress but he kept going back and forth between the two residents (his resident and Resident #1). He helped with CPR. RN Staff C said he has been employed at the facility for five months, he received training related to advance directives, including CPR, he knew what to do and was comfortable with the process. On [DATE] at 1:30 p.m., a review of the surveillance video provided by the Maintenance Director showed: On [DATE] at 5:19 a.m., RN Staff A entered Resident #1's room. On [DATE] at 5:20 a.m., RN Staff A came out of Resident #1's room. RN Staff A was seen putting gloves on and walk down the hallway. She walked back toward her medication cart, stopped and was seen looking in another room. On [DATE] at 5:22 a.m., RN Staff A stood at the medication cart for a few seconds then walked toward the nurse's station at the end of the hallway. On [DATE] at 5:23 a.m., RN Staff A and CNA Staff D entered Resident #1's room, followed by an unidentified staff member. On [DATE] at 5:24 a.m., RN Staff A came out of Resident #1's room and walked towards the nurse's station. On [DATE] at 5:25 a.m., RN Staff A walked down the hallway and went back in Resident #1's room. On [DATE] at 5:26 a.m., RN Staff A came out of Resident #1's room and walked down the hallway toward the nurse's station. On [DATE] at 5:27 a.m., RN Staff A and RN Staff C were at the nurse's station. They walked down the hall. RN Staff C entered Resident #1's room, while RN Staff A stood at the medication cart in the hallway across from Resident #1's room. On [DATE] at 5:28 a.m., RN Staff C walked out of Resident #1's room and stood at the medication cart with RN Staff A. RN Staff A was looking through a green binder. CNA Staff D was observed leaving Resident #1's room and walked down the hallway. On [DATE] at 5:28 a.m., CNA Staff D walked back in Resident #1's room. On [DATE] at 5:31 a.m., CNA Staff D walked out of Resident #1's room carrying linen and went down the hall. On [DATE] at 5:32 a.m., RN Staff A walked down the hallway toward the nurse's station. RN Staff C remained standing at the medication cart. On [DATE] at 5:33 a.m., RN Staff C walked in Resident #1's room. On [DATE] at 5:34 a.m., RN Staff A and LPN Staff B walked down the hallway to the medication cart. RN Staff A opened and was turning the pages of a binder with LPN Staff B standing next to her. On [DATE] at 5:35 a.m., RN Staff C walked out of Resident #1's room and stood at the medication cart with RN Staff A and LPN Staff B. LPN Staff B was turning the pages of a green binder. On [DATE] at 5:37 a.m., LPN Staff B walked into Resident #1's room. RN Staff A followed LPN Staff B into the room. RN Staff C remained at the medication cart. On [DATE] at 5:38 a.m., LPN Staff B, and RN Staff A walked out of Resident #1's room, and stood at the medication cart with RN Staff C. On [DATE] at 5:39 a.m., RN Staff A walked down the hallway to the nurse's station, then walked back to the medication cart. LPN Staff B was opening and turning the pages of a green binder. On [DATE] at 5:40 a.m., RN Staff C, and LPN Staff B walked down the hallway to the nurse's station. On [DATE] at 5:42 a.m., RN Staff A walked down the hallway to the nurse's station. On [DATE] at 5:43 a.m., RN Staff A walked back to the medication cart, retrieved a green binder, and walked back to the nurse's station. RN Staff A, LPN Staff B, and RN Staff C stood at the nurse's station. On [DATE] at 5:46 a.m., RN Staff A walked back to the medication cart. On [DATE] at 5:47 a.m., LPN Staff B walked to the medication cart. On [DATE] at 5:48 a.m., RN Staff C, LPN Staff B, and RN Staff A walked down the hallway to the nurse's station. On [DATE] at 5:50 a.m., RN Staff A walked down the hallway to the medication cart. On [DATE] at 5:52 a.m., RN Staff A walked back to the nurse's station. On [DATE] at 6:07 a.m., RN Staff A walked back to the medication cart. On [DATE] at 6:08 a.m., RN Staff A pushed the medication cart down the hallway toward the nurse's station. On [DATE] at 6:09 a.m., LPN Staff B pushed a red cart down the hallway towards Resident #1's room, RN Staff A followed LPN Staff B down the hall. On [DATE] at 6:10 a.m., LPN Staff B walked back to the nurse's station and RN Staff A entered Resident #1's room, followed by CNA Staff D. On [DATE] at 6:11 a.m., RN Staff C entered Resident #1's room. On [DATE] at 6:12 a.m., LPN Staff B entered Resident #1's room. Review of the Emergency Medical Services Patient Care Record dated [DATE] noted the call to EMS was received on [DATE] at 6:14 a.m. The EMS Patient Care record documented, Primary impression: Cardiac arrest; Secondary impression: Respiratory arrest. The narrative read, Patient is in cardiac arrest. Nursing home facility staff state that patient was last seen normal around 4:15 this morning. Facility staff stated that when they went to check on her at 5:45 she was found in cardiac arrest. According to facility staff, CPR was delayed until shortly before contacting 911 . Oral tracheal intubation was elected and attempted. While attempting to intubate patient, it was noted patient had rigor mortis (post-mortem stiffening of muscles) to her jaw. Attempt was abandoned and time of death called shortly after. deceased patient was left with NH (Nursing Home) facility RN that was on scene. No further treatment was provided. On [DATE] at 11:35 a.m., in an interview the Administrator said the nurse is supposed to discuss the code status with the resident upon admission but they do not document it anywhere in the record or on the Electronic Medical Record (EMR). She said the facility's management company does not allow it. She said it was clear in the video footage. The nurses can be seen checking the EMR, and the hard chart and they still did not administer CPR for 51 minutes. She said the standard of practice is, If there is no DNR they have to start CPR. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures: [DATE] for Advanced directives, DNRO policy and procedure, CPR, Code policy procedure. On [DATE] and [DATE] the surveyor verified through review of items discussed during QAPI on [DATE] to include a review of the policies and procedures related to Advanced Directives, DNRO and CPR, Code policy procedure. The facility immediately reviewed, audited all residents who are considered a full code [DATE]. On [DATE] the surveyor verified through review of the audit completed and comparison of the audit results with random residents chart reviewed. The facility immediately audited and reviewed for completion required onboarding and annual education for Advanced Directives, DNRO policy and procedure and CPR, Code policy and procedure for all staff. [DATE]. On [DATE] the surveyor verified through review of the audit completed, and annual education for Advanced Directives, DNRO policy and procedure and CPR, Code policy and procedure for all staff. Corrective actions for nurses involved includes immediate suspension pending investigation. On [DATE] the surveyor verified through telephone interview of all three nurses involved in the incident on [DATE]. Completed mock code drills on [DATE] at 3:00 p.m., with nine employees responding, [DATE] at 3:43 p.m., with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m., with 16 employees responding, and 10:08 p.m., with eight employees responding. On [DATE], [DATE], [DATE] and [DATE] the surveyor verified through review of the mock drills completed with critique form. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE], [DATE] and [DATE] the surveyor verified through review of individual checklist of steps when a resident is found unresponsive and interview of six Licensed Nurses and six Certified Nursing Assistants. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives, DNRO policy and procedure, CPR, Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of the orientation and education plan provided Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) completed on [DATE] at 10:30 a.m. Attended: Administrator, DON, Medical Director, Infection Preventionist/Staff Educator, Rehabilitation Director, Social Services Director, Social Services Coordinator, Nurse Managers (3), Life Enrichment Director. On [DATE] the surveyor verified through review of the sign-in sheet and items discussed in QAPI and formulation of a Performance Improvement Plan, and interview with the Administrator and the DON.

Based on observation, record review, facility's policies and procedures review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR) when residents with full code status experience cardiac or respiratory arrest. On [DATE] at 5:19 a.m., clinical staff found Resident #1 in cardiac and respiratory arrest. Three nursing staff on duty (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and the calling for Emergency Medical Services (EMS) for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced deceased by EMS. The facility failure to ensure nursing staff were trained and competent in facility's policies related to advance directives, including CPR created a likelihood for residents identified as a full code being denied lifesaving emergency treatment to include CPR, intubation and defibrillation which can result in serious medical injury or death. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of pattern (K). On [DATE] at 11:28 a.m., the facility Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F678, and F835. The Gulf Coast Village Facility Assessment revised on [DATE] and reviewed by the Quality Assessment and Quality Assurance and Performance Improvement committed on [DATE] noted, Staff training/education and competencies. On hire mandatory (online training) is completed prior to staff stating on the floor training. They also complete an on-site nursing orientation that includes competencies and scenarios. Clinical checklist are completed upon hire for direct care nursing staff during orientation . Annual skills fairs maintain staff competencies. Drills including . code blue . are facilitated on a schedule throughout the year . The facility's policy and procedure titled, CPR-Cardiopulmonary Resuscitation Policy with a reviewed date of ,d+[DATE] noted, . Prompt initiation of CPR (cardiopulmonary resuscitation) is essential as brain death begins four to six minutes following cardiac arrest if CPR is not initiated within that time . Purpose. The facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders . Procedure . Identify code status/advance directive preferences by checking for a signed DNRO (Do Not Resuscitate Order) form in front of the chart . If no DNR order/advance directive exists or if advance directive does not indicate Do Not Resuscitate, begin resuscitation efforts . Review of the facility's incidents investigations revealed on [DATE] the facility initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . On [DATE] at 12:33 p.m., in an interview the Registered Nurse (RN) Staff Educator said on [DATE] during morning meeting she found out about an incident with the process for CPR. From information gathered CPR was initiated late when Resident #1 was found without a pulse or respirations. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR (Do Not Resuscitate) paper. She said, she (RN Staff A) was looking for the DNR or Full Code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and she also called the DON. The Nurse Educator said the process when a resident is found unresponsive is for staff to dial (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and the Certified Nursing Assistants (CNAs) respond right away. They check the code status by looking in front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. She said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping and maintenance. If there is no yellow DNR from in front of the chart, the resident is a full code and staff initiates CPR. She said RN Staff A did not follow the process. The Staff Educator said since the incident, she started educating the staff about the process and conducted a code blue drill since the incident. She provided a sign-in sheet for a topic of, Code Blue Drill dated [DATE] at 3:00 p.m. The form was signed by three therapists, one receptionist, two Certified Nursing Assistants, one Registered Nurse and two Licensed Practical Nurses. The form did not describe the content of the drill, or an evaluation of the response to the drill. The Nurse Educator said she did not document the staff response to the drill but there were some areas for improvement, not everyone responded or signed the form. On [DATE] at 2:48 p.m., in a telephone interview the Director of Nursing said she has been employed at the facility for one year. The initial training for Advance Directives and Code status is done in general orientation. She said the licensed nurses all went to school and also have the CPR certification verifying they are competent. The facility tells them where to get the DNR information. The process for DNR is done by the Social Worker during orientation. She said she has not looked at the content of the training. Everything is kept by the facility's management company. She said the Regional Nurse Consultant conducts code blue drills periodically but she did not know how often they were done. When asked how she verified the competency of the nursing staff to respond appropriately when a resident is found unresponsive, the DON said she's had conversations with all the nurses to make sure they know what to do if a resident is found unresponsive but since it's not documented anywhere, so it didn't happen. Review of the employee file for Registered Nurse Staff A revealed a date of hire of [DATE]. Review of the training transcript showed on [DATE] Staff A completed one hour of online training on Do Not Resuscitate Orders and 30 minutes training on Essential of Resident Rights. A Basic Life Support certificate with an issue date of [DATE] and a renew by date of ,d+[DATE] noted Staff A had successfully completed basic life support program. The employee file did not include a competency checklist for Registered Nurses. It included a competency checklist for Certified Nursing Assistant dated [DATE]. The competency/skills verification included the location of the crash cart and AED (Automated External Defibrillator). The checklist did not include a competency evaluation of Staff A's response in the event a resident is found unresponsive. On [DATE] at 2:18 p.m., in a telephone interview RN Staff A said the training she received during orientation included CPR and DNR but in her opinion, it wasn't extensive and was not very good. She said on [DATE] at approximately 5:30 a.m., she found Resident #1 unresponsive. She knew the first step was to find out is Resident #1 was a DNR. She went to D wing to get help from RN Staff C. They both looked in the chart and the computer but could not locate a DNR. They then went to B wing nurse to get help from LPN Staff B since he had more experience. They could not find a DNR. RN Staff A said she drew her own conclusion, called the resident's daughter, the Unit Manager on call and told them Resident #1 had expired. RN Staff A said she just got her nursing license. She said, they left three brand new nurses alone at night. She said she felt it was not safe, and the information provided was not clear enough. She needed to figure out for herself what to do. Review of the Florida Department of Health license verification website revealed RN Staff A's original license issue date was [DATE]. Review of the personnel file for LPN Staff B revealed a date of hire of [DATE]. Review of the training transcript showed on [DATE] Staff B completed one hour of online training on Do Not Resuscitate Orders and on [DATE] completed 30 minutes training on Essential of Resident Rights. A certificate of completion dated [DATE], noted Staff B successfully completed, and was certified in standard CPR/AED. The personnel file contained a Certified Nursing Assistant competency checklist dated [DATE]. The competency/skills verification included the location of the crash cart and AED (Automated External Defibrillator). The checklist did not include an evaluation of Staff B's response in the event a resident is found unresponsive. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of one of his residents when RN Staff A came to the door and asked him to come out to help her. He said he went in Resident #1's room. She did not have a pulse. RN Staff A said she did not know what to do. He called RN Staff C from another unit. He checked for the code status in the computer and in the file. He did not find a DNR. She was a full code. That's why he ran to the cart to start CPR. LPN Staff B said he works at night. He had three or four days of training. He said he did not know what happens during the day but at night there has been no training or code blue drill. He knew where the crash cart was because he's seen it. Review of the personnel file for RN Staff C revealed a hire date of [DATE]. Review of the training transcript showed on [DATE] Staff C completed one hour of online training on Do Not Resuscitate Orders and 30 minutes training on Essential of Resident Rights. The RN competency checklist signed by the Registered Nurse Consultant on [DATE] was not signed by RN Staff C. A certificate of completion dated [DATE], noted Staff C successfully completed, and was certified in Basic Life Support. On [DATE] at 3:01 p.m., the Administrator said, The nurses are nurses, had CPR certification and passed board. She said they were all CPR certified and it was not the facility's responsibility to teach them CPR. The Administrator looked at the competency checklist for RN Staff A and said she thought it included what to do when a resident is found unresponsive. On [DATE] at 3:09 p.m., in an interview CNA Staff E said he has been employed at the facility for less than three months and received orientation. He said the process when a resident is found unresponsive, without a pulse or respiration is to call the nurse. If he couldn't find the nurse, he would go and get the nurse from a different unit. If he couldn't find a nurse he would start CPR by himself. He said he would start CPR no matter what. He said he did not receive training at the facility but knew what to do from previous employment. On [DATE] at 3:15 p.m., CNA Staff F said if she found a resident without a pulse or respiration she would call the nurse. If she cannot find a nurse, she would call 911 first and then tell the nurse manager and they would call the resident's family. She said she would get the nurse manager's number from a book at the nurse's station of the unit. Staff F said they also have a book on the unit with all the yellow DNR forms. On [DATE] at 3:30 p.m., RN Staff G said if a resident is found unresponsive she would call for help, check the code status, and start CPR. When asked about the process to call for help to get assistance, she pulled her personal cellular phone and said she would use it to call someone. There's always someone around on the unit. She said she did not know about the facility's process to dial an established code from the phone to get assistance. She said, To be honest, I don't know. On [DATE] at 3:43 p.m., a Code Blue drill was observed in room [ROOM NUMBER] B. The Staff Educator dialed (four digits code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying what is the code status, someone please check the code status after the staff educator went back to nursing station. RN Staff G yelled Full code from the hallway. When asked how she determined the code status, she did not answer. On [DATE] at 4:15 p.m., the Staff Educator provided an evaluation of the drill which noted, Stop once heard EMS arrived. The Staff Educator said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was on duty when RN Staff A came to ask for help. He said he received training on CPR/DNR which included what to do when a resident is found unresponsive. He said he did not remember participating in any code blue drills. He said he was busy taking care of one of his resident and kept going back and forth between his resident and Resident #1. He said his assigned resident was not in distress but he kept going back and forth between the two residents. He helped with CPR. On [DATE] at approximately 7:30 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said a long time ago they used to receive in-services related to CPR, DNR. She said, Now they just put a paper in front of you and tell you to sign it. They don't explain anything. She said there are a lot of new graduates working the night shift. They do not know what to do and are left without supervision. She said they eliminated the night shift supervisor. She told the DON they were endangering the residents' lives. On [DATE] at 10:22 a.m., in an interview the Manager on Duty verified she was on call on [DATE] when Resident #1 passed away. She said RN Staff A called her at 6:00 a.m. and told her Resident #1 had died . Staff A was upset, she was crying. She said it was the first time she experienced a death. She had to tell her to calm down and breathe. Staff A told her Resident #1 was a Full Code. She asked specifically if she initiated CPR and called EMS, Staff A said, Yes. She then directed her to call the DON. When she came to work later that day the DON informed her Staff A never started CPR. On [DATE] at 10:59 a.m., in a telephone interview the Regional Nurse Consultant said the last mock code was done in [DATE] but she did not have the documentation. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures: [DATE] for Advanced directives/DNRO policy and procedure, CPR/Code policy and procedure. On [DATE] the surveyor verified through review of documentation the policies and procedures were reviewed. The facility immediately reviewed/audited all resident who are a full code [DATE]. On [DATE] the surveyor verified through review of audits and compared with five random residents records for accuracy, residents #2, #3, #4, #5, #6. The facility immediately audited and reviewed for completion of the required onboarding and annual education for Advanced Directives/DNRO policy and procedure and CPR/Code policy and procedure for all staff. On [DATE] the surveyor verified through review of plan for onboarding and annual education. The facility immediately reviewed CPR certifications for all appropriate staff. [DATE]. On [DATE] the surveyor verified through review of a sample of five nurses and five CNAs for CPR certification. The facility immediately provided education: Advanced Directives/DNRO policy and procedure, CPR/ code policy and procedure. [DATE]. On [DATE] the surveyor verified by review of the education provided and interview of four nurses and four CNAs. Administrator educated Social Services Director on determining code status on admission within 48 hours. Admissions RN will assist with this process. On [DATE] the surveyor verified through review of education provided and verification of code status for five new residents admitted within 48 hours, and documentation in baseline care plan. Corrective actions for nurses involved included immediate suspension pending investigation. [DATE]. On [DATE] the surveyor verified through review of schedule and telephone interview with the three nurses involved. Completed mock code drills on [DATE] at 3:00 p.m. with nine employees responding, [DATE] at 3:43 p.m. with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m. with 16 employees responding and 10:08 p.m. with eight employees responding. On [DATE] the surveyor verified through review of the documentation of the mock drills and documented response to the mock drills. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE] the surveyor verified through review of the signed individual step by step procedure when a resident is found unresponsive. On [DATE] five licensed nurses and five CNAs interviewed were able to describe the process to follow when a resident is found unresponsive. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives/DNRO policy and procedure, CPR/Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of the education plan and policies and procedures. Systemic revision made to include Code Drills quarterly with debrief, feedback and plan, introduced a CPR checklist in clinical orientation. On [DATE] the surveyor verified through review of the mock code drills with debrief and review of the CPR checklist in clinical orientation.

Based on observation, record review and staff interview, the facility's Administration failed to utilize its resources effectively by failing to ensure staff was adequately trained and knowledgeable in policies and procedures to honor residents' rights to advance directives, including the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. On [DATE] at 5:19 a.m., Resident #1 was found without pulse or respiration. The clinical staff on duty did not initiate CPR until 6:10 a.m., 51 minutes after Resident #1 was found unresponsive. Resident #1's wishes to be a full code and receive CPR was not documented in the baseline care plan, despite the Social Services Department being aware of the resident's full code status on [DATE]. Resident #1 was pronounced dead by Emergency Medical Services. The facility's failure to manage resources to ensure staff are aware of and honor a resident's expressed advance directives created a likelihood for residents to be identified as a full code being denied lifesaving emergency treatment to include CPR, intubation and defibrillation which can result in serious medical injury or death. This failure resulted in the determination of Immediate Jeopardy (IJ) as a scope and severity of pattern, (K). On [DATE] at 11:28 a.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F678, and F726. The Administrator's job description signed by the Administrator on [DATE] noted the Administrator provides the management expertise for achieving the goals and objectives of the program in accordance with the mission of the organization. The Administrator should develop an organizational plan that clearly assigns responsibilities for the program's services to functional departments and to individuals. The Administrator should develop, recommend, and implement a plan for continuity that ensures ongoing stability of the program. Such a plan should include performance standards that are stated in terms of continuous improvement targets, opportunities for internal and external development, and a system for evaluating the performance levels of all employees, consultants, and other service providers. The Director of Nursing job description signed by the Director of Nursing on [DATE] noted the Director of Nursing is responsible for ensuring that an adequate level of services is provided to each resident, documented appropriately and regularly evaluated. Instruct staff on various federal, state and facility's regulations, policies and procedures; monitors compliance. Delivery of Nursing Services: Analyzes and evaluates nursing care and related ancillary and therapeutic services rendered to improve quality of patient care and to plan the best utilization of staff time and activities. Develops, monitors, and maintains required and appropriate documentation on the residents' medical records to include a multi-disciplinary plan of care. Review of the facility's incidents investigations revealed on [DATE] the facility Administrator initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . On [DATE] at 3:48 p.m., the Administrator documented in the incident investigation, Determined that the licensed staff involved failed to honor resident's advanced directives as a full code in a timely manner . Conclusions: It is verified that the licensed staff involved delayed the provision of CPR. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR paper. She said, she (RN Staff A) was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs respond right away. They check the code status by looking in the front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. The RN Staff Educator said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping, and maintenance. She said the first thing you see is the yellow DNR form in front of the chart. If there is no yellow DNR, the resident is full code and staff initiates CPR. The Staff Educator said since the incident, she started educating the staff about the process and conducted a code blue drill since the incident. At this time, she provided a sign-in sheet for a topic of, Code Blue Drill dated [DATE] at 3:00 p.m. The form was signed by three therapists, one receptionist, two Certified Nursing Assistants, one Registered Nurse and two Licensed Practical Nurses. The form did not describe the content of the drill, or an evaluation of the response to the drill. The RN Staff Educator said she did not document the staff response to the drill but there were some areas for improvement, not everyone responded or signed the form. On [DATE] at 2:48 p.m., in a telephone interview the Director of Nursing said she has been employed at the facility for one year. The initial training for Advance Directives and Code status is done in general orientation. She said the licensed nurses all went to school and also have the CPR certification verifying they are competent. The facility tells them where to get the DNR information. The process for DNR is done by the Social Worker during orientation. She said she has not looked at the content of the training. Everything is kept by VOA (Volunteers of America). She said the Regional Nurse Consultant conducts code blue drills periodically but she did not know how often they were done. When asked how she verified the competency of the nursing staff to respond appropriately when a resident is found unresponsive, the DON said she's had conversations with all the nurses to make sure they know what to do if a resident is found unresponsive but since it's not documented anywhere, so it didn't happen. On [DATE] at 3:01 p.m., the Administrator said, The nurses are nurses, had CPR certification and passed board. She said they were all CPR certified and it was not the facility's responsibility to teach them CPR. On [DATE] at 3:43 p.m., a code blue drill was observed in room [ROOM NUMBER] B. The Staff Educator dialed (four digits code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying what is the code status, someone please check the code status after the staff educator went back to nursing station. RN Staff G yelled Full code from the hallway. When asked how she determined the code status, she did not answer. The Staff Educator provided an evaluation of the drill which noted, Stop once heard EMS (Emergency Medical Services) arrived. On [DATE] at 4:15 p.m., the Staff Educator said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. The Gulf Coast Village Facility Assessment revised on [DATE] and reviewed by the Quality Assessment and Quality Assurance and Performance Improvement committed on [DATE] noted, Staff training/education and competencies. On hire mandatory (online training) is completed prior to staff stating on the floor training. They also complete an on-site nursing orientation that includes competencies and scenarios. Clinical checklist are completed upon hire for direct care nursing staff during orientation . Annual skills fairs maintain staff competencies. Drills including . code blue . are facilitated on a schedule throughout the year . On [DATE] at 10:59 a.m., in a telephone interview the Regional Nurse Consultant said the last mock code drill was done in [DATE] but she did not have the documentation. The Registered Nurse Consultant said they do not use the term Code Blue when a resident is found unresponsive, staff has to call for help. She said last March she remember conducting some mock code drills when the facility had an interim Director of Nursing. They covered all shifts on all units. She said they went through two other staff educators and did not know where the documentation of the mock drills went. On [DATE], review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation, and generalized muscle weakness. The physician's orders as of [DATE] did not include a code status. The care plan initiated on [DATE] did not include a code status. On [DATE] the physician documented in a progress note, Advanced Directives: Full code. Full code means if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. On [DATE] at 10:22 a.m., in an interview the Staff Social Worker verified Resident #1's advance directives and code status were not documented in the baseline care plan. She said Resident #1 was admitted on a Friday. No one from the Social Service department work on weekends therefore she did not meet with Resident #1 until [DATE], three days after admission. Upon request for documentation of Resident #1's advance directives discussion, the Social Worker said the documentation was on a paper form kept in her office. She brought back a paper copy of section C of the Minimum Data Set Assessment with the word Full circled which she said meant full code and No AD which she said meant no advance directives. She verified the information of Resident #1's code status was not documented in the baseline care plan and not available to staff on [DATE] when Resident #1 was found unresponsive. On [DATE] at 11:35 a.m., in an interview the Administrator said the nurse is supposed to discuss the code status on admission with the resident but they do not document it anywhere in the clinical record or the electronic record. She said in the surveillance video, you can see the nurses checking the electronic record, the hard chart and they still did not administer CPR to Resident #1 for 51 minutes. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures for Advanced directives/DNRO policy and procedure, CPR/Code policy and procedure. On [DATE] the surveyor verified through review of documentation of facility's policies and procedures review. Administrator and DON educated by Clinical consultant on Advanced Directive/DNRO policy and procedure, CPR/Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of education provided and interview with the Administrator and the DON during a review of Quality Assurance and Performance Improvement process. The facility immediately reviewed/audited all residents who are considered a full code. [DATE]. On [DATE] the surveyor verified through review of the audits completed. The facility immediately audited and reviewed for completion required onboarding and annual education for Advanced Directives/DNRO policy and procedure and CPR/Code policy and procedure for all staff. [DATE]. On [DATE] the surveyor verified through review of the facility's audits of completion of onboarding and annual education for advance directives, DNRO policy and procedure and CPR/Code policy and procedure for all staff. The facility immediately reviewed CPR certifications for all appropriate staff [DATE]. On [DATE] the surveyor verified through review of CPR certification provided for licensed nurses and CNAs. The facility immediately provided education: Advanced Directives/DNRO policy and procedure, CPR/Code Policy and procedure. [DATE]. On [DATE] the surveyor verified through review of education provided for five licensed nurses and five CNAs. Corrective actions for nurses involved included immediate suspension pending investigation [DATE]. On [DATE] the surveyor verified through review of the staffing schedule, and on [DATE] by telephone interview with the three nurses involved. Completed mock code drills on [DATE] at 3:00 p.m. with nine employees responding, [DATE] at 3:43 p.m. with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m. with 16 employees responding and 10:08 p.m. with eight employees responding. On [DATE] the surveyor verified through review of the documentation of the mock drills and documented response to the mock drills. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE] the surveyor verified through review of the signed individual step by step procedure when a resident is found unresponsive. On [DATE] five licensed nurses and five CNAs interviewed were able to describe the process to follow when a resident is found unresponsive. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives/DNRO policy and procedure, CPR/Cod policy and procedure [DATE]. On [DATE] the surveyor verified through review of the education plan and policies and procedures. Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) completed on [DATE]. On [DATE] the surveyor verified through review of the Ad Hoc QAPI meeting and attendance sign in sheet. On [DATE] the surveyor verified through interview with the Administrator, DON and telephone interview with the Medical Director.

Based on review of facility policy and procedures, record review and staff interviews, the facility failed provide the necessary supervision and assistance to prevent avoidable accidents for 1 (Resident #900) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility. The failure to implement appropriate supervision resulted in Resident #900 sustaining a fall with major injury requiring the residents transfer to a higher level of care. The findings included: The facility policy Fall Management Protocol (revised 10/24/22) specified all residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. Preventive measures shall be taken to decrease the number of falls whenever possible . all staff will be responsible for fall prevention and monitoring. Review of the clinical record showed Resident #900 had an admitted [DATE] with diagnoses including cognitive communication deficit, hypertension, atrial fibrillation, and major depressive disorder. The Admission MDS (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 12/12/22 documented Resident #900 required limited assistance of 1 for ambulation in room. The MDS noted Resident #900's cognitive function was intact. The care plan initiated on 12/14/22 identified Resident #900 as at risk for falls and fall related injuries. The intervention included, keep needed items in reach, labs per physician order and report abnormal values, maintain a clear pathway free of obstacles. The Social Services progress note dated 12/20/22 documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The progress note documented resident #900 was packing her belongings and going to the front lobby. A wander guard was placed on the resident's right ankle. Resident demonstrated disorganized thinking, rambling and illogical flow of ideas. The physician was notified and ordered blood work to be obtained. The nurse progress noted dated 12/21/22 documented Resident #900 refused the blood work and was observed to be upset. Certified Nursing Assistant (CNA) was staying close to resident for safety related to high fall risk and previous elopement incident on 12/20/22. Review of the nurse progress note dated 12/21/22 at 4:58 a.m., documented Resident #900 was observed more agitated and requesting to go home. Resident said if she was not allowed to go home by 1:00 p.m., she would walk out the door and leave. The Registered Nurse Practitioner (RNP) was notified. The RNP note dated 12/21/22 at 10:52 a.m., documented resident had episode of increased agitation/confusion/elopement yesterday, safety measures implemented. Today at assessment patient is alert, oriented, cooperative, back to her baseline, no behaviors noted. Per Social Services discussed with patient/family discharge home on Friday after tests are done and reviewed, psych to evaluate, no other concerns today, nursing to monitor for changes. Review of the nursing progress note dated 12/21/22 at 7:07 p.m., documented the resident was alert with some confusion. The CNA reported resident having medications from home in her room. Resident had 2 pill bottles, nurse asked to take them and store them until discharge or family can pick up at facility. The medications included amitriptyline (an antidepressant) and Xanax (medication used to treat anxiety and panic disorders) 0.5 milligrams. Resident continues to ambulate with walker unassisted, nurse reminded resident to use call light when assistance is needed, wander guard in place. Review of the RNP progress note dated 12/23/22 documented increased confusion and weakness today, increased anxiety. Will postpone discharge until next week when resident is more stable. Nursing to monitor. The Social Services progress note dated 12/23/22 documented Resident #900 was weaker, showing some confusion this morning. Planned discharge for today cancelled. Review of the nurse progress note dated 12/24/22 at 7:05 a.m., documented at 5:55 a.m., CNA called nurse to residents room. Resident #900 was lying on the floor, right side. Noted large amount of blood on resident and on floor. Large laceration to the left side of the resident's scalp. The resident was responding to voice by opening her eyes and looking at this writer. Breathing was normal at 16 respirations per minute. Resident was not verbally responsive. This writer called 911 per protocol. When this writer returned to the room after obtaining demographics, it was noted the resident was no longer breathing. Code status of full code was established. This writer was attempting to access facility phone to announce, Code Blue, EMS arrived and started code. After 30 minutes, EMS established a pulse and transported the resident to the hospital. On 4/18/23 at 11:15 a.m., in an interview CNA Staff A said she was working the 11 p.m., to 7 a.m., shift on 12/24/22 and received report from the previous shift CNA. I was informed Resident #900 was a fall risk and had been up ambulating. The resident used a 2 wheeled walker and a wheelchair and had days when she required more assistance than other days. No one informed me she had recent changes in her mental status or behaviors, I did not know that. She needed a good bit of help that night, she was anxious, and she wanted to go home so I sat with her and talked with her. I last checked on her at 1:00 a.m., she was in her bed sleeping. I checked on her again at 5:00 a.m. and found her on the floor next to her bed. She was breathing at that time, and I ran to get the nurse. Review of the Post Incident Review dated 12/28/22 documented Resident #900 had a fall with suspected head injury. The form documented the incident could have been related to a change in condition. The document specified the resident was not utilizing her walker and the walker was against the wall away from the resident. The root cause of the incident specified, Resident has known gait and balance issues hence the need for assistive device. Due to lack of assistive device near her, it can be presumed that she may have lost her balance and fell . On 4/18/22 at 11:07 a.m., in an interview, Resident #900's daughter said the facility knew my mother was wandering and trying to elope and they placed a wander guard on her. My mother called me on 12/24/22 at 2:00 a.m., and was agitated, anxious and wanted to go home. I calmed her down and spoke with her for a while. At 7 a.m., the facility called to say she fell and was sent to the emergency room (ER). She passed away at the hospital on 12/26/22. The ER doctor told me she must have been on the floor for a while because her core body temperature was very low. They said she had a heart attack but did not know if the heart attack caused the fall or the fall caused the heart attack. My concern was how long was she on the floor before she was found.

Based on observation, record review and interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of advanced stage pressure ulcers for 3 of 11 sampled residents (Resident #55, #27, and #74) identified at risk for pressure ulcer development. Resident #55 was admitted on [DATE] with a stage 3 (full thickness tissue loss) pressure ulcer to the coccyx and was dependent on staff for all activities of daily living. The facility neglected to complete a thorough skin assessment upon admission. The pressure ulcer was not identified until 11/4/22 and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to assess, obtain orders, and treat an additional in-house acquired pressure ulcer to the right inner knee identified on 11/8/22 and not treated until 11/15/22 for Resident #55. Resident #27 was readmitted to the facility on [DATE] after a surgical repair of a right [CONDITION(S)] and was dependent on staff for repositioning. The facility neglected to consistently implement preventive measures to prevent the development of an avoidable advanced stage pressure ulcer. On 11/4/22, the facility identified an infected pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) right heel pressure ulcer with 100% thick necrotic (dead) tissue. The facility neglected to consistently implement the daily wound care and offload the area to promote healing. On 11/16/22, the wound care physician documented the wound had deteriorated. Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcers and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22 Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55, #27 and #74 suffered serious harm from the development and/or worsening of pressure ulcers. The facility's failure to provide the necessary care and services to prevent the development and worsening of pressure ulcers resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Administrator was notified of the determination of Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F686, F835 and F867. The facility's policy and procedure titled, Abuse, Neglect, Mistreatment And Misappropriation Of Resident Property with a date revised of 9/2019 noted, An .employee . of a nursing home shall not .mistreat or neglect a resident . Mistreatment means inappropriate treatment or exploitation of a resident . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's Policy and Procedure for the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less . Nutrition. The Dietitian will be notified: If a resident is considered nutritionally at risk, upon the discovery of a wound, when a wound declined unexpectedly. 1. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/25/22 Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Braden Scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by a Licensed Practical Nurse (LPN) noted a score of 14 indicative of moderate risk for pressure ulcer. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 has severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record did not include a rationale for discontinuing the air mattress. The MARs for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the Director of Nursing (DON) said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22 and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 Licensed Practical Nurse (LPN) Staff R documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 the physician issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during multiple random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27's heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/9/22 at 2:36 p.m., the nurse obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. The wound care physician said a resident with a broken hip, and immobile is at risk for developing a pressure ulcer. He said they should offload the heels in bed and out of bed. He said they cannot move, and they are in pain. They cannot rotate the leg. They may develop a pressure ulcer on the heel, ankle, lateral heel. They should have an orthotic device (device designed to protect an existing limb) in place in the wheelchair. The wound care physician said sometimes they develop a pressure ulcer despite all interventions, but you don't know until you try all interventions. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. The physician performed a surgical excisional debridement (removal of dead tissue to promote wound healing) of the right heel. The recommendations included to offload wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said she did not consider it neglect since at the beginning, Resident #27 had all the interventions in place. She said the facility was using a lot of agency nurses and she had not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. The DON said she did not look into why the air mattress was discontinued or why preventive measures, including applying the No Sting Barrier Film liquid were not implemented. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., Registered Nurse (RN) Staff CC said she was assigned to care for Resident #27. She verified the resident has a pressure ulcer to the right heel. She said she normally gives report to the CNAs when they come in, but she has not given report to CNA BB assigned to Resident #27 and offered no explanation. She said the resident should have a pillow between her legs, so they don't touch the mattress, be careful so we won't bump her legs to anything, turn every 2 hours in bed. After looking at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/14/22 at 9:45 a.m., RN Staff CC verified Resident #27 was not wearing the offloading boots as ordered and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22. The dressing bore RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR for November 2022 showed RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered to the resident's right heel. On 11/14/22 at 2:40 p.m., the Director of Nursing (DON) said, It's a huge issue if you are signing for things you didn't do, it's neglect. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22 and 11/13/22. He said he was only human and had a lot of work to do. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22 the wound care physician wrote deteriorated on the wound progress section for the unstageable full thickness right heel pressure ulcer. Review of the Nursing Homes Federal Reporting website revealed on 11/15/22 the facility submitted an Immediate Report to the State Survey Agency for an allegation of neglect. The report read, It was noted by the floor nurse (name) RN during her rounds on 11/14/22 that the resident [Resident #27] had a dressing on her wound that was dated 11/11/22. This resident had treatment orders for daily dressing changes. Therefore, it was determined that the treatment was not completed for 2 days. However, the treatment was signed off as completed on the treatment record by nurse [RN Staff DD] on 11/12/22 and 11/13/22, although it was not completed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/22 at 2:50 p.m., the Registered Dietitian said the nursing staff was supposed to document the percent of the supplement consumed. She said she looks in the clinical record to check if the resident is taking the supplement or not. She also asks the nurse if the resident is taking the supplements. She said the facility only notified her today (11/9/22) of Resident #27's pressure ulcer. Review of the MAR from 11/1/22 through 11/8/22 revealed the licensed nurses placed a check mark on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/11/22, RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. and 5:00 p.m., and 50% of the house shake at 1:00 p.m. On 11/14/22 RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. On 11/14/22 at 9:35 a.m., Resident #27's breakfast tray was observed and did not contain a house shake. On 11/14/22 at 12:15 p.m., Resident #27's lunch tray was observed and did not include a frozen nutritional supplement. On 11/14/22 at 12:20 p.m., RN Staff CC verified she documented the amount of supplement Resident #27 consumed on 11/11/22 and 11/14/22 at 9:00 a.m. She said the supplements come on the resident's meal trays. She said she documented the percentage consumed based on what the CNA reported but did not personally see the resident taking the supplements. On 11/14/22 at 12:50 p.m., the Certified Dietary Manager (CDM) provided a list of residents who received supplements on their meal trays. Resident #27 was not included in the list. She said the dietary department did not provide any supplement to Resident #27. On 11/14/22 at 1:05 p.m., Agency CNA EE said the resident did not receive any supplement with her breakfast or lunch meal. RN Staff CC present during the interview said it was a problem and she'll let the DON know about it. On 11/15/22 at 10:15 a.m., the Registered Dietitian (RD) said she needed an accurate report of the resident's meals and supplement intake for her assessments. She said it's been a struggle to obtain the wound report to implement adequate nutritional interventions for residents with pressure ulcers. She said she emailed her concerns to the administrative staff on 10/11/22. The RD provided a copy of an email dated 10/11/22 at 3:15 p.m., addressed to the Administrator, the DON and the CDM that read, Just wanted to let you know I have not received a wound report for several weeks. I am concerned that there may be pressure injuries that have not been addressed. She said the very next day she got a wound report but the next one she received was on 11/9/22. 2. Clinical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for 10/1/22 through 10/13/22 noted Resident #55 had a stage 2 (partial thickness loss of tissue) pressure ulcer to the buttocks. Resident #55 was discharged to an acute care hospital on 10/13/22 and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician, revealed a skin assessment noting Resident #55 had a stage 3 (full thickness tissue loss) pressure injury to the buttock and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/Readmission Day dated 10/25/22 did not identify the presence of the existing pressure ulcer to the buttocks or the coccyx (tailbone). The form noted Resident #55 was Alert. Confused/Dementia/Alzheimer's. The resident was not able to reposition self while lying in bed or sitting. On 11/2/22, the Nursing Weekly Skin Check completed by a Registered Nurse (RN) noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22, RN Staff DD completed a skin check and documented a stage 2 (shallow open ulcer with a red, pink wound bed without dead tissue) pressure ulcer to the left, and right gluteal (buttock) fold. On 11/4/22, the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet (used on wounds with moderate to heavy drainage) and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet and boarded gauze dressing was not documented as implemented until 11/8/22. Review of the Nursing Homes Federal Reporting website revealed on 11/10/22 the facility submitted a report to the State Survey Agency substantiating the allegation of neglect. The report read, Resident has an unstageable wound that went untreated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated the resident had a stage 3 pressure ulcer on his coccyx that was identified on the hospital documents upon readmission (on 10/25/22) but not documented by facility staff until 11/2/22. Resident was seen by the wound physician on 11/2/22 but treatment orders were not entered or initiated until 11/7/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., observation of the resident's right inner knee with RN Staff CC revealed a stage 2 pressure ulcer with copious amount of greenish/brownish malodorous exudate. RN Staff CC said Resident #55 acquired the pressure ulcer to the right inner knee due to the resident's knees pressing against each other. She said there was no treatment order in place for the pressure ulcer to the right inner knee. On 11/14/22 at 5:15 p.m., the Director of Nursing (DON) presented the survey team with a single sheet of paper titled Skin check audit dated 11/8/22 handwritten by an LPN which noted Resident #55 had an abrasion to the right knee. She said she could not find documentation the physician was notified of the new pressure ulcer to obtain treatment orders. There was no documentation of an RN assessment to the new impaired skin integrity noted by the LPN on 11/8/22. On 11/16/22 at 4:20 p.m., the wound care physician said he had just assessed the resident's pressure ulcer to the coccyx. He said no one told him Resident #55 had an open area to the right inner knee. The wound care nurse, LPN Staff R, present during the interview said, I knew about it, but I didn't tell him (the wound care physician) because it's just an abrasion. On 11/16/22 at 4:30 p.m., the wound care physician assessed and diagnosed Resident #55 with a stage 2 pressure ulcer to the right inner knee with redness to the surrounding area. On 11/16/22 the wound care physician wrote on a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. 3. Review of the clinical record revealed Resident #74 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #74 required extensive assistance of one person for bed mobility, transfers, and toileting. The MDS documented Resident #74 was at risk for pressure ulcer and had no pressure ulcers at the time the assessment was completed. Resident #74 had a Brief Interview for Mental Status score of 4 indicating severe cognitive impairment. The Braden Scale for predicting pressure sore dated 9/17/22 documented the risk score was 14, indicating Resident #74 was at moderate risk for developing a pressure wound. A review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 identifying Resident #74 had skin concerns on both heels. The care plan interventions included to offload heels to decrease pressure. On 9/14/22, the Nurses Weekly Wound Documentation completed by the DON identified Resident #74 had a new onset, in-house acquired, stage 2 pressure wound to the right heel measuring 2.0 centimeters (cm) length by 2.0 cm width with 0.2 cm depth, with small amount of serosanguineous exudate. On 10/5/22 the wound care physician assessed and documented in a progress note Resident #74 had an unstageable (due to necrosis) pressure ulcer to the right heel measuring 2.3 centimeters (cm) length by 1.5 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The wound care physician specified to offload pressure to the heels. The record showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks. Her feet and heels were planted firmly on the floor and not offloaded to reduce pressure. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff AA said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., the wound on Resident #74's heel was observed with LPN Staff AA. There was no dressing observed on the right heel to cover the resident's wound, exposing the wound to lint from the sock. LPN Staff AA said she had not removed any dressings from the resident's right foot. LPN Staff AA said she had not completed wound care yet. She said it was just Dakin's solution to the right heel, no dressing was required, the order was to just apply the solution to the wound. A heel protector was noted on the left foot, and there was none on the right foot. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity room. Her feet were firmly planted on the floor, she had grip socks on, and her heels were not offloaded to decrease pressure. LPN Staff Q confirmed the resident's heels were not offloaded and there was no dressing covering Resident #74's right heel wound. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q said the Dakin's Solution was in the medication cart and retrieved it form the cart. LPN Staff Q said the pharmacy filled the Dakin's Solution on 11/7/22, the date written on the label. On 11/15/22 at 9:45 a.m., the DON said the process for wound care when an ordered treatment was not available, was the nurse was responsible to contact the physician and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided.

Based on record review and resident and staff interview, the facility's administration failed to use its resources effectively to protect residents' rights to be free from neglect and ensured staff implemented processes and physician's orders to prevent the development and/or worsening of pressure ulcers for 3 (Resident #55, #27, and #74) of 4 residents sampled for development or worsening of pressure ulcers. Resident #27 was dependent on staff for turning and repositioning following a fall and fracture of the right femur. The facility failed to consistently offload the heels of the resident. On 11/4/22, the facility identified an avoidable, infected, advanced stage pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable pressure ulcer of the right heel with 100% necrotic (dead) tissue requiring a surgical debridement (removal of dead tissue). The facility failed to consistently implement the physician's orders to prevent the worsening of the pressure ulcer. On 11/16/22, the wound care physician documented the pressure ulcer had deteriorated. Resident #55 admitted on [DATE] and was dependent on staff for all activities of daily living, including turning and repositioning. The facility failed to identify, assess, and obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/22, the wound care physician diagnosed an unstageable 100% necrotic pressure ulcer to the coccyx requiring surgical debridement. The wound care orders dated 11/4/22 were not implemented until 11/7/22. On 11/8/22, the Licensed Practical Nurse documented an abrasion of the resident's right knee. The area was not assessed or treated until 11/15/22. On 11/16/22, the wound care physician diagnosed a stage 2 (partial thickness) pressure ulcer to the right inner knee. Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcer and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. The failure of the facility's administration to ensure the ongoing implementation of a process to prevent the development, assess, and treat avoidable pressure ulcers resulted in a determination of isolated (J) Immediate Jeopardy beginning on 11/4/22. The Administrator was notified of the determination of ongoing Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F686, F867 Review of the Nursing Home Administrator's Position Description revised 4/25/22 revealed the position summary was to Plan and direct all day-to-day functions of the Care Center in accordance with applicable company, Federal, State, and local standards to promote that the highest degree of quality is provided to its residents .Plans, develops, organizes, implements, and evaluates the Care Center's programs and activities with strong collaboration with other organizational leaders . Ensures that adequate number of appropriately trained professionals and auxiliary personnel are on duty at all times to meet the needs of the residents. Review of the Director of Nursing's job description dated November 2017 revealed the primary purpose of the position is to plan, budget, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times. Responsible for ensuring that an adequate level of services is provided to each resident, documented appropriately and regularly evaluated. The facility's Policy and Procedure for the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less. 1. Clinical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 was discharged to an acute care hospital on 10/13/22 and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician revealed a skin assessment noting Resident #55 had a stage 3 pressure injury to the buttock, and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/Readmission Day dated 10/25/22 did not note the presence of the existing pressure ulcer to the buttocks or the coccyx (tailbone). The resident was not able to reposition self while lying in bed or sitting. On 11/2/22 the Nursing Weekly Skin Check completed by a Registered Nurse (RN) noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22 the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet and boarded gauze dressing was not documented as implemented until 11/8/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., observation of the resident's right inner knee with RN Staff CC revealed a stage 2 pressure ulcer with copious amount of greenish/brownish malodorous exudate. She said there was no treatment orders for the pressure ulcer to the right inner knee. On 11/16/22 at 4:30 p.m., the wound care physician assessed and diagnosed Resident #55 with a stage 2 pressure ulcer to the right inner knee with redness to the surrounding area. On 11/16/22 the wound care physician wrote in a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. 2. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/25/22, Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Braden scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by a Licensed Practical Nurse noted a score of 14 indicative of moderate risk for pressure ulcer. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 had severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders dated 10/3/22 included an air mattress to the bed for pressure ulcer prevention. Review of the Medication Administration Record (MAR) for October 2022 showed documentation the air mattress was applied on 10/3/22 and discontinued on 10/11/22. The clinical record did not include a rationale for discontinuing the air mattress. The MAR for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the DON said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22, and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 a Licensed Practical Nurse Staff I documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 the physician issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during multiple random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27' heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said the facility was using a lot of agency nurses and she has not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. The DON said she did not look into why the air mattress was discontinued or why preventive measures, including applying the No Sting Barrier Film liquid were not implemented. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., Agency CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., RN Staff CC said she was assigned to care for Resident #27. RN Staff CC said Resident #27 was supposed to wear offloading boots in and out of the bed. On 11/14/22 at 9:45 a.m., RN Staff CC verified the offloading boots were not in place for the resident and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22. The dressing bore RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR showed nurse RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22 and 11/13/22. He said he was only human and had lot of work to do. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22, the wound care physician wrote deteriorated on the wound progress section for the unstageable full thickness right heel pressure ulcer. On 11/9/22 at 2:50 p.m., the Registered Dietitian said the facility only notified her today (11/9/22) of Resident #27's pressure ulcer. On 11/15/22 at 10:15 a.m., the Registered Dietitian (RD) said it's been a struggle to obtain the wound report to implement adequate nutritional interventions for residents with pressure ulcers. She said she emailed her concerns to the administrative staff on 10/11/22. The RD provided a copy of an email dated 10/11/22 at 3:15 p.m., addressed to the Administrator, the DON, and the Certified Dietary Manager (CDM) that read, Just wanted to let you know I have not received a wound report for several weeks. I am concerned that there may be pressure injuries that have not been addressed. She said the very next day she got a wound report but the next one she received was on 11/9/22. Review of the physician's orders for October 2022 revealed to administer a house shake to Resident #27 three times a day for nutritional supplement as of 10/27/22 and a [brand name for frozen nutritional supplement] two times a day for impaired appetite. On 11/9/22 at 2:50 p.m., the Registered Dietitian said the nursing staff was supposed to document the percent of the supplement consumed. She said she looks in the clinical record to check if the resident is taking the supplement or not. She also asks the nurse if the resident is taking the supplements. On 11/11/22 RN Staff CC documented on the MAR Resident #27 consumed 100 % of the house shake at 9:00 a.m. and 5:00 p.m., and 50% of the house shake at 1:00 p.m. On 11/14/22 RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. On 11/14/22 at 9:35 a.m., Resident #27's breakfast tray was observed and did not contain a house shake. On 11/14/22 at 12:15 p.m., Resident #27's lunch tray was observed and did not include a frozen nutritional supplement. On 11/14/22 at 12:20 p.m., RN Staff CC said the supplements come on the resident's meal trays. She said she documented the percentage consumed based on what the CNA reported but did not personally see the resident taking the supplements. On 11/14/22 at 12:50 p.m., the Certified Dietary Manager (CDM) provided a list of residents who received supplements on their meal trays. Resident #27 was not included in the list. She said the dietary department did not provide any supplement to Resident #27. On 11/14/22 at 1:05 p.m., Agency CNA EE said the resident did not receive any supplement with her breakfast or lunch meal. RN Staff CC present during the interview said it was a problem and she'll let the DON know about it. 3. Review of the clinical record revealed Resident #74 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Braden Scale for predicting pressure sore dated 9/17/22 documented the risk score was 14, indicating Resident #74 was at moderate risk for developing a pressure wound. A review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 identifying Resident #74 had a skin concern on both heels. The care plan interventions included to offload heels to decrease pressure. On 9/14/22 the Nurses Weekly Wound Documentation, completed by the Director of Nursing (DON), identified Resident #74 had a new onset, in-house acquired, stage 2 (partial thickness) pressure wound to the right heel measuring 2.0 centimeters (cm) length by 2.0 cm width with 0.2 cm depth, with small amount of serosanguineous exudate. On 10/5/22 the wound care physician assessed and documented in a progress note Resident #74 had an unstageable (due to necrosis) pressure ulcer to the right heel measuring 2.3 centimeters (cm) length by 1.5 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The wound care physician specified to offload pressure to heels. The record showed a physician order dated 11/3/22 to cleanse right heel with Dakin's (strong antiseptic) solution 1/4 strength wet to moist packing, apply border gauze dressing once daily for 16 days. On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks on and her feet and heels were planted firmly on the floor and not offloaded to reduce pressure. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff AA said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., observation of the wound on Resident #74's heels with LPN Staff AA revealed there was no dressing observed on the right heel to cover the resident's wound, exposing the wound to lint from the sock. LPN Staff AA said she had not removed any dressings from the resident's right foot. LPN Staff AA said she had not completed wound care yet and said it was just Dakin's solution to the right heel, no dressing was required; the order was to just apply the solution to the wound. A heel protector was noted on the left foot, and there was none on the right foot. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity room. Her feet were firmly planted on the floor, and she had grip socks on, and her heels were not offloaded to decrease pressure. LPN Staff Q confirmed there was no dressing covering Resident #74's the right heel wound. Review of the Medication Administration Record for November 2022 revealed the wound care with the Dakin's solution was not provided as ordered on 11/4/22, 11/7/22, 11/12/22, and 11/13/22. The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q said the Dakin's solution was in the medication cart and retrieved it form the cart. LPN Staff Q confirmed the date the Dakin's solution was filled by the pharmacy was 11/7/22. On 11/15/22 at 9:45 a.m., the DON said she was aware the Dakin's solution was delivered by the pharmacy on 11/7/22, and was available, but did not know why the nurse had documented the solution was unavailable. The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided. On 11/15/22 at 10:54 a.m., Unit Manager Registered Nurse Staff T said the wound care to the right heel was done five times on 11/14/22 because Resident #74 removes the dressing. The Unit Manager said the right heel wound was wrapped together with the right shin wound so the resident would not be able to remove the right heel dressing. The Unit Manager confirmed there was no documentation the wound care was provided five times on 11/14/22 and no physician order to wrap the resident's entire right leg and combine the two separate wound dressings. The Unit Manager said the Dakin's solution was pulled from the medication cart because of concerns last week the ordered solution was not the correct dosage. She said once we determined it was correct, it was placed back in the cart. The Unit Manager said she did not know how many days the Dakin's solution was not in the cart and said the nurse just provided standard wound care. The Unit Manager said the nurse just followed the physician order without applying the Dakin's solution, and that was considered standard wound care. The Unit Manager confirmed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/14/22 at 2:40 p.m., the Director of Nursing (DON) said the unit managers and supervisors were responsible to conduct audits to ensure timely and accurate completion of skin checks. On a day-to-day basis the nurses on the unit along with the unit managers were responsible to make sure the care was being provided and supervise the Certified Nursing Assistants (CNAs). The DON said she did not have documentation of the audits performed by the unit managers. On 11/15/22 at 9:25 a.m., RN Unit Manager Staff N said she has been a unit manager at the facility for approximately 10 months. She said her responsibilities are a lot. She has a whole book on responsibilities. They do not include making sure the wound care physician's orders are implemented timely. On 11/15/22 at 10:30 a.m., Unit Manager Staff II said she has been a unit manager at the facility for almost three years. She said there was no specific focus on residents with pressure ulcers. She said she was not responsible to make sure the wound care physician's orders were implemented. She said it was the wound care nurse's responsibility to make sure the orders are entered in the system, and the primary nurse's responsibility to make sure the orders are implemented. On 11/15/22 at 10:55 a.m., RN Staff T said she has been the unit manager for Unit B and C for about two months. She said she rounds her unit as soon as she gets in the building. She makes sure the air mattress is on and inflated properly, heels are up, drinks in front of them. She offered no explanation for the observation on 11/14/22 of Resident #27's not wearing the offloading boots. She said Resident #27 was transferred to her unit on Friday and they should have brought the Kardex to her room. She said she also completes audits for skin checks. She looks over and verifies the accuracy of the skin assessments on the resident. She said she went over all the skin checks from 11/8/22 and 11/11/22. She said the wound care nurse mentioned the area to Resident #55's right inner knee but from the description she wasn't sure what it was. She cleaned it and left it open to air. On 11/15/22 at 3:15 p.m., a review of the Quality Assurance and Performance Improvement (QAPI) program related to pressure ulcers was conducted with the Administrator. She declined for the DON to attend. She said the DON was busy doing other things. She said a skin PIP (Performance Improvement Plan) was introduced in QAPI on 7/13/22. The PIP was developed because they identified skin checks were not done timely and skin issues were not identified timely. They discussed completing a head-to-toe assessment as a baseline. Skin assessments were reviewed to make sure appropriate interventions were in place. She said she did not have information of the findings from the head-to-toe assessments. The Administrator said from what she was told, the skin protocol was reviewed at the time and appropriate interventions were put into place, but she just does not have the documentation to show that. There was no set completion date for the PIP. It was ongoing for three months and then reviewed to determine if an extension was needed. On 8/10/22 the PIP was reviewed. They discussed auditing the new admissions by the wound nurse to make sure appropriate interventions were in place if residents were deemed at risk. She said she could not speak to why this intervention was added. As far as the head-to-toe assessment, she said she did not have documentation it was done, one way or the other. On 9/14/22 the PIP was reviewed again. They reviewed implementation of appropriate interventions. On 9/14/22 they had a total of 10 active wounds. One was facility acquired and it was a vascular issue. The Regional Clinical Manager or designee was going to audit 100% of the skin assessments and skin checks weekly to ensure compliance for the next three months. She said she did not have documentation of how many audits were done and the results of the audits. On 10/19/22 the PIP was reviewed again. It was decided all nursing staff needed to be reeducated on completion of the weekly skin checks. She said she did not have the data or rationale for the decision to reeducate the nurses. As of 10/19/22, the Nurse Managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. She said she was not certain they reviewed Resident #55's 3008 form when he was admitted on [DATE]. She said she wasn't sure where they document the audits.

Based on record review and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to develop and implement effective corrective actions for identified quality deficiencies related to skin assessment, prevention, identification, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #27 and #74 developed an unstageable (advanced stage) pressure ulcer. The facility failed to consistently implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 was admitted on [DATE] with a pressure ulcer to the coccyx. The facility failed to identify, assess, and treat the pressure ulcer upon admission until 11/7/22. Resident #55 suffered worsening of the pressure ulcer. The facility failed to implement effective corrective actions and monitor results, creating a likelihood of serious harm and impairment to other residents. The facility failure to have an effective Quality Assurance and Performance Improvement (QAPI) program resulted in a determination of isolated (J) Immediate Jeopardy beginning on 11/4/22. The Administrator was notified of the determination of Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F686 and F835 The facility's Quality Assurance Performance Improvement (QAPI) Plan with an annual update of 4/19/22 noted the purpose of the QAPI plan is to ensure a systematic approach to performance excellence of the organization that includes all stakeholders and is on-going. The Quality Assurance and Performance Improvement plan ensures the organization is always providing surveillance to ensure systems and processes are in place and effective. When there is a change in the metrics/outcomes, the communities will be tracking and trending to identify issues early and avoid adverse events from reaching the individuals they serve. When key issues are identified and/or data indicating potential system breakdown, communities will consider this a proactive opportunity for improvement. Communities will be identifying and addressing the key issues by engaging the stakeholders in the identification of opportunities for improvement, providing a safe environment for reporting issues, and participation in seeking the right improvement interventions. The plan also noted the organization will conduct Performance Improvement Projects (PIP's) that are designed to take a systematic approach to revise and improve care or services in areas identified as needing attention. The facility will conduct PIP's that will lead to changes and guide corrective actions in the systems, which cross multiple departments, and have impact on the quality of life and quality of care for residents living in the community. They will conduct PIPs that will improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of the PIP is a plan to determine the effectiveness of the performance improvement activities and whether the improvement is sustained. 1. Review of the facility's compliance history revealed on 10/8/21 the facility failed to implement timely effective measures in accordance with professional standards of practice to prevent the development of pressure ulcers for two residents identified at risk for pressure ulcers. 2. Clinical record review revealed Resident #27 was readmitted to the facility on [DATE] after a surgical repair of a right [CONDITION(S)]. The resident was dependent on staff for repositioning. The facility failed to consistently implement preventive measures to prevent the development of an avoidable advanced stage pressure ulcer. On 11/4/22 the facility identified an infected, pressure ulcer of the right heel. On 11/9/22 the wound care physician diagnosed an unstageable right heel pressure ulcer with 100% thick necrotic tissue. The facility failed to consistently implement the daily wound care, offload the area to promote healing. On 11/16/22, the wound care physician documented the wound had deteriorated. 3. Clinical record review revealed Resident #55 was admitted on [DATE] with a stage 3 pressure ulcer to the coccyx and was dependent on staff for all activities of daily living. The facility failed to complete a thorough skin assessment. The pressure ulcer was not identified until 11/4/22, and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to assess, obtain orders, and treat an additional in-house acquired pressure ulcer for Resident #55 identified on 11/8/22 until 11/15/22. 4. Review of the clinical record revealed Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcer. Resident #74 was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. 5. On 11/9/22 review of the facility's wound tracking log revealed the facility had 12 residents with pressure ulcers, 11 of the 12 residents acquired the pressure ulcer at the facility. 6. On 11/14/22 at 2:40 p.m., an interview was conducted with the Director of Nursing (DON) in the presence of the facility Administrator. The DON said since the survey of 10/8/21 that identified noncompliance with development of pressure ulcers, the facility made sure skin assessments were completed to ensure appropriate interventions were in place such as turning and repositioning, air mattress as appropriate. The nurse managers were to review the electronic clinical records daily to ensure all skin issues were addressed appropriately. All nursing staff were educated on pressure ulcer prevention including floating heels, turning, and repositioning. The target date was February 2022, but they were to continue with all interventions and audits. The DON said in July 2022, they developed a PIP because skin concerns were missed on admission. The nurse assigned to round with the wound care physician said, they were doing well. She was accountable to speak with the unit managers if something was not taken care of. The unit managers and supervisors were responsible to conduct audits to ensure timely and accurate completion of skin checks. On a day-to-day basis, the nurses on the unit, along with the unit managers, were responsible to make sure the care was being provided and supervise the Certified Nursing Assistants (CNAs). The DON said the wound care physician does not attend QAPI meetings. Review of the PIP with a date initiated of 7/8/22 and revised 9/30/22 revealed the problem was the facility failure to identify and manage skin issues, weekly skin checks not completed timely. The goal of the PIP was to ensure all skin issues were identified and managed timely and appropriately. The date expected to be completed was Ongoing. The interventions listed included staff education on pressure ulcer prevention, including floating heels, turning, and repositioning, change of condition, stop and watch, and skin checks. The nurse managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. On 11/14/22 at 2:40 p.m., at the time of the interview, the DON and the Administrator said they did not have documentation of education or audits completed since the development of the PIP in July 2022. On 11/15/22 at 3:15 p.m., a review of the QAPI program related to pressure ulcers was conducted with the Administrator. She declined for the DON to attend. She said the DON was busy doing other things. She said the skin PIP was introduced in QAPI on 7/13/22. The PIP was developed because they identified skin checks were not done timely and skin issues were not identified timely. They discussed completing a head-to-toe assessment as a baseline. Skin assessments were reviewed to make sure appropriate interventions were in place. She said she did not have information of the findings from the head-to-toe assessments. The Administrator said from what she was told the skin protocol was reviewed at the time and appropriate interventions were put into place, but she just does not have the documentation to show that. There was no set completion date for the PIP. It was ongoing for three months and then reviewed to determine if an extension was needed. On 8/10/22 the PIP was reviewed. They discussed auditing the new admissions by the wound nurse to make sure appropriate interventions were in place if residents were deemed at risk. She said she could not speak to why this intervention was added. As far as the head-to-toe assessment, she said she did not have documentation it was done, one way or the other. On 9/14/22 the PIP was reviewed again. They reviewed implementation of appropriate interventions. On 9/14/22 they had a total of 10 active wounds. One was facility acquired and it was a vascular issue. The Regional Clinical Manager or designee was going to audit 100% of the skin assessments and skin checks weekly to ensure compliance for the next three months. She said she did not have documentation of how many audits were done and the results of the audits. On 10/19/22 the PIP was reviewed again. It was decided all nursing staff needed to be reeducated on completion of the weekly skin checks. She said she did not have the data or rationale for the decision to reeducate the nurses. As of 10/19/22 the nurse managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. She said she was not certain they reviewed Resident #55's 3008 form when he was admitted on [DATE]. She said she wasn't sure where they document the audits. The Administrator said she offers the CNAs to attend QAPI, but they don't have any interest. 8. On 11/16/22 at 1:25 p.m., the Area Clinical Manager said she provides support to the nursing home and the nursing home administrator. When she comes to the facility, she meets with the DON and Administrator and to discuss concerns or issues they'd like her to assist with. She said she recommended a PIP for pressure ulcer in July based on a review of the new skin integrity risk management reports. She found skin issues not identified and treatments not done. She said she did not develop the PIP for the pressure ulcers. She makes her recommendations but they're not final. The Administrator and DON are the ones who ultimately decide what they'll end up doing. She did some education after July and would look on her calendar. She said she also completed some audits which she shared on a weekly basis with the DON, the Administrator, the CEO, and the Area Operation Supervisor. Review of the Support Services Report-Clinical reports completed by the Area Clinical Manager showed the week of 7/11/22 the areas of review included, Skin Concerns/Any New Facility Acquired Pressure Ulcer-Any stage. Ensure prevention measures are in place. PIP initiated and brought to QAPI. The week of 7/25/22 the report noted improvements were made. She noted the wound care nurse was not numbering wounds in the weekly wound documentation and would talk to her the following week. Skin assessment had improved but five were overdue for the week. The week of 8/1/22 the report noted the PIP was being worked by the DON. The unit managers were doing weekly skin assessment audits, to be turning in to the DON. The week of 8/15/22 the report noted she needed to work with the wound care nurse on doing electronic wound logs for all departments to access. The paper copy was not being shared with everyone. The Area Clinical Manager also noted the facility needed to start weekly wound meetings and review all wounds weekly to ensure care plans and protocols are in place. She also wrote Skin PIP-no audits in house for me to review. Please continue. The week of 8/22/22 the report noted, Electronic wound log still not being updated correctly. Uncertain if wounds were discussed in Standards of Care. Skin integrity RM (Risk Management) reports: Need to establish process for ensuring treatment is set up for New Skin integrity concerns. 4 of 5 reviewed the RM report stated a treatment was initiated, but there was no treatment put in place. The week of 9/12/22 the report noted, Wound log is not being saved to the G drive for everyone to access. RM reports reviewed for skin still with trouble following through with orders. Weekly skin assessments continue with some incomplete, missing or late. Recommend a pip or process of ensuring that orders get put in place from Risk Management reports. Reviewing Risk management reports in IDT (Interdisciplinary Team) for new skin issues, the nurse indicated that she put a treatment on, which was an appropriate treatment, but an order was not written. Nurse manager is following up but remains a problem. An undated report noted, There were some pressure ulcers identified that did not have weekly wound documentation. Weekly skin assessments still not 100%. Concerns with wound log not accurate. Reviewed a handful of skin integrity RM reports to see if treatment, care plan and follow up completed as to what the RM report stated. Orders were in place, but I did not see wound tracking for those that were pressure ulcers. One Right buttock wound the weekly wound report said it was Vascular. The report for the week of 10/21/22 noted, [DON] is working on updated wound and skin logs. [DON] is working on long term plan for wound management in the building. Please ensure wounds are discussed weekly in Standards of care. I have not seen audits skin wound PIP status? Continued wound concerns. The report for the week of 10/25/22 noted, At the end of last week, there were 10 Facility acquired Pressure Ulcers at various stages, and a handful to follow up on. I did a whole house review of skin checks: 10 residents were not timely with weekly skin checks, 5 of them had not had a skin check in over a month. The list was sent to [DON] to follow up on last week. I provided all the VOA (Volunteers of America) Wound Skin Protocol and policies to [DON] and [Administrator], which were already on the G drive, but provided again for references. The report for the week of 11/7/22 noted, We reported as a Federal Day 1 for a facility acquired Pressure Ulcer that went without treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . [DON] is working on having whole house skin audits completed. All the reports noted the responsible person was the DON. 9. On 11/17/22 at 8:23 a.m., the DON said sometimes she would talk to the unit managers about the issues identified in the reports and sometimes she would take care of it herself. The DON had no documentation verifying she addressed the concerns with pressure ulcers noted on the Area Clinical Manager's weekly reports and said, The skin audits were improving.

Based on observation, record review, review of policies and procedures, and staff interview, the facility failed to provide the necessary care and services to prevent the development and worsening, and to promote healing of advanced stage pressure ulcers for 4 of 11 sampled residents (Resident #55, #27, #72 and #74) identified at risk for skin breakdown. Resident #27 was dependent on staff for turning and repositioning following a fall and fracture of the right femur. The facility failed to consistently offload the heels of the resident. On 11/4/22, the facility identified an avoidable, infected, advanced stage pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable (wound bed covered with dead tissue) pressure ulcer of the right heel with 100% necrotic (dead) tissue requiring surgical removal of the devitalized tissue. The facility failed to consistently implement the physician's orders to prevent the worsening of the pressure ulcer. On 11/16/22, the wound care physician documented the pressure ulcer had deteriorated. Resident #55 admitted on [DATE] and was dependent on staff for all activities of daily living including turning and repositioning. The facility failed to identify, assess, and obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/22, the wound care physician diagnosed an unstageable 100% necrotic pressure ulcer to the coccyx (tail bone) requiring surgical debridement. On 11/8/22 the Licensed Practical Nurse (LPN) documented an abrasion to Resident #55's right knee. The area was not assessed or treated until 11/15/22. On 11/16/22, the wound care physician diagnosed a stage 2 (partial thickness loss of tissue) pressure ulcer to the right inner knee. Resident #74 admitted on [DATE] was at moderate risk for development of pressure ulcer and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. Resident #27, #55, and #74 suffered serious harm from the development and/or worsening of the pressure ulcers. The facility's failure to consistently ensure accurate assessment, implement preventive measures, treatments, and physician's orders timely resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) beginning on 11/4/22. The Facility Administrator was notified of the determination of ongoing Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F835 and F867. The facility's Body Audit Policy and Procedures with a revision date of 7/2022 indicated, To be completed on admission and weekly for all residents to identify any alterations in skin integrity. On admission the licensed nurse will complete the body audit/integumentary system section on the Admission Day/Data Collection form in the electronic health record. The licensed nurse will need to complete the Nursing Weekly Skin Check weekly thereafter . The Licensed Nurse completes a head to toe inspection of the skin with notation of any new alterations in skin condition on the electronic medical record . Communicate to Interdisciplinary Team, Physician . any changes in skin integrity . 1. Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 was discharged to an acute care hospital on 10/13/22 and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician revealed a skin assessment noting Resident #55 had a stage 3 (full thickness tissue loss) pressure injury to the buttock and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/Readmission Day dated 10/25/22 noted Resident #55 was Alert. Confused/Dementia/Alzheimer's. The resident was not able to reposition self while lying in bed or sitting. The licensed nurse completing the form did not document the presence of the existing pressure ulcer to the buttocks or the coccyx. On 11/2/22, the Nursing Weekly Skin Check completed by Agency Registered Nurse (RN) K noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22, the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet (used on wounds with moderate to heavy drainage) and boarded gauze dressing was not documented as implemented until 11/8/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. His heels were not offloaded and were firmly pressing into the mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., RN Staff CC verified the dressing to the resident's right inner knee was dated 11/11/22. Observation of the right inner knee wound with RN Staff CC revealed an open ulcer (stage 2) with copious amount of greenish/brownish malodorous exudate. RN Staff CC said Resident #55 acquired the pressure ulcer to the right inner knee due to the resident's knees pressing against each other. RN Staff CC said she would classify the pressure ulcer as a stage 1 (intact skin with non-blanchable redness) even though the wound was open and draining. Upon review of the clinical record, RN Staff CC said she could not find a physician's wound care order for the pressure ulcer to the right inner knee. On 11/14/22 at 5:15 p.m., the Director of Nursing (DON) presented the survey team with a single sheet of paper titled Skin check audit dated 11/8/22 in which a Licensed Practical Nurse (LPN) noted Resident #55 had an abrasion to the right knee. The DON said she just assessed the area to the resident's right inner knee as a stage 2 pressure ulcer. She said she could not find documentation the physician was notified of the new pressure ulcer to obtain treatment orders. On 11/15/22 at 7:40 a.m., Resident #55 was observed in bed, on his back with legs rotated to the right. The resident's heels were not offloaded and pressing firmly into a folded sheet placed on the air mattress. On 11/15/22 at 7:45 a.m., the Agency Nurse assigned to the resident said he could not help or answer any questions regarding Resident #55 as this was his first day working at the facility. On 11/15/22 at 7:45 a.m., Agency Certified Nursing Assistant (CNA) GG said she was assigned to Resident #55, and verified his heels were not offloaded. She said no one gave her report and she did not know how to care for the resident. On 11/15/22 at 8:00 a.m., the DON said approximately a year ago she implemented printing the Kardex (document that provides a summary and overview of the resident's care) and placing them inside the residents' closets. This way any staff member could answer call lights and it would be easier for agency staff to care for the residents. She said she did not know if the two agency CNAs on the unit today were aware of it. On 11/15/22 at 8:15 a.m., the DON verified the resident's heels were not offloaded and said they should have been. The DON verified the Kardex was in the closet and specified to elevate heels off the bed to maintain pressure relief. The Kardex also had instructions for the CNAs to re-educate/encourage on positioning in bed. On 11/15/22 at 8:20 a.m., Agency CNA GG said she did not know where to locate the Kardex and said, Maybe in the chart?. The DON was present during the interview. Review of the CNA documentation from 10/25/22 through 11/17/22, revealed instructions for the CNAs to encourage to turn and reposition in bed every two hours and as needed. There was no documentation the resident was encouraged or assisted to turn and reposition every two hours and as needed from 11/1/22 through 11/13/22. On 11/16/22 at 4:20 p.m., the wound care physician said he had just assessed the resident's pressure ulcer to the coccyx. The wound care physician said no one told him about an open area to the right inner knee. The wound care nurse Licensed Practical Nurse Staff R was present during the interview. She said she knew about the resident's wound to the right inner knee. She said, I knew about it, but I didn't tell him (the wound care physician) because it's just an abrasion. On 11/16/22 at 4:30 p.m., the wound care physician assessed Resident #55's right inner knee and said it was a stage 2 pressure ulcer with redness to the surrounding area. On 11/16/22 the wound care physician wrote on a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. The facility's policy and procedure for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less. The manufacturer's insert for the No Sting Barrier Film Liquid noted it was intended for use as a film-forming product that upon application to intact or damaged skin forms a long-[MEDICATION(S)] waterproof barrier, which acts as a protective interface between the skin. and friction and shear. 2. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/25/22, Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Braden scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by an LPN noted a score of 14 indicative of moderate risk for pressure ulcer. The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 has severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders dated 10/3/22 included an air mattress to the bed for pressure ulcer prevention. Review of the Medication Administration Record (MAR) for October 2022 showed documentation the air mattress was applied on 10/3/22 and discontinued on 10/11/22. The clinical record did not include a rationale for discontinuing the air mattress. The MARs for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the DON said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float (offload) heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22 and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 LPN Staff X documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 LPN Staff X documented on an Incident-Post incident review form Resident #27 developed a pressure injury to the right heel. The form noted the resident was resting in bed and the nurse observed drainage to the bed linen. The clinical record lacked documentation of a Registered Nurse assessment of the right heel ulcer. On 11/4/22 the physician issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 at 5:54 p.m., the Area Clinical Manager verified the lack of an RN assessment of the right heel pressure ulcer. She said it should have been communicated to the Nurse Manager who would have completed an assessment of the wound. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27's heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/7/22, three days after the advanced stage pressure ulcer to the right heel was identified, the physician issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/22 at 1:35 p.m., the wound care physician said if a resident has a broken hip and is not able to move, preventive measures would include prevalon boots (help reduce the risk of bed sores by keeping the heel floated, relieving pressure), offload on pillows, cover bony prominences, cushions, even a low air loss mattress. On 11/9/22 at 2:36 p.m., the nurse obtained a physician's order to apply podus boots to offload Resident #27's heels while in bed and out of bed. On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. The wound care physician said a resident with a broken hip and immobile is at risk for developing a pressure ulcer. He said they should offload the heels in bed and out of bed. He said they cannot move, and they are in pain. They cannot rotate the leg. They may develop a pressure ulcer on the heel, ankle, lateral heel. They should have an orthotic device in place in the wheelchair. The wound care physician said sometimes they develop a pressure ulcer despite all interventions, but you don't know until you try all interventions. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. The physician performed a surgical excisional debridement of the right heel. The recommendations included to offload wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said the facility was using a lot of agency nurses and she has not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., RN Staff CC said she was assigned to care for Resident #27. She verified the resident has a pressure ulcer to the right heel. She said the resident should have a pillow between her legs, so they don't touch the mattress, be careful so we won't bump her legs to anything, turn every 2 hours in bed. She said she normally gives report to the CNA when they come in, but she has not given report to CNA HH assigned to Resident #27 and offered no explanation. After looking at the Medication Administration Record (MAR) RN Staff CC said Resident #27 was supposed to wear offloading boots in and out of the bed. On 11/14/22 at 9:45 a.m., RN Staff CC verified Resident #27 was not wearing the offloading boots and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22 and RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR for November 2022 showed RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22, and 11/13/22. He said he was only human and had a lot of work to do. On 11/15/22 at 8:10 a.m., a joint observation with the DON of Resident #27's closet failed to reveal a Kardex available for staff to safely care for the resident. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22 the wound care physician wrote deteriorated on the wound progress section for the in house acquired unstageable full thickness right heel pressure ulcer. 3. Resident #74 was admitted to the facility on [DATE] with [CONDITION(S)], hypertension, dementia, difficulty walking and muscle weakness, depression, and anxiety. The most recent Minimum Data Set (MDS) dated [DATE] showed Resident #74 had a Brief Mental Health Interview Score (BIMS) of 7 which indicated a severe cognitive deficit. A Nurses Weekly Wound Documentation dated 9/14/22 showed a new onset, stage 2 pressure ulcer to Resident #74's right heel. The wound measured 2 centimeters (cm) in length by 2 cm in width by 0.2 cm in depth. There were no further wound assessments documented until 10/5/22 (more than 3 weeks later). The nurses weekly wound documentation dated 10/5/22 showed the pressure ulcer to the resident's right heel had worsened to an unstageable pressure ulcer measuring 2.5 cm in length by 2 cm in width. On 10/10/22, five days after documentation of the worsening of the pressure ulcer, the physician ordered Santyl ointment (used to remove dead tissue) to be applied to the wound bed. The facility also had a two-week gap in assessing the wound from 10/19/22 to 11/3/22. On 11/9/22 at approximately 2:00 p.m., Resident #74's right outer heel was observed to have a round unstageable pressure ulcer measuring approximately 2.1 cm circumference. On 11/9/22 at approximately 7:00 p.m., the Director of Nursing (DON) said the facility had no additional wound documentation assessments. The DON verified Resident #74's pressure ulcer to the right heel had not been assessed weekly. The DON said the facility had identified the nurses were not completing the weekly wound assessments but provided no documentation of staff education or audits to ensure weekly completion of wound assessments. Resident #74's clinical record showed a physician order dated 11/3/22 to cleanse the right heel pressure ulcer with Dakin's solution (strong topical antiseptic) 1/4 strength wet to moist packing, apply border gauze dressing once daily for 16 days. Review of the MAR for November 2022 revealed the wound care was not provided 11/4/22, 11/7/22, 11/12/22, and 11/13/22. The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q retrieved the Dakin's solution dated 11/7/22 from the medication cart. LPN Staff Q confirmed the Dakin's solution was filled by the pharmacy on 11/7/22. On 11/15/22 at 9:45 a.m., the DON said the process for wound care when an ordered treatment was not available, was the nurse was responsible to contact the physician and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided. Further review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 to offload the resident's heels to decrease pressure due to skin concerns on both heels which identified Resident #74 had a skin concern on both heels. On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks on. Her feet and heels were planted firmly on the floor. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff BB said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., Resident #74's right heel in-house acquired advanced stage pressure ulcer was observed with LPN Staff BB. The right heel ulcer was not covered with the border gauze dressing as per the physician's order, exposing the wound to the lint from the sock. LPN Staff BB verified the pressure ulcer was not covered with the physician's ordered dressing. She said she had not removed any dressing from the resident's right foot. LPN Staff BB said the wound care order was to just apply the Dakin's solution to the right heel and no dressing was required. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity/day room. There was no dressing covering the resident's right heel pressure ulcer, and her heels were not offloaded. The resident was wearing grip socks and both her feet and heels were firmly planted on the floor. LPN Staff Q confirmed there was no dressing covering the right heel wound. 4. Review of the facility Policy and Procedure for the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) for Resident #72 with an assessment reference date of 8/21/22 revealed Resident #72 was at risk for developing pressure ulcers but did not have any unhealed pressure ulcers. Review of the Nursing Weekly Skin Checks dated 8/17/22, 8/24/22 and 8/31/22 indicated Resident #72 did not have any pressure ulcers to the coccyx area. Review of the Nursing Weekly Skin Checks dated 10/7/22 and 10/14/22 revealed Resident #72 had blanchable redness to the coccyx indicating no skin damage. Review of the Nursing Weekly Skin Check dated 10/21/22 revealed Resident #72 had a new (single) blister to the left gluteal fold described as a Purple/maroon area/blood blister. Review of the October 2022 Medication Administration Record (MAR) indicated a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Weekly Skin Check dated 10/28/22 revealed Resident #72 had two blisters, one to the right gluteal fold, and one to the left gluteal fold, Review of the Nursing Weekly Skin Check dated 11/4/22 revealed Resident #72 had blisters to bilateral buttocks. Review of the Initial Wound Evaluation and Management Summary dated 11/4/22 revealed Resident #72 was assessed by the wound care physician and had a (single) stage 2 pressure wound to the coccyx for at least 14 days. The new treatment plan for Resident #72 included collagen sheet (supports wound healing) apply once daily for 30 days; Alginate Calcium - apply once daily for 30 days; foam silicone border - apply once daily for 30 days. The Initial Wound Evaluation and Management Summary did not indicate Resident #72's pressure ulcer was unavoidable. Review of Resident #72's MARs from 11/4/22 through 11/9/22 did not include the new treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/7/22 at 11:15 a.m., during an observation, Resident #72 was in her room, lying in bed on her back, yelling out, My butt hurts and I don't know what to do about it. On 11/7/22 at 11:18 a.m., Resident #72 yelled out, My butt is on fire. These complaints by Resident #72 were loud and could be heard in the hall. On 11/7/22 at 11:20 a.m., Licensed Practical Nurse (LPN) Staff Q entered Resident #72's room. On 11/7/22 at 11:23 a.m., Staff Q exited Resident #72's room and said she gave Resident #72 a pain medication and positioned her on her right side. On 11/7/22 at 11:25 a.m., Resident #72 was observed in bed, lying on her back. On 11/7/22 at 11:39 a.m., Resident #72 yelled, Help I want to move, but I can't move. On 11/7/22 at 11:41 a.m., Staff Q offered Resident #72 a drink of water. On 11/7/22 at 11:43 a.m., Resident #72 yelled, My butt is on fire. On 11/7/22 at 8:51 p.m., during a telephone interview, Resident #72's son said he was visiting his mother at the facility on Sunday, and she complained to him about her butt hurting. He said his brother told him she said it feels like her butt is on fire. On 11/8/22 at 8:11 a.m., observed Resident #72 in her room, in bed lying flat on her back. There were no pressure relieving pillows or devices on Resident #72's bed to relieve pressure on the coccyx. On 11/8/22 at 9:22 a.m., an observation of Resident #72's coccyx revealed a palm-size, purple-pink area of intact skin above the gluteal (buttocks) folds. Within this purple- pink area, there were two dime-size, open ulcers with red-pink wound beds. Staff Q applied barrier film swabs to the open ulcers. Resident #72 moaned during the application of the barrier film, and said the area was painful. On 11/8/22 at 9:42 a.m., Certified Nursing Assistant (CNA) BB said Resident #72 complains her butt is on fire when she cleans her. On 11/9/22 at 10:30 a.m., the Director of Nursing (DON) said the barrier film was part of the facility's wound care protocol for stage 2 pressure ulcers. She acknowledged the wound care physician saw Resident #72 on 11/4/22 for an initial wound care evaluation and ordered a new treatment plan for the stage 2 pressure ulcer. She acknowledged the new treatment order from the wound care physician of collagen sheets, Alginate Calcium, and foam silicone border had not been added to Resident #72's MAR and the resident would not be benefiting from the new treatment. On 11/9/22 at 12:31 p.m., the wound care physician confirmed he saw Resident #72 on 11/4/22 for an initial wound evaluation for a stage 2 pressure ulcer to the coccyx. The wound care physician said the facility uses a wound protocol including a barrier film he does not always agree with. He said the barrier film can sting even if it is the no-sting version and it has no healing properties. He said he would not use the barrier film if the wound was open. He said the new treatment he prescribed on 11/4/22 would promote healing to the Resident #72's stage 2 pressure ulcer of the coccyx. He said he was not aware the facility was not using the new treatment plan. The wound care doctor said he could not conclude Resident #72's pressure ulcer was unavoidable.

Based on observation, record review, review of the policies and procedures, and staff interview, the facility failed to evaluate and modify interventions to prevent avoidable accidents for 3 of 5 residents (Resident #82, #9 and #27) reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including falls with major injury. The failure to implement appropriate interventions to prevent falls and fall-related injuries resulted in Resident #82, #9 and #27 sustaining preventable falls, including falls with major injury requiring the residents to be transferred to a higher level of care. The findings included: The facility policy Fall Data Collection Policy and Protocol specified, All residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. Preventive measures shall be taken to decrease the number of falls whenever possible . All staff will be responsible for fall prevention and monitoring. 1. Review of the clinical record revealed Resident #82 admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], cognitive communication deficit, and Alzheimer's disease. The Significant Change Minimum Data Set (MDS) with an assessment reference date of 9/20/22 documented Resident #82 scored a 14 on Brief Interview of Mental Status (BIMS), indicating intact cognition. Resident #82 required limited physical assistance of one for transfers and toileting. The Morse Fall Scale Data Collection (tool used to identify risk factors for falls) with an effective date of 8/28/22 noted Resident #82 was at high risk for falls. The form noted the resident had weak gait, stooped but able to lift head without losing balance, steps were short, resident may shuffle. The form also noted under mental status, Resident #82 knows own limits. The plan of care initiated on 5/14/22 identified Resident #82 was at risk for falls. The care plan also noted the resident had muscle weakness and reduced functional mobility related to left knee [CONDITION(S)] and effusion. The interventions included to anticipate and meet needs, be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance, keep needed items, water, etc., in reach, and make sure personal needs were met-pain, hunger, and toileting needs. A review of the facility's Incident Report and Investigation Report forms revealed Resident #82, from his admission on 5/13/22 to 10/24/22, had 14 unwitnessed falls including a fall with major injury on 10/24/22. The incident report created on 6/9/22 at 5:35 a.m. noted Resident #82 was found in a crawling position around at 5:35 a.m., no injuries found. The incident and investigation report dated 6/9/22 said they took vital signs and started neurological (neuro) checks. The incident and investigation report did not document the timeline of the event and only one witness statement was obtained. The incident and investigation form noted Resident #82 was alert and confused. No new interventions were initiated to help prevent further falls. The incident report created on 6/9/22 at 6:53 p.m. noted Resident #82 was found on the floor beside the bed and the wall lying on his right side. The incident and investigation report noted staff assessed Resident #82 and transferred him back to bed. The incident and investigation report did not document a timeline of the event and included no witness statements. No new interventions were initiated to help prevent further falls. The incident report created on 6/17/22 at 5:48 p.m. noted Resident #82 was found on the floor in his room in between bed and wheelchair, was lying on his side. Resident #82 was assessed, denied hitting his head, but he was holding his head saying ouch. The resident was sent to the emergency room and returned the same day, everything negative. The incident and investigation did not document a timeline of the event or include any witness statements. No new interventions were initiated to help prevent further falls. The incident report created on 6/19/22 at 1:30 a.m. noted, CNA (Certified Nursing Assistant) called nurse to the room and found resident lying face down beside of the bed, patient said he lost his balance and tried to get back to bed but legs were too weak, so he lowered himself to the floor and put on the call light. The incident and investigation report noted, Resident #82 was assessed by nurse, vital signs taken, assisted back to bed, noted to have 2 small skin tears to left forearm, cleanse and bandage applied. He complained of bilateral hip pain, pain medication was given. The incident and investigation report included no witness statements, no timeline of the event, and no initiation of new interventions to help prevent further falls. The incident report created on 7/4/22 at 2:15 a.m. noted, Nurse heard resident yelling out in the hallway, nurse observed resident sliding out of his bed, he was then observed sitting on the ground. The incident and investigation report noted Resident #82 was assessed and no injuries were noted. Resident #82 denied any new pain but did admit to his chronic pain. Resident #82 was assisted back to bed, and pain medication was given. The resident said he was trying to go to the bathroom. An intervention was added to the fall care plan was to encourage toileting before meals and bedtime. The incident report created on 7/9/22 at 10:00 a.m. noted, CNA notified the nurse that resident was on the floor in the room lying on his left side. Resident #82 was assessed, his brief was wet and changed at this time, vital signs taken, no injuries noted. Resident was described as alert and confused. The incident and investigation report included no witness statements and no timeline of the event. The intervention added to the fall care plan on 7/13/22 was for therapy to place [brand name for non-slip mat] on wheelchair. The incident report created on 7/11/22 at 3:15 a.m. noted staff heard Resident #82 yell, went into room, and found resident on the floor. Resident #82 was assessed, and noted with laceration on the head and skin tear to left arm. The resident said he was trying to get out of bed. The incident and investigation report noted resident was sent to the emergency room (ER) for evaluation. The incident and investigation report had no witness statements and no timeline of the event. Resident #82 returned to the facility on [DATE] with two staples to a head laceration. No new interventions were initiated to help prevent further falls. The incident and investigation report dated 7/15/22 at 12:30 p.m. noted Resident #82 was found lying on the floor next to the window with a skin tear to the hand. The resident said he hit his head on the air conditioning unit, and [CONDITION(S)] (swelling) was noted to his scalp. The incident and investigation report noted nurses assessed Resident #82, assisted him into a wheelchair, cleansed, and dressed the skin tear, and neurological checks were initiated. Resident #82 was sent out to the ER for evaluation. The incident and investigation report had no witness statement. The resident returned to the facility the same day without injuries. New interventions added to the care plan on 7/18/22 (3 days after the fall) included for the resident to be relocated to the memory care unit and ensure staff do not leave unattended in the bathroom. The incident and investigation report dated 7/16/22 at 11:40 a.m. noted the nurse was notified by the resident's wife that the resident needed assistance. When the nurse went in the room, Resident #82 was on the floor. The wife said he started to lose his balance when he was on the toilet, and she lowered him to the floor. The incident and investigation report dated 7/16/22 noted nurse assessed resident no injuries noted, assisted by nurse and CNA to wheelchair. The incident and investigation report had no witness statements. No new intervention initiated until 7/18/22 to ensure staff do not leave unattended when in the bathroom. The incident and investigation report dated 7/30/22 at 4:30 p.m. noted, Wife notified the nurse that the resident was on the floor. The incident and investigation report noted the nurse assessed Resident #82. He complained of left leg and knee pain. The resident said he was walking to the bathroom and tripped over his feet. Resident #82 was sent to ER for evaluation. The incident and investigation report had no witness statements and no timeline of the event. The intervention added to the fall care plan on 7/31/22 was to ensure lights were on for good visibility. The incident and investigation report dated 8/3/22 at 7:17 p.m. noted Resident #82 was found on the floor outside of his bedroom. The incident and investigation report noted Resident #82 was assessed with no injuries observed. The incident and investigation report had no witness statement and no timeline of the event. An intervention added to the fall care plan on 8/4/22 was to evaluate for anti-roll back device to the wheelchair. The incident and investigation report dated 10/18/22 at 11:20 a.m. noted Resident #82 was found sitting on the floor next to the bathroom. The incident and investigation report noted Resident #82 was assessed and had no injuries. The incident and investigation report contained no witness statements. An intervention added to the fall care plan on 10/19/22 was resident has idiosyncratic ways of performing tasks. The incident and investigation report dated 10/24/22 at 12:37 p.m. showed Resident #82 was found on the floor face down. It was reported to the nurse by Physical Therapy the resident was asking for help to get him to the bed. Resident was unable to say what happened. The incident and investigation noted Resident #82 was assessed, was observed with bleeding to left forearm and bruise to his cheek. Resident #82 was sent out to ER for evaluation. The incident and investigation report dated 10/24/22 noted Resident #82 was alert and confused. Resident #82 returned to the facility on [DATE] at 4:47 p.m. No new interventions were initiated to help prevent further falls. The incident and investigation report dated 10/24/22 at 8:34 p.m. showed Resident #82 was found on the floor laying on his back. The incident and investigation report noted Resident #82 was assessed, complained of a lot of neck pain, and was sent out to ER for evaluation. Resident returned to facility on 10/25/22 at 4:00 p.m. with a cervical collar (provides motion restriction) and a diagnosis of C4 (cervical) fracture. No new interventions were initiated to help prevent further falls. On 11/16/22 at 10:10 a.m., the Administrator verified new interventions were not initiated for multiple falls. She said some of the interventions listed on the fall care plan had already been in place. 2. Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including dislocation of internal right hip prosthesis and unspecified dementia. The plan of care initiated on 12/4/21 identified Resident #9 was at risk for falls and had frequent falls. The interventions included to anticipate and meet the resident's needs, be sure the call light was within reach, and encourage the resident to use it for assistance as needed. Prompt response to all requests for assistance, keep needed items, water, etc., in reach, and making sure personal needs are met, pain, hunger, and toileting needs. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 8/30/22 noted Resident #9's cognition was intact. Resident #9 required extensive assistance of two people for transfers and toileting. The Morse Fall Scale Data Collection with an effective date of 9/3/22 noted Resident #9 was at high risk for falls. Resident #9 had impaired gait, difficulty rising from chair, used chair arms to get up and bounced to rise, grasped furniture, person or aid when ambulating, and could not walk unassisted. The form also noted Resident #9 overestimated or forgot limit. A review of Resident #9's Incident Report and Investigation Report forms revealed Resident #9 sustained 14 unwitnessed falls from 12/4/21 to 11/11/22, including a fall with major injury on 2/11/22. The incident report created on 2/11/22 at 2:31 p.m. noted Resident #9 was found on the floor in his room. The resident said he was going to the bathroom to wash his hands and fell . The incident and investigation report noted Resident #9 was assessed, complained of right hip and leg pain, and was sent out to ER for evaluation. Resident #9 was diagnosed with a dislocation of the right hip. The incident and investigation report noted Resident #9 was alert and confused. The form had no witness statements and no timeline of the event. There were no new interventions initiated to help prevent further falls. The incident report created on 2/27/22 at 6:20 p.m. noted Resident #9 was heard calling for help. Staff went to check and found the resident on the floor. He had been trying to reach the TV controller that fell on the floor. The incident and investigation report noted Resident #9 was assessed, complained of right hip pain, and was sent out to ER for evaluation. The incident and investigation report had no witness statements and no timeline of the event. Interventions put in place on 2/28/22 were to encourage the resident to use the call light and wait for assistance, have his remote close for easy access. Therapy was to screen the resident for the use of a reacher (helps to grab out-of-reach items). A reacher was provided to the resident on 3/2/2022. On 11/15/22 at 7:05 p.m., an observation of Resident #9's room failed to reveal a reacher. Resident #9 could not recall having a reacher. The incident report created on 3/14/22 at 4:00 a.m. showed Resident #9 was found on the floor between the two beds, lying on his back with no reports of pain. The incident and investigation report noted Resident #9 was assessed and no injuries noted. The incident and investigation form had no witness statements. Interventions put in place on 3/15/22 were for staff to ensure the bed was at appropriate height, and staff to offer toileting throughout HS (bedtime) during periods of restlessness. The incident report created on 4/5/22 at 5:50 p.m. noted a CNA found Resident #9 with upper body on the floor and legs over the mattress, called the nurse to assist. The incident and investigation report noted Resident #9 was assessed, vital signs taken, and assisted back to bed, no injuries noted. The incident and investigation report had no witness statements, and no new interventions were initiated to help prevent further falls. The incident report created on 4/7/22 at 3:00 a.m. noted staff found Resident #9 coming off the bed, had thrown the linen on the floor, mattress was halfway out. The incident and investigation report documented Resident #9 was assessed, assisted back to bed, no injuries noted. The incident and investigation had no witness statements, and no new interventions were initiated to help prevent further falls. The incident report created on 6/5/22 at 3:29 p.m. showed a CNA notified the nurse Resident #9 was on the floor. The nurse went to the room and found the resident lying on the right side on the floor. The incident and investigation report noted Resident #9 was assessed, said he was trying to reach the nightstand, slid, and hit his head on the nightstand. Resident #9 was sent out to ER for evaluation and returned to the facility with a negative Computerized Tomography (CT) scan of the head. An intervention added to the fall care plan on 6/8/22 (three days after the fall) was for therapy to screen for bolsters (long cylindrical cushion). The incident report created on 6/22/22 at 2:30 p.m. showed a CNA reported to the nurse Resident #9 was on the floor. The nurse went into the room and found Resident #9 on his back. The resident said he tried to reach for his water on the table and slid. The incident and investigation report dated 6/22/22 noted Resident #9 was assessed, assisted back to bed, and no injuries noted. The incident and investigation report had no witness statements. An intervention added to the fall care plan on 6/23/22 was U/A (urinalysis) sample for a urinary tract infection. The incident report created on 6/23/22 at 3:00 a.m. showed Resident #9 was found sitting on the floor at a 90-degree angle with his back supported on the bed. Resident #9 said he was trying to get up. The incident report had no witness statements and no new fall interventions. The incident report created on 6/30/22 at 1:55 a.m. showed Resident #9 was found on the floor on the right side, complained of right sided soreness and pain. The nurse administered pain medication. The incident and investigation report noted Resident #9 was assessed, no injuries noted. The care plan had no new interventions. The incident report created on 10/6/22 at 7:33 p.m. noted Resident #9 was on the floor. The nurse went in and found the resident lying on his back next to the bed. The incident and investigation report noted nurse assessed Resident #9 with no visible injuries noted. Resident #9 said he hit his head and was sent to the ER for evaluation. No new interventions were initiated to help prevent further falls. The incident report created on 10/11/22 at 8:30 p.m. noted Resident #9 was found on the floor sitting by the bed. The incident and investigation documented the nurse assessed, and assisted him back to bed, and no injuries noted. The incident and investigation had no witness statement and no timeline of the event. The intervention added to the fall care plan was to continue to follow the care plan. The incident report created on 11/11/22 at 7:20 p.m. showed the resident was found on his back next to the bed by the air conditioning unit. The incident and investigation report noted Resident #9 said he hit his head and was sent to the ER for evaluation. No new interventions were initiated to help prevent further falls. A review of the investigation of the 12 falls revealed documentation the facility determined the root cause of each fall was The resident did not ask for assistance. On 11/16/22 at 10:10 a.m., the Administrator said she had no additional information related to Resident #9's fall investigations. 3. Review of the clinical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, [CONDITION(S)] to the right eye, and [CONDITION(S)] and collapse. The Admission Assessment Minimum Data Set (MDS) with an assessment reference date of 8/20/22 documented that Resident #27's cognition was severely impaired. Resident #27 was totally dependent on the assistance of two people for transfers and extensive assistance of two people for toileting. The plan of care initiated on 8/17/22 identified Resident #27 was at risk for falls. The care plan did not indicate the residents had any falls. The interventions included anticipate and meet resident needs, be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance, and make sure personal needs are met, pain, hunger, toileting needs, ensure has appropriate assistive devices. The Morse Fall Scale Data Collection with an effective date of 8/20/22 noted Resident #27 was at high risk for falls. The form noted the resident had impaired gait, difficulty rising from chair, used chair arms to get up and bounced to rise, and grasps furniture, person, or aid when ambulating cannot walk unassisted. The form also noted Resident #27 knows own limits. A review of Resident #27's Incident Report and Investigation Report forms revealed Resident #27 from her admission on 8/17/22 to 9/25/22 had 2 unwitnessed falls including a fall with major injury on 9/25/22. The incident report created on 9/9/22 at 7:44 p.m. noted the CNA notified the nurse that Resident #27 was found on the floor near the bed, said she was trying to get up to turn off the light. The incident and investigation report noted nurses assessed Resident #27, noted a hematoma (pooling of blood outside of the blood vessels) to left side of the head. Resident #27 was sent out to hospital. No new interventions were initiated upon her return to help prevent further falls. The incident report created on 9/25/22 at 5:13 a.m. noted Resident #27 was found lying on the floor on the window side of the bed. The incident and investigation report noted the nurse assessed Resident #27, assisted back to bed, no visible injuries noted at the time. On 9/25/22 at 12:25 p.m., Resident #27 was sent out to the ER and was admitted with a fracture of unspecified part of neck of right femur. Resident #27 returned to the facility on [DATE]. No new interventions were initiated to help prevent further falls. A review of Resident #27's fall investigations for 9/9/2022 and 9/25/22 were started but did not include a timeline of events leading to the unwitnessed falls or staff interviewed to determine the root cause of the falls. Interventions discussed by the interdisciplinary team were not reflected in Resident #27's medical record. On 11/16/22 at 5:03 p.m., the Administrator said she had no additional information related to the resident's fall on 9/25/22. She verified no new interventions were initiated for Resident #27 to help prevent further falls.

Based on medical record review, policy review, and interview the facility failed to have documentation of timely preventive measures in accordance with professional standards of practice to prevent the development of pressure ulcers for 2 (Resident #1 and #22) of 3 sampled residents at risk for pressure ulcers. The findings included: The Pressure Injury Prevention Points as outlined in the National Pressure Injury Advisory Panel (NPIAP) noted, Risk Assessment . Use heel offloading devices or [MEDICATION(S)] foam dressings on individuals at high-risk for heel ulcers . https://npiap.com/page/PreventionPoints The quick reference guide for repositioning for Preventing Heel Pressure Ulcers noted, Ideally, heels should be free of all pressure- a state sometimes called floating heels . Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows . Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy, Treatment/Prevent Pressure Ulcers created 2010, and revised 7/2018, 4/2019, and 10/2019 read, It is the policy of [Organization] to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures . the facility provides care and services consistent with standards of practice to: Promote the prevention of pressure ulcer/injury development . 1. Record review revealed Resident #1 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment with a reference date of 5/2/21 noted Resident #1 required extensive physical assistance of two persons for bed mobility, transferring, dressing, toilet use and personal hygiene including bathing. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment noted the resident was at risk of developing pressure ulcers. The Care Assessment Summary (identifies key issues) listed Pressure Ulcers as a target care area for additional assessment and review and noted it was addressed in a Care Plan. The admission data collection form dated 4/29/21 noted Resident #1 had a surgical incision to the left hip and was not able to reposition self while lying in bed. Resident #1 scored 18 on the Braden Scale (used to predict pressure ulcer risk), indicating she was at risk for developing pressure ulcers. The care plan initiated on 4/30/21 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan noted the resident was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal included to minimize the risk for complications in skin integrity. The interventions initiated on 4/30/21 included a pressure reducing device for the bed and the chair, weekly skin assessment by licensed nurses, assistance of one person for bed mobility and assistance of two persons for transfer. The care plan did not list preventive measures to keep Resident #1's heels offloaded to minimize the risk of developing a pressure ulcer. On 5/26/21 at 11:58 p.m., the nurse bath skin document noted Resident #1 had developed a left heel fluid filled blister. On 5/27/21 the physician ordered to offload the left heel when in bed and apply [MEDICATION(S)] no sting barrier film (skin protection film for people with damaged skin or at risk for damage) daily to the left heel. On 6/10/21 the physician ordered a heel medix (offloading) boot to the left foot as tolerated every shift for pressure offloading. There was no documentation the facility initiated preventive measures to minimize the risk of developing a pressure ulcer to the right heel. On 7/27/21 the nurse's weekly wound documentation noted Resident #1 had a new right heel unstageable pressure ulcer as evidenced by dark purple tissue that does not blanch. On 7/27/21 the facility initiated a physician's order for a heel medix boot to the right foot. On 7/28/21 the wound care physician documented in an initial wound evaluation and management Resident #1 had an unstageable (due to necrosis) pressure ulcer to the left heel and an unstageable deep tissue injury of the right heel. The wound care physician recommended to float heels in bed, off-load wounds and Prevalon (off-loading) boots for both heels. The objective was to heal both heels' wounds. On 7/30/21 the physician ordered a culture of the left heel for wound [CONDITION(S)]. The result of the culture dated 7/31/21 and reported on 8/2/21 noted moderate growth of normal skin flora (bacteria normally found on the skin). On 7/30/21 the physician ordered [MEDICATION(S)] (antibiotic) 100 milligrams by mouth twice a day for 10 days for left heel wound [CONDITION(S)] (presence of bacteria in the wound). On 8/4/21 the wound care physician documented both heel wounds had deteriorated and performed a surgical excisional debridement procedure of the left heel to remove necrotic (dead) tissue. On 10/7/21 at 1:30 p.m., in an interview the MDS Coordinator confirmed Resident #1 did not have a pressure ulcer on admission. He said the development of the two wounds on two different sites triggered a significant change assessment. He said the left heel pressure ulcer worsened from a stage II to an unstageable and the resident developed a new right heel deep tissue injury. On 10/7/21 at 3:25 p.m., in an interview the wound care nurse said she was notified on 7/27/21 of the pressure ulcer of both heels for Resident #1. She said the wound care physician assessed the heels on 7/28/21. The physician did not document the pressure ulcers were unavoidable. The physician's assessment noted the goal was for them to heal. She said Resident #1 was diagnosed on [DATE] with [CONDITION(S)] after several tests were done. She had a regular mattress at the time of admission. She said, we decided it was safer than to give her an air mattress because she would roll out of bed. We decided to use a Medix heel boot on 6/10/21 for the left heel because she had the hip surgery on that side. She verified the lack of preventive measures for the left and right heel until after the resident developed a pressure ulcer of the left and right heel. 2. Record review revealed Resident #22 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment with a reference date of 8/16/21 noted Resident #22 required extensive physical assistance of two persons for bed mobility and transfer. The MDS noted the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Area Assessment (CAA) summary noted Resident #22 triggered for Pressure ulcer and an initial care plan was developed. The care plan for activities of daily living initiated on 8/13/21 noted Resident #22 has decreased mobility and required assistance. The interventions as of 8/13/21 included assistance of two persons for bed mobility and transfers. The care plan for at risk for skin breakdown noted Resident #22 had decreased mobility and required assistance. The goal was to minimize the risk for complications in skin integrity. The interventions as of 8/18/21 included a pressure reducing device for the bed and the chair. The care plan did not list measures to keep Resident #22's right heel offloaded to minimize the risk of developing a pressure ulcer. The post incident review form dated 8/26/21 noted Resident #22 developed an unstageable ulcer to the right heel related to pressure and medical condition of PVD and Diabetes Mellitus (DM). Review of the Treatment Administration Record (TAR) for 8/2021 showed on 8/26/21 the physician issued an order to offload the right heel while the resident was in bed. The physician also issued wound care orders for the newly identified right heel pressure ulcer. There was no documentation facility staff were offloading the resident's right heel prior to him developing the wound. On 8/30/21, during an initial wound visit with the physician, Patient #22 was diagnosed with a pressure wound to his right heel. The wound care physician note dated 8/30/21 noted a stage 3 pressure wound of the right heel. The plan included a foot elevator or foam heel offloading boot to the right lower extremity when in bed or 24/7 (24 hours, 7 days a week). On 10/8/21 at 3:30 p.m., the Director of Nursing (DON) verified staff were not offloading Resident #22's right heel prior to the development of the pressure ulcer to his right heel, and could not provide documentation Resident #22's right heel was offloaded. The Director of Nursing said the Nurse Manager told her she felt since Resident #22 had an air mattress, it was sufficient at the time of admission to prevent the resident from developing a pressure ulcer to his right heel.

Based on record review, resident and staff interviews, the facility failed to follow care plan and therapy recommendations and ensure adequate supervision to prevent fall with injury for 1 (Resident #500) of 3 residents reviewed who were identified at risk for falls. The failure to follow the plan of care and implement appropriate interventions to prevent falls resulted in Resident #500 sustaining a fall with major injury requiring the resident's transfer to a higher level of care. The findings included: The facility policy Fall Data Collection Policy and Protocol specified, All residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. Preventive measures shall be taken to decrease the number of falls whenever possible . All staff will be responsible for fall prevention and monitoring. Review of the clinical record revealed Resident #500 was admitted to the facility on [DATE] with diagnoses including toxic [CONDITION(S)], dementia, muscle weakness, [CONDITION(S)], and Alzheimer's disease. The Admission Minimum Data Set (MDS) with an assessment reference date of 5/15/21 documented Resident #500 scored a 14 on Brief Interview of Mental Status (BIMS), indicating intact cognition. Resident #500 required limited physical assistance of one for transfers and toileting. The Fall Scale Data Collection with an effective date of 5/13/21 noted Resident #500 scored 56, indicating the resident was at high risk for falls. The form noted the Resident had impaired gait, difficulty rising from chair, used chair arms to get up and bounced to rise. The form also noted under mental status,Resident #500 overestimated or forgot limit. The plan of care initiated on 5/13/21, identified resident #500 was at risk for falls. The interventions included to provide prompt assistance to all requests, anticipate and meet needs. The care plan also noted the resident had increased weakness and required assistance. The interventions specified Resident #500 used one person for transfers and required one person assistance for toileting. As of 5/14/21 the care plan noted to refer to the therapy updates, notes, documentation for current status or changes. A review of the Occupational Therapist (OT) notes with a start date of care of 5/14/21, revealed documentation as of 5/20/21 The patient is able to safely perform all toileting tasks utilizing walker requiring contact guard assist (contact with patient due to unsteadiness) . The Physical Therapist (PT) progress report noted as of 5/21/21, Toilet Transfer. Supervision or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout activity or intermittently. Transfers sit to stand . Contact guard assist (Contact with patient due to unsteadiness) . A review of the Certified Nursing Assistant (CNA), Kardex (provided instruction on the care a resident required) with a handwritten date of 5/19/21, documented Resident #500 was Not steady during transitions/walking, moving on and off the toilet. Review of the progress notes revealed Registered Nurse (RN) Staff F documented on 5/22/21 at 5:40 a.m., CNA Staff E transferred Resident #500 with the walker to the bathroom and she lost her balance. CNA Staff E and Registered Nurse RN Staff F quickly went to the resident's room upon hearing the noise, finding the resident on the floor. CNA Staff E and RN Staff F tried to assist the resident to move her extremities and found she could not move her right leg and the area of the right thigh was bulging. RN Staff F documented, . when I asked (CNA Staff E) if he had helped her put her on the toilet he said yes, he assisted her by her side walking to the bathroom with her walker and that he gave her privacy after putting her on the toilet and she said that when she finished she would touch the call light and he would help her but apparently (Resident #500) tried to readjust her sitting position on the toilet and lost her balance and fell to the floor . The physician was notified and ordered to send the resident to the hospital for evaluation. Review of the Nursing Home Adverse Incident Report initially submitted on 6/4/21 to the Agency for Health Care Administration noted Resident #500 was immediately transferred to the hospital where she had imaging done and was found to have a comminuted (bone broken in more than two pieces) fracture of the distal right femur. The Resident had surgery the same day. The facility documented the analysis and apparent cause of the incident was the resident tried to readjust her sitting position on the toilet, lost her balance and fell on the floor. On 6/16/21 at 10:33 a.m., in a telephone interview, Resident #500 said she fell on [DATE] on the way to the toilet, but never made it to the toilet. Resident #500 said she was using a walker and the CNA assisted her. Resident #500 said the CNA walked her into the bathroom and left, shutting the door for privacy and she fell . The resident said the CNA did not assist her to pull her pants down or to get onto the toilet. Resident #500 said I never did make it to the toilet. I guess he was not aware of how I usually do it. I do not want to get anyone in trouble. I was doing good, walking with therapy, and planning to go home. Now I am in a leg brace, and I cannot bear weight. I cannot do anything now and I need help with toileting and changing my diaper, it is embarrassing. I was not wearing diapers before. It is unfortunate, I do not know when I will get to go home now, it has been a setback. Resident #500 confirmed three times during the interview she had her clothes on and did not make it to the toilet. She repeated I did not make it to the toilet, I was standing there, and I guess I lost my balance and fell . No one was with me, I guess they should have been. On 6/16/21 at 11:30 a.m., in a telephone interview CNA Staff E said on 5/22/21 at 5:30 a.m., I walked Resident #500 to the bathroom and pulled her pants down and sat her on the toilet. I left to give her privacy and within five seconds I heard a noise, and she is on the floor. The CNA said the resident was able to ambulate with a two wheeled walker and said she walked, I stood by her, and I put her on the toilet. The CNA said he gets his patient information and care needs from the CNA going off shift and the nurse during shift report. On 6/16/21 at 12:00 p.m., in a telephone interview RN Staff F, said on 5/22/21 at 5:30 a.m., she was in the hallway outside of the Resident #500's room getting ready to administer medications and saw the CNA walking her to the bathroom, so she walked back to the cart. The RN said she visually saw CNA pull the residents pants down and put her on the toilet with the walker in front of her. The RN said, we closed the door and within 5 seconds she was on the floor. On 6/16/21 at 12:30 p.m., in an interview Physical Therapy Assistant (PTA) Staff G said she was working with Resident #500 before her fall. PTA Staff G said Resident #500 was doing well before the fall but always required stand by assistance (SBA) of one for ambulation and toileting. PTA Staff G said, when toileting the resident was to always have a gait belt on and provide SBA. PTA Staff G said Resident #500 should not have been left alone on the toilet because she did not have good trunk control yet. The PTA said, that means, I stay with her by her side, but I turn my back while holding the gait belt to give her privacy, but you needed to be right there. PTA Staff G confirmed the resident was not safe to be left on the toilet alone. PTA Staff G said she reviews the therapy goals for the resident and what they are working on, with the nurse and CNA so they know what to do for the resident. PTA Staff G said the Occupational Therapist and her were both working with Resident #500 on toileting and our plan was the same, Resident #500 was not safe alone and required SBA with toileting. On 6/16/21 at 3:42 p.m., in an interview the Director of Nursing (DON) said the resident stated she was adjusting herself on the toilet and she fell off. The DON said she interviewed the two staff involved in the incident and had witness statements. The DON said the therapy communicates with the staff and the staff report to each other at change of shift. The DON confirmed she had no documentation of therapy communication with the nurse or CNA's regarding Resident #500 transfer and toileting abilities, goals and what the therapist was working on. She said the Resident had a care plan and staff could review the Plan of Care. The DON confirmed she did not have documentation of education with staff after Resident #500 had a fall, she said there was no need because, the resident said it was her fault that she fell , she lost her balance.

Based on record reviews, and staff interviews, the facility failed to ensure medical records were complete and readily accessible including advanced directives for 1 (Resident #1) of 3 residents sampled who had been found unresponsive at some point. Failure to file the Do Not Resuscitate Order (DNRO) document lead to cardiopulmonary resuscitation (CPR) contrary to the resident's formulated advanced directives. Resident #1 expired on [DATE], after approximately 40 minutes of attempted resuscitation. CPR can result in the resident experiencing severe pain, broken ribs, broken sternum, internal bleeding, organ damage, or brain damage. It could also result in undesired intubation (a tube inserted through the mouth to assist with breathing, but prevents talking or eating), mechanical ventilation, medical life support, a prolonged dying process, and deprive the resident of a natural death. This situation was determined to at immediate jeopardy level. The facility corrected the deficient practice by [DATE] rendering it past noncompliance. The findings included: On [DATE] record review revealed Resident #1 was admitted [DATE]. This [AGE] year old man suffered from multiple chronic and acute [DIAGNOSES REDACTED].#1 on [DATE]. The physician signed the form on [DATE]. In an interview on [DATE] at 4:44 p.m., Licensed Practical Nurse (LPN) Staff A said she was passing medication around 6:00 a.m. on [DATE] when the certified nurse aide Staff K shouted to come see Resident #1. LPN Staff A said she grabbed the chart, did not find a DNRO, indicating he was a full code. LPN Staff A said she yelled to LPN Staff B who came and verified the lack of a DNRO. LPN Staff A said LPN Staff B grabbed the crash cart and both LPNs went to Resident #1's room to begin CPR. LPN Staff A said she began CPR, then switched with LPN Staff B who continued CPR. LPN Staff A said she went to call [DATE], the Administrator, and the Director of Nursing (DON). She then returned and assisted with the oxygen via an Ambu-bag. She said Emergency Medical Services (EMS) arrived and released them. LPN Staff A said she returned to the nurses' station and called Resident #1's spouse. The spouse asked why CPR was being done when he had a DNRO. LPN Staff A said she and the Assistant Director of Nursing (ADON) began a search of the nurses' station. They located the DNRO in the physician's colored folder at the nurses' station. LPN Staff A said the ADON took the DNRO form to the EMS and they stopped CPR. EMS pronounced the death at 6:40 a.m. (40 minutes after unnecessary CPR). In an interview on [DATE] at 3:30 p.m., LPN Staff B said LPN Staff A called her. She said she saw the chart and there was no DNRO on it. She said LPN Staff A started CPR, but she changed places and took over the CPR from LPN Staff A so LPN Staff A could make phone calls. She said she continued CPR until EMS arrived and relieved her. She said it was the next day when she heard there had been a DNRO. LPN Staff B said she had been in-serviced on [DATE] on checking physician folders for signed orders. The facility's investigation, Quality Assurance/Program Improvement (QAPI) review, and staff interviews showed the DNRO had not been filed into Resident #1's chart and was therefore not available on [DATE] when needed. On [DATE] and [DATE], Registered Nurse/Staff Trainer (the former ADON) provided multiple documents showing training of 100% of all staff nurses. He also provided training information from [DATE] for the current Social Services, Admissions, and Medical Records staff. In an interview on [DATE] at 2:44 p.m., the Administrator said she and the Executive Director (ED) interviewed Resident #1's physician on [DATE] and educated him on the facility's procedure to handle all physician orders. They immediately implemented a weekly code status tracking log which is updated each week for all current residents. She said the facility implemented a position for a desk manager split between 2 nurses. The desk managers check all orders, physician folders, and filings. She said Medical Records Staff L would check the to be filed boxes and physician folders. In an interview on [DATE] at 11:40 a.m., Resident #1's physician said his normal standard procedure was to take the folder (review and sign) and leave the folder on the nurses' desk, tell them everything is signed, and they take it from there. There is usually a nurse there. Can't tell you who, but that is my standard procedure. Now they fax me any DNROs that need to be signed. I or (named partner physician) signs when received and faxes it back. Record review revealed a [DATE] e-mail from Resident #1's physician validating the [DATE] meeting, with the ED's notation of the re-education training content. Review of the facility policy titled Medical Records (undated) included: The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, systematically organized and include: a. The resident's admissions and discharges; b. Code Status, Advance Directives; . On [DATE] at 11:30 a.m., Medical Records Staff L said she pretty much filed all documents daily. She now checked the physician's folders also. She tried to ensure all filing was done daily or less than 4 days. She said in (YEAR) she took over the full range of filing. She said she was always within ,[DATE] days and now strived for same-day filing. The facility had identified the deficient practice and began putting corrective actions into place on [DATE] through [DATE] removing the immediacy of the situation. The facility investigated the death and completed Federal 1-day and 5-day Adverse Incident reports on [DATE] through [DATE]. In an interview on [DATE] at 3:10 p.m., LPN Staff M verified she had been in-serviced on [DATE] on advanced directives and to check physician folders and the to be filed box daily. She said she was responsible for checking units A, B, D, and the Cove for the physicians' folders and filing. In an interview on [DATE] at 5:21 p.m., Registered Nurse (RN) Staff D said she does chart checks and checks the folders for signed orders nightly. She verified she had received the in-service training on [DATE]. She also verified she had provided CPR to a resident on [DATE] who was a full code and continued CPR until the emergency medical arrived to relieve her. In an interview on [DATE] at 5:30 p.m., LPN Staff C said he had been in-serviced on [DATE] on advanced directives and had participated in a mock drill. LPN Staff C verified he had successfully initiated CPR on a resident on [DATE]. The resident regained vital signs and was sent to the hospital. In an interview on [DATE] at 6:30 p.m., RN Staff N verified she had been in-serviced on [DATE] on advanced directives and to check physician folders and the to be filed box daily. She said she was responsible for checking the Transitional Care Unit (TCU) for the physicians' folders and filing. The facility's investigation, Quality Assurance/Program Improvement (QAPI) review, and staff interviews showed the DNRO had not been filed into Resident #1's chart and was therefore not available on [DATE] when needed. The facility called an emergency Quality Assurance/Program Improvement (QAPI) meeting to approve the Quality Assurance and Performance Improvement Plan on [DATE]. The policies were in place but procedures not being followed. The QAPI plan included educating licensed nurses to check the physician's folders and physician mailboxes for signed orders/advanced directives each shift. All current residents were audited for accuracy of current orders and current advanced directives. An Advance Directive Tracking Tool was initiated by Social Services. The admissions Department was educated to request advance directives information/forms upon admission. The Social Services Department was tasked with monitoring the QAPI plan with the administrator completing spot checks behind Social Services. In-service was begun on [DATE] with the nursing staff; 42 nurses were in-serviced about the correct CPR procedure. The PowerPoint documented, Code Status will be addressed by a licensed nurse upon admission to Gulf Coast Village. In the event the resident wishes to be a Do Not Resuscitate (DNR) the Licensed Nurse and/or the Social Services Coordinator will alert the Primary Physician of the Resident's wishes. The resident will remain a Full Code until the Physician signs the DNRO form. Once the Physician signs the DNRO form, the physician hands it to a Licensed Nurse or Social Services Designee. The in-service included the new requirement to check the physician's folders each shift for signed orders. The 11 remaining nursing staff were in-serviced before returning to the floor to work. On [DATE] a mock drill was conducted to reinforce hands-on policy and procedure when a resident was found unresponsive. There were 22 nursing staff who participated in the mock drill and education. Additionally, 13 deaths occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The 2 deaths without DNROs were provided resuscitation, 1 of which was successful. The 11 deaths with a DNRO were correctly identified by staff, responsible parties notified and death with dignity was allowed to occur. On [DATE] at tour of nurse stations A, B, D, TCU, and the Cove found no DNRO forms in the physician folders. The monitoring reports for the Code Status tracking were reviewed from [DATE] to [DATE]. The facility identified this as an incident that needed to be looked at in their QAPI and had put into place a system which would be monitored indefinitely. The procedures for record handling was improved. The corrective actions put into place, the code drills, and the QAPI reviews corrected the noncompliance effective [DATE].

Based on record reviews and staff interviews, the facility failed to ensure a Do Not Resuscitate Order (DNRO) was honored for 1 (Resident #1) of 3 sampled residents who were found unresponsive. The facility failed to file the signed DNRO leading to cardiopulmonary resuscitation (CPR) in Resident #1's medical record. The resident received approximately 40 minutes of attempted resuscitation. The facility's actions to perform CPR against the resident's established DNRO, could result in the resident experiencing severe pain, broken ribs, broken sternum, internal bleeding, aspiration pneumonia, organ damage, permanent brain damage, or coma. If the resident was resuscitated, this could also result in undesired intubation (a tube inserted through the mouth to assist with breathing, but prevents talking or eating), mechanical ventilation, sophisticated medical life support, a prolonged dying process, and deprive the resident of a natural death. This situation resulted at an immediate jeopardy level. The facility corrected the deficient practice by [DATE] making it past noncompliance. The findings included: Record review revealed Resident #1 was a [AGE] year old male admitted on [DATE] with multiple chronic and acute [DIAGNOSES REDACTED]. A Florida Department of Health DNRO Form 1896 was signed by Resident #1 on [DATE]. The physician signed the form on [DATE] establishing the resident's advanced directives. In an interview on [DATE] at 4:44 p.m., Licensed Practical Nurse (LPN) Staff A said she was passing medication around 6:00 a.m. on [DATE] when the certified nurse aide Staff K shouted to come see Resident #1. LPN Staff A said she grabbed the chart, did not find a DNRO, and knew he was a full code. LPN Staff A said she yelled to LPN Staff B who came and verified the lack of a DNRO. LPN Staff A said LPN Staff B grabbed the crash cart and both LPNs went to Resident #1's room to begin CPR. LPN Staff A said she began CPR, then switched with LPN Staff B who continued CPR. LPN Staff A said she then went to call [DATE], the Administrator, and the Director of Nursing (DON). She then returned and assisted with the oxygen via an Ambu-bag. She said Emergency Medical Services (EMS) arrived and released them. LPN Staff A said she returned to the nurses' station and called Resident #1's spouse. The spouse asked why CPR was being done when he had a DNRO. LPN Staff A said she and the Assistant Director of Nursing (ADON) began a search of the nurses' station. They found the DNRO in the physician's colored folder at the nurses' station. LPN Staff A said the ADON took the DNRO form to the EMS and they stopped CPR. The EMS pronounced the death at 6:40 a.m. (40 minutes after unnecessary CPR had begun). LPN Staff A also verified she had received the Quality Assurance/Program Improvement (QAPI) in-service on [DATE] and now checks for new orders. In an interview on [DATE] at 3:30 p.m., LPN Staff B said LPN Staff A called her. She said she saw the chart and there was no DNRO on it. She said LPN Staff A started CPR, but she changed places and took over the CPR from LPN Staff A so LPN Staff A could make phone calls. She said she continued CPR until EMS arrived and relieved her. She said it was the next day when she heard there had been a DNRO. LPN Staff B said she had been in-serviced on [DATE] on checking physician folders for signed orders. In an interview on [DATE] at 3:10 p.m., LPN Staff M verified she had been in-serviced on [DATE] on advanced directives and to check physician folders and the to be filed box daily. She said she was responsible for checking units A, B, D and the cove for the physicians' folders and filing. In an interview on [DATE] at 5:21 p.m., Registered Nurse (RN) Staff D said she does chart checks and checks the folders for signed orders nightly. She verified she had received the in-service training on [DATE]. She also verified she had provided CPR to a resident (not Resident #1) on [DATE] who was a full code and continued CPR until the emergency medical arrived to relieve her. The correct procedures were followed. In an interview on [DATE] at 5:30 p.m., LPN Staff C said he had been in-serviced on [DATE] on advanced directives and had participated in a mock drill. LPN Staff C verified he had successfully initiated CPR on a resident (not Resident #1) on [DATE]. The resident regained vital signs and was sent to the hospital. The correct procedures were followed. In an interview on [DATE] at 6:30 p.m., RN Staff N verified she had been in-serviced on [DATE] on advanced directives and to check physician folders and the to be filed box daily. She said she was responsible for checking the Transitional Care Unit (TCU) for the physicians' folders and filing. In an interview on [DATE] at 11:40 a.m., Resident #1's physician said his normal standard procedure was to take the folder (review and sign) and leave the folder on the nurses' desk, tell them everything is signed, and they take it from there. There is usually a nurse there. Can't tell you who, but that is my standard procedure. Now they fax me any DNROs that need to be signed. I or (named partner physician) signs when received and faxes it back. He verified the counseling he received on [DATE] spoke to the procedure for signed orders to be handed to a nurse upon being signed. In an interview on [DATE] at 2:44 p.m., the Administrator said the first week she started, the Executive Director (ED) and herself interviewed Resident #1's physician on [DATE] and educated him on the facility's procedure to handle all physician orders. She said they immediately implemented a weekly code status tracking log which is up-dated weekly each for all current residents. She said the facility implemented a desk manager position split between 2 nurses. They check all orders, physician folders, and filings. She said Medical Records Staff L would check the to be filed boxes and physician folders. In an interview on [DATE] at 11:30 a.m., Medical Records Staff L said she pretty much filed all documents daily. She now checked the physician's folders also. She tried to ensure all filing was done daily or less than 4 days. She said she took the full range of filing over in (YEAR). She said she was always within ,[DATE] days and now strived for same-day filing. Record review revealed a [DATE] e-mail, from Resident #1's physician, validating the [DATE] meeting with the ED's notation of the re-education training content. On [DATE] at tour of nurse stations A, B, D, TCU, and Cove found no unfiled DNRO forms in the physician folders. The monitoring reports for the Code Status tracking were reviewed from [DATE] to [DATE]. On [DATE] and [DATE], Registered Nurse/Staff Trainer (the former ADON) provided multiple documents showing training of 100% of all staff nurses. He also provided training information from [DATE] for the current Social Services, Admissions and Medical Records staff. In-service was begun on [DATE] with the nursing staff. 42 nurses were in-serviced on [DATE] about the correct CPR procedure. The PowerPoint documented, Code Status will be addressed by a licensed nurse upon admission to Gulf Coast Village. In the event the resident wishes to be a Do Not Resuscitate (DNR) the Licensed Nurse and/or the Social Services Coordinator will alert the Primary Physician of the Resident's wishes. The resident will remain a Full Code until the Physician signs the DNR Form. Once the Physician signs the DNR Form, the physician hands it to a Licensed Nurse or Social Services Designee. The in-service included the new requirement to check the physician's folders each shift for signed orders. The 11 remaining nursing staff were in-serviced before returning to the floor to work. The facility had identified the deficient practice and began putting corrective actions into place on [DATE] through [DATE] removing the immediacy of the situation. The facility investigated the death and completed Federal 1-day and 5-day Adverse Incident reports on [DATE] through [DATE]. The facility called an emergency Quality Assurance/Program Improvement (QAPI) meeting to approve the Quality Assurance and Performance Improvement Plan on [DATE]. The policies were in place but procedures not being followed. The QAPI plan included educating licensed nurses to check the physician's folders and physician mailboxes for signed orders/advanced directives each shift. All current residents were audited for accuracy of current orders and current advanced directives. An Advance Directive Tracking Tool was initiated by Social Services. The admissions Department was educated to request advance directives information/forms upon admission. The Social Services Department was tasked with monitoring the QAPI plan with the administrator completing spot checks behind Social Services. A mock drill was conducted on [DATE] to reinforce hands-on policy and procedure when a resident was found unresponsive. Some 22 nursing staff participated in the mock drill and education. Additionally, 13 deaths occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The 2 deaths without DNR orders were provided resuscitation, 1 of which was successful. The 11 deaths with a DNR order were correctly identified by staff, responsible parties notified and death with dignity was allowed to occur. The facility's investigation, QAPI review, and staff interviews all showed the DNRO had not been filed into Resident #1's chart and was therefore not available on [DATE] when needed triggering the performance of CPR. The facility identified this as an adverse incident that needed to be looked at in their QAPI and had put into place a system which would be monitored indefinitely. The procedures were improved and staff instructed. The corrective actions put into place, the code drills, and the QAPI reviews corrected the noncompliance by [DATE].

Based on facility policy review, record review, and staff interview, the facility failed to ensure residents were free from neglect for 1 (Resident #105) of 3 residents sampled of 27 full code residents in the facility plus a closed record. Facility staff neglected to perform cardiopulmonary resuscitation (CPR) when Resident #105 was found unresponsive. This neglect resulted in denial of any chance of successful resuscitation. Resident #105 expired on [DATE]. This situation was determined to be past noncompliance at the immediate jeopardy level. The findings included: 1. Review of the facility's policy and procedure #,[DATE] titled Code Status Orders and Response (revised [DATE]) included the purpose To ensure Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. Procedure step 3 directed the Response: a. Upon finding a resident unresponsive, yell for help. b. Evaluate for heartbeat, respiration and pulse. c. The respondent to call for help will immediately page a 'code blue' and indicate the room number, or location of the resident and deliver the Clinical Record and emergency Cart to the location of the Code Blue. d. If heartbeat, respirations and pulse cannot be identified, 2 associates will promptly verify the Code Status of the resident . f. If the resident is a 'Full Code' BEGIN Cardiopulmonary resuscitation. g. If Code Status is not designated, the resident is a 'Full Code' and CPR will be initiated. h. CPR will continue until relieved by EMS, a physician orders [REDACTED]. 2. On [DATE] at 11:34 a.m., Resident #105's record revealed he was a full code. There was no Do Not Resuscitate Order (DNRO) in Resident #105's chart. In an interview on [DATE] at 9:30 a.m., CNA Staff W said she noticed the plastic bag on Resident #105 head when she answered the call light around 4:45 a.m. She turned on the light over the resident in Bed B who needed to go to the bathroom and noticed the plastic bag on Resident #105's head. She called his name and there was no response or movement. She then went for assistance. In a telephone interview on [DATE] at 1:10 p.m., Licensed Practical Nurse (LPN) Staff A said he was on duty the early morning of [DATE]. He said he was putting medications away when he heard a certified nursing assistant (CNA) yell for a nurse. The CNA said Resident #105 had a plastic bag over his head. Upon entering the room, Resident# 105's face was darkish and discolored. LPN Staff A shook the resident and there was no reaction, then checked for carotid, brachial, and radial pulse. The resident was not breathing. LPN Staff A ran out to call [DATE]. Another nurse came down the hall and entered the room. LPN Staff A told the nurse he was going to call [DATE]. During the call, the [DATE] operator asked if they started CPR. Then LPN Staff A said he saw the nurses outside the door. LPN Staff A hung up from [DATE] as EMS arrived. He gave EMS a verbal report while walking to Resident #105's room. LPN Staff A did not recall the disposition of the plastic bag. LPN Staff A said when he had checked on Resident #105, the skin temp on his face was very cold to the touch. He did not recall if the resident's arm was stiff. LPN Staff A did not notice if there was any lividity (purple discoloration) as the resident was covered with a blanket. LPN Staff A said when he returned to the room, EMS was hooking up a (cardiac) monitor to Resident #105. In an interview on [DATE] at 11:03 a.m., CNA Staff D said he took care of Resident #105 during the night shift on [DATE]. The CNA said that around midnight Resident #105 was mentioning death. The resident asked asked what the CNA was doing there; CNA Staff D said he was there to take care of him. Resident #105 said he was worth more dead than alive. CNA Staff D told LPN Staff A about the strange conversation. The resident was very polite, not crying, but everything he said related to death. CNA Staff D last saw the resident at approximately 4:00 a.m. CNA Staff D went on break around 4:30 a.m. When he returned from break around 4:55 a.m., someone told him a resident died . Going to the resident's room, he saw two nurses in the room. CNA Staff D saw the resident when EMS walked in. EMS said it was a crime scene and not to touch anything. CNA Staff D did not recall seeing a crash cart or anyone doing CPR. There was a plastic bag at the feet of the resident. LPN Staff A was on the phone, and the other 2 nurses were at the nursing station. EMS asked questions and requested the resident's chart. On [DATE] the surveyor attempted to interview LPN Staff B. The surveyor was directed to LPN Staff B's attorney. A summary statement was received on [DATE] from the attorney: LPN Staff B was on duty the evening of [DATE] on the Cove Unit. Around 4:45 a.m., a nursing assistant reported a patient was found dead on the A wing. LPN Staff A was on the phone with EMS. LPN Staff B proceeded to the resident's room. LPN Staff C was in the room and said the resident had been examined and was dead. LPN Staff B's examination found no pulses, very rigid and cold to the touch, with mottled, pale and discolored skin. All of those signs indicated to (LPN Staff B) the (resident) had been deceased for quite some time. The resident's face was discolored and a foamy substance had been extruded from his mouth. After her examination, EMS arrived. In a telephone interview on [DATE] at 11:50 a.m., the Medical Director said, I am aware of the case. I think technically we should have done CPR. They should have initiated CPR. No one notified me of the resident expressing death. 3. In an interview on [DATE] at 5:34 p.m., the Director of Nursing and the Administrator said we began re-training and in-service on [DATE]. The facility CPR policy was revised. Staff were retrained on the new CPR policy. Records showed on [DATE] 18 staff nurses were inserviced on CPR. The inservice contained information on what to do when a resident is found without a pulse or respiration and does not have a Do Not Resuscitation Order: a. Always yell for help b. Immediately determine the code status as every second counts. c. Two staff members must verify the physician order [REDACTED]. d. When a resident does not have a Do Not Resuscitate Order: you must always initiate CPR e. When a resident does not have a signed Do Not Resuscitate form signed by both the resident or responsible party and the physician: You must always initiate CPR f. Ask someone to bring emergency equipment - such as code cart; ambu bag, suction machine, oxygen g. Ask someone to call 911 h. Have someone notify the physician of the resident's observation i. Notify the family of other resident's condition j. CPR continues until: The resident responds, The staff are relieved by EMS, or The physician orders [REDACTED]. In an interview on [DATE] at 5:53 p.m., the Assistant Director of Nursing said all the nurses were educated on [DATE]; full-time, part-time and prn (as needed), it didn't matter what shift they worked, they were all inserviced. The education was done on that day to the people who do CPR. CPR certifications were verified for all Licensed Nurses. Upon a resident's statement they are a danger to themselves or others, a sitter will be provided to promote safety of the residents and others. The facility identified the immediate jeopardy and began putting corrective actions into place on [DATE] which removed the immediacy of the situation. The facility investigated the death and completed the Federal 1-day and 5-day adverse incident reports, as well as the state 15-day report. Mock drills were done on all shifts to reinforce hands-on policy and procedure when a resident is found unresponsive. Mock Code Blue drills were conducted [DATE] on the ,[DATE] shift with 10 staff members attending, [DATE] with 20 staff attending, [DATE] with 13 staff attending, and [DATE] with 25 staff attending. The facility's investigation, their Quality Assurance / Program Improvement (QAPI) review, and staff interviews showed the Licensed Nurses did not follow the facility policy and procedure related to CPR. The nurses were suspended and later terminated at the conclusion of the facility internal investigation. The facility identified this as an incident that needed to be looked at as part of their QAPI process and put into place a system which will be monitored until (MONTH) (YEAR). The corrective actions that were put into place, the code drills, and QAPI reviews corrected the noncompliance.

Based on staff interview, record review, and facility policy review, the facility failed to provide basic life support for 1 (Resident #105) of 3 residents sampled for resident rights by not providing cardiopulmonary resuscitation (CPR). Resident #105 did not have advanced directives to withhold life-prolonging procedures. Failure to provide proper CPR resulted in denial of any chance of resuscitation for the resident. Resident #105 expired on [DATE]. This situation was determined to be past noncompliance at the immediate jeopardy level. The findings included: 1. Full-code status means if a person's heart stops beating, CPR should be initiated. On [DATE] at 11:34 a.m., a review of Resident #105's record revealed he was a full code. There was no Do Not Resuscitate Order (DNRO) in Resident #105's chart. In an interview on [DATE] at 9:30 a.m., Certified Nursing Assistant (CNA) Staff W said she turned on the light over the resident in bed B who needed to go to the bathroom. CNA Staff W said she noticed the plastic bag on Resident #105's head when she answered the call light around 4:45 a.m. She called his name, and there was no response or movement. She then went for help. In an interview on [DATE] at 11:03 a.m., CNA Staff D said he took care of Resident #105 on [DATE] during the night shift. He said around midnight the resident was talking about death. The resident asked why he was there; CNA Staff D responded he was there to take care of him. The resident said he was worth more dead than alive. CNA Staff D said he told Licensed Practical Nurse (LPN) Staff A about the strange conversation. The CNA said Resident #105 was very polite, not crying. Everything he said related to death. CNA Staff D said he went on break around 4:30 a.m. When he returned from break around 4:55 a.m., someone told him a resident had died . CNA Staff D observed two nurses in Resident #105's room. The CNA was present when emergency medical services (EMS) walked in at 4:54 a.m. EMS said it was a crime scene and not to touch anything. CNA Staff D did not recall seeing a crash cart or anyone doing CPR. There was a plastic bag at the feet of the resident. LPN Staff A was on the phone, and the other 2 nurses were at the nursing station. EMS staff asked questions and requested the resident chart. During a telephone interview on [DATE] at 1:10 p.m., LPN Staff A said he was on duty [DATE] during the early morning and was putting medications away when he heard a CNA yell for a nurse. The CNA said Resident #105 had a plastic bag over his head. Staff A observed the face of Resident# 105's was darkish and discolored. LPN Staff A shook the resident and there was no reaction, then checked for carotid, brachial, and radial pulse. The resident was not breathing. LPN Staff A ran out to call [DATE]. Another nurse came down the hall, and LPN Staff A told the nurse he was going to call [DATE]. The nurse went into the room. The [DATE] operator asked if they had started CPR, LPN Staff A answered there were two other nurses down there. LPN Staff A then saw the nurses outside the door. LPN Staff A did not recall the disposition of the plastic bag. LPN Staff A said when he checked on Resident #105, the skin temp on his face was very cold to the touch. LPN Staff A did not recall if the resident's arm was stiff. LPN Staff A said he did not notice if there was any lividity (purple coloration of the body); the resident was covered with a blanket. LPN Staff A said when he returned to the room, EMS was hooking up a (cardiac) monitor to Resident #105. During a telephone interview on [DATE] at 11:50 a.m., the Medical Director said, I am aware of the case. I think technically we should have done CPR. They should have initiated CPR. No one notified me of the resident expressing death. On [DATE], LPN Staff B was contacted for an interview and the surveyor was directed to Staff B's attorney. Summary statement received on [DATE] from the attorney representing Staff B included: LPN Staff B was on duty the evening of [DATE] on the Cove Unit. Around 4:45 a.m., a nursing assistant reported a patient was found dead on the A wing. LPN Staff A was on the phone with EMS. LPN Staff B proceeded to the resident's room. LPN Staff C was in the room and said the resident had been examined and was dead. LPN Staff B's examination found no pulses, very rigid and cold to the touch, with mottled, pale and discolored skin. All of those signs indicated to (LPN Staff B) that the (resident) had been deceased for quite some time. The resident's face was discolored and a foamy substance had been extruded from his mouth. After her examination, EMS arrived. 2. Review of the facility's policy and procedure #,[DATE] titled Code Status Orders and Response (revised [DATE]) specified the purpose To ensure Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. Step 3 of the procedure directed the Response: a. Upon finding a resident unresponsive, yell for help. b. Evaluate for heartbeat, respiration and pulse. c. The respondent to call for help will immediately page a 'code blue' and indicate the room number, or location of the resident and deliver the Clinical Record and emergency Cart to the location of the Code Blue. d. If heartbeat, respirations and pulse cannot be identified, 2 associates will promptly verify the Code Status of the resident. e. If Code Status is 'DNR', DO NOT initiate CPR. Notify Physician, Supervisor and Family. f. If the resident is a 'Full Code' BEGIN Cardiopulmonary resuscitation. g. If Code Status is not designated, the resident is a 'Full Code' and CPR will be initiated. h. CPR will continue until relieved by EMS, a physician orders [REDACTED]. i. An associate will be designated to notify the following persons upon initiation of CPR: -Emergency Medical Services (EMS) (911) -Physician -Family/Legal Representative. 3. During an interview on [DATE] at 5:34 p.m., the Director of Nursing and the Administrator said we began re-training and in-service on [DATE] (the day of the incident). The facility policy was revised after review on [DATE] . Staff were retrained on the new policy. Records showed 18 staff nurses were inserviced on CPR on [DATE]. The inservice contains information on what to do when a resident is found without a pulse or respiration and does not have a Do Not Resuscitation Order: a. Always yell for help b. Immediately determine the code status as every second counts. c. Two staff members must verify the physician order [REDACTED]. d. When a resident does not have a Do Not Resuscitate Order: you must always initiate CPR e. When a resident does not have a signed Do Not Resuscitate form signed by both the resident or responsible party and the physician: You must always initiate CPR f. Ask someone to bring emergency equipment - such as code cart; ambu bag, suction machine, oxygen g. Ask someone to call 911 h. Have someone notify the physician of the resident's observation i. Notify the family of other resident's condition j. CPR continues until: The resident responds, The staff are relieved by EMS, or The physician orders [REDACTED]. During an interview on [DATE] at 5:53 p.m., the Assistant Director of Nursing said all the nurses were educated on [DATE]: full-time, part-time and prn, it didn't matter what shift they worked, they were all inserviced. The education was done on that day to the people who do CPR. Facility nurses were interviewed and answered questions correctly regarding current DNRO and CPR policies and procedures at the facility. All Licensed Nurses CPR certifications were verified. Upon a resident's statement they are a danger to themselves or others, a sitter will be provided to promote safety of the residents and others. The facility identified the immediate jeopardy and began putting corrective actions into place on [DATE] removing the immediacy of the situation. The facility investigated the death and completed Federal 1 and 5-day adverse incident reports as well as the state 15-day report. Mock drills were done on all shifts to reinforce hands-on policy and procedure when a resident is found unresponsive. A Mock Code Blue drill was conducted [DATE] on the ,[DATE] shift, 10 staff members attended. Mock Code Blue drills were conducted [DATE] with 20 staff attending, [DATE] with 13 staff attending, [DATE] with 25 staff attending. The facility's investigation, Quality Assurance / Program Improvement (QAPI) review, and staff interviews showed the Licensed Nurses did not follow the facility policy and procedure related to CPR. The nurses were suspended and later terminated at the conclusion of the facility internal investigation. The facility identified this as incident that needed to be looked at in their QAPI and have put into place a system which will be monitored until (MONTH) (YEAR). The corrective actions put into place, the code drills, and the QAPI reviews corrected the noncompliance.

Based on record reviews, observations and interviews, the facility failed to accurately assess, monitor, and evaluate 2 (Residents #75 and #23) of 3 residents reviewed for pressure ulcers. The facility failed to provide interventions to prevent the development/worsening of a pressure ulcer for 1 (Resident #110) resident who acquired the pressure ulcer after being admitted to the facility. The lack of assessment, monitoring and early aggressive interventions resulted harm as the resident developed a full thickness stage IV pressure ulcer. The findings included: According to the Florida Board of Nursing, the performance of an assessment was a function of a Registered Nurse (RN) and was not within the scope of practice for a Licensed Practical Nurse (LPN). The Florida Board of Nursing, Nurse Practice Act Chapter 464 Florida Statutes; 464.003 Definitions, (3) (a) 1. Practice of professional nursing (RN); was defined as The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care . Under section 3. (b) 'Practice of Practical Nursing' (LPN) means the performance of selected acts, including the administration of treatments and medications . Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP web site at http://www.npuap.org). The NPUAP describes pressure ulcer assessment: Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings. The assessment should include location, stage, tissue type, periwound and wound edges, sinus tract/tunneling, exudate, and odor. A stage II category is partial loss of dermis, presents as shallow open ulcer with red/pink wound bed without slough (dead tissue). A stage III is a full thickness skin loss and slough may be present in the wound. A stage IV is full thickness skin loss with exposed bone, tendon or muscle, slough or eschar (black dead tissue) may be present. The NPUAP defines deep tissue Injury as purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure. Under prevention and treatment; if sitting in a chair is necessary for individuals with a pressure ulcer on the sacrum/coccyx, limit sitting to 3 times a day in periods of 60 minutes or less. When pressure ulcer deteriorates or fails to heal more frequent repositioning, preventative interventions, and local wound care should be intensified as needed. On 8/9/16 at 1:41 p.m., LPN Staff G said she was the facility's wound care nurse until April 2016. Staff G said Resident #110 developed a stage II pressure ulcer at the facility and did have a turning and repositioning program initiated. Staff G defined the program as staff were to turn and reposition the resident every 2 hours. Staff G acknowledged this would be the routine for any dependent resident. On 8/9/16 at 1:54 p.m., Resident #110 was observed sitting in her high back wheelchair. The resident's family member was present and said the resident had a sore on her bottom and thought the cause was the mattress she had when on the other unit. The family member said the facility did get her a new mattress a while ago. Resident #110 acknowledged the area on her coccyx was painful. On 8/10/16 at 10:09 a.m., Resident #110's wound was observed along with RN Staff D. A stage IV area, 1.0 centimeters (cm) x 0.25 cm in size with undetermined depth, was observed on the resident's lower coccyx. The area surrounding the wound was reddened and extended out 2 to 3 cm. RN Staff D said the area of redness was worse from when she did the dressing yesterday. RN Staff D instructed Certified Nursing Assistant (CNA) Staff K to not let the resident sit up for so long today. RN Staff D said the resident usually got up around this time and would go back to bed around noon. RN Staff D said sometimes the resident would sit up longer until 1:00 p.m. or 2:00 p.m. RN Staff D said there was a cushion in the resident's wheelchair. On 8/10/16 at 10:44 a.m., Resident #110 was observed sitting upright in the wheelchair in her room. The resident was observed to still be sitting in the same position at 11:52 a.m.; 12:35 a.m.; 1:23 p.m.; and 1:55 p.m. At 2:20 p.m. the resident was back in bed. Resident #110's family member said the resident asked to go back to bed and they came in and put her back about 5 minutes ago (after sitting up in the wheelchair for over 3 hours). The family member said the resident usually went back to bed about this time each day. On 8/10/16 at 2:40 p.m., CNA Staff N said she did assist with Resident #110. Staff N said the resident would get up around 11:00 a.m. and would ask to go back to bed at 2:00 p.m. as her bottom will hurt. On 8/11/16 at 10:13 a.m., CNA Staff K said she had taken care of Resident #110 for over a year. She said the resident did not resist care and did not object to being turned and repositioned every 2 hours. CNA Staff K said she did not reposition the resident when she was in the wheelchair unless she asked. CNA Staff K said she got the resident up around 10:00 a.m. and she went back to bed around 2:00 p.m., sometimes before if resident requested. She said the resident would stay where she was positioned when in the bed. On 8/10/16 at 4:10 p.m., discussed with Acting DON the issue with inaccurate staging of the resident's pressure ulcer and lack of documentation on the pressure ulcer identified on 10/3/15. The Acting DON confirmed there was no documentation of an assessment or treatment of [REDACTED]. She was unable to locate any policy on the turning and positioning program. On 8/11/16 at 12:45 p.m., the Acting DON acknowledged the facility was not following the wound physician's instruction and the Resident #110 should not be sitting for over 2 hours. From 10/15/15 through 11/26/15, the facility inaccurately assessed Resident #110's wound as being a stage II when slough was present in the wound bed (stage III). Staff G noted on 11/5/15, slough was covering the wound bed which would be considered untraceable (unable to determine depth). The presence of purple discoloration in the wound suggests deep tissue injury and also was untraceable. There were no additional interventions documented as being in place from 10/3/15 until 10/22/15 when a turning and repositioning program was initiated after the wound had increased in size and depth. The facility was unable to provide a policy or procedure to describe this program as being something other than a standard of care to turn the resident every 2 hours. There was no documentation or indication the resident was being turned and repositioned on a more frequent basis to relieve the pressure on her coccyx area. The resident's wound continued to worsen, an air mattress to provide a higher level of pressure relief was not ordered until 12/3/15. The wound care physician instructed on 12/22/15 and on each subsequent visit, to limit sitting to under 2 hours daily. The facility had not been following these instructions. 2. Resident #75's clinical record indicated on 7/1/16 the resident was readmitted to the facility. At that time, the resident had a blister to his right heel. In a nursing note, LPN Staff F documented the blister was clear, filled fluid, and 4.0 cm x 4.0 cm in size. On 7/7/16 RN Staff D documented Resident #75 had an open fluid filled blister on his right heel measuring 5.0 cm x 4.0 cm. RN Staff D identified the blister as a pressure ulcer. A Minimum Data Set (MDS) admission assessment dated [DATE] indicated the resident had an unstageable pressure ulcer not present on admission. On 8/11/16 at 2:26 p.m. the Acting DON confirmed there was no initial assessment of Resident #75's pressure ulcer by an RN or clinician until 7/7/16. The Acting DON said the pressure ulcer was not acquired but was present on admission. 3. Resident #23 was admitted to the facility on [DATE]. Review of the Non-Pressure Skin Condition Report showed the resident had a stage II pressure ulcer to the right side of his buttocks on admission. On 8/11/16 at 11:13 a.m., the Acting DON verified the current pressure ulcer being treated by the facility was the pressure ulcer that the resident was admitted with on 1/27/16. Initially this was a stage II pressure ulcer 1 cm in length x 1 cm in width. Review of Resident #23's medical record showed no documentation of assessments of the wound until 5/12/16. The wound was assessed weekly as an unstageable wound from 5/12/16 to 6/2/16. No treatments were documented for the wound until 6/2/16. On 6/2/16 Sanytl (a topical [MEDICATION NAME] medication) was documented as being used to treat the wound. On 6/9/16 the wound was documented as being an unstageable wound 4.1 cm x 3.0 cm with tunneling to a depth of 0.5 cm. On 6/16/16 the wound was documented as being a stage II wound 4.1 x 3.5 with tunneling 1.2 cm in depth. Documentation showed the resident was sent to wound care physician on 6/16/16. On 6/23/16 the wound was documented as a stage IV wound 4.3 x 3.5 tunneling. There was a 16-day gap in the documentation of the wound from 7/19/16 to 8/4/16. The wound was documented on 7/19/16 to be decreasing in size to 2.4 cm x 2.0 cm with a depth of 1.4 cm. On 8/4/16 the wound had increased in size to 3 cm x 2 cm and a depth of 2 cm. On 8/11/16 at 2:00 p.m., the Acting DON verified there was no additional documentation in Resident #23's medical record to show his wound was assessed weekly.

Based on record reviews, observations and interviews, the facility failed to provide the care and services needed for 2 (Resident #75, and #110) of 3 residents reviewed for pressure ulcers and for 1 (Resident #18) of 5 residents reviewed for unnecessary drugs. The facility failed to accurately document and treat a pressure ulcer for Resident # 110 who acquired a pressure ulcer after being admitted to the facility. The lack of assessment, monitoring and early aggressive interventions resulted harm as the resident developed a full thickness stage IV pressure ulcer. The facility failed to accurately assess, monitor, and evaluate pressure ulcers on Resident #75 putting them at risk. The facility failed to communicate and coordinate care for Resident #18 between the facility staff, the resident representative, and the physician resulting in a delay of treatment. The findings included: 1. Under the Nurse Practice Act (Florida Statute 464.003), the practice of professional nursing for a registered nurse (RN) is defined as The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care . The practice of practical nursing for a licensed practical nurse (LPN) means the performance of selected acts, including the administration of treatments and medications . Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP web site at http://www.npuap.org). The NPUAP describes pressure ulcer assessment: Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings. The assessment should include location, stage, tissue type, periwound and wound edges, sinus tract/tunneling, exudate, and odor. A stage II category is partial loss of dermis, presents as shallow open ulcer with red/pink wound bed without slough (dead tissue). A stage III is a full thickness skin loss and slough may be present in the wound. A stage IV is full thickness skin loss with exposed bone, tendon or muscle, slough or eschar (black dead tissue) may be present. The NPUAP defines deep tissue Injury as purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure. Under prevention and treatment; if sitting in a chair is necessary for individuals with a pressure ulcer on the sacrum/coccyx, limit sitting to 3 times a day in periods of 60 minutes or less. When pressure ulcer deteriorates or fails to heal more frequent repositioning, preventative interventions, and local wound care should be intensified as needed. In an interview on 8/9/16 at 1:41 p.m., LPN Staff G said she was the facility's wound care nurse until April 2016. LPN Staff G said Resident #110 developed a stage II pressure ulcer at the facility and did have a turning and repositioning program initiated. She defined the program as staff were to turn and reposition the resident every 2 hours. She acknowledged this would be the routine for any dependent resident. On 8/9/16 at 1:54 p.m., Resident #110 was observed sitting in her high back wheelchair. The resident's family member was present and said the resident had a sore on her bottom and thought the cause was the mattress she had when on the other unit. The family member said the facility did get her a new mattress a while ago. Resident #110 acknowledged the area on her coccyx was painful. On 8/10/16 at 10:09 a.m., Resident #110's wound was observed along with RN Staff D. A stage IV area, 1.0 centimeters (cm) x 0.25 cm in size with undetermined depth, was observed on the resident's lower coccyx. The area surrounding the wound was reddened and extended out 2 to 3 cm. RN Staff D said the area of redness was worse from when she did the dressing yesterday. RN Staff D instructed Certified Nursing Assistant (CNA) Staff K to not let the resident sit up for so long today. RN Staff D said the resident usually got up around this time and would go back to bed around noon. RN Staff D said sometimes the resident would sit up longer until 1:00 p.m. or 2:00 p.m. RN Staff D said there was a cushion in the resident's wheelchair. On 8/10/16 at 10:44 a.m., Resident #110 was observed sitting upright in the wheelchair in her room. The resident was observed to still be sitting in the same position at 11:52 a.m.; 12:35 p.m.; 1:23 p.m.; and 1:55 p.m. At 2:20 p.m. the resident was back in bed. Resident #110's family member said the resident asked to go back to bed and they came in and put her back about 5 minutes ago (after sitting up in the wheelchair for over 3 hours). The family member said the resident usually went back to bed about this time each day. In an interview on 8/10/16 at 2:40 p.m., CNA Staff N said she did assist with Resident #110. Staff N said the resident would get up around 11:00 a.m. and would ask to go back to bed at 2:00 p.m. as her bottom will hurt. In an interview on 8/11/16 at 10:13 a.m., CNA Staff K said she had taken care of Resident #110 for over a year. She said the resident did not resist care and did not object to being turned and repositioned every 2 hours. CNA Staff K said she did not reposition the resident when she was in the wheelchair unless she asked. She said she got the resident up around 10:00 a.m. and she went back to bed around 2:00 p.m., sometimes before if resident requested. She said the resident would stay where she was positioned when in the bed. On 8/10/16 at 4:10 p.m., discussed with Acting Director of Nursing (DON) the issue with inaccurate staging of the resident's pressure ulcer and lack of documentation on the pressure ulcer identified on 10/3/15. The Acting DON confirmed there was no documentation of an assessment or treatment of [REDACTED]. She was unable to locate any policy on the turning and positioning program. In an interview on 8/11/16 at 12:45 p.m., the Acting DON acknowledged the facility was not following the wound physician's instruction and the Resident #110 should not be sitting for over 2 hours. From 10/15/15 through 11/26/15, the facility inaccurately assessed Resident #110's wound as being a stage II when slough was present in the wound bed (stage III). Staff G noted on 11/5/15, slough was covering the wound bed which would be considered untraceable (unable to determine depth). The presence of purple discoloration in the wound suggests deep tissue injury and also was untraceable. There were no additional interventions documented as being in place from 10/3/15 until 10/22/15 when a turning and repositioning program was initiated after the wound had increased in size and depth. The facility was unable to provide a policy or procedure to describe this program as being something other than a standard of care to turn the resident every 2 hours. There was no documentation or indication the resident was being turned and repositioned on a more frequent basis to relieve the pressure on her coccyx area. The resident's wound continued to worsen, an air mattress to provide a higher level of pressure relief was not ordered until 12/3/15. The wound care physician instructed on 12/22/15 and on each subsequent visit, to limit sitting to under 2 hours daily. The facility had not been following these instructions. 2. Resident #75's clinical record indicated the resident was readmitted to the facility on [DATE]. At that time, the resident had a blister to his right heel. In a nursing note, LPN Staff F documented the blister was clear, filled fluid, and 4.0 cm x 4.0 cm in size. On 7/7/16 RN Staff D documented Resident #75 had an open fluid filled blister on his right heel measuring 5.0 cm x 4.0 cm. RN Staff D identified the blister as a pressure ulcer. A Minimum Data Set (MDS) admission assessment dated [DATE] indicated the resident had an unstageable pressure ulcer not present on admission. On 8/11/16 at 2:26 p.m. the Acting DON confirmed there was no initial assessment of Resident #75's pressure ulcer by an RN or clinician until 7/7/16 (a week after admission). The Acting DON said the pressure ulcer was not acquired but was present on admission. 3. Review of Resident #18's records documented she was admitted to the facility on [DATE] with a mass in her neck. Review of Resident #18's lab reports from 11/6/15 to 6/17/16 showed the resident's [MEDICAL CONDITION] stimulating hormone (TSH) level was less than 0.18 (normal range 0.5-4.5). Review of the physician's orders [REDACTED]. In an interview on 8/10/16 at 3:00 p.m., the Acting DON said Resident #18's son had refused for the resident to see the endocrinologist. In an interview on 8/10/16 at 3:10 p.m., Resident #18's son said the facility staff had not explained to him clearly why Resident #18 needed to see the endocrinologist. He said if it was important for her to go, and it was going to help her, he wanted her to go to the consult. In an interview on 8/11/16 at 8:39 a.m., Resident #18's physician verified he had not spoken to the resident's representative about the importance of the resident seeing the endocrinologist. The doctor said low TSH level showed the resident was suffering from [MEDICAL CONDITION]. She needed to see the endocrinologist to treat her [MEDICAL CONDITION] with [MEDICAL CONDITION] treatments to treat the condition. The doctor said if the resident was not treated it could cause her to have heart problems and could cause her to expire if left untreated. The doctor said the facility staff had not informed him that the resident's representative had refused for Resident #18 to go to the endocrinologist. The doctor said he would be in the following day and contact the resident's son to ensure the resident received treatment. On 8/11/16, the Acting DON said she was unable to find documentation Resident #18's son had refused the resident to go to the endocrinologist or that the resident's physician had been notified the resident's son had refused the consult.