Every finding on record at Gulf Shore Care Center

Based on observation, interviews and record reviews the facility failed to ensure Pre admission Screening and Resident Review (PASARRs) were accurate for five residents (#78, #5, #77, #2, #8) out of six residents sampled.Findings Included: 1. Review of Resident #78's admission record revealed an admission date of 02/20/2026. Resident #78 was admitted to the facility with diagnosis to include post-traumatic stress disorder, unspecified, major, depressive disorder, recurrent, moderate, alcohol abuse, and generalized anxiety disorder. Review of Resident #78's PASARR dated 02/20/2026 revealed section A. MI (Mental illness) was blank. Section II. Questions 1-7 were marked no. Section III revealed it was marked: no to provisional admission. IV. No diagnosis or suspicion or Serious MI or ID indicated. Level II PASARR eval not required was marked. 2. Review of Resident #5's admission record revealed an admission date of 02/21/2026. Resident #5 was admitted to the facility with diagnosis to include epilepsy, unspecified, intractable, with status epilepticus, generalized anxiety disorder, brief psychotic disorder, Parkinson's disease without dyskinesia, without mention of fluctuations, Parkinson's disease without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, and major depressive disorder, recurrent, moderate. Review of Resident #5's PASARR dated 02/20/2026 revealed section A. MI (Mental illness) was blank. Section II. Questions 1-7 were marked no. Section III revealed it was marked: no to provisional admission. IV. No diagnosis or suspicion or Serious MI or ID indicated. Level II PASARR eval not required was marked. During an interview on 03/25/2026 at 9:44 a.m. the Director of Nursing (DON) and Social Services Director (SSD) stated when residents are admitted to the facility, the SSD reviews the PASARR and confirms the diagnosis that are listed in the chart. Psych sees the resident and confirms the diagnosis. If they add diagnosis or there are changes to the PASARR, the SSD tells the DON so she can update the PASARR. They stated Resident #78 and Resident #5 should have updated PASARR's to reflect their current diagnoses. 3. Review of Resident #77's admission record dated 02/25/2026 revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, generalized anxiety disorder, brief psychotic disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Review of Resident #77's Preadmission Screening and Resident Review dated 02/25/2026 revealed the psychotic disorder was not listed on the Level I PASARR. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had diagnoses of anxiety disorder, depression, and psychotic disorder. On 03/25/2026 at 2:41 p.m., an interview was conducted with the DON) and the SSD. They stated Resident #77's PASARR should have had a new level I completed to show he had psychotic disorder. 4. A record review of Resident #2's admission record revealed an initial admission date of 11/07/2023 and readmission date of 11/08/2025. Resident #2 was admitted to the facility with diagnoses to include brief psychotic disorder (10/02/2025), bipolar disorder (3/21/2025), major depressive disorder (3/21/2025), and generalized anxiety disorder (11/07/2023). A review of Resident #2's Level I PASRR, dated 10/6/2025, revealed: Section I: Mental Illness (MI) or suspected MI (check all that apply): bipolar disorder was marked. Findings based on documented history, behavioral observations, medications was marked. Section II: Other Indications for PASRR Screen Decision-Making question 3: A: psychiatric treatment more intensive than outpatient care was marked No. 4: Has the individual exhibited actions or behaviors that may make them a danger to themselves or others was marked No. An observation and interview on 3/22/2026 at 12:34 p.m. with Resident #2 was conducted. During the interview Resident #2 was speaking very loudly and using aggressive language toward staff members. Staff F, Certified Nursing Assistant (CNA) assisted Resident #2 with her wheelchair; Resident #2 slapped and pushed Staff F, CNA, on the left arm. An interview on 3/22/2026 at 12:42 p.m. with Staff F, CNA, was conducted. Staff F, CNA said Resident #2 often pushed, slapped, and yelled at staff. Staff F, CNA said Resident #2 had aggressive behaviors toward the staff. A review of Resident #2's progress notes revealed she had a change in condition on 3/22/2026 at 2:02 p.m. of, Behavioral symptoms (e.g. agitation, psychosis). The Primary Care Provider responded with the following feedback: A. Recommendations: Psych- BA52 (voluntary/involuntary psychiatric treatment). The police and emergency medical technician (EMT) transported Resident #2 to the hospital. A review of Resident #2's progress notes revealed a nurses note dated 3/8/2026 at 3:32 p.m. showing on 7a.m. to 3 p.m. shift patient was changed four times. She was put in bed. Writer assisted with care. She keeps throwing things at staff and yelling at staff. She is pulling her brief to the side and urinating on the floor several times. Writer has encourage patient to use call light. Resident #2's psychiatry notes were requested on 3/24/2026 at 3:00 p.m. and not provided. 5. A record review of Resident #8's admission Record revealed an initial admission date of 8/6/2024 and readmission date of 12/2/2025. Resident #8 was admitted to the facility with diagnoses to include suicidal ideations (12/2/2025), bipolar disorder (5/21/2025), major depressive disorder (5/21/2025), anxiety disorder (5/21/2025) primary insomnia (5/21/2025), and unspecified dementia (8/6/2024). A review of Resident #8's Level I PASRR, dated 8/29/2025, revealed: Section I: Mental Illness (MI) or suspected MI (check all that apply): anxiety disorder, bipolar disorder, depressive disorder, other: dementia and insomnia was marked. Findings based on documented history and medications was marked. Section II: Other Indications for PASRR Screen Decision-Making question 3: A: psychiatric treatment more intensive than outpatient care was marked No. 4: Has the individual exhibited actions or behaviors that may make them a danger to themselves or others was marked No. A record review of Resident #8's progress notes revealed an activity/recreation note dated 12/3/2025 at 12:32 p.m. Note Text: (Readmit) Resident had and interruption of stay; a brief hospitalization for suicidal ideations. Resident #8's psychiatry notes were requested on 3/24/2026 at 3:00 p.m. and not provided. An interview was conducted on 3/24/2026 at 10:45 a.m. with Staff A, Registered Nurse (RN) was conducted. Staff A, RN said she thinks Resident #8 received (voluntary/involuntary psychiatric treatment) in December 2025 for suicidal ideations. An interview on 3/24/2026 at 3:00 P.M. with the DON was conducted. The DON said Resident #2 was she's the worst resident we have and always causing us problems. The DON said Resident #2 was [NAME] Acted on 3/22/2026 due to her behaviors. The DON said Resident #2's PASRR was not correct and should have been updated when Resident #2 was readmitted to the facility on [DATE] and 3/23/2026. The DON said Resident #8 was [NAME] Acted for suicidal ideations. The DON said Resident #8's PASRR was not correct and should have been updated after her hospitalization. The facility did not provide a policy on the PASARRs.

Based on observation, interview and record review the facility failed to ensure residents received care and treatment in accordance with professional standards of practice, the comprehensive care plan, and resident choice related to: 1) positioning of one (Resident #18), 2) communication with hospice for one (Resident #14), and 3) documentation of physician orders related to behavior monitoring, medications administration, wound care and tube feeding for three (Resident #5, Resident #11 and Resident #1) of six residents sampled. Findings Included: During an observation on 3/22/2026 at 12: 30 p.m., Resident #18 was observed in the dining room sitting in her wheelchair. Resident #18's torso was shifted off center towards the left of the wheelchair. During an observation on 03/23/2026 at 1:22 p.m., Resident #18 was observed sitting in a wheelchair near the nurse's station. Resident #18's torso shifted off center towards the right of the wheelchair. Review of Resident #18's admission record revealed an admission date of 01/17/2025. Resident #18 was admitted to the facility with diagnosis to include unspecified dementia with other behavioral disturbance, major depressive disorder, tachycardia, pseudobulbar affect and vitamin deficiency. Review of Resident #18 Minimum Data Set (MDS) dated [DATE] revealed, Resident #18 required substantial/maximal assistance (meaning helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort for mobility) with most activities of daily living (ADLs). Review of Resident #18's care plan dated 12/22/2021 revealed: Resident 18 has a functional abilities deficit related to cognitive deficits, generalized weakness, impaired mobility, requires queuing from staff. Interventions. turn and reposition as needed, shifting weight to enhance circulation. During an interview on 03/25/2026 at 9:40 a.m., Staff H, Certified Nursing Assistant (CNA) stated, Resident #18 requires assistance for most of her needs. Resident #18 likes to sit in her wheelchair and attend activities. She primarily enjoys feeding herself. She does not really like it when we try to assist her with meals, so we try to let her do it on her own. Resident #18 has a high back wheelchair with a neck pillow to help with her positioning. She likes to position herself in the chair where she is comfortable. I frequently reposition her when I see her needing to be adjusted. During an interview on 03/25/2026 at 2:41 p.m., the Director of Nursing (DON) stated I would expect staff to reposition the residents if they see they are leaning or not properly sitting in their wheelchair. They can look in the Kardex and check to see if they need repositioning or if there are any special cushions they should be using. CNAs should tell the nurse if the resident is slouching or leaning in their wheelchair is happening often, so we can get therapy to see them. Review of Resident #14's admission record revealed an admission date of 11/07/2023. Resident #14 was admitted to the facility with diagnosis to include unspecified dementia, major depressive disorder, anxiety disorders, cirrhosis cutis, and traumatic subarachnoid hemorrhage without loss of consciousness. Review of Resident #14's MDS dated [DATE], revealed skin conditions one stage four pressures ulcer. Review of Resident #14's orders revealed: 02/08/2026 Hospice to follow for treatment related to Cerebral Atherosclerosis . Review of resident #14's medication administration record (MAR) and treatment administration record (TAR) for February 2026 revealed: Collagenase ointment 250 unit/gram apply to right lateral foot topically everyday shift for wound care . no documentation was found on 02/19/2026, 02/23/2026 and 02/26/2026. Collagenase ointment 250 unit/gram apply to sacrum topically every day shift for wound care . no documentation was found on 02/05/2026, 02/09/2026, 02/12/2026, 02/19/2026, 02/23/2026 and 02/26/2026. Left lateral foot: skin prep every shift for wound care no documentation was found 02/07/2026 and day 02/22/2026. Offload bilateral heels, place pillow between legs, as tolerated by resident . no documentation was found on day 02/07/2026 and day 02/22/2026. Review of Resident #14's MAR and TAR for March 2026 revealed: Collagenase ointment 250 unit/gram Apply to left foot topically everyday shift for wound care . no documentation was found on 03/19/2026. Collagenase ointment 250 unit/gram apply to right lateral foot topically everyday shift for wound care . no documentation was found on 03/02/2026, 03/03/2026, 03/06/2026, 03/10/2026, 03/12/2026, and 03/17/2026. Collagenase ointment 250 unit/gram apply to sacrum topically everyday shift for wound care . no documentation was found on 03/02/2026, 03/03/2026, 03/06/2026, 03/10/2026, 03/12/2026, 03/17/2026, and 03/19/2026. Superior back-cleanse with normal saline pat dry, apply foam dressing . no documentation was found on 03/19/2026. Left lateral foot: skin prep every shift for wound care no documentation was found on 03/14/2026. Off load bilateral heels, place pillow between legs, as tolerated by resident . no documentation was found on 03/14/2026. Review of Resident #14's electronic medical record and paper medical record revealed no notes or documentation of communication with hospice. During an interview on 03/24/2026 at 5:23 p.m., Staff I, Licensed Practical Nurse (LPN), stated hospice comes in and sees the resident a few times a week. They are the primary for her care. If they change any orders they come to us, and we call the physician and confirm before we change it. They come and talk with us after each visit. There is a binder at the nurses' station that we keep, as well. The hospice notes are scanned into her chart or located in the binder at the nurses' station. During an interview on 3/25/2026 at 1:00 p.m. with Staff J, Registered Nurse (RN), stated she is responsible for completing the MAR and TAR for wound care treatments. She said sometimes the nurses will sign off that the treatments have been completed. She said sometimes she does not go back into the TAR and click off that the treatments are completed. I completed the treatments, but if it's not documented it looks like it was not completed. I could go back into the TAR and mark completed if that would help. During an interview on 3/25/2026 at 2:10 p.m. the Director of Nursing (DON) stated the wound care nurse should not go back into the MAR/TAR and mark that treatments are completed, if she did not complete the dressing. If the MAR/TAR is not completed, then the treatment was not completed. My expectation is for the nurse who completes the treatment, to document on the MAR/TAR. During an interview on 03/25/2026 at 5:36 p.m., the Director of Nursing (DON) stated the only hospice note they have is from December. There are no further notes for Resident #14 in the chart. We are having them faxed over now. Review of Resident #5's admission record revealed an admission date of 02/21/2026. Resident #5 was admitted to the facility with diagnosis to include unspecified epilepsy, intractable with status epilepticus, generalized anxiety disorder, brief psychotic disorder, Parkinson's disease without dyskinesia without mention of fluctuations, other specified persistent mood disorders, and recurrent moderate major depressive disorder. Review of Resident #5's MDS dated [DATE] revealed resident is taking or has taken the following medications in the last 7 days and has a documented indication for the medication: antipsychotic, antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant. Review of Resident #5's MAR/TAR for February 2026 revealed: Behavior monitoring was not documented on 02/22/2026 and 02/26/2026. Digoxin Oral Tablet 250 microgram (MCG) give one tablet via peg tube in the afternoon for heart failure.was not documented on 02/22/2026. Vital signs twice daily was not documented on 02/25/2026 at 0900. Glycopyrrolate oral tablet 1 milligram (MG), give 1 tablet via peg tube.was not documented on 02/22/2026. Valproate sodium oral solution 250 mg/5 milliliter (ml) give 10 ml via peg tube.was not documented on 02/22/2026 and 02/26/2026 at 1400. Enteral feed order . was not documented on 02/26/2026 at 2200. Flush feeding tube 180 ml of water every four hours was not documented on 02/22/2026 at 1000 and 1400. Review of Resident #5's MAR/TAR for March 2026 revealed: Behavior monitoring was not documented on 03/17/2026 and 03/20/2026. Digoxin Oral Tablet 250 MCG Give 1 tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube was not documented on 03/01/2026. Mirtazapine Tablet 15 MG Give 1 tablet via PEG-Tube was not documented on 03/07/2026 and 03/14/2026. Vital signs twice daily was not documented on 03/01/2026 at 0900 and 03/14/2026 at 1700. Flush tube with 30 ML of water before and after.was not documented on 03/14/2026. Glycopyrrolate Oral Tablet 1 MG Give 1 tablet via PEG-Tube.was not documented on 03/01/2026 at 1400, 03/06/2026 and 03/14/2026 at 2200. Risperidone Tablet 0.5 MG Give 1 tablet via PEG-Tube.was not documented on 03/01/2026 at 0900 and 1300, 03/06/2026 and 03/14/2026 at 2100. Valproate Sodium Oral Solution 250 MG/5 ML Give 10 ml via PEG-Tube.was not documented on 03/01/2026 at 0600, 03/06/2026 at 1400, and 03/14/2026 at 2200. Enteral Feed Order.was not Percutaneous Endoscopic Gastrostomy on 03/01/2026 at 1000, 03/06/2026 at 2200, 03/14/2026 at 2200 and 03/14/2026 at 2200. During an interview on 03/24/2026 at 1:18 p.m., Staff K, RN stated Resident #5 is a bolus eternal feed. I keep the MAR/TAR pulled up here on the computer and once I have provided the eternal feed or the medication I mark it as completed. It shows a check mark if it has been completed. If it is not documented on the MAR/TAR, then it means the order or medication has not been completed. During an interview on 03/24/2026 at 5:50 p.m., the DON stated nurses are responsible for documenting behaviors. It is documented on MAR/TAR. If a medication is given it is documented on the MAR/TAR by the nurses as it is given. They should document if the resident is refused and add a note to the progress notes. She reviewed Resident #5's MAR/TAR and stated they did miss a few days during a certain shift. I would expect there to be documentation to show the medication or treatment has been completed. Review of the facility policy dated April 2019, titled Administering Medications, Policy: Medications are administered and is safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.22. The individual administering the medication initials the residents mar on the appropriate line after giving each medication and for administering the next ones.24. Topical medications used in treatments are recorded on the residence treatment record (TAR). Review of the facility policy dated July 2017, titled Charting and Documentation revealed, Policy: All services provided to the resident, progress toward the care plan goals, or any change in the residence medical, physical, functional or psychosocial condition, shall be documented in the residence medical record. The medical records that facilitate communication between the interdisciplinary team regarding the residents condition and response to care. Policy interpretation and implementation,.7. Documentation of procedures and treatments will include care specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual who provided the care; c. The assessment date and or any unusual findings obtained during the procedure/treatment. A review of the facility's Charting and Documentation policy revealed the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: Medications administered; Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: The date and time the procedure/treatment was provided; How the resident tolerated the procedure/treatment; Whether the resident refused the procedure/treatment. A review of Resident #11's admission record revealed an initial admission date of 05/28/2025 and re-admission date of 01/22/2026. Further review of the admission record revealed diagnoses to include encephalopathy, unspecified, unspecified sequelae of cerebral infarction, aphasia following unspecified cerebrovascular disease, Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, and major depressive disorder, recurrent, moderate. A review of Resident #11's active physician orders revealed the following: Pimavanserin Tartrate Oral Capsule 34 MG [milligrams] (Pimavanserin Tartrate) Give 1 capsule by mouth one time a day for parkinsons/dementia Monitor for Adverse Effects. Indicate- N [no] if not observed, Y [yes] if observed. If observed, notify physician, with a start date of 1/30/26. A review of Resident #11's care plan revealed the following: [Resident #11] is at risk for falls and/or fall related injury r/t [related to]: dx [diagnosis] of Parkinson's, generalized weakness, impaired balance, requires staff assist with transfers and ambulation, hx [history] of falls, uses w/c [wheelchair] as primary mode of locomotion, has a hx of falls, receives psychotropic meds [medications], use of medication that could increase risk for bruising and bleeding. Date Initiated: 01/25/2026. Revision on: 01/25/2026, with interventions to include, . Administer medications as ordered; observe for effectiveness and for SEs [side effects]. Review of medications effecting fall risk as needed. [Resident #11] has a potential for alteration in thought process r/t: dx of dementia, psych [psychiatry] dx: depression, insomnia Date Initiated: 01/12/2026 Revision on: 01/12/2026, with interventions to include, Administer medications as ordered; observe for effectiveness and for SEs . A review of Resident #11's medication administration record (MAR) for February 2026 showed the following for the pimavanserin oral capsule 34 mg order and adverse effects monitoring: Adverse effect monitoring was not documented on 2/3/26, 2/4/26, 2/8/26, 2/18/26, 2/19/26, 2/21/26, and 2/26/26. On 2/1/26 to 2/9/26, 2/11/26, 2/13/26 to 2/17/26, 2/19/26 to 2/28/26, the code of 9 was documented. A review of the chart codes showed the following, 9=Other/See Nurse's notes. A review of Resident #11's MAR for March 2026 showed the following for the pimavanserin oral capsule 34 mg order and adverse effects monitoring: Adverse effect monitoring was not documented on 3/1/26 to 3/4/26, 3/8/26, 3/21/26, and 3/24/26. On 3/2/26 to 3/10/26, 3/12/26 to 3/21/26, and 3/23/26 to 3/25/26, the code of 9 was documented. A review of Resident #11's progress notes revealed the following: 2/2/26, 2/4/26, 2/6/26, 2/9/26, 2/13/26, 2/20/26, 2/23/26, 2/25/26, 3/13/26, 3/16/26, 3/18/26, 3/23/26, and 3/25/26, Note Text: Pimavanserin Tartrate Oral Capsule 34 MG Give 1 capsule by mouth one time a day for parkinsons/dementia Monitor for Adverse Effects. Indicate- N if not observed, Y if observed. If observed, notify physician. med [medication] on order. 2/3/26, 2/5/26, 2/17/26, 2/19/26, 2/24/26, 2/26/26, 3/2/26, 3/3/26, 3/10/26, 3/12/26, 3/17/26, 3/19/26, and 3/24/26, Note Text: Pimavanserin Tartrate Oral Capsule 34 MG Give 1 capsule by mouth one time a day for parkinsons/dementia Monitor for Adverse Effects. Indicate- N if not observed, Y if observed. If observed, notify physician. Unavailable. 2/27/26, 3/4/26, 3/5/26, 3/6/26, and 3/9/26, Note Text: Pimavanserin Tartrate Oral Capsule 34 MG Give 1 capsule by mouth one time a day for parkinsons/dementia Monitor for Adverse Effects. Indicate- N if not observed, Y if observed. If observed, notify physician. on order. 3/21/26, Note Text: Pimavanserin Tartrate Oral Capsule 34 MG Give 1 capsule by mouth one time a day for parkinsons/dementia Monitor for Adverse Effects. Indicate- N if not observed, Y if observed. If observed, notify physician. spoke to family regarding medication. On 03/25/2026 at 3:48 p.m., an interview was conducted with the DON. She reviewed the February 2026 and March 2026 MAR for the pimavanserin medication administration and adverse effect monitoring. The DON said she understood the concern and confusion about the chart codes and the medication administration. She said she did not have an explanation and would find out. On 3/25/26 at 5:12 p.m., a follow up interview was conducted with the DON. She said she spoke with the unit manager and was told the order for pimavanserin was supposed to be discontinued. She said she would check if there was documentation about the medication being discontinued. A record review of Resident #1's admission record showed he was readmitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus, pulmonary fibrosis, dependence on renal dialysis, heart failure, cardiomyopathy, and hypertension. A review of Resident #1's MDS, 02/19/2026 revealed a brief interview for mental status (BIMS) score of 14 indicating cognitively intact. An interview on 03/22/2026 at 9:15 a.m. with Resident #1 was conducted. Resident #1 said he receives dialysis on Monday, Wednesday, and Fridays. Resident #1 said he is not sure he receives all his medications due to him being at dialysis. A record review of Resident #1's care plan revealed a focus: has a potential for complications related to hemodialysis for treatment of ESRD (end stage renal disease) with inventions including but not limited to: adjust medication schedule as required to accommodate for dialysis treatments. A record review of Resident #1 orders revealed the following orders: Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/(airway clearance techniques) ACT 2 puff inhale orally one time a day related to acute and chronic respiratory failure Sevelamer Carbonate Oral Tablet 800 MG Give 2 tablet by mouth with meals for hyperphosphatemia Sacubitril-Valsartan Oral Tablet 97-103 MG Give 1 tablet by mouth two times a day for HTN (hypertension) Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT\/ML Inject as per sliding scale: if 151 - 199 = 2 units; 200 - 249 = 3units; 250 - 299 = 4units; 300 - 349 = 6 units; 350 - 425 = 8 units, subcutaneously before meals and at bedtime for DM (diabetes mellites) Incruse Ellipta 62.5 MCG\/ACT Aerosol Powder, breath activated 1 inhalation inhale orally one time a day related to chronic obstructive pulmonary disease hydralazine HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day for HTN (hypertension) Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for Hypertension Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 MG Give 1 tablet sublingually three times a day for pain Artificial Tears Ophthalmic Solution Instill 1 drop in both eyes four times a day for dry eyes A record review of Resident #1's medication administration record for February and March 2026 revealed no documentation for the medications as ordered by the physician on the following days: 3/2/2026 3/4/2026 3/6/2026 3/9/2026 3/11/2026 3/13/2026 3/16/2026 3/18/2026 3/20/2026 3/23/2026 An interview on 03/24/2026 at 10:43 a.m. with Staff A, Registered Nurse (RN) was conducted. Staff A, RN said Resident #1 should receive his medications before he leaves for dialysis and after he returns. Staff A, RN said Resident #1 did not receive some of his medications on dialysis days. Staff A, RN said the administration time of the medications should be changed to accommodate dialysis. An interview on 03/25/2026 at 10:10 a.m. with the DON was conducted. The DON said the process should be to reconcile medications around the dialysis time frame. The DON said Resident #1 did not receive his medications as ordered. A record review of a policy issued 4/1/2022 titled, Policy and Procedure Hemodialysis, revealed the policy is .to provide the necessary care and services to those residents receiving hemodialysis. The procedure is: 3. Recommendations will be verified with the physician and medications administered according to the times ordered by the physician or recommended by the dialysis center. Review of the facility policy needed July 2017 titled Hospice program revealed, Policy: Hospice services are available to residents at the end of life.10. In general it is the responsibility of the facility to meet the residents personal care and nursing needs and coordination with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual residents needs these include.d. Communicating with the Hospice provider and documenting such communication to ensure that needs of the residents are addressed.12. Nursing services will coordinate care provided to the resident and the Hospice staff to include.b. Communicating with Hospice representatives and other health care providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident my family.d. obtaining the following information from the Hospice the most recent Hospice plan of care specific to each resident Hospice election form .e. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forums, and record keeping requirements, to Hospice staff furnishing care to the residents.

Based on interviews and record review, the facility failed to ensure the resident's right to be treated with dignity was honored, related to untimely incontinence care, resulting in anxiety for one resident (#13) out of one resident sampled.Findings included: On 3/22/26 at 11:53 AM an interview was conducted with Resident #13. Resident #13 revealed for at least the past two weeks they have had to sit in their own bowel movement for over an hour waiting for care on Thursdays and Fridays. The resident stated it is the same aides on both shifts that continue to lack timeliness in providing incontinence care. Resident #13 stated it upsets her when she has to wait so long. The resident said they never use their call light unless they have a bowel movement. Resident #13 said they were not a high-maintenance resident and only call for an aide when they needed assistance with bowel incontinence care. Resident #13 stated the aide will come and turn off the call light, tell them they will be right back and then take over an hour to come and perform incontinence care.On 3/25/26 at 2:02 PM an interview was conducted with Resident #13. Resident #13 stated she was nervous about tomorrow because it will be Thursday and then Friday and the aides taking care of her will be on duty. Resident #13 said she had anxiety and was worried about not being cared for timely if she has to go to the bathroom. The resident stated she hoped with the State being at the facility things would get better.A review of Resident #13's admission record revealed an initial admission date of 7/21/21 and a readmission date of 11/25/23 with diagnoses to include progressive multiple sclerosis, major depressive disorder, insomnia, gastroparesis, and constipation.A review of Resident #13's quarterly Minimum Data Set (MDS) assessment, dated 12/23/25 section C - cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. Section E- Behavior revealed a score of 0, meaning the behavior for rejection of care was not exhibited.A review of Resident #13's progress notes revealed there was no documentation of Resident #13's refusals for incontinent care or expressing any behaviors noted in the resident's care plan. A review of Resident #13's care plan dated 11/25/23 revealed the resident has potential for or actual psychosocial wellbeing. Resident is to remain free of issues with psychosocial well-being by being encouraged to voice concerns/feelings; and be provided with reassurance as needed. The resident has a potential for traumatization. Provide the resident with a calming and reassuring environment. The resident has an alteration or potential for alteration in mood and displays the following: Feeling down, depressed, or hopeless. Encourage the resident to voice feelings, and provide reassurance as needed.Provide 1:1 visits as needed. A review of Resident #13's Bowel Task from December 1,2025-March 24,2026 revealed Resident #13 did not have care documented for the following Thursday and Friday shifts:7 AM-3 PM: 12/5/25, 12/11/25, 12/12/25, 12/19/25, 12/26/25, 1/2/26, 1/8/26, 1/9/26, 1/15/26, 1/16/26, 1/22/26, 1/23/26, 1/29/26, 2/5/26, 2/12/26, 2/20/26, 2/27/26, 3/5/26, 3/6/26, 3/12/26, 3/13/26.3 PM-11 PM: 1/8/26, 1/15/26, 1/23/26, 2/12/26, 3/13/26.11 PM-7 AM: 3/19/26.On 3/25/26 at 2:12 PM an interview was conducted with Staff H, Lead CNA (LCNA). Staff H, LCNA stated residents should be checked on or changed at least every 2 hours and as needed/requested by the resident. Staff H, LCNA stated there should be documentation on whether or not care was provided for each shift, including refusals and if the resident did not need to be changed. Staff H, LCNA stated if there is no documentation then it is hard to prove if care was provided during a shift for a resident.On 3/25/26 at 2:12 PM an interview was conducted with Staff G, Registered Nurse (RN). Staff G, RN stated every time incontinence care is provided there should be documentation that follows. Even if the resident refused or if care did not need to be provided, documentation should still be input per shift.On 3/25/26 at 4:14 PM an interview was conducted with the Director of Nursing (DON). The DON stated the residents care plan and Kardex (a specialized nursing reference care documentation worksheet) should be followed, and all documentation related to bowel and bladder should be documented on the residents' profile. The standard is for incontinence car to be provided every two hours or as needed, and if a resident has more than one bowel movement (BM) a day, then at least just one documentation per shift is required. The DON stated if a resident does not have a BM for the shift, then 0 should be documented. If there is no documentation for the shift, it is audited the next morning during the clinical meeting to see what percentages are being complete and to see where there might be forgotten documentation. The DON stated the expectation for care staff is to document as their job description describes, and they are unable to verify a completed task if there is no documentation. The DON stated the circumstance for Resident #13 was not the expectation of the facility, and the staff will need to be educated. The DON stated it is not okay for Resident #13 to be feeling nervous and have anxiety about the Thursday and Friday shift coming on. The DON stated Resident #13 has the right to be provided with incontinent care when the resident needs it. The DON stated she must get with the staff coming on the next day shifts and educate them on documentation and providing timely incontinence care to residents in order to prevent feelings of anxiety or not being cared for properly.A review of the facility's Certified Nursing Assistant Job Description revealed the following: The primary purpose of your position is provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and any other duties that may be directed by your supervisor. As Certified Nursing Assistant you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Record all entries on flow sheets, notes, charts, and computer programs in an informative and descriptive manner. Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors. Follow work assignments, and/or work schedules in completing and performing your assigned tasks. Keep residents dry (i.e. change gown, clothing, linen etc., when it becomes wet or soiled). Assist resident with bowel and bladder functions (i.e. take to bathroom, offer bedpan or urinal. Portable commode, etc.). Maintain intake and output records, as instructed. Keep incontinent residents clean and dry. Check and report bowel movements and character of stools, as instructed.A review of the facility's Quality of Life-Dignity Policy, revised February 2020, revealed the following: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individualization of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: Promptly responding to a resident's request for toileting assistance.A review of the undated facility policy and procedure titled, Bladder and Bowel Incontinence Policy, revealed the following: It will be the policy of this facility to ensure that residents that are incontinent will receive appropriate care and services based on the resident's comprehensive assessment. Residents that are incontinent or bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observations, interviews and record reviews the facility failed to ensure a call light was within reach for one (Resident #127) out of one residents sampled. Findings Included: During an observation on 3/23/2026 at 2:36 PM Resident #127 was observed seated in a wheelchair on the right side of the bed, facing east, a table in front of him with an open styrofoam container with spaghetti and meatballs. Resident #127 raised his left wrist and pointed saying pain. Resident #127 pointed to his neck with his right hand and said pain. I have told many people, and they have not done anything. I cannot walk or move and my pants are dirty. Resident #127's call light was observed to be hanging on the left side of his bed, out of his reach. During an observation on 3/24/2026 at 8:49 AM Resident #127 was observed wearing a hospital gown, sitting on the right side of the bed facing the door. Resident #127 pointed to his neck and stated pain, can you help me. Resident #127's call light was observed on the floor underneath the left side of his bed, out of his reach. (photographic evidence obtained) During an observation on 3/25/2026 at 9:44 AM Resident #127 was observed lying on his right side dressed in a hospital gown. Resident #127 stated I want to sit up, I cannot sit up, can you help me sit up? Resident #127 pointed to his neck and stated Pain. Resident #127's call light was observed hanging behind him on the left side of the bed from the bed rail. Resident #127 could not reach the call light. Review of Resident #127's admission record revealed an initial admission date of 7/21/2025 and a re-entry date of 3/11/2026. Resident #127 was admitted to the facility with diagnosis to include encephalopathy, acute respiratory failure with hypoxia, unspecified dementia with other behavioral disturbance, brief psychotic disorder, other specified persistent mood disorders, aphasia, repeated falls, primary osteoarthritis, and other seizures. Review of Resident #127's admission minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) of 6 out of 15 showing severe cognitive impairment. The Functional Abilities section revealed for self-care, toileting hygiene and lower body dressing Resident #127 is dependent, meaning helper does all of the effort. Resident does none of the effort to complete the activity. For mobility, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer Resident #127 needs partial/moderate assistance where helper does less than half the effort, Helper lifts, holds, and supports trunk or limbs, but provides less than half the effort. During an interview on 3/25/2026 at 3:30 p.m., Staff B, Certified Nursing Assistant (CNA), stated she checks on residents every two hours. I am checking to see if they need to be changed or need a drink. I also look to see if the call light is within reach. The call light should be clipped to the resident or near them. Resident #127 needs assistance with getting in and out of bed and moving around he cannot do a lot for himself. During an interview and observation on 3/25/2026 at 9:50 AM the Assistant Director of Nursing (ADON) stated, she spoke with the physician yesterday and the physician will be seeing Resident #127 for pain. The ADON stated no the call light is not within reach of Resident #127. She moved the call light from the left side of the bed and placed it on the right side of the bed. During an interview on 3/25/2026 at 2:38 PM the Director of Nursing (DON) stated call lights should be within reach of the resident so they can call for assistance if needed. Staff should check on residents at least every two hours. When checking on the resident they should ensure the call light is able to be reached by the resident. Review of the facility policy dated 4/1/2022, titled Call Lights, revealed Policy: It will be the policy of this facility to respond to the residents request and needs via notification with the call light system. Procedure: . 4. Twitter, the call light should be within easy reach of the resident. 5. Some residents may not be able to use their call light or may have visitors that may move belongings, including the call light. Staff should check on these residents regularly.

Based on observations, record review and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was accurately coded for two (2) out of six sampled residents (Resident #6 # 77). Findings included: Review of Resident # 6 admission record dated 03/25/2026 revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to recurrent moderate major depressive disorder, unspecified post- traumatic stress disorder, and unspecified personality disorder. Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/2026 revealed Section A Identification information A1500 Preadmission Screening and Resident Review (PASRR) revealed no for answer to is the resident currently considered by the state Level II PASRR process to have a serious mental illness and/ or intellectual disability or a related condition. Further review of the MDS revealed Resident # 6 should have been considered for a level II PASRR due to his mental illness for depression and post-traumatic stress disorder. Review of Resident # 77 admission record dated 02/25/2026 revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to recurrent moderate major depressive disorder, generalized anxiety disorder, unspecified brief psychotic disorder, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #77's MDS with an ARD of 03/02/2026 revealed Section A Identification information A1500 Preadmission Screening and Resident Review (PASRR) revealed no for answer to is the resident currently considered by the state Level II PASRR process to have a serious mental illness and/ or intellectual disability or a related condition. Further review of the MDS revealed Resident # 77 should have been considered for a level II PASRR due to his serious mental illness. On 03/25/2026 at 2:16 PM, an interview was conducted with Staff D, Minimum Data Set Director (MDSD). Staff D stated she completed Resident # 6's MDS Initial assessment. When she reviewed his preadmission screening and resident review (PASRR) in January it showed he did not have a Mental illness noted that supported the need of a level II. So, she marked no in section A1500 to the answer should the resident be considered for a level II. Staff D stated when she conducted Resident #77 assessment and reviewed his PASRR it did not click that she should have selected yes to show he should have been considered for a level II PASRR based on his diagnoses. Staff D stated she will fix the assessment and put a plan of correction in place. On 3/25/2026 at 2:30 PM an interview was conducted with the Director of Nurses (DON). The DON stated her expectations are that residents' assessments are completed accurately.

Based on observations, record reviews and interviews, the facility failed to ensure appropriate supervision during smoking time for one (Resident #77) out of four residents sampled. Findings included: On 03/22/2026 at 9:40 AM, and 1:45 pm, Resident # 77 was observed sitting outside smoking a cigarette with a smoke apron on. A staff member was observed sitting behind a table inside the facility with a cart observed next to the table. On 03/22/2026 at 9:40 AM. An interview was conducted with Staff B, Certified Nursing Assistant (CAN). Staff B, CNA stated she is the smoking aid for today. Staff B stated she always sits inside the facility when she provides supervision during smoking times. Review of Resident #77's admission record dated 02/25/2026 revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, generalized anxiety disorder, brief psychotic disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Review of Resident #77's physician order summary dated 03/25/2026 showed an electronic monitoring device, everyday shift check for function. Order date 3/12/2026. Review of an Elopement Risk Evaluation dated 3/12/2026 showed Resident #77 scored 14 indicating he is at risk for an elopement. Review of a Nursing Progress note dated 3/24/2025 showed Resident #77 exhibited exit seeking behaviors- Redirection was effective. Review of Resident #77's care plan showed a focus showing he has been assessed as able to smoke with supervision. Resident/responsible party have been informed of the facility smoking policy. Date initiated 03/12/2026, revised on 03/12/2026. Review of the care plan goals showed Resident #77 will adhere to the smoking policy daily. Resident will demonstrate safe smoking practices through the next review date. Target date 06/13/2026. Review of the care plan intervention showed accompany resident to designated smoking areas and provide supervision. On 03/25/2026 at 10:00 AM, Staff E, CNA was observed assisting Resident #77 with his cigarettes outside. Then Staff E returned to the facility to get something off the smoking cart while Resident #77 remained outside smoking. Later Staff E was observed back outside providing Resident #77 with supervision. Staff E stated she has to remain outside with Resident #77 while he is outside smoking because his hands shake while he smokes and he requires supervision. Staff E stated every resident that is marked to have supervision has to have staff outside with them during smoking times. They are not allowed to be left outside by themselves. On 03/25/2026 at 10:40 AM with the Director of Nurses (DON) and the Nursing Home Administrator (NHA). The DON stated if a resident needs supervision, then the aid could sit inside the facility and watch them from the window, even if the resident has dementia. If they require 1:1 then that's a different story. Then they would require staff to sit outside with them. The NHA stated her expectation is if a resident requires supervision, then that resident needs are met according to their care plan. The NHA stated supervision doesn't mean the aids have to sit outside with the residents because they can provide supervision while in the facility looking through the window. The NHA and DON both stated their definition of supervision is that staff monitor residents that require supervision from inside or outside the facility during smoking times. Review of the facility policy titled, Resident Smoking Policy, no date showed Policy Statement, it is the policy of this facility to establish and maintain safe smoking policies, in accordance with resident's rights and preferences, and in accordance with Life Safety Code requirements, and state and local laws governing safe practices for the facility. Direct Supervision of Residents, after residents has a smoking assessment performed by a licensed nurse and it is found that safety smoking equipment is necessary, smoking aides and residents must comply with the safety equipment is necessary, smoking aids and residents must comply with the safety equipment to ensure safety. The care plan must be reviewed to ascertain if any specific safety devices such as a non-flammable apron must be used during the smoking period. Residents must comply with any and all safety interventions.

Based on observations, record reviews and interviews, the facility failed to ensure a medication was obtained one (Resident #27) of seven residents sampled. Findings include: On 03/22/2026 at 9:20 AM, Resident # 27 was observed in bed with the bed at a 90-degree angle. A pillow was observed under his legs to keep his feet offloaded while in bed. Resident # 27 stated he has felt weak, so he has not been out of bed or participated in therapy. On 03/22/2026 at 12: 50 PM, Resident # 27 was observed sitting up in bed eating lunch and visiting with his wife. Review of an admission record dated 03/25/2026 revealed Resident # 27 was admitted to the facility originally on 01/20/2026 and readmitted on [DATE] with diagnoses to include but not limited to metabolic encephalopathy, generalized anxiety disorder, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, obstructive sleep apnea (adult) (pediatric) Review of nursing progress note dated 3/11/2026 showed Modafinil Tablet 200 milligram (MG), give 1 tablet by mouth two times a day for obesity. Note showed order awaiting script medical doctor notified. Review of a nursing progress note dated 3/12/2026 showed Modafinil Tablet 200 milligram (mg), give 1 tablet by mouth two times a day for obesity. Note showed pharmacy to deliver. Review of a nursing progress note dated 3/13/2026 showed Modafinil Tablet 200 milligram (mg), give 1 tablet by mouth two times a day related to obstructive sleep apnea. Observe for adverse effects. Note showed awaiting from pharmacy medical doctor aware noted. Review of a nursing progress note dated 3/14/2026 showed Modafinil Tablet 200 milligram (mg), give 1 tablet by mouth two times a day related to obstructive sleep apnea. Note showed awaiting on pharmacy. Review of a change in condition dated 03/14/2026 revealed Resident # 27 was noted lethargic and hard to arouse, altered level of consciousness Review of a care plan focus for Resident # 27 showed he has a potential for respiratory complications or respiratory distress related to (r/t) acute and chronic respiratory failure and obstructive sleep apnea, Resident # 27 becomes shortness of breath when lying flat. Date initiated 02/01/2026 and revised date 02/01/2026. Review of the care plan goals showed Resident # 27 will remain free from symptoms of respiratory distress. Resident # 27 will be able to maintain patent airway and will not exhibit signs of respiratory distress through next review date 03/11/2026, Target date 04/19/2026. Review of the care plan intervention showed administer medication as ordered; observe for effectiveness and side effects. On 03/24/2026 at 5:00 PM an interview was conducted with Staff C, Registered Nurse (RN)/Unit Manager (UM) and the Director of Nurses (DON). Staff C, RN/UM stated when Resident # 27 was admitted to the facility the hospital did not send a script for the Modafinil medication. He was admitted to the facility on the evening shift, so he would not receive his medication the same day he came to the facility due to his arrival time. They reached out to the Advanced Registered Nurse Practitioner (ARNP), to find out if she could fill the script or if they had to reach out to psych or pain management. Staff C, RN/UM stated the medication is used for his sleep apnea. Staff C stated Resident # 27 primary provider confirmed she would send over a script for the medication on the 12th, but they did not receive it. Staff C stated Resident # 27 missed a total of three days of his medication. During that time, they closely monitored his labs. Staff C stated they reached back out to the primary to inform them they did not receive the script to fill for the Modafinil, and she sent over another one on the 16th. Staff C stated it is not acceptable Resident # 27 had to go 5 days without his medication. On 3/25/2026 at 6:00 PM, an interview was conducted with the Medical Director. The Medical Director stated it was not acceptable that the resident did not receive his medication for the days he missed. If the facility could not get one of the resident's doctor, then they should have reached out to him, and he would have filled the script for the Modafinil. He stated he is always available and Resident # 27 should have never had to go without his medication for that amount of time. On 3/25/2026 at 6:11 PM, an interview was conducted with the pharmacy consultant. He stated he is not responsible for medication scripts at the facility. He only conducts pharmacy reviews, and gradual dose reductions. He stated he can provide information on what would happen if a resident went without Modafinil for a few days. He stated a resident would be extremely weak and would not be able to participate in anything because they would be very lethargic. Review of the facility policy titled, Medication Ordering and Prescribing: New Orders, Revision date 9/2014 showed Purpose, to ensure that residents receive newly ordered medications in a timely manner. Policy, the facility will submit new orders to the pharmacy in a consistent manner.New admissions: Facility will send orders for new admission to the pharmacy using a blank Physician Order Sheet or the facility's preprinted admission Order Sheet. Orders will be submitted to the pharmacy via facsimile.

Based on observations, interviews, and record review the facility did not ensure narcotics were double locked and stored safely, medications were labeled with an opened date and an expiration date, and thickened liquids requiring refrigeration were removed from one of two medication storage rooms and one of four medication carts.Findings included: An observation on 3/22/2026 at 9:50 A.M. of the East side medication storage room revealed several narcotics were stored in an unlocked box in the refrigerator labeled B Box. An observation on 3/22/2026 at 10:00 A.M. of East Hall 200 medication cart revealed a Symbicort inhaler was opened, used, and undated; an opened box of thicken liquids dated 2/22/2026 in third drawer of the medication cart. The directions on the thickened liquids box were: Refrigerate prior to serving.After opening, may be kept up to 7 days under refrigeration. An interview on 3/22/2026 at 10:02 A.M. with Staff K, Licensed Practical Nurse (LPN) was conducted. He said the narcotics should have been locked. He said he did not have a key for the lock. He said that narcotics in the box were for his residents, and he is responsible for keeping the narcotics locked. He said he did not know when the inhaler was opened, stating, I will date it for today. He said the thickened liquids should have been stored in the refrigerator and he did not know why it was stored in the medication cart. An interview on 3/22/2026 at 10:16 with Staff L, LPN/Unit Manager was conducted. She said the narcotics in the refrigerator should have been locked and she did not know why or how long the narcotics were unlocked. She said the inhaler should have been labeled with the opened date. She did not know when it was opened. She said the box of thickened liquids was expired and does not belong in the medication cart. An interview on 3/25/2026 at 9:51 A.M. with Director of Nursing (DON) was conducted. The DON said the narcotic box in the refrigerator should have been locked. The DON said the box of thickened liquids was not supposed to be stored in the medication cart and should have been discarded. The DON said the expectation was for all medications to be labeled with the date the medication was opened and the expiration date. A record review of an undated policy titled Medication Labeling and Storage interpretation for medication storage was 2: The nursing staff is responsible for maintaining medication storage and preparation areas; 6: Medications are stored separately from food and are labeled accordingly; 7: Controlled substances are separately locked in permanently affixed compartments. A record review of an undated policy titled Administering Medication interpretation was 12: When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, record review, and staff interview, the facility failed to ensure the sanitizer solution reached the low temperature dish machine by way of pump and tubing, failed to maintain the chlorine concentration between 50-100 ppm (parts per million) per manufacturer recommendations, and failed to maintain the ice machine in one of two nourishment rooms in a clean and sanitary manner. Findings included: On 11/06/2023 at 9:07 a.m., a general tour of the kitchen was conducted. While conducting the tour, the Dietary Manager was observed operating the dish machine. The dish machine log was reviewed for the week of (10/30-11/05) and revealed daily water temperatures as well as sanitizer concentration logged three times a day except for 11/05 at 1:00 p.m. and 7:00 p.m. The log revealed water temperatures of 150 degrees F and sanitizer concentration of 200 ppm (parts per million) for each day the log was completed. The instructions at the bottom of the form showed chlorine concentration must be between 50-100 ppm. Per the instructions, the logged sanitizer concentration was outside of range requirements. The Dietary Manager revealed they have and operate a Low temperature dish washing machine with wash temperatures to reach at least 120 degrees F and the rinse temperatures to reach at least 120 degrees F. The dish machine was observed with the Dietary Manager running empty crates through the dish washing machine. The Dietary Manager stated you must prime the dish machine three or four times to reach the required range for the sanitizer concentration and she was usually the one to get it started in the morning. Observations of the front of the machine revealed the specification place which indicated the sanitizer requirement was 50 ppm. The first dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The second dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The third dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated that was too high. The fourth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The fifth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The sixth dish machine operation demonstration revealed the Dietary Manager placed the paper used to test the chlorine sanitizer on a plastic container and the color changed to a very light color of purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The seventh dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The eighth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated she had never had the machine not reading accurately this many times and that she would give the dish machine company a call. The Dietary Manager stated they would not use the dish machine and they would use the three compartments sink to wash dishes. On 11/06/2023 at 10:53 a.m., the Dietary Manager reported the dish machine was fixed. There was a crack in the line, and it was causing negative pressure. The sanitizer was getting to the machine, but the machine was not allowing it to flow through. On 11/06/2023 at 11:33 a.m., dining was observed in the main dining room. Staff H, Dietary Aide, was observed placing utensils (spook, fork, and knife) on the table and on a white napkin for each resident. The utensils were observed wet. Staff H, Dietary Aide, stated the utensils were wet because they had just finished washing dishes because the dish machine was broken. We had to rush rush, stated Staff H, Dietary Aide. The utensils were observed in a crate, and they were all wet. The cart that the crate was sitting on was wet also. On 11/08/2023 at 11:45 a.m., a tour of the nourishment room on the east wing was conducted with the Dietary Manager. A pink and black buildup was observed underneath the dispenser on the ice machine (photographic evidence obtained). This was confirmed by the Dietary Manager. On 11/09/2023 1:44 p.m., an interview was conducted with the Dietary Manager and the Administrator. The Dietary Manager reported they switched to a new form to document water temperatures and sanitizer concentration so that was probably where the confusion came in and why staff were documenting 200 ppm. She said she was responsible for checking the forms to ensure staff were documenting and testing sanitizer accurately. The policy provided by the facility Ware Washing revised October 2019 revealed the following: 3. The Dining Services Director is responsible for insuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate. 4. The Dining Services Director ensures that all dishware is air dried and properly stored. The policy provided by the facility Ice Machines and Ice Storage Chests revised January 2012 revealed the following: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions.

Based on observations, interviews, and review of facility policy, the facility failed to ensure appropriate care and services for urinary catheters were provided to prevent infection for one (Resident #455) of one resident sampled for urinary catheters. Findings included: A review of Resident #455's medical record revealed Resident #455 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, retention of urine, and flaccid neuropathic bladder. A review of Resident #455's physician's orders revealed an order, dated 11/1/2023 for Ciprofloxacin 500 milligrams (mg) by mouth every 12 hours for 7 days for a diagnosis of urinary tract infection. An observation was conducted on 11/6/2023 at 10:04 AM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter drainage bag stored inside of a privacy bag hanging from the left side of the bed. The privacy bag was observed resting on the floor and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An observation was conducted on 11/7/2023 at 1:17 PM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter bag hanging from the left side of the bed. The catheter drainage bag and catheter tubing were not stored inside of the privacy bag hanging from Resident #455's bed and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An interview was conducted on 11/7/2023 at 1:21 PM with Staff B, Certified Nursing Assistant (CNA), Resident #455's assigned CNA for 11/7/2023 during the 7 AM to 3 PM shift. Staff B, CNA stated when she had a resident with a urinary catheter under her care, they were to ensure the catheter drainage bag and catheter tubing were kept off of the floor when hanging from the side of the resident's bed and should be stored in the privacy bag. Staff B, CNA observed Resident #455's urinary catheter tubing and addressed the catheter tubing was resting on the floor and she did not notice previously the urinary catheter tubing was resting on the floor. An interview was conducted on 11/7/2023 at 2:36 PM with Staff A, Registered Nurse (RN), Resident #455's assigned nurse on 11/7/2023 for the 7 AM to 3 PM shift. Staff A, RN stated when caring for a resident with a urinary catheter, they were to ensure the resident's catheter drainage bag and catheter tubing were kept off of the floor. Staff A, RN observed Resident #455's catheter tubing on the floor and stated the tubing should not be on the floor and should be stored in the privacy bag on the side of the bed. An interview was conducted on 11/9/2023 at 11:43 AM with the facility's Director of Nursing (DON). The DON stated if a resident with a urinary catheter was in their bed, the catheter drainage bag should be stored in the privacy bag provided with the catheter tubing tucked into the bag so it was not touching the floor. The DON also stated if the urinary catheter drainage bag and catheter tubing was stored inside of the privacy bag and the privacy bag was touching the floor it would be acceptable because the privacy bag is acting as a barrier to protect the catheter drainage bag and catheter tubing from any potential infection issues. The DON stated if catheter tubing or the catheter bag were observed resting on the floor she would expect it to be changed out by the nursing staff and it was best practice to ensure the catheter bag and catheter tubing were kept off of the floor. A review of the facility policy titled Catheter Care, Urinary, last revised in August 2022, revealed under the section titled Purpose the purpose of the procedure is to prevent urinary catheter-associated complications, including urinary tract infection. The policy also revealed under the section titled Infection Control staff are to ensure the catheter tubing and drainage bag are kept off of the floor. Photographic evidence was obtained.

Based on observation, interview, and review of facility procedures, the facility failed to ensure proper storage of respiratory equipment in accordance with professional standards of practice for two (Resident #92 and Resident #32) of two residents sampled for respiratory care. Findings included: A review of Resident #92's medical record revealed Resident #92 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia. A review of Resident #92's physician's orders revealed an order, dated 10/26/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #92's care plan revealed a focus area initiated on 6/27/2023, Resident #92 had a potential for complications of respiratory distress related to COPD and shortness of breath when lying flat with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/6/2023 at 12:46 PM in Resident #92's room. Resident #92 was observed sitting in a wheelchair in front of his bed and wearing a nasal cannula. Resident #92 stated he used oxygen because he had COPD and he also received breathing treatments when needed. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A nasal cannula attached to an oxygen concentrator was observed next to Resident #92's bed. The oxygen cannula and tubing were observed tucked between the bed rail and mattress on Resident #92's bed and not stored inside of an infection control bag. An observation was conducted on 11/7/2023 at 1:15 PM in Resident #92's room. Resident #92 was observed resting in bed with an oxygen nasal cannula applied to his face. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A review of Resident #32's medical record revealed Resident #32 was admitted to the facility with diagnoses of COPD and traumatic brain injury. A review of Resident #32's physician's orders revealed an order, dated 3/14/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #32's care plan revealed a focus area initiated on 9/26/2023, Resident #32 had a potential for complications of respiratory distress related to COPD with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/7/2023 at 10:45 AM in Resident #32's room. Resident #32 was observed resting in bed. An oxygen concentrator was observed at Resident #32's bedside. An oxygen nasal cannula was observed inside of a storage bag hanging from the oxygen concentrator and resting on the floor. The storage bag was dated 11/2/2023. An interview was conducted on 11/7/2023 at 2:44 PM with Staff A, Registered Nurse (RN). Staff A, RN stated respiratory equipment, such as nebulizer masks and oxygen tubing, were stored in a bag when not in use by the resident and were usually changed on a weekly basis or as needed. Staff A, RN also stated he ensured nebulizer masks were stored in the appropriate bag after administering a breathing treatment to a resident. An interview was conducted on 11/9/2023 at 11:32 AM with the facility's Director of Nursing (DON). The DON stated oxygen tubing and nebulizer masks were changed out on a weekly basis by a third party company and on an as needed basis by the facility nursing staff if the item was soiled or dropped on the floor. Respiratory equipment was stored inside of an infection control bag when not in use, which was also changed out on a weekly basis. If facility staff observed a resident did not have an infection control storage bag for their respiratory equipment, it should be replaced. The DON stated if respiratory equipment was stored in an infection control bag and the bag was resting on the floor, there would not be any issues related to infection control because the bag was protecting the respiratory equipment. The DON also stated she would expect facility staff to ensure the infection control bags were kept off of the floor but they would not need to replace the bag if it had been on the floor as long as the infection control bag was not compromised. A review of the facility procedure titled Administering Medications through a Small Volume (Handheld) Nebulizer, last revised in October 2010, revealed under the section titled Purpose the purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The procedure also revealed under the section titled Steps in the Procedure after obtaining post-treatment pulse, respiratory rate, and lung sounds, discard any left over solution and allow container to air dry. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. A policy related to storage of oxygen tubing was requested on 11/8/2023 at 12:35 PM from the facility's Director of Nursing. A policy was not provided by the facility.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and eleven errors were identified for one (Resident #355) of three residents. These errors constituted a 44% medication error rate. Findings Include: On 11/08/23 at 10:55 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted for Resident #355. Staff C dispensed the following medications: -Multivitamin tablet (one) -Aspirin 81 milligrams (mg) chewable (one) -Iron 65 mg tablet (one) -Lisinopril 5 mg tablet (one) -Plavix 75 mg tablet (one) -Cymbalta 30 mg tablet (one) -Meloxicam 7.5 mg tablet (one) -Miralax 75 grams (gr) (one) Ketoralac 0.5% eye drops (one drop in each eye) A review of Resident #355's November Medication Administration Record (MAR) revealed medications were scheduled for 9:00 a.m. An interview with Staff C was conducted immediately after medication administration of Resident #355. Staff C admitted the medications were outside the allotted time to give the medication, She stated the expectation was to administer medication one hour prior to and up to one hour after the scheduled time ordered by the physician. When asked what should be done if medications are out of the time allotted for medication, Staff C said the physician should be notified immediately prior to medication being administered for further update or orders. Staff C did not call the ordering physician prior to administration of late medications. Resident #355 swallowed the prescribed chewable Aspirin along with her other medications from one medication cup. The resident was never instructed to take the Aspirin as a chewable per physician orders. Staff C admitted to not following physician orders by instructing Resident #355 to chew the Aspirin. Resident #355 had a physician order for [brand name] oral capsule (Multiple Vitamins with Minerals). Resident #355 received a multivitamin tablet. An interview was conducted with Staff D, RN/Unit Manager (UM) for the [NAME] wing on 11/08/23 at 11:24 a.m. regarding timeliness of medication administration. Staff D stated medications should be dispensed one hour up to scheduled time and up to one after scheduled time per physician orders. Staff D stated the ordering physician should be notified of the late time frame either for notification purposes or for new orders. Staff D stated time management should have been factored in and if this nurse was behind on medication administration, she, Staff D, would have assisted Staff C. A review of Resident #355's November Medication Administration Record (MAR) identified the following physician orders: Aspirin 81 mg Chewable, give one by mouth one time a day related to Transient Cerebral Ischemic Attack, [brand name] oral capsule (Multivitamin with Minerals), give one tablet by mouth one time a day for vitamins. An interview was conducted on 11/09/23 at 2:20 p.m. with the contracted pharmacist consultant. The pharmacy consultant was updated on the medication incident and stated the expectation was to administer medication on a timely basis. The pharmacy consultant also stated [brand name] was a special multivitamin which included Vitamin A added for vision health. An interview with the Director of Nursing (DON) was conducted on 11/09/23 at 12:17 p.m. regarding the timeliness of residents' medication administration. The DON's expectations were for the medications to be pulled based on the physician's orders and based on the Five Rights of Medication: Right resident, Right drug, Right time, Right dose, and Right route. The DON stated timeliness of medication administration was one hour prior to and up to one hour after scheduled ordered time. This time frame would be considered timely and any time after would warrant a call to the physician and family. The DON stated medications should be administered by the correct route in which case Resident #355's Aspirin should have been separated from the other medication with the instructions for the resident to chew the medication as ordered. The DON stated [brand name]oral capsule (Multiple Vitamins with minerals) was in the medication cart but Staff C, RN inadvertently gave a multivitamin. The DON stated she would run the Dashboard from the electronic charting to look to see how medication pass could be more effective and manageable. The DON stated Staff C should have asked for assistance from fell ow coworkers. A review of the facility's policy, Administering Medication, revised April 2019, states the following in relation to medication administration: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one hour of their prescribed time unless otherwise specified, for example before and after meal orders. 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method or route of administration before giving the medication. A review of the facility's policy, Medication Administration Schedule, revised December 2012 states the following in relation to scheduling of medication(s). Daily medications scheduled for 9:00 a.m. and medications that are two times daily are scheduled for 9:00 a.m. and 5:00 p.m.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards by 1.) failing to ensure medications were securely stored and dispensed for two (Resident #83 and Resident #355) of thirty five sampled residents, 2.) failing to ensure one of six medication carts in the facility were kept locked when unattended by staff, 3.) failing to ensure medications were properly dated when opened in three of three medication carts, and 4.) failing to ensure medication carts were free of expired medications in one of three medication carts. Findings included: An observation was conducted on 11/7/2023 at 10:14 AM in Resident #83's room. A medication bottle containing over-the-counter medication was observed on Resident #83's bedside table. Resident #83 was not observed in the room at the time of the observation. An interview was conducted on 11/7/2023 at 1:27 PM with Resident #83. Resident #83 stated she brought the over-the-counter medication into the facility when she was admitted to the facility. An observation was conducted on 11/6/2023 at 11:46 AM on the 600 unit of the facility. A medication cart was in the unit hallway and was unlocked. No staff members were in the proximity of the unlocked medication cart. Staff A, Registered Nurse (RN), who was assigned to the medication cart, was observed at the unit nurse's station sitting in a chair. An interview was conducted on 11/7/2023 at 2:50 PM with Staff A, RN. Staff A stated all medications should be stored in the medication cart and if a resident brought a medication from home it would be stored inside of the medication room. Staff A also stated residents were not permitted to have medications in their rooms. Staff A stated medication carts should be locked if they were left unattended and should not be left unlocked. An observation was conducted on 11/8/2023 at 11:07 AM in Resident #355's room during medication administration with Staff C, RN. A medication bottle containing over-the-counter medication, a bottle of nasal spray, and a tube containing a topical medication was observed on Resident #355's bedside table during medication administration. Resident #355 stated she brought the medications from home when she was admitted to the facility. Staff C observed the medications on Resident #355's bedside table and informed the resident the medications needed to be taken out of the room and secured due to not having a physician's order to self-administer medications. Staff D, RN Unit Manager (UM) entered the room and informed Resident #355 she would contact the resident's physician to get approval for having the medications with her in the room and the medications would be secured in the medication cart until then. An interview was conducted following the observation with Staff D, RN UM. Staff D stated residents who wish so self administer medications must be assessed for their ability to self administer the medications and the resident's care plan must be update. Staff D also stated medications must be kept secured at all times, even if the medications were approved to be located in the resident's room. An inspection of a medication cart on the 200 unit was conducted on 11/9/2023 at 9:42 AM with Staff E, RN. The inspection of the medication cart revealed the following: - An open Humalog insulin KwikPen stored in a plastic bag with a hand written date of 10/11/23 on a label affixed to the bag. Pharmacy directions on printed on the label read once opened, store at room temperature for 28 days. Staff E verified the KwikPen was opened on 10/11/2023 and the medication expired after 28 days. Staff E addressed the insulin KwikPen expired on 11/8/2023 and the insulin pen should be removed from the medication cart. - A card containing seven tablets of Alprazolam 1 milligram (mg) with a printed expiration date of 10/31/2023. Staff E verified the medication was expired and should be removed from the medication cart. An inspection of a medication cart on the 300 unit was conducted on 11/9/2023 at 10:07 AM with Staff F, Licensed Practical Nurse (LPN) UM. The inspection revealed an open insulin glargine KwikPen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff F was not able to state when the insulin KwikPen was opened and stated the medication should be dated when opened. An inspection of a medication cart on the 500 unit was conducted on 11/9/2023 at 10:22 AM with Staff G, LPN. The inspection revealed an open Lantus insulin pen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff G was not able to state when the insulin pen was opened and stated the medication should be dated when opened. An interview was conducted on 11/9/2023 at 11:47 AM with the facility's Director of Nursing (DON). The DON stated when a resident was admitted to the facility, an inventory of the resident's belongings was taken and the resident's nurse would ask the resident or representative if any medications had been brought into the facility. If a resident brought medications into the facility, the medication was sent home with the resident's family unless the resident was assessed and was able to self administer the medications. If a resident wished to self administer medications, the resident's physician was notified and an order for the medication would be obtained. The resident was provided a locked box or drawer to ensure the medications were secured inside of the room because medications could not be left out at the resident's bedside. The DON stated she would expect nursing staff to keep the medication carts clean, ensure medications were not expired, and to discard medications appropriately if an expired medication was discovered. Insulin vials and pens should be dated when they were opened and the expiration date of the medication should also be documented. Expired medications should be returned to the pharmacy and expired controlled medications should be taken to the DON's office after the pharmacy was notified. The DON also stated she would expect nursing staff to ensure medication carts were locked at all times. An telephone interview was conducted on 11/9/2023 at 3:08 PM with the facility's Consultant Pharmacist (CP). The CP stated a nurse from the pharmacy conducted regular visits to ensure medication carts were clean, medications were all dated when opened, and no expired medications were in the medication carts. All insulins were good for 28 days after they were opened with the exception of Levemir, which had a 42 day expiration window. Expired medications should be removed from the medication cart and reordered from the pharmacy. The CP stated medications should not be left out in a resident's room and should be stored securely. The CP also stated medication carts should not be left unlocked unless the nurse is present at the medication cart. A review of the facility policy titled Administering Medications, last revised in April 2019, revealed under the section titled Policy Statement medications are administered in a safe and timely manner, and as prescribed. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. - During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. - Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely. A review of the facility policy titled Self-Administration of Medications, last revised in February 2011, revealed under the section titled Policy Interpretation and Implementation self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. A review of the facility policy titled Medication Labeling and Storage, last revised in February 2023, revealed under the section titled Policy Statement the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observations, interviews, and record review, the facility failed to ensure meals were served in a dignified manner related to: 1) Staff standing when assisting residents with a meal for four (#81, #16, #15, and #19) of four residents observed; and 2) waiting for greater than 30 minutes for meal assistance for one resident (#19) of four residents observed. Findings included: During a facility tour on 09/02/21 at 09:12 a.m., an observation was made of Resident #81 being assisted with a breakfast meal. Staff W, CNA (Certified Nursing Assistant) was observed standing by the resident's left side of the bed, while assisting her with meal. On 09/02/21 at 09:19 a.m., an interview was conducted with Staff W, CNA. Staff W stated she works this hall and knows the residents well. Staff W stated when assisting a resident, you don't have to sit. Staff W said, it is staff's preference, you can sit or stand if you like. When asked if she had received training related to assisting residents with meal, Staff W said, yes. I was told it is what I prefer. Staff W stated that she received training a long time ago and could not remember who provided training. A review of Resident #81's admission record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial MDS (Minimum Data Set) dated 07/30/21 showed: Section C, cognitive patterns showed unassessed BIMS (Brief Interview for Mental Status) indicating severe impairment; Section G - functional status showed Resident #81 required extensive assistance for ADL's (Activities of Daily Living) including eating, with one-person physical assistance. A care plan for Resident #81 dated 07/29/21 showed Resident #81 was at risk for nutritional and/or hydration and received a mechanically altered diet. Resident #81 has a variable P.O. (by mouth) intake, visual impairment and is nonverbal. Interventions include to provide hands on assistance with eating meals. On 09/02/21 at 09:26 a.m., a tour was conducted of Hall 100. An observation was made of Staff X, CNA assisting Resident #16 with breakfast while standing over her. Staff X was observed standing on the left side of the bed, spooning food into the resident's mouth. In an interview conducted at 09:29 a.m. on 09/02/21, Staff X stated she was agency staff, and it was her first day at this facility. Staff X stated she did not know about this facility's policies. Staff X stated that it did not matter if she stood over the resident when providing feeding assistance. Staff X further stated, I guess I could get a chair if you want me to. Staff X was asked if she had received training related to assisting a resident meal. Staff X stated, I don't work here. A review of Resident #16's admission record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial MDS dated [DATE] showed: Section C, cognitive patterns showed unassessed BIMS score indicating severe impairment; Section G - functional status showed Resident #16 was totally dependent and requires extensive assistance for ADL's including eating, with one-person physical assistance. A care plan for Resident #16 with a quarterly review date 08/26/21 showed Resident #16 was at risk for nutritional and/or hydration and has a swallowing problem. Resident #16 received a mechanically altered diet. Interventions included to provide hands on assistance with eating meals. An interview was conducted with Staff Y, LPN (Licenses Practical Nurse) on 09/02/21 at 09:29 a.m. Staff Y stated that staff should not be standing over residents during meal assistance. Staff Y said, They are supposed to be eye level, comfort for the resident. Staff Y said she was agency staff, and she knows this from her training. On 09/02/21 at 09:32 a.m., an interview was conducted with Staff L, CNA. Staff L stated that they [CNA's] had been trained on meal supervision expectations. Staff L said, we should not be standing. It is overpowering the resident. Staff L stated they were trained that staff should sit at bedside and have eye contact with the resident. A follow up interview was conducted with Staff H, LPN/Unit Manager on 09/02/21 at 09:41 a.m. Staff H stated the expectation related to meal assistance is to bring a chair to the resident's room and sit. Staff H said, We encourage them to sit unless there is specified resident's preference. Staff H stated there are residents who prefer staff stand when assisting with meal. When asked which residents had expressed that staff should stand during meal assistance, Staff H said, I don't have anyone in mind. I can't remember. Staff H stated that it was not a staff's preference if they should sit or stand during meal assistance. Staff H confirmed that neither Residents #81 nor #16 had made that choice. Staff H further said that Resident # 81 was non-verbal and did not have the ability to make such a choice. Staff H said that if a resident wanted a staff to stand during meal assistance, it would be indicated in the care plan. Staff H stated, this as a dignity concern. An interview was conducted with the Nursing Home Administrator (NHA) on 09/02/21 at 02:54 p.m. The NHA stated staff should sit, preferably at eye level during meal assistance. The NHA said, the expectation is for staff not to be standing over a resident. The NHA stated that they have folded chairs in the nurse's station for them [staff] to grab if there is no chair in the room. Resident #19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] reflected a BIMS of 0 indicating severe cognitive impairment. Further review revealed Resident #19 required supervision of one person for eating. A review of the Care Plan dated 8/26/21 reflected a nursing diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Dx [diagnosis] of adult failure to thrive. Interventions included provide tray set up; assist as needed. Provide hands assist with eating at meals and as needed. On 8/31/21 at 12:23 p.m., an observation was conducted. The dining cart was delivered to the 400 Hall. There were three staff serving the lunch trays to the rooms on the 400 Hall. At 12:32 p.m. on 8/31/21 all the trays had been delivered to the residents on the 400 Hall. On 8/31/21 at 12:48 p.m., Resident #19 was observed sitting in a Broda chair at the right side of her bed, awake, clean and groomed. The lunch tray was on the opposite side of the bed out of the Resident's reach and had not been set up. On 8/31/21 at 12:54 p.m., an observation was conducted. Staff L, CNA put on a gown and gloves and entered Resident #19's room. Resident #19's roommate was already finished eating her lunch. Staff L, CNA moved Resident #19 to the left side of her bed after moving the lunch meal that was sitting on the bedside table out of the way. She left the bedside table at the foot of the bed. Staff L, CNA removed the gown and gloves and performed hand hygiene upon exiting the room. During an interview conducted at that time, Staff L, CNA said Resident #19 eats with her hands all the time. She doesn't know who put the tray in the room. Staff L, CNA then asked Staff M, CNA if she would feed Resident #19 while she assists another resident. Greater than thirty minutes had passed since the dining cart had been delivered to the 400 Hall. A further observation was conducted on 8/31/21 at 1:04 PM. Staff M, CNA was in Resident #19's room wearing full PPE (Personal Protective Equipment). Staff M, CNA moved the bedside table with the lunch tray in front of Resident #19 and set it up. Staff M, CNA stood over Resident #19 and began assisting her with the lunch meal. Thirty-two minutes had passed since all the lunch meals had been delivered. There was not a chair observed in the room during the observation. On 9/01/21 at 12:38 p.m. an observation was conducted. Resident #19 was sitting in a Broda chair on the right side of her bed, awake, dressed, and groomed. On the left side of her bed was a lunch tray sitting on the bed side table out of the resident's reach. Resident #19's roommate was already finished with her lunch. During the observation Staff O, LPN (Licensed Practical Nurse), MDS (Minimum Data Set) said the CNA asked her if she would help feed Resident #19. Staff O, LPN, MDS brought a chair to the doorway, put on a gown and gloves, entered the resident's room, and moved Resident #19 to the left side of the bed and began assisting her with the lunch meal. Resident #15 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] Section C reflected a BIMS score of 0, indicating severe cognitive impairment. Review of Section G, Functional Status of the MDS assessment revealed Resident #15 required extensive assistance of one person for eating. A review of the 9/1/21 Care Plan revealed a nursing diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included provide tray set up; assist as needed and provide hands on assist with eating at meals and as needed. On 9/01/21 at 12:31 p.m. an observation was conducted. Staff N, CNA was standing in front of Resident #15, who was sitting at the bedside in a wheelchair with the lunch meal in front of her. Staff N, CNA was providing feeding assistance to Resident #15. There was not a chair in the room. On 9/01/21 at 12:36 p.m. an interview was conducted with Staff N, CNA after she exited Resident #15's room. Staff M, CNA confirmed there wasn't a chair in the room, so she had to stand to feed Resident #15. On 9/02/21 at 3:39 p.m., an interview was conducted with the Unit Manager for the 400 Hall. The Unit Manager said it's unacceptable for them to be standing. We saw that some of the agency staff needed to be re-educated on that. They are supposed to be eye level with the patient. I would say five to ten minutes max to wait for assistance. Any longer and they need to reorder the tray. The trays should stay on the cart to keep them warm until they are ready to assist. The trays should be served at the same time. You don't want someone to eat while the roommate has to wait. Resident #19 has [CONDITION(S)] disorder, and she has outburst moments. There are times where she has outbursts and will refuse. Other times you put the tray in front of her and she will eat right away. If she refuses, we reapproach and try to assist. The tray should not have been left sitting there because obviously after a half an hour the food is cold. We have had her a long time. We know to reapproach her if she refuses. On 9/03/21 at 3:44 p.m., an interview was conducted with the NHA and Staff F, Regional Nurse Consultant. The NHA said a lot of times the residents don't want the chair in their room because the space is limited. We have folding chairs in an alcove that are available. The agency staff will be educated that they are available. A review of the policy, 'Assistance with Meals,' dated July 2017, revealed the following: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals.

Based on observations, record review, and staff interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner, and food was stored appropriately related to maintenance of the ice machine, maintenance of the microwave, maintenance of the dish machine, and dating opened foods in the walk-in cooler. Findings included: On 08/31/21 at 9:35 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager. During the tour, the inside of the ice machine was observed to have brown stains on both sides of the ice machine (photographic evidence obtained). The inside of the microwave was observed with a splattered brown substance (photographic evidence obtained). The policy provided by the facility Ice dated October 2019 revealed the following: Policy Statement It is the center policy that ice is prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 4. The Dining Services Director will ensure that the ice bins are cleaned monthly and as needed. The policy provided by the facility Equipment dated October 2019 revealed the following: Policy Statement It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. Action Steps 1. The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. 2. The Dining Service Director will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 4. The Dining Services Director ensures that all non-food contact equipment is clean. The temperature for the dish machine was observed at 114 degrees Fahrenheit for wash. The dietary aid ran the dish machine three times and the temperature gauge for wash did not move. This was confirmed by the Kitchen Manager, and he stated that he would contact the chemical company. The policy provided by the facility Ware washing dated October 2019 revealed the following: 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. An opened package of hotdogs and diced ham was observed without a date in the walk-in cooler. The policy provided by the facility Food Storage: Cold dated October 2019 revealed the following: Policy Statement It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director/ Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. On 08/31/21 at 2:07 p.m., the Certified Dietary Manager (CDM) reported that the dish machine was up and running. She stated the relay switch on the dish machine was out. On 09/02/21 at 12:20 p.m., the CDM reported that an outside company comes to break down the ice machine for cleaning. The kitchen staff were responsible for the general cleaning of the ice machine. She stated the ice machine should be cleaned every day or every other day. The CDM stated the microwave should be cleaned daily. The microwave was used to heat up sauce that morning it was not cleaned after it was used. She reported that the dish machine was a low temperature machine, and the temperature should be at 140 degrees Fahrenheit for wash. The staff member that sets the machine up and doing the washing was responsible for documenting the temperature and making sure it was running appropriately. The CDM stated all staff was responsible for making sure foods in the walk-in cooler were labeled and dated.

Based on record reviews, interviews, and a review of the policy and procedure Resident Mistreatment, Neglect and Abuse Prohibition Guidelines, the facility failed to ensure an alleged allegation related to abuse for one resident (Resident #32) out of the sampled twenty-nine residents was reported immediately to the governing agency in accordance with the State law. Findings included: A review of the Admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported that the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him that he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported that the incident happened on 08/14. The SSD reported that there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported that when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from staff T that revealed that Resident #32 accused him and another CNA of verbally assaulting him. On 09/01/21 at 4:13 p.m., Staff T stated that he did not remember the day the incident happened. He was asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, chimed in because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated that the resident was very mean to him and started yelling. The SSD reported that she had Staff T to write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Reporting/Response Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services.

Based on record reviews and interviews, the facility failed to take the appropriate actions in response to an alleged violation related to abuse inflicted by direct care staff such as thoroughly investigate the alleged violations to prevent further abuse, neglect, and mistreatment from occurring for one resident (Resident #32) out of the sampled twenty-nine residents. Findings included: A review of the Admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported the incident happened on 08/14/21. The SSD reported there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from Staff T that revealed that Resident #32 accused him and another CNA of verbally assaulting him. On 09/01/21 at 4:13 p.m., Staff T stated he did not remember the day the incident happened. He was asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, interjected because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated the resident was very mean to him and started yelling. The SSD reported she had Staff T write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Reporting/Response Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and two errors were identified for two (Resident #81 and #258) of five residents observed. These errors constituted a medication error rate of 8.00 percent. Findings included: On 09/02/2021 at 8:45 a.m., an observation was conducted of Staff A, Licensed Practical Nurses (LPN) administering medication to Resident #81. During the observation Staff A, LPN was observed administering [MEDICATION(S)] (Extended-Release) 24 Hour 50 milligrams (MG) Give one (1) Tablet by one time a day for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A, LPN was observed to place the tablet in a clear packet and crushed the medication, and then placed them in apple sauce in a clear medication cup with other 9:00 a.m. medications and administered them to Resident #81. An immediate interview was conducted with Staff A, LPN, who revealed that she did realize they were Extended-Release medications and should not be crushed. She stated, I didn't see that. On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff B, LPN, on the 300 Hall, administering medications to Resident #258. Staff B, LPN was observed administering [MEDICATION(S)] Kwik-Pen Solution Pen Injector 100 Unit/milliliter (ML) ([MEDICATION(S)] 1 Unit) Dial Inject 12 Units Subcutaneously with meals for Diabetes Mellitus (DM). Record review of active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/02/2021 at 12:05 p.m. an interview was conducted with the Staff C, LPN, Unit Manager (UM) for the 100-300 Halls. Staff C, UM was informed of the observations made of Staff B, LPN administering insulin late and stated, The staff that work here know the importance of giving insulin on time, because it can mess everything up. An interview was conducted on 09/02/2021 at 12:13 p.m. with the Regional Nurse Consultant, she was informed of observations made during medication administration for Resident #81 and #258. She stated, the physician was in just now, and he reviewed all the medications for Resident #81, because ER should not be crushed. She further indicated the physician changed all the of Resident #81's medications to be crushed. The Regional Nurse Consultant stated, For Resident #258 the insulin medication was late, and that is an error. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of observations made of Staff A, LPN and Staff B, LPN administering medications late and crushing an Extended-Release medication, both of which were not administered according to the Physician orders. He stated Did she (Staff A) not read the label on the card of crushing the Extended-Release medication? That is bad, and the insulin was given incorrectly not at the correct time, they are both medication errors. A facility provided policy titled, Administering Medications, revision date April 2019, Page 01 of Page 03 reads under Policy and Procedure, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) before giving the medication.

Based on observation, interviews and record review the facility failed to ensure medications were secured appropriately, as evidenced by: 1) an unsecured and unattended box of medications on top of one (300 hall) of three medication carts observed; 2) loose and unidentified medications in two (100 hall and 300 hall) of three medication carts observed; and 3) staff personal items stored in one (100 hall) of three medication carts observed. Findings included: On 09/02/2021 at 9:45 a.m., Staff J, Certified Nursing Assistant (CNA)/Central Supply Technician was observed placing a box of [MEDICATION(S)] Step One Patches on top of the 100-hall medication cart and walking away. There were no staff nearby or in the vicinity of the medication cart. Several residents were observed to be self-propelling in wheelchairs nearby the medication cart which was located in a high traffic area on the 300 Hall. The surveyor was observed by Staff F, Regional Nurse Consultant and went over to the cart, and removed the medication from the top of the medication cart. In an immediate interview during the observation, she said the medication should not be left out. On 09/03/2021 at 10:30 a.m., observation of the medication cart on 300 Hall included in the second draw from the top of the medication cart, 1 ½ a loose tablets. Staff D Registered Nurse (RN) confirmed the presence of the unsecured white tablets On 9/03/2021 at 11:15 a.m., an observation was conducted of the 100 Hall medication cart. During the observation a loose yellow capsule was observed in the third draw from the top of the medication cart, and a bottle of Fuji water was observed in the fourth draw. Staff E, Licensed Practical Nurse (LPN) confirmed the presence of the loose capsule, and the water bottle. She stated, That's my water, I put it there because I was thirsty. On 09/03/2021 at 11:58 p.m. an interview was conducted with Staff J, related to leaving the medication out on top of the 300-medication cart. Staff J stated I know I am not supposed to put the [MEDICATION(S)] patches on the cart, I thought she (Staff B, LPN) was coming to get the patches, and she did not, I should have looked to see if she was getting them. Normally I give it to them, and they put it in the draw. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of the observations made and stated, there should be no loose medications in the medications carts, no medications should be left out, and there should not be any personal items of the nursing staff, left in the medication carts. On 09/03/2021 at 2:00 p.m. a subsequent interview was conducted with Staff F. She was made aware of further observations made of the 100 and 300 Hall medication carts. Staff F stated The Bubble Packs are paper thin. The pharmacy consultant was here the other day, and there should be no loose pills, or water or personal items in the medication carts. She further revealed that no medications should be left out on top of the medication carts too. A facility provided policy titled, Storage of Medications, with Revision Date November 2020, was reviewed and read under Policy Heading The Facility stores all drugs and biologicals in a safe secure and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging containers or dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observations, interviews, policy review, photographic evidence, and CDC (Centers for Disease Control) guidelines the facility failed to ensure appropriate infection control standards were followed related to: 1) PPE (Personal Protective Equipment) use and storage for five staff members (Staff L, N, P, Q, and Z) on two of four days observed and; 2) appropriate storage of personal items in one of one laundry rooms observed. Findings included: On 9/01/21 at 12:36 p.m. an observation was conducted. Staff N, CNA (Certified Nursing Assistant) exited room [ROOM NUMBER] wearing a gown, mask, and eye protection; she was carrying a lunch tray. Staff N, CNA walked down the 400 hall with the tray and brought it to the dining cart that was located outside room [ROOM NUMBER]. Staff N, CNA placed the lunch tray on the dining cart. Staff O, LPN (Licensed Practical Nurse) told Staff N she had to take the gown off in the room. In an interview with Staff N, CNA conducted during the observation, she said she was supposed to take the gown off in the room, but she didn't know how she could take the tray out if she took the gown off. On 9/01/21 at 9:32 a.m. an observation was conducted in the staff break room. Staff P, Floor Technician was observed in the staff break room removing a lunch bag from the refrigerator. On a table nearby was a KN95 mask and a pair of goggles. Staff P put the lunch bag on the table. An interview was conducted during the observation. Staff P said he can clean the goggles. Staff P said there isn't anywhere to put the mask and goggles. He can throw the mask away. They either clean them or throw them away. Staff P removed a mask from his pocket and disposed of the mask that was on the table in the trash receptacle nearby. On 9/01/21 at 9:33 a.m. an observation was conducted in the staff break room. Staff Q, Housekeeper entered the breakroom with an N-95 mask on top of her head. Staff Q placed her face shield on a table. An interview was conducted during the observation through translation by Staff P, Floor Technician. Staff Q said there isn't a designated area to place the mask or face shield. Staff Q also said she was not aware that putting the mask on top of her head was unsanitary. On 9/02/21 at 3:39 p.m. an interview was conducted with the unit manager. The unit manager said the gown has to be taken off inside the room. On 9/03/21 at 9:56 a.m. an observation was conducted in the laundry room. Staff P, Floor Technician and Staff Q, Housekeeper were in the clean laundry folding room with the Social Services Director (SSD), a Laundry Attendant, and Staff AA, Housekeeper. The room was approximately 8x10 feet. Staff P and Staff Q were not wearing a mask or eye protection. There were clean linens and resident personal clothing on carts, bins and a folding table in the room that were uncovered. Staff F, Regional Nurse Consultant was present during the observation and confirmed the observation. She instructed Staff P and Staff Q that they must wear their PPE. Staff AA, Housekeeper stated she was the supervisor. Staff AA said the last Covid education was about two weeks ago. Further observation of the clean folding room revealed a lunch bag and two beverages sitting on one of the clean folding tables; photographic evidence was obtained. Staff AA, Housekeeper confirmed they should not be there. On 9/03/21 at 10:50 a.m. an interview was conducted with Staff R, RN (Registered Nurse), the Infection Preventionist (IP), and the Regional Director of Clinical Services (Staff F). They stated the agency staff are educated prior to coming into the facility and when they arrive in the building, they are provided a document to read and sign specifically related to infection control. They are informed the facility is on droplet precautions, and the PPE requirement. Staff R, RN said he monitors throughout the day also, and stated, We sent the one walking around in the gown from room-to-room home. He further said, every shift is educated, and there are signs on every door. Staff R, RN said he thinks they are using the brown paper bags for PPE storage. He also said he asked the staff in the laundry room about the observations, and they didn't have an answer. On 9/03/21 at 3:58 PM an interview was conducted with the NHA (Nursing Home Administrator) and Staff F, Regional Nurse Consultant. The NHA said Staff P, Floor Technician is not usually in the laundry room. The SSD was in there looking for a resident's belongings because she was being discharged in an hour. Staff P, Floor Technician and Staff Q, Housekeeper were getting ready to go to lunch and the SSD asked for their help. They set their things on the table and began helping her get the resident's things together. The NHA stated staff can throw the masks and eyewear away. We have plenty of masks and eye protection. They are everywhere. They don't have to keep the same mask. They can bag it or throw it away during their break. Review of the policy, Coronavirus Disease (Covid-19)-Infection Prevention and Control Measures, updated October 2020, revealed the following information: Policy Statement This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of Covid-19 within the facility, Policy Interpretation and Implementation 1. This policy is based on current recommendations for standard and transmission-based precautions, environmental cleaning, and social distancing for Covid-19. 2. While in the building personnel are required to strictly adhere to established infection prevention and control policies, including: Hand hygiene; Appropriate use of PPE; Transmission-based precautions where indicated; Laundry Practices 3. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented. Anyone entering the facility is required to wear face covering regardless of symptoms. 1. Cloth face coverings for source control are not considered PPE. Staff and visitors should wear a facemask at all times when in the facility. Upon review of the policy, Isolation-Categories of Transmission-Based Precautions, revised October 2018, the following information was discovered: Policy Statement Transmission based precautions are initiated when the resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. Contact precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident care items in the resident's environment. 5. Staff and visitors well wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The following CDC guidelines were found on 9/7/21 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe: Source Control and Distancing Measures Implement Source Control Measures HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Personal Protective Equipment Ensure Proper Use and Handling of Personal Protective Equipment Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Implement Universal Use of Personal Protective Equipment Transmission from asymptomatic or pre-symptomatic residents with [CONDITION(S)]-CoV-2 infection can occur in healthcare settings, particularly in geographic areas with moderate to substantial community transmission. One of the following should be worn by HCP while in the facility and for protection during resident care encounters: A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask ' s ear loops and tucking in the side pleats; fastening the facemask ' s ear loops behind the wear ' s head; use of a cloth mask over the facemask to help it conform to the wearer's face) On 09/01/21 at 09:22 a.m., a tour of hall 100 was conducted. An observation was made of Staff Z, CNA going room to room picking up breakfast trays from 09:22 a.m. to 09:32 a.m. Staff Z, was observed without wearing a gown in rooms noted with droplet precautions posted on the doors. Staff Z, went to room [ROOM NUMBER] walked out without tray, went to room [ROOM NUMBER] and grabbed a tray, then room [ROOM NUMBER], 105 and 107, grabbing trays. Staff Z then went back to room [ROOM NUMBER] and was there for 5 minutes and walked out with a tray. Staff Z was observed without a gown during the entire process and did not change gloves or use ABHR between room to room encounters. An interview was conducted with Staff Z on 09/01/21 at 09:32 a.m. Staff Z stated that she was going in to pick up trays and assist the residents who are finishing up with breakfast. Staff Z stated that she was an agency staff. When asked what the PPE expectation was, Staff Z said, I am supposed to put on a new gown and change gloves between each room. Staff Z said, I was in a hurry trying to get to all these people, my bad. I should have changed gloves. Staff Z said she forgot to wear the right PPE. Review of a pink sign posted on all the doors in rooms 101, 105, 106, 107 and 108 showed droplet precautions STOP attention please carefully review the instructions below Everyone clean their hands, including before entering and when leaving the room with ABHR [alcohol-based hand rub] PPE requirement: Gown and gloves, face shield or goggles. N95 mask or higher-level respirator must be worn at all times while in patient room. Photographic evidence was obtained. An interview was conducted on 09/01/21 at 10:30 a.m., with Staff L, CNA. Staff L stated they had been trained to wear full PPE, change gowns and gloves between rooms and use sanitizer. On 09/03/21 at 10:02 a.m., an interview was conducted with Staff R, RN, IP. Staff R stated that his expectation would be that staff will don new PPE before going into each room and doff before they exit. Staff R said, They [staff] should not go room to room wearing the same PPE. They should not go into a droplet precautions room without a gown. Staff R stated they have educated all staff and are giving the agency staff training materials right at the door. Staff R said, they know.

Based on facility staff and family interviews, record review, facility policy review, and facility educational in-servicing records, it was determined that the facility failed to protect, and honor the end of life rights of one (Resident #1) of eight sampled residents in regards to their right to not receive cardiopulmonary resuscitation should they be found unresponsive. Resident #1 was an [AGE] year-old male with a family member designated as his legal guardian, who had the legal authority to make medical decisions on his behalf. Resident #1's Legal Guardian/Son verbally expressed to the facility, upon Resident #1's admission, to have a Do Not Resuscitate order in place so if Resident #1 was found unresponsive, not breathing, and without a pulse, he would not be resuscitated. Before being admitted to the facility, Resident #1's family communicated to the hospital that they did not want Resident #1 to receive any aggressive medical life-saving measures with a focus on comfort. The family discussed their goal of having hospice follow the resident upon his discharge from the hospital due to his age and declining health. The facility failed to honor Resident #1 and his family's wishes when his nursing aide found him unresponsive at 9:21 a.m. on [DATE]. The nursing staff did not honor the advanced directive physician's orders [REDACTED].#1's suffering. Nursing staff and Emergency Medical Services (EMS) performed cardiopulmonary resuscitation (CPR) for thirty-four minutes prior to EMS transporting him to the emergency room (ER). CPR was administered during transport and upon arrival to the hospital until the Legal Guardian requested that the ER Physician cease CPR efforts at 10:42 a.m. Resuscitative efforts were administered to Resident #1 from the time he was found unresponsive at 9:21 a.m. to his time of death at 10:42 a.m., a total of 1 hour and 20 minutes. The failure of nursing staff to honor and respect, Resident #1's Advance Directive to die naturally when found unresponsive, represented a failure in the facility's Advance Directives system. On the day Resident #1 died , [DATE], the facility census was 79, of which 39 had Do Not Resuscitate Orders. The failure of the facility to correctly implement Advance Directives resulted in findings of Immediate Jeopardy, past noncompliance, on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE] before the survey. Findings included: 1. Resident #1's Nursing Home to Hospital Transfer Form, dated and signed on [DATE] by Staff A, Licensed Nurse Practitioner (LPN), revealed, Pt (Patient) approached during med (Medication) pass @ 0921 (9:21a.m.). Pt warm to touch, 0 breaths noted. Pulse absent. Chart verification of Full code status. CPR (Cardiopulmonary Resuscitation) initiated by writer. 911 called, code blue initiated. Family called and aware of pt status. Pt transported to (Hospital Name). Resident #1's Code Blue Record, dated [DATE], revealed a code blue was initiated at 9:21 a.m., and emergency medical services (EMS) was called at 9:21 a.m. Once Staff A, LPN verified Resident #1's full code status after he was found unresponsive, not breathing, and without a pulse, she began compressions at 9:22 a.m. The Director of Nursing (DON) started the Bag Valve Mask (Ambu bag) at 9:23 a.m. to assist Resident #1 with breathing. EMS arrived on scene at approximately 9:30 a.m. Resident #1 was transported to the hospital at approximately 9:56 a.m. The facility notified Resident #1's Legal Guardian/Son at 9:37 a.m. regarding the event. According to Merriam-Webster Medical Dictionary definition, dated [DATE], found at https://www.merriam-webster.com/medical/code%20blue, a code blue is a Declaration of or a state of medical emergency and a call for medical personnel and equipment to attempt to resuscitate a patient especially when in [MEDICAL CONDITION] or respiratory distress or failure. Resident #1's Progress Notes, signed by the DON on [DATE] at 10:00 a.m. revealed, Resident was observed non-responsive while in his room. Resident did have a DNR (Do Not Resuscitate) physician order [REDACTED]. CPR was initiated. EMS notified, arrived to facility, and took over CPR. Resident was transferred to (Hospital Name) via EMS. According to a State Agency web page, dated [DATE], a Golden Rod is a form developed by the state of Florida to be a portable communication of a patient's wishes not be resuscitated. The original intent was use by EMS personnel. It is called the Golden Rod because in order to be legally valid this form MUST be printed on yellow paper prior to being completed. http://www.floridahealth.gov/about/patient-rights-and-safety/do-not-resuscitate/index.html According to the Centers for Medicare and Medicaid Services CPR in nursing homes memorandum, revised [DATE], page 3 revealed, . Facility policy should specifically direct staff to initiate CPR when [MEDICAL CONDITION] occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order . Page 9 revealed, The facility must ensure compliance with Federal and State requirements regarding advance directives. At the time the resident is admitted to a nursing home, staff must determine whether the resident has executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. Such a directive or instructions could be . a pre-existing medical order for do not resuscitate (DNR) . During an interview on [DATE] at 11:59 a.m. with Resident #1's Legal Guardian he stated that (Resident #1) had a DNR advanced directive status prior to arriving at the facility. The Legal Guardian said he verbally told the facility upon Resident #1's admission that he should have a DNR code status. However, the facility still attempted to resuscitate his father and performed CPR. He said he received a call from the facility when (Resident #1) was receiving CPR, and he told the nurses to stop because his father was a DNR. The facility told him the golden rod was not completed and a verbal was not enough to end resuscitative efforts so they would be sending Resident #1 to the hospital. From there, the Legal Guardian got in contact with the Hospital emergency room (ER) Doctor who stated they have been attempting to resuscitate (Resident #1) for a while. The Legal Guardian told them to stop because (Resident #1) is a DNR. Resident #1's Legal Guardian stated the facility did not follow (Resident #1's) wishes related to a DNR code status selection. A follow-up interview on [DATE] at 1:51 p.m. with Resident #1's Legal Guardian revealed the reason they chose a DNR status rather than a full code status is because, (Resident #1) was 87-years old, my wife is a nurse and they know how much a person goes through with CPR, so we felt it best to have him as a DNR. According to the Journal of Intensive Care, published [DATE], revealed, Effective chest compression remains the cornerstone of successful CPR, and manual chest compression is still a standard procedure. However, a variety of internal injuries to intra-[MEDICATION NAME] organs as well as abdominal viscera has been recognized Generally, pericardial injury develops together with rib or sternal fracture. During repetitive compressions of the chest wall, displaced fragments of rib or sternal fracture directly injure the pericardium and the heart . The study can be found at https://jintensivecare.biomedcentral.com/articles/10.1186/s[DATE]-5#:~:text=Although%20chest%20compression%20is%20a%20standard%20technique%20in,dissection%2C%20many%20patients%20die%20before%20reaching%20the%20hospital. Resident #1's hospital records from (Hospital Name), dated [DATE] at 11:05 a.m., page 1, revealed, . CPR in progress on patient arrival. Patient is from assisted living facility. Last seen normal at 7:00 a.m. CPR in progress 40 minutes prior to patient arrival . Patient receiving ventilation via (Laryngeal Tube) airway . EMS states they achieved to rest once prior to arrival for only 1 minute . On EMS arrival they found vomitus all over patient. Page 5 revealed, . CPR in progress on arrival. CPR continued following ACLS (Advanced Cardiovascular Life Support) protocol on arrival . We achieved ROSC (Return of Spontaneous Circulation) briefly . Patient coded again . CPR continued IV (Intravenous) following ATLS (Advanced Trauma Life Support) protocol . we achieved ROSC again. Patient coded shortly after and CPR was again resumed. I called patient's son . his healthcare proxy (Legal Guardian). I informed him of patient's condition. He asked me to stop CPR and terminate resuscitative efforts. resuscitative efforts were therefore terminated per healthcare proxy's request. time of death was called at 10:42am . 2. Resident #1's Admission Hospital Paperwork, dated [DATE], page 1, revealed prior to Resident #1 arriving to the facility, . Long discussion with (Legal Guardian) and his wife who informed . they were going to pleasure feeds with the pt however he has failed every other speech evaluation, Thy (They) do not want aggressive measures want to resume pleasure feeds and have hospice follow. Family goal is to discharge . with 24 hrs private care and hospice f/u (follow-up). Resident #1's Admission Record revealed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. His Minimum Data Set, dated dated [DATE], Section C: Cognitive Patterns revealed he had severely impaired cognitive skills for daily decision making. A review of Section G: Functional Status revealed he had total dependence on direct care staff for dressing, bed mobility, transfer, eating, and personal hygiene. Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated [DATE], revealed in Section H: Advanced Care Planning, the Do Not Resuscitate (DNR) box was checked as yes. Resident #1's Care Plan, initiated [DATE], revealed a focus of (Resident #1) has expressed the following wishes regarding code status and has the following advanced directives in place: is DNR, dated ([DATE]). Goals included, If the resident heart stops or if they stop breathing CPR will not be initiated in honor with their DNR wishes. Interventions included verifying the presence of the golden rod in the medical chart and the presence of a physician's orders [REDACTED]. Resident #1's Order Summary Report, order date of [DATE], revealed a physician order [REDACTED].>3. During a phone interview on [DATE] at 3:08 p.m. with Staff A, LPN, she confirmed she was the nurse that found Resident #1 unresponsive on [DATE]. She went into his room to give care and medications. He was found unresponsive and without a pulse. She then checked the paper chart and did not see a yellow sheet (golden rod). She checked his orders and found a DNR order in place. She said . But instructions at that point was to go by the golden rod. She stated she was not the one that called EMS but did remember speaking to the Legal Guardian. She told the Legal Guardian that chest compressions had been started and he voiced that there was a DNR in place from the hospital, and he thought there was a DNR in place at the facility, but he was unsure. She stated that she spoke to the Unit Manager (Staff B, LPN), the DON and Social Services regarding the discrepancy between the incomplete golden rod and the physician order. She stated social services is responsible for completing the golden rod. Review of Resident #1's golden rod form revealed the requirement of both a patient, or the patient's responsible party, and a physician's signature. The form was signed and dated by a physician on [DATE], however, the form was not signed by Resident #1's Legal Guardian. During an interview on [DATE] at 3:19 p.m. with the Social Services Director (SSD), she stated she has worked at the facility for about 3 to 4 years. Some of her job responsibilities include completing advance directives and discharge planning. If a resident is a DNR and has a Legal Guardian, she will reach out to the family members to get a copy of the golden rod or complete the required documents. Due to current COVID restrictions, they can also e-mail or fax the golden rod form to the responsible person for their signature. She said, We try our best to complete everything immediately. She stated that since (Resident #1) resided on the COVID unit during his stay, the Social Services Assistant (SSA) was responsible for completing his admission paperwork, including the golden rod form. During an interview on [DATE] at 3:27 p.m., with the DON and the Nursing Home Administrator (NHA), the DON stated it is the nurse's responsibility to check a resident's code status. Prior to the incident on [DATE], the DON said, The policy was to check the golden rod and if it was not completed then they were to initiate CPR . the DNR policy was revised in [DATE]. The DON stated they have the old DNR policy for review if needed. The NHA stated a Performance Improvement Plan (PIP) was started to address the incident on [DATE] involving (Resident #1). The NHA stated they have information on the attempted communication between Social Services and the Legal Guardian to get the golden rod completed. The DON reviewed the golden rod and stated that the name of the doctor on the form is not a doctor with the facility, so the form must be from the hospital. The SSD stated that she spoke to the SSA. The SSA told her that she attempted to contact Resident #1's family to complete the golden rod. During a follow-up interview on [DATE] at 3:41 p.m. the DON, NHA, and SSD confirmed there was no written documentation that the SSA attempted to contact Resident #1's family to complete the golden rod. The SSD stated that despite no documentation, there was a conversation that occurred between herself and the SSA about the SSA's responsibility to contact the family. During a phone interview on [DATE] at 3:54 p.m. the SSA stated if a resident is admitted during the night, the following morning she will verify their admission information. If the resident selects a DNR status, she will check their documentation. She checked Resident #1's golden rod form and saw it was only signed by a physician but did not have a signature from the Legal Guardian. She spoke to her supervisor, (SSD) who instructed her to follow protocol and call the family. She said, So, I called the family and left a message. They did not call back. The SSA confirmed she did not make a follow-up attempt with the Legal Guardian to complete the DNR. The time she remembers speaking directly with the Legal Guardian was on the phone after the incident on [DATE] to notify him about the incomplete golden rod form. The Legal Guardian stated he had told the hospital it was okay verbally for a DNR. She said, However, there was no verbal consent on the form. The SSA stated she could not remember if she wrote any documentation about communications between her and the Legal Guardian. She stated she was responsible for completing the admission assessments within 48 hours. During an interview on [DATE] at 12:50 p.m. the DON stated she and Staff B, LPN/Unit Manager were the other two people who responded to the code with Staff A, LPN on [DATE]. She stated the Certified Nursing Assistants (CNAs) on the unit were not involved in the event beyond waving EMS into the building. During an interview on [DATE] at 12:55 p.m. Staff B, LPN/Unit Manager stated she works full-time and has worked at the facility for approximately 2 years. She remembered Resident #1 was found unresponsive and they initiated the protocol for code blue on [DATE]. Staff B stated all three staff members (DON, Staff A, and Staff B) checked the hard chart and the computer which was when the discrepancy was found between the active physician order [REDACTED]. selection. She stated the new procedure is to follow the code status in the physician orders. During an interview on [DATE] at 1:22 p.m. with the DON and the NHA, the DON stated she started working in the facility in [DATE]. Upon reviewing the original DNR policy, revised [DATE], she does not recall if she had any concerns with the it. She stated she has worked at other facilities under the same company which also instruct staff to refer to the golden rod to determine DNR code status. The DON stated when Resident #1 went into a code, she went onto the unit and Staff A notified her about the discrepancy between the physician order [REDACTED].#1's hard chart. Staff A asked her what to do, and the DON instructed them to initiate CPR. The NHA stated the drafting of facility policies is a team effort between the corporate office and the interdisciplinary team. The NHA and DON stated nursing staff were provided with education and mock codes prior to the event on [DATE] and the information would be kept in the Staff Development Coordinator's Office. The DON stated they would reach out to the Clinical Vice President to determine who drafted the policy to go by the golden rod rather than the physician order. During a follow-up interview on [DATE] at 4:20 p.m. the DON stated the facility did conduct mock codes on [DATE] after a resident expired, however, they were unable to find any of the recent educational in-servicing or mock code documentation conducted prior to the event on [DATE]. During an interview on [DATE] at 1:47 p.m. the Regional Nurse Consultant stated she had been in the position a little over a year and had worked with this facility for about six months. She is never involved in policy drafting or policy review. Since she is not involved in policy drafting and reviewing, she could not answer why the facility chose to use the golden rod to honor a DNR. During an interview on [DATE] at 2:20 p.m. Staff C, CNA stated she has worked in the facility for [AGE] years. She confirmed she was working on [DATE] and remembered the event involving (Resident #1). She stated she remembered a nurse was walking down the hallway stating a resident was unresponsive. She called the front office and notified them someone was coding; the DON and the Unit Manager came onto the unit to assist. She grabbed the book (paper medical chart) for the nurse but is not allowed as a CNA to check a resident's code status. She held the door open for the paramedics. She stated part of her job as a CNA during a code is to call a supervisor, call 911 if needed/instructed, open the door for paramedics, and grab a crash cart if close by. If a resident requested to have their code status changed, then she must report it and follow the chain of command. During an interview on [DATE] at 2:03 p.m. the Medical Director (MD) stated after the event on [DATE] involving (Resident #1), the facility had an immediate AD HOC meeting. To his knowledge, Resident #1 was admitted and there was a physician order [REDACTED]. The ultimate result of the meeting was that within 24 hours of a DNR request, the golden rod must be filled out and the physician order [REDACTED]. He confirmed he was involved in the policy re-drafting post-event on [DATE]. He felt that a doctor's order should suffice but the facility still felt that both the golden rod and the physician order [REDACTED]. He stated he did not know why the facility went by the golden rod and confirmed the form was for EMS usage. When he brought up what would happen on weekends, the facility stated they would have fail safes in place. The MD said, Our goal is to honor the resident's wishes, unfortunately, there are issues with having the proper documentation done and I think this is what happened here. During an interview on [DATE] at 10:06 a.m. the Clinical Vice President Consultant stated she began working with the facility in [DATE]. She confirmed that each center has their own policies and if they have any questions about them, then they can ask, and we can provide recommendations. She confirmed she was involved in the drafting of the new Do Not Resuscitate Policy (revised [DATE]) but was not involved in the drafting in the previous Do Not Resuscitate Policy (revised [DATE]). She stated that when drafting the new policy, she gave them the regulation and the rule, however, each facility operates independently, and it ultimately falls on them to interpret and implement a policy. During an interview on [DATE] at 2:27 p.m., where both the DON and the NHA were present, the DON stated the root-cause of the event on [DATE] was due to not completing the golden rod form and having it in place. She said, If we would have just had the golden rod in place, we could have followed through with the DNR. The old policy stated that we had to have the golden rod in place. The NHA and DON confirmed that the golden rod form was a document only required for EMS. The NHA and the DON reviewed their old DNR policy to confirm where in the language it specified that a golden rod must be present to honor a resident's DNR status in facility. After a moment of reviewing the old DNR policy, the NHA said, It just says order. The DON then stated that bullet point number two refers to the requirement of having both an active DNR physician order [REDACTED]. 4. A policy review of Do Not Resuscitate Order, revised [DATE], stated Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in Effect . 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. 3. In addition to the advanced directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency 4. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order . a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request and both individuals must document such information on the physician's orders [REDACTED]. c. The Attending Physician must be informed of the resident's request to cease the DNR order. 6. The Interdisciplinary Care Planning Team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 7. The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effect to clarify and adhere to the resident's wishes . During an interview on [DATE] at 1:22 p.m. the DON and the NHA confirmed that references to the DNR order form and the DNR Form in the Do Not Resuscitate Order policy, revised [DATE], are the golden rod form. A policy review of Emergency Procedure- Cardiopulmonary Resuscitation, revised February 2018, revealed, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION] . 1. Sudden [MEDICAL CONDITION] is a loss of heart function due to abnormal heart rhythms (arrhythmias). [MEDICAL CONDITION] occurs soon after symptoms appear. It is a leading cause of death among adults . 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. A policy review of Advanced Directives Policy and Acknowledgement, undated, stated, It is the policy of the Center that every competent adult has the right to make decisions concerning his or her health, including the right to choose or refuse medical treatment, in accordance with the law. The Center acknowledges the right of a competent adult to make an advanced directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or indicate the desire to make an anatomical donation after death. 5. To verify the removal of the Immediate Jeopardy with a past noncompliance date of [DATE], interviews were conducted from [DATE] to [DATE] with nursing staff responsible for verifying a resident's code status, that were not involved in the event on [DATE] to ensure they received education from the facility on verifying advance directives and participated in code blue drills. During an interview with a day shift nursing staff member on [DATE] at 2:31p.m., Staff D, LPN stated that the new procedure to determine a resident's code status is to check the online system. If a resident has a physician order [REDACTED]. She stated CNAs are not allowed to log into the nurse's computer and they are not allowed to check a resident's code status during a code situation. She stated she does not remember the last time she participated in a mock code but she remembers they had one within the last month. During an interview with a day shift nursing staff member on [DATE] at 2:35 p.m., Staff E, LPN stated that if a resident is found unresponsive, they must initiate a code response. The protocol is to check for signs of life and then immediately check for code status. If the resident has selected a full code status, then they must call a code blue. Staff H confirmed receiving education a few weeks ago, and on the morning of [DATE], on how to access a resident's code status. If a resident is a DNR, they will have a physician order [REDACTED]. During a phone interview with a day shift nursing staff member on [DATE] at 3:08 p.m., Staff F, LPN stated she received education from the facility on the process of confirming a resident's code status. The code status will be within the resident's online physician orders. If a resident is a DNR and the resident does not have a completed golden rod, then they would still honor their choice based on the presence of a DNR physician order. During an interview with an evening shift nursing staff member on [DATE] at 4:13 p.m., Staff G, LPN stated he had worked in the facility for approximately a year. He stated if a resident is found unresponsive, they must check their code status, get another nurse, and if the resident has a full code status then they initiate a code blue. He stated he would have another nurse get the crash cart. He stated to confirm a resident's code status they must check the online medical chart. He stated if a resident selected a DNR status then they need to have a physician order [REDACTED]. He confirmed the facility provided in-servicing on checking a resident's code status. He stated he has received and participated in various mock codes over the past few weeks. During an interview with an evening shift nursing staff member on [DATE] at 4:18 p.m., Staff H, LPN stated she had worked in the facility for approximately 2 years. She stated if a resident is unresponsive then they must look in the computer for their code status orders. She stated if the resident has a full code status then they initiate a code blue. She stated if a resident has a DNR order in place then it would be under their physician orders. She stated she has participated in numerous in servicing and mock codes related to verifying a resident's code status. During a phone interview with a day shift nursing staff member on [DATE] at 12:18 p.m., Staff I, LPN/Weekend Supervisor confirmed she has received education and in-servicing related to the new facility procedures on verifying a resident's code status. She stated to verify a resident's code status, you must check the physician orders. During a phone interview with a night shift nursing staff member on [DATE] at 1:41 p.m., Staff J, RN/ Night Supervisor confirmed she has received education and in-servicing related to the new facility procedures on verifying a resident's code status. She stated to verify a resident's code status, you must check the physician orders. During an interview on [DATE] at 3:19 p.m. the NHA stated that after providing education and in-servicing to all facility staff members regarding code statuses and the new processes, they felt the SSA still did not understand the process in place and therefore made the determination to suspend her until an investigation was completed. The NHA said, She was suspended two days ago ([DATE]). During an interview on [DATE] at 8:23 a.m. the DON provided a signed statement which revealed, We are 100% completed for education on who needed to be in-serviced on code status. The DON stated they reached 100% educational completion on [DATE] for nursing staff who are responsible for verifying resident code statuses. She stated the facility cross-referenced education against a staffing list to verify all nurses were educated on the new process for verifying a code status. She stated any nursing staff that were not present in the facility were called and provided with a verbal in-servicing. She confirmed that PRN (as needed) nursing staff will be educated if they are needed and added to a schedule. During a follow-up interview on [DATE] at 2:27 p.m. the DON stated post-event on [DATE] the DNR policy was revised, a facility wide audit was completed on resident records to make sure their code status was correct and documentation was correctly in place, nursing staff were provided education on following the physician's orders [REDACTED]. A review of the Facility Quality Assurance, AD HOC Meeting dated [DATE], r (TRUNCATED)