Every finding on record at Hawthorne Center for Rehab & Healing of Sarasota

Based on resident and staff interview and facility policy and medical record review the facility failed to implement adequate individualized interventions to prevent falls, including fall with major injury for 1 (Resident #43) of 4 residents reviewed for falls. The findings included: Review of the facility Policy titled Incident Management (no initiation date) stated, An incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve an injury or damage to property. Incidents/accidents to be recorded, using the incident report form, and reported according to the Reporting Guidelines include but not limited to falls/found on floor. Review of the facility Policy titled Risk Management - Post Incident Evaluation, Root Cause Analysis and Plan (no initiation date) stated, The facility will use a consistent approach for post incident evaluations which will include a thorough investigation to determine how and why the incident occurred. Root Cause Analysis is a process for identifying the basic or contributing causal factors that are responsible for incidents. Root causes will guide changes in systems or processes to reduce the risk of the event recurring. Post Incident Evaluation includes Immediately following any incident - actions to support resident safety will be the priority. For falls, the Fall Risk Reduction Program will be followed to include post fall intervention and care; Incidents will be recorded according to policy; Incidents will be reported according to the reporting guideline. The Risk Manager or designee will be notified per the reporting guidelines and will be responsible for investigating and reporting any allegations of abuse, neglect, exploitation, injuries of unknown origin and or any adverse incidents as defined by State or Federal Regulation according to facility policy. Review of the clinical record for Resident #43 revealed a date of admission of 9/28/2023. Diagnoses included Cerebral Infarction (stroke), Aphasia (language disorder), Dysphagia (swallowing disorder), and Osteoarthritis. Resident #43 shared a room with his wife (Resident #37). Review of the significant change in status Minimum Data Set assessment dated [DATE] noted Resident #43 was cognitively impaired and unable to answer questions with a Brief Interview for Mental Status (BIMS) score of 99. The assessment noted Resident #43 had short term and long term memory problems. A check mark on the assessment noted Resident #43's cognitive skills for daily decision making were moderately impaired-decisions poor, cues/supervision required. The fall risk evaluations completed on 9/28/23, 11/16/23, 11/24/23, 1/2/24 and 1/19/24 noted Resident #43 was at moderate risk for falls. On 1/23/24, 2/17/24 and 3/13/24 the fall risk evaluations noted Resident #43 was at high risk for falls. The care plan created on 9/29/23 noted Resident #43 was at risk for falls due to having decreased mobility with weakness secondary to a CVA. The goal was for the resident not to sustain serious injury. The interventions dated 9/29/23 included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Review of Resident #43's care plan initiated on 10/10/23 noted the resident had impaired cognitive function/dementia or impaired thought process related to disease process, CVA (cerebrovascular accident). Review of Fall Investigations and Incident Log revealed Resident #43 sustained a fall on 11/16/23, 11/24/23, 1/19/24, 2/17/24 and 3/13/24. Review of the nursing progress note dated 11/16/23 noted Resident #43 complained of right side back pain. During assessment Resident #43 was observed to have a big bruise to the right side of the back and the back side of the right upper arm. The resident was nonverbal and not able to explain what happened. The resident's wife said on 11/13/23 Resident #43 was trying to get out of bed by himself and fell from the bed. He hit his back with the bed edge but did not hit his head. She did not call for assistance, she helped him off the floor and did not report the fall to anyone. The fall care plan updated on 11/17/23 noted Resident #43 had a fall on 11/13/23. The interventions listed were laboratory work and therapy to screen. Educate wife to inform if resident has falls and/or injury. Bruise to his back. The care plan did not include the result of the therapy screen or measures to prevent further falls. On 11/24/23 at 12:46 p.m., a nursing progress note documented Resident #43 was sent to the hospital after an unwitnessed fall in his room. The resident's wife said he hit his head. Blood was coming out, from the inside of his right ear. On 11/24/23 at 5:16 p.m., a nursing progress note documented Resident #43 came back from the hospital at approximately 3:00 p.m. with sutures. On 11/25/23 at 11:04 a.m., a nursing progress note documented the resident's right ear continued to bleed, blood-saturated gauze changed to right ear . The fall care plan was updated on 11/27/23 noting Resident #43 had a fall on 11/24/23. The new intervention was to post environmental cues call don't fall in Spanish. Therapy to screen. Resident #43 was sent to the emergency room due to a laceration to his right ear. On 1/19/24 at 7:23 a.m., a nursing progress note documented at 6:20 a.m., the nurse was called to Resident #43's room. The resident was lying on the floor in front of the clothes closet over the right side of his body, right arm, and right shoulder. The resident denied any pain, was able to move all extremities, no deformity of hip, legs, arm even shoulder. Per the wife Resident #43 got out of bed walking to the door without his walker, shoes and non sole sock. Small laceration was noted to the left eyebrow. The resident was assisted back to bed. On 1/19/24 at 9:08 a.m., a nursing progress note documented the nurse was called to Resident #43's room. The resident was sitting on the toilet, complained of pain to the left hip with the left hip bone protruding. Resident #43 was sent to the emergency room for evaluation and treatment. Review of the hospital progress note dated 1/20/24 revealed Resident #43 was diagnosed with a nondisplaced Acetabular (hip socket) fracture, left shoulder dislocation, and multiple pubic rami (bones that make up the pelvis) fractures. Review of the root cause analysis worksheet for the incident noted the root cause of the fall was the resident did not use his walker, not fully aware of his physical limitations and need for walker, and impaired cognition. On 1/22/24 the fall care plan was updated and noted Resident #43 was readmitted with the multiple fractures and left shoulder dislocation. The goal was for the resident to remain free from complications related to the fracture. The new interventions included floor mats when in bed, modify environment as needed to meet current needs: Non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, adequate glare-free light. On 2/17/24 at 1:37 a.m., a nursing progress note documented Resident #43 was observed lying face down on the floor with his head nearer to the lower quarter of the bed. The resident was barefoot. The outer aspect of right eye sclera (white of the eye) was red. On 2/19/24 the care plan was updated with interventions to obtain a left hip X-ray, toilet the resident upon rising, before or after meals, at bedtime and as needed. On 3/13/24 at 3:36 p.m., a nursing progress note documented per Resident #43's wife, the resident was sitting in a wheelchair close to the bed without his walker. The resident walked to the door of the room and returned. When trying to go back to bed, lost his balance, slid out of the bed over his knee with half of his body over the bed. On 3/14/24 the care plan was updated to obtain laboratory work and neurological checks were initiated. On 3/25/24 at 11:10 a.m., observed Resident #43 sitting in wheelchair in the common area with other residents monitored by staff. On 3/27/24 at 11:30 a.m., Resident #43 and his wife were observed sitting in their room located down the hall from the nursing station with the call light on. On 3/27/24 at 11:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said Resident #43 has had multiple falls, including a fall with injury. She said she frequently took care of Resident #43 since he only spoke Spanish and she spoke Spanish. She said Resident #43 shares a room with his wife who is wheelchair bound and requires assistance with activities of daily living. She tries to take care of him and help him instead of calling for help. On 3/27/2024 at 3:00 p.m., in an interview the Risk Manager said Resident #43 fell and was a stubborn man. She said the fall was investigated the day of the fall (1/19/24), his wife witnessed the fall. She said the wife told the nurse that the resident got up and walked without his walker with no shoes on. The resident was placed back in bed by two staff members, no pain or sign of injury were noted. She said three hours later the resident was found sitting on the toilet by the CNA (Certified Nursing Assistant) who noticed his left hip protruding. She did not know if the injury was from the original fall or if the resident fell again. The fall investigation did not have documentation of any timed or signed interviews. She said after the facility investigation the IDT (Interdisciplinary Team) met the next morning and decided the accident, was not preventable, was not considered neglect or abuse so was not a reportable incident. She said the resident had his wife (Resident #37) in his room to help look after him. She said the wife was not employed by the facility and was not responsible for his safety. Review of Resident #37's clinical record revealed a Quarterly Minimum Data Set assessment dated [DATE] which noted the resident's cognition was moderately impaired with a BIMS score of 09. On 3/28/2024 at 4:00 p.m., in an interview the Administrator said he did not see falls as abuse or neglect because it was not an injury of unknown origin. When asked if the investigation was thorough, since it was based on the statement from another resident with a BIMS score of 9, he said it could have been better.

Based on record review and staff and resident interview, the facility failed to continue to assess after a change in condition and failed to ensure prescribed medications were available for administration for 3 (Resident #1, #3 and #6) of 5 residents reviewed. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses not limited to personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke) with no residual effects. Record review revealed on 4/4/23 at approximately 5 p.m., Resident #1 complained of numbness to the bottom lip and unintentional biting her inner cheek to Licensed Practical Nurse (LPN) Staff C. LPN Staff C noted there was no facial droop, smile even and speech clear. Physicians Assistant notified of issue. On 4/10/23 at 12:02 p.m., in a phone interview, LPN Staff C said on 4//4/23, Resident #1 had complained of mouth pain and involuntarily biting of her inner cheek. She said she had the usual smile, normal vital signs, no slurred speech and seemed the same as always. She said she texted the Physician's Assistant (PA)to notify her but never heard back from the PA. Further record review revealed no evidence of ongoing assessment of Resident #1 until seen by the PA on 4/5/23 at approximately 1p.m. There was no evidence another attempt to contact the PA was made until 10:37 a.m. on 4/5/23. On 4/11/23 at 2:40 p.m., in an interview, the facility Director of Nursing said there was no evidence of assessment of Resident #1 after the initial assessment at 5 p.m. on 4/4/23 until approximately 1 p.m. on 4/5/23 and there was no evidence of an attempt to contact the PA after the initial attempt at approximately 5 p.m. on 4/4/23 until approximately 10:37 a.m. on 4/5/23. 2. Facility policy 1.0 Medication Shortages/Unavailable Medications, no policy number or effective date, noted: A. If a medication shortage is noted at the time of medication administration (Med Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. B. If a medication shortage is noted during normal pharmacy hours: 1. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order. C. If a medication shortage is noted after normal pharmacy hours: 1. A licensed nurse obtains the ordered medication from the emergency stock supply. If the ordered medication is unavailable in the emergency stock supply, a licensed nurse calls the pharmacy's emergency answering service and request to speak with the registered pharmacist on call to determine the plan of action Resident #3 was admitted to the facility on [DATE] with diagnoses not limited to history of leukemia (blood cancer). On 4/10/23 at approximately 11:45 a.m., in an interview, Resident #3 said she had not been receiving her Imbruvica (medication used to treat Leukemia) medication. She said the medication is used to Help keep my white blood cells down. She said she thought she came to the facility with two doses and has not received anything after the 2 doses. She said her daughter has been looking into why she is not getting it. Review of the record for Resident #3 revealed an admission order for Imbruvica Oral tablet 420 milligrams (mg) one time a day. Review of the Medication Administration Record (MAR) for Resident #3 for March 2023 revealed the medication Imbruvica was not administered on 3/29, 3/30 and 3/31 and coded with a number 9 for each date. The number 9 code corresponded with Other/See Nurses Notes. Review of the nurses notes for 3/29/23 noted Not available was entered. Review of the nurses notes for 3/30/23 and 3/31/23 noted On order was noted. There was no evidence the pharmacy had been contacted by the nurse on any of the dates noted. Review of the MAR for Resident #3 for April 2023 revealed the medication Imbruvica was not administered on 4/2, 4/4, 4/5, 4/6,4/7, 4/8, 4/9, and 4/10. The entries for 4/2, 4/4, 4/5, 4/7,4/8 and 4/9 were coded with the number 5 which corresponded with Hold/See Nurses Notes. Review of the nurses notes for 4/2/23 noted not available was entered. Review of the nurses notes for 4/4, 4/5, 4/6, 4/7, 4/8 and 4/9 revealed no explanation as to why the medication was not administered. There was no evidence the pharmacy had been contacted by the nurse on any of the days noted. Review of the nurses notes for 4/10/23 noted med not on hand, pharmacy contacted. On 4/11/23 at 9:43 a.m. the Director of Nursing confirmed Resident #3 did not receive the medication Imbruvica 420 mg daily as ordered on 3/29, 3/30, 3/31, 4/2, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9 and 4/10/23. She also confirmed the pharmacy was not contacted about the medication shortage by any of the nurses on the days noted until 4/10/23. She said none of the nurses informed her Resident #6 was not getting the medication. 3. Resident #6 was admitted to the facility on [DATE]. Review of the record for Resident #6 revealed an admission order for Tylenol PM Extra Strength 500-25 milligrams by mouth at bedtime. Review of the MAR for Resident #6 for April 2023 revealed the Tylenol PM Extra Strength 500-25 mg was not administered on 4/3, 4/4, 4/5 and 4/9/23. There was no evidence the pharmacy had been contacted by the nurse on any of the days noted. On 4/11/23 at approximately 12:05 p.m. the Director of Nursing confirmed Resident #6 did not receive the medication Tylenol PM Extra Strength 500-25 mg at bedtime as ordered on 4/3, 4/4, 4/5 and 4/9/23. She also confirmed the pharmacy was not contacted about the medication shortage by any of the nurses on the days noted. She said she was not aware Resident #6 was not getting the medication as ordered.

Based on review of the clinical record, resident and staff interviews, the facility failed to provide the necessary care and services to maintain ambulation status for 1(Resident #16) of 1 resident reviewed with a restorative ambulation program. Review of Resident #16's clinical record showed an admitted [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 required limited physical assistance of one person for transfers, walking in room and corridor. The Certified Nursing Assistant Kardex (form used to communicate resident's care needs) documented Resident #16 required assistance with ambulation. A fall risk evaluation dated 3/8/22 documented Resident #16 scored an 11 indicating a high risk for falls. On 5/9/22 at 2:41 p.m., Resident #16 said she was supposed to receive restorative nursing (program to promote improvement in function and minimize deterioration) but said I only get it one day a week if someone is here. The aides and nurses say they can't ambulate me with the four wheeled seated walker. Resident #16 reported generalized weakness. The resident said, I'm not supposed to walk by myself outside of the room, but they don't have the time to walk me, I understand they are busy. I am trying to get stronger. I am a former Registered Nurse and I know therapy is important. Once you reach your goal you want to maintain and not slip back. Resident #16 said, I would like to have someone ambulate me more frequently, at least from my room to the dining area, but they say it is better if I use the wheelchair. A review of the Restorative Nursing Program referral for Resident #16 dated 12/8/21 and signed by the therapist, and the restorative aide on 2/16/22 documented Resident #16 was referred to the program for ambulation with a goal to maintain/improve current level of function. The referral documented, Pt [Patient] is at risk for decline and increased level of care. The listed interventions were for gait as tolerated or 50 feet using a four-wheel walker and wheelchair to follow with three liters of oxygen. Rest as needed, assist with the oxygen tubing. The frequency of the ambulation program was three times a week. Review of the Certified Nursing Assistant (CNA) documentation for March 2022, and April 2022 failed to show documentation Resident #16 received the restorative ambulation on scheduled days, nine times in March, and seven times in April. On 3/2/22, 3/4/22, 3/7/22, 3/11/22, 3/16/22, 3/21/22, 3/23/22, 3/25/22, 4/6/22, 4/13/22, and 4/20/22 NA [Not applicable] was entered. On 3/18/22, 4/8/22, 4/11/22, 4/15/22 and 4/29/22, the form was left blank, making it impossible to determine if the resident received the restorative program. On 3/28/22, 3/30/22, 4/4/22 and 4/18/22 the form noted Resident #16 refused to participate in the restorative program. On 5/11/22 at 8:37 a.m., the Director of Rehab (DOR) said the facility had one restorative aide, and she was often pulled to work on the floor providing patient care. The DOR said no one was available to do the restorative programs when the Restorative CNA was pulled from her assignment. On 5/11/22 at 9:32 a.m., the Assistant Director of Nursing (ADON) said she was responsible for the Restorative program. She said the facility was experiencing staffing issues and often has to pull the restorative CNA to the floor to help. On 5/11/22 at 11:56 a.m., the Restorative CNA said she was the only restorative aide for the facility. The CNA said Resident #16 was on a restorative ambulation program to be done three times a week. The CNA said she was often pulled to work the floor to provide resident care and then no one was available to do the restorative program.

Based on observation, record review and staff interview, the facility failed to ensure medications remained locked and inaccessible to unauthorized personnel when out of sight on 3 (Independence Place, Liberty Lane, Bounce Back Lane) of 4 units. The facility failed to discard expired medication in 1 (Bounce Back Lane) of 4 medication carts reviewed, and failed to ensure safe storage of medications at the bedside for 2 (Resident #24 and #44) of 2 residents observed with unsecured medications at the bedside. The findings included: The facility's Medication Storage Policy provided by the Director of Nursing (DON) noted Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by the facility's policy. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with the facility policy. The Medication Dispensing System Policy provided by the Director of Nursing (DON) Medications, biologicals, or chemicals of any kind are never to be left unattended on top of medication cart. The Policy also noted Medication carts are always to be locked when out of sight or unattended. On [DATE] at 9:30 a.m., a Medication Cart at the nurse's station on Independence Place on the second floor was observed unlocked, unattended, and unsecured. Licensed Practical Nurse (LPN) Staff O approached the cart, retrieved some medications and walked into Resident #44's room, and closed the resident's door. The medication cart remained unlocked. LPN Staff O returned shortly to the cart without any medications. On [DATE] at approximately 9:35 a.m., a cup of pills was observed on Resident #44's bed. The Resident said the nurse had just handed her the cup of pills and left the room. Resident #44 said she had to wait and take the medications with food at lunch time. She said she usually took the medications with breakfast, but the nurse was late administering her medications. On [DATE] at 9:40 a.m., LPN Staff O said it was her first day working at the facility and she had the whole floor. She verified she left the cup of medications with Resident #44 because the resident was with it and could administer her own medications. She said they were just vitamins anyway. LPN Staff O said she did not know if Resident #44 was assessed to safely self-administer medications. She said, That's just the way we do it here. On [DATE] at 10:10 a.m., a review of Resident #44's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:45 a.m., a Medication Cart on Independence Place on the second floor, was observed unlocked, and unsupervised. The cart was not within direct observation of authorized staff. No staff was observed in the vicinity of the cart. On [DATE] at 2:06 p.m., LPN Staff O said she was aware she left the medication cart unlocked and unattended. She said she was busy. On [DATE] at 9:07 a.m., a medication cart on Liberty Lane on the second floor was observed unattended in the dining room area. A clear plastic medicine cup with a mixture of crushed pills in applesauce was on the medication cart. LPN Staff B was observed approaching the cart. She verified the unattended medicine cup on the cart contained crushed medications mixed in apple sauce. LPN Staff B verified medications should not be left unattended and said she forgot to discard the medications. On [DATE] at 1:48 p.m., a Treatment Cart in Bounce Back Lane on the first floor was observed unlocked, and unattended. LPN Staff B emerged from a patient's room, moved the cart, and locked it. On [DATE] at 1:50 p.m., observation of the medication cart on Bounce Back Lane on the first floor with LPN Staff B showed a [MEDICATION(S)] Kwik Pen (insulin pen) with a date opened of [DATE]. LPN Staff B said once opened the [MEDICATION(S)]'s expiration date was either 28 or 30 days. LPN Staff B removed the [MEDICATION(S)] pen from the cart. Review of the manufacturer's specification for [MEDICATION(S)] kwik pen showed the pen must be used within 28 days or discarded, even if it still contains [MEDICATION(S)]. On [DATE] at 10:03 a.m., the Director of Nursing said no medication should ever be left unattended on top of the medication cart, the medication carts should always be locked and never left unattended. The Director of Nursing said insulin should be disposed of after 28 to 30 days after the date opened. On [DATE] at 12:15 p.m., a bottle each of Super B complex vitamins, Vitamin D3, Tylenol 650 milligrams (mg), calcium 600 mg with Vitamin D and mega-reg (omega-3 [NAME] oil) were observed in an opened drawer of the night table of Resident #24. The resident said she has had the medications since her admission to the facility on [DATE] and took them daily. On [DATE] at 12:23 p.m., Registered Nurse (RN), Staff I said she had no idea Resident #24 kept medications at the bedside. On [DATE] at 12:35 p.m., Certified Nursing Assistant (CNA) Staff H said the medications have been in Resident #24's unlocked drawer for a while now. On [DATE] at 9:01 a.m., CNA Staff J said she knew residents were not to keep medications, ointments in their rooms since this unit was the dementia unit. She said other residents may wander and have access to those medications. On [DATE] at 12:55 p.m., the Director of Nursing confirmed the medications should be secured and kept with a nurse.

Based on record review and interviews, the facility failed to ensure nebulizer machines used for residents are maintained under safe operating conditions according with the manufacturer's recommendations. The findings included: The compressor nebulizer (Machines that create a mist out of liquid medication for easier absorption into the lungs) manufacturer's manual for the nebulizers used at the facility noted, Filter change: . Do not wash or clean the filter. Only use filters supplied by your distributor. And do not operate without a filter. Change the filter every 30 days or when the filter turns gray . On 5/10/22 at 10:37 a. m., the housekeeping supervisor said the housekeepers were responsible to clean nebulizers The housekeeper assigned to the soiled utility room sprays the soiled nebulizer with a disinfecting solution, ensuring it stays wet for 10 minutes. The housekeeper takes the filter out and washes it. The housekeeping supervisor said they did not change the filters, they just washed it. She said the facility did not have a policy or a process for disinfecting nebulizers. The Director of Nursing and the Maintenance supervisor were present during the interview. On 5/10/22, at 12:20 p.m., the Director of Nursing said the facility had a total of 25 Nebulizers, 15 were in storage, and 10 were currently being used by residents. He said he heard about the housekeepers washing the nebulizer filters.

Based on observation, review of the clinical record, family and staff interviews, the facility failed to provide the necessary care and services to maintain hygiene for 1 (Resident #4) of 4 sampled residents who required assistance with activities of daily living (ADLs). The findings included: Clinical record review revealed a Quarterly Minimum Data Set (MDS) assessment with a target date of 2/9/22 which documented Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 required extensive physical assistance of one staff for hygiene, and limited physical assistance of one staff for bathing. The assessment documented Resident #4 scored an 8 on the Brief Interview for Mental Status, indicative of moderate cognitive impairment. The care plan initiated on 5/24/21 noted Resident #4 required assistance with ADLs, including assistance of one staff for bathing. Interventions included showers, check nail length, clean and trim on bath days as necessary. On 5/10/22 at 10:23 a.m., during a phone interview Resident #4's family member, said he reported care concerns to the facility staff. The family member said Resident #4 was not receiving scheduled showers, staff were not trimming her fingernails and cleaning her left hand. He said the residents' nails were long and dirty, especially the left hand which had a contracture (tightening of the muscles and tendons that cause the joints to become stiff). He said he filed two grievances with the facility regarding the same concerns and had verbally reported his concerns to the Director of Nursing (DON). A review of the facility Grievance/Complaint Report showed a grievance dated 2/16/22 in which Resident #4's family member stated the resident's contracted hand needed to be cleaned better and her nails needed to be cut on an ongoing basis. The grievance form documented the family complained they have made this request before and have not seen an improvement. A grievance dated 4/7/22 for Resident #4 documented the family had strong concerns about care when visiting this week. They observed that resident's fingernails were filthy, hands smelled, nails were very long with crud under them, teeth looked like they hadn't been brushed in a long time, body odor . On 5/10/22 at 1:39 p.m., Resident #4's fingernails were observed extending approximately ½ inch from the tip of the finger with a brown substance under the nail beds. Resident #4 was not able to answer any question. On 5/10/22 at 1:44 p.m., Registered Nurse Manager, Staff M confirmed Resident #4's fingernails were long with a black /brown substance under some of the fingernails on both hands. Staff M said she would clean and trim Resident #4's fingernails. Review of the Certified Nursing Assistant (CNA) daily charting for February, March and April 2022 showed Resident #4 was scheduled to receive showers every Wednesdays and Saturdays. There was no documentation Resident #4 received her scheduled showers on 2/2/22, 2/9/22, 2/16/22, 2/23/22, 2/26/22, 3/2/22. 3/9/22, 3/16/22, 3/19/22, 3/23/22, 3/26/22, 3/30/22, 4/2/22, 4/6/22, 4/13/22, 4/20/22, 4/27/22. The CNA documentation showed Resident #4 received two bed baths in February, one bed bath in March, and three bed baths in April. The CNA's daily charting for February, March and April lacked documentation Resident #4 received assistance with personal hygiene 41 of 84 scheduled shifts in February 2022, 64 of 93 scheduled shifts in March 2022, and 55 of 90 scheduled shifts in April 2022. On 5/11/22 at 8:45 a.m., in an interview CNA Staff N said she provided care for Resident #4 on 5/10/22 but did not cut or trim her fingernails. She said only the nurse can do that. CNA Staff N confirmed she did not clean Resident #4 fingernails. On 5/11/22 at 9:49 a.m., in an interview Licensed Practical Nurse Staff O said looking at the CNA documentation for February and April 2022, she was not able to verify if Resident #4 received showers or personal hygiene on the days that were not documented by the CNA.

Based on observation, clinical record review, review of facility policies and procedure, resident and staff interviews, the facility failed to provide the necessary care and services to maintain continence for 2 (Resident #16 and #75) of 2 residents reviewed for incontinence. The findings included: The facility policy titled Restorative Nursing - Bowel and Bladder Program (undated) specified residents who have had any episodes of incontinence will be assessed for the need of a bowel and bladder program upon admission, quarterly, upon removal of an indwelling catheter, or with a significant change. The procedure noted, To begin the evaluation of the resident's bowel and bladder function. The Restorative Nurse/designee will: Complete the first 3 sections of the Bowel and Bladder Evaluation. If the resident is to proceed to the 3-Day Bowel & [and] Bladder Patterning Diary, instruct the CNAs that a 3-Day bowel and bladder patterning diary has been implemented. Instruct the CNAs to cue and assist the resident to toilet and to check the resident for episodes of incontinence and mark the diary as indicated. On day 4 when the diary is completed, the Restorative nurse or designee will review the 3-day patterning. The nurse will check for patterns of continence and incontinence to determine if a resident is eligible for retraining, prompted voiding, scheduled toileting, or placed in the incontinent care (check and change program). 1. A review of Resident #16's clinical record showed an Admission Minimum Data Set (MDS) assessment dated [DATE] and a Quarterly MDS assessment dated [DATE], which documented Resident #16 required limited physical assistance of one for transfers, ambulation, toileting, and personal hygiene. The MDS documented Resident #16 was frequently incontinent of bowel and occasionally incontinent of bladder. The assessment documented a toileting program was not currently being used to manage the resident's bowel continence. The clinical record lacked documentation of a bowel and bladder patterning and evaluation to address the specific incontinence needs of Resident #16. The care plan initiated on 9/3/21 and revised on 10/6/21 noted Resident #16 required assistance of one person for transfer and toilet use, had functional incontinence (Incontinence occurs when an individual has difficulty getting to the toilet on time) due to having decreased mobility with weakness. The goal was for the resident to remain free from skin breakdown due to incontinence and brief use. The interventions included to offer and assist with toileting. Check for incontinence, wash, rinse, and dry perineum. Clean peri-area with each incontinence episode. On 5/9/22 at 2:24 p.m., Resident #16 said she was not able to get up on her own and required assistance to go to the bathroom. Resident #16 said sometimes she is incontinent because the staff do not come when she needs to be toileted, and she has to wait for staff to assist her on the toilet. Review of the Certified Nursing Assistant (CNA) documentation for March and April 2022 failed to show Resident #16 received assistance with toileting on the night shift (10:00 p.m. to 6:00 a.m.) on 3/3/33 through 3/6/22, 3/9/22 through 3/12/22, 3/14/22, 3/16/22, 3/17/22, 3/19/22, 3/23/22, 3/26/22, 3/29/22 through 3/31/22, 4/1/22 through 4/7/22, 4/9/22 through 4/13/22, 4/15/22 through 4/21/22, 4/23/22, 4/24/22, 4/26/22 through 4/28/22 and 4/30/22. There was no documentation Resident #16 received assistance with toileting during the day shift (6:00 a.m. to 2:00 p.m.) on 3/24/22, 3/30/22, 4/7/22, 4/14/22, 4/17/22, 4/24/22 and 4/29/22. There was no documentation Resident #16 received assistance with toileting during the evening shift on 3/5/22, 3/6/22, 3/17/22, 4/7/22, 4/14/22, 4/17/22, 4/24/22 and 4/29/22. On 5/11/22 at 3:00 p.m., in an interview Registered Nurse (RN) Staff M confirmed Resident #16 was not on a bowel and bladder program. On 5/12/22 at 9:41 a.m., CNA Staff K said she was assigned to Resident #16 and knew her care needs. CNA Staff K said Resident #16 used a walker and sometimes needed help since she was incontinent of loose stool. 2. A review of Resident #75's clinical record showed an admitted [DATE]. The Admission MDS assessment dated [DATE] documented Resident #75 was frequently incontinent of bladder and always incontinent of bowel. Resident #75 required extensive assist of one for bed mobility, toileting, and dressing. The MDS assessment also noted Resident #75 was not on a bowel and bladder program to maintain or restore continence. On 5/9/22 at 11:39 a.m., Resident #75 said when she needs to be toileted no one comes and if she wets herself, she will wait for someone to change her. Resident #75 said the prior week she had to call her spouse in the middle of the night to come to the facility and change her because no one would answer the call light. On 5/10/22 at 8:51 a.m., Resident #75 said when she puts her call light on for toileting assistance the staff tell her, It's not my job or I can't help you because it will hurt my back. On 5/10/22 at 2:03 p.m., Resident #75's spouse said his wife had called him in the middle of the night to come and help her because she had her light on and no one would answer it. The resident's spouse said, I have her on speaker phone and as I'm driving there, I can hear the call light on for 20 minutes and I hear someone in the room with her arguing with her and telling her we can't hurt our backs with you, you are not wet. He said by the time he got there the staff were leaving the room and had changed her. A review of the CNA documentation from 4/18/22 through 4/30/22 showed no documentation staff assistance for personal hygiene was provided to Resident #75 for 25 CNA scheduled shifts. The CNA documentation showed no documentation Resident #75 was assisted to use the toilet on 23 CNA scheduled shifts. On 5/11/22 at 10:33 a.m., Registered Nurse (RN) Staff P said Resident #75 required the assistance of two persons with incontinent care and toileting. RN Staff P said the CNAs get information on the care needs of the resident from the CNA Kardex (form used to communicate resident's care needs) and documents in the CNA electronic records. On 5/11/22 at 2:57 p.m., RN Staff M reviewed Resident #75's CNA documentation for April and confirmed there was missing documentation of care. RN Staff M said she would not be able to say if Resident #75 received toileting and hygiene assistance since it was not documented. RN Staff M said, I believe she received the care because she would not be able to go for an extended period without toileting or receiving incontinent care. On 5/11/22 at 3:26 p.m., the Director of Nursing confirmed a lack of CNA documentation for Resident #75's toileting and personal hygiene and said without the documentation there was no way to know if Resident #75 had received the toileting and personal hygiene care. On 5/12/22 at 10:45 a.m., CNA Staff Q said Resident #75 required physical assistance of two with incontinent care and toileting.

Based on personnel file review, resident medical record and staff interview, the facility failed to ensure 2 (Licensed Practical Nurses (LPN) E, and F) of 7 Licensed Practical Nurses, who are assigned to the medication carts, had the required Certification to administer Intravenous Medication. The findings included: Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR for May 2022 for Resident #62 revealed LPN Staff F administered the antibiotic Cefazoline on 5/1/22, 5/5/22 and 5/6/22 via the intravenous route. On 5/10/22 review of the personnel files revealed an annual task competency completed respectively on 2/6/21 and 2/12/21 for Staff E and F, including infusing IV (intravenous) medications. The files lacked documentation Staff E and Staff F had completed the required Intravenous certification for LPNs. On 5/10/22 at 4:25 p.m., in an interview, the facility Regional Clinical Consultant confirmed the lack of Intravenous certification for LPN Staff E and Staff F.

Based on record review and staff interview, the facility failed to ensure 1 resident (resident #83) of 5 sampled residents for drug regimen review was free from a significant medication error. The findings included: The Policy for Medication Dispensing System provided by the Director of Nursing states: Verify that the Medication Administration Record reflects the most recent medication order . Follow appropriate medication administration guidelines . Document necessary medication administration/treatment information (e.g., medications are administered, medication injection site, refused medications and reason, prn medication, etc.) on appropriate forms. Record review of Resident #83's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order specified to hold the [MEDICATION(S)] if the systolic (top number) blood pressure was below 110. Review of the Medication Administration Record for May 2022 showed on 5/11/22 at 8:00 a.m., the nurse documented administering the [MEDICATION(S)]. The systolic blood pressure documented was 97. On 5/11/22 at 2:16 p.m., Licensed Practical Nurse (LPN) Staff O verified she administered the [MEDICATION(S)] as documented on the Medication Administration Record despite the documented systolic blood pressure of 97. On 5/12/22 at 10:03 a.m., the Director of Nursing said if a medication like [MEDICATION(S)] is administered outside of the physician's specified parameters, they would notify the physician, monitor the blood pressure for signs and symptoms of adverse effects of the medication, and it would be a medication error.

Based on observation and interview, the facility failed to store and serve food in a sanitary manner to prevent potential contamination. This failure had the potential to cause food borne illness in residents receiving an oral diet. The findings included: 1. On 10/26/20 at 7:15 a.m., during an initial tour of the kitchen, the door to the walk-in freezer was noted to be slightly ajar. There was a large area of semi-solid ice was noted along the edge of the door frame to the walk-in freezer and extended out about an inch away from the frame on each side and along the top. The plastic protective curtain strips were coated with partially frozen condensation; the floor to the left of the entrance around the wheel of the food storage cart had a large pile of snow-like condensation; and there was a large area of frozen condensation extending along the top of the ceiling in front of the fans with large droplets hanging down. On 10/26/20 at 7:30 a.m., in an interview Dietary Staff A said the condensation in the walk-in freezer had been like that for many months. On 10/29/20 at 9:46 a.m., a second tour of the walk-in freezer was conducted along with the Food Services Supervisor (FSS). The condensation was still present with more accumulation present on the floor and walls just inside the entrance. The frozen condensation droplets along the ceiling were still present. Discussed condensation on ceiling of freezer had potential to contaminate food with door being left open or so heavily coated with frost cannot close properly. This potentially could cause food to partially thaw with warming of freezer and then refreeze. The FSS acknowledged the concern and confirmed this problem had been going on for months. On 10/29/20 at 10:45 a.m., in an interview the Director of Maintenance said he had someone out to install a new door closer on 6/15/20 for this and fix a threshold screw on 10/9/20. He said there was nothing wrong with the seals of the door and condensation was from staff not closing the door properly and leaving it ajar. 2. On 10/26/20 at 7:15 a.m., during an initial tour of the kitchen, the following observations were made: the front of the stove was heavily coated with a large area of grease drippage going into a metal pan on the floor; the metal vent grates over the stove were heavily soiled with a brown grease like substance; the front, ides, and top of the dish machine was heavily coated with dried residue from water creating a thick crust along the top and edges; and all 3 hand sinks were soiled/stained with rust and drippage along the inside and outside of the metal frames. On 10/26/20 at 7:50 a.m., a tour of the kitchenettes on Independence Place revealed the inside glass door of the microwave was damaged and the interior was stained brown along the top and sides. On 10/26/20 at 8:15 a.m., a tour of the Bounce Back Lane kitchenette revealed a corroded and heavily stained microwave; and the ceiling above the drink and ice machines were heavily stained brown. On 10/29/20 at 9:46 a.m., a second tour of the kitchen was conducted along with the FSS. The areas previously identified were still present. The FSS said the grease drippage on the front of the stove had been like that for about a year and was probably a broken trap. The grates over the stove were cleaned by Maintenance and she acknowledged they appeared to be soiled with grease. The FSS confirmed the hand sink in the dish room had rusted areas and the dish machine was heavily soiled with crusted white residue creating uncleanable surfaces. **photographic evidence obtained**

Based on record review and interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment as required by regulation for 2 (Residents #22 and #24) of 6 sampled residents reviewed for hospitalization and falls. This had the potential to delay revision of the resident's plan of care and services. The findings included: According to the Resident Assessment Manual, a significant change was a major decline in a resident's status, determined by a completed assessment of the resident. If the facility deemed the resident had met the guidelines for a major decline, the facility was required to complete a significant change MDS within 14 days of the identification of the major decline. 1. Record review of the resident's hospitalization s revealed Resident #22 had five hospital admissions with returns to the facility between 2/14/20 and 7/24/20. Record review of Resident #22's MDS admission and quarterly assessments between 3/4/20 and 9/2/20, revealed Resident #22 had multiple physical declines that required an increase in staff assistance and services. On 10/29/20 at 12:00 p.m., facility MDS Coordinator Licensed Practical Nurse (LPN) Staff E acknowledged there should have been a significant change MDS done for Resident #22. 2. Resident #24 was an [AGE] year-old female resident who was admitted to the facility on [DATE] with a fracture to her left femur and left radius after a fall. On 8/23/20 the resident was assessed with [REDACTED]. The tool rated a person who scored greater than a score of 13 as a high fall risk. Resident #24 was care planed for falls related to the resident recent fall with fracture, status [REDACTED]. The only documented interventions for falls on 8/23/20 was to instruct the resident to call for assistance when getting out of bed and transferring, to encourage the resident to stand slowly, orient the resident to the room, surrounding areas, and use of call light. On 8/31/20, the intervention of being aware of the residents Dementia and forgetfulness when providing reminders and support was added to the fall prevention interventions. The MDS dated [DATE] showed Resident #24 needed extensive assistance with bed mobility and transfers and was not ambulating. Resident #24 needed extensive assistance with toileting and was frequently incontinent of both bowel and bladder. On 10/1/20 Resident #24 had an unwitnessed fall at the facility and was hospitalized with a second fracture to her left hip. The MDS assessment completed on 10/1/20 showed Resident #24 needed limited assistance with bed mobility, limited assistance with toileting, and had occasionally urinary incontinence prior to her fall at the facility. Resident #24 was admitted to the hospital on [DATE] with a fractured left hip. The resident was readmitted to the facility on [DATE] after having surgical repair to her left hip. On 10/29/20 the Director of Nursing (DON) was asked to provide the facility's fall prevention policy. A form titled ACCIDENT/INCIDENT PREVENTION was provided by DON as the facility policy for fall prevention. The form had no dates of review by the facility. The form consisted of 21 interventions that could be initiated for residents assessed as a high fall risk. One of the interventions on the list was to ensure that residents wear proper fitting shoes/slippers with non-skid surfaces. On 10/29/20 at 9:15 a.m., Resident #24 was observed lying in the bed. The bed was observed to be elevated from the floor and not in the lowest position to prevent injury to the resident should she attempted to get out of bed or fell out of the bed. On 10/29/20 at 9:25 a.m., in an interview Licensed Practical Nurse (LPN) Staff I verified the bed was not in the lowest position while the resident was in the bed. She stated she was not aware if the bed being in the lowest position was a current fall intervention for Resident #24. Staff I said she did feel the bed should be in the lowest position while the resident was in bed due to her high fall risk. On 10/29/20 keep bed in lowest position at all times was added as an intervention to Resident #24's fall care plan. On 10/29/20 at 10:51 a.m., in an interview the Director of Physical Therapy (DOPT) said after the resident was admitted to the facility, she had improved to stand by assist of one staff prior to her falling on 10/1/20. The DOPT said after the resident was readmitted on [DATE] she lost her ability for mobility and needed two staff members to assist her with transferring and toileting. The DOPT said Resident #24 currently was a two person assist with both transferring and toileting. On 10/29/20 at approximately 11:30 a.m., the MDS Coordinator LPN, Staff E said she should have completed a significant change on Resident #24, but she was waiting to see if she had any improvement with rehabilitation. Staff E verified Resident #24 was a high fall risk and that her current fall interventions needed to be updated due to her recent fall. Staff E said the certified nursing assistant staff were informed verbally by nursing when residents were a high fall risk. After reviewing the form that was provided as the facility's fall policy, Staff E said the facility currently did not have a fall program in place to identify those residents at high risk for falls. On 10/29/20 at 12:30 p.m., Resident #24 was observed sitting in a chair beside her bed. She was observed to be sitting forward in the chair as though she had been attempting to get out of the chair on her own. The resident had one green non-skid sock on her right foot and her left foot was barefoot. There was no other sock observed on the floor near the resident. The resident said staff had not been able to find her other sock and they were looking for it. When asked if she would call for assistance if she needed to get anything she said no. The resident was asked to find her call light. The call light was attached to her wheelchair arm on the left side. The resident was not able to locate the call light at that time. On 10/29/20 at 12:45 p.m., LPN Staff I found a second non-skid green sock in the resident's top dresser drawer. She said she could not explain why Resident #24 did not have a non-skid sock on her left foot. When asked about the resident's tennis shoes observed near the resident, Staff I said the shoes had caused a sore on the resident's left foot. A foam bandage was observed at that time to the resident's left foot. On 10/29/20 at 1:57 p.m., Certified Nursing Assistant (CNA), Staff J said she was assigned to Resident #24 and had worked with her several times. She said if residents were a high fall risk the nurse told the aides in a report. CNA Staff J said staff nursing had not informed her that Resident #24 was a high fall risk. CNA Staff J said Resident #24 would use her call light very infrequently. She said Resident #24 would scoot forward in her chair and attempt to get up on her own. She said she thought the nurse just added an order for [REDACTED]. On 10/29/20 at 2:20 p.m., the DON verified Resident #24 had had a change in condition on 10/1/20 when she fell and fractured her hip at the facility. The DON said they had investigated Resident #24's fall on 10/1/20 and had found the resident thought she had heard her phone ringing and was attempting to reach for her phone. On being readmitted to the facility on [DATE] the intervention to ensure her belongings were within reach was added to her care plan. The DON would not answer why the intervention had not been in place prior to 10/1/20 due to her high risk for falls.

Based on record review, policy and procedure review, interview, the facility failed to provide a Restorative Nursing program as ordered by the physician to prevent decline in ambulation for 1 (Resident #29) of 1 resident reviewed for Activities of Daily Living. The findings included: The facility's Restorative Nursing/Nursing Rehabilitation program's primary focus was Nursing interventions to promote the resident's ability to attain or maintain his or her maximum functional potential. On 10/27/20 at 9:05 a.m., Resident #29 was observed sitting in her wheelchair, propelling herself with her feet. Resident #29 said she fell a long time ago and tried to walk but it hurts her legs and knees. Resident #29's clinical record indicated she had a fall on 8/11/20, went to the hospital and was re-admitted to the facility on [DATE]. The resident received skilled Physical Therapy (PT) from 8/17/20 through 9/18/20. The resident was ambulating 50 feet using an assistive device with stand by assistance (SBA) upon discharge from therapy. There was no referral for a Restorative Nursing program. The clinical record also included a physician's orders [REDACTED]. The Activities of Daily Living (ADL) Restorative nursing records for Resident #29 were reviewed from 6/29/20 through 10/27/20. Under the area of how many feet did the resident walk on 10/19/20 the resident walked 15 feet and on 10/23/20 walked 12 feet. There was no other documentation of the resident walking as per the Restorative Nursing program. On 10/27/20 at 1:54 p.m., in an interview Certified Nursing Assistant (CNA) Staff F said Resident #29 was walking about 30 feet with stand by assist pushing her wheelchair before she broke her hip. Since then she was not able to walk. CNA Staff F said the resident was no on any restorative program. In 10/27/20 at 2:21 p.m., in an interview Licensed Practical Nurse (LPN) Staff G said before Resident #29 broke her hip, she was able to get up and walk a short distance. LPN Staff G said the resident has been up walking in her room but was not aware of any ambulation program. LPN Staff G checked the restorative book and said there was no restorative program for Resident #29. On 10/27/20 at 2:53 p.m., in an interview Restorative CNA Staff H said Resident #29 was on an active range of motion program to her upper and lower extremities but no ambulation or gait training program. Restorative CNA Staff H said the resident was walking about 20 to 30 feet before the last fall where she broke her hip. On 10/27/20 at 3:09 p.m., in an interview the Director of Rehabilitation said when Resident #29 was discharged from skilled therapy, she was walking 50 feet. He said the resident had been on case load previously and was discharged to nursing restorative on 6/29/20. The Director of Rehabilitation confirmed he did not make any new referral to restorative when the resident was discharged on [DATE]. On 10/28/20 at 12:52 p.m., in an interview Registered Nurse (RN) Staff D said she never received any referral from therapy for a restorative ambulation program for Resident #29. She confirmed there was a physician's orders [REDACTED]. RN Staff D said she sent a request for therapy to determine her current level of ambulation to see if she was still able to walk 50 feet.

Based on observation, interview, and record review, the facility failed to provide an activities program to meet the residents choices and encourage both group and independent activities by failing to assess the residents activity choices and care planning and structured group and individual activities for 3 (Resident #24, #127, and #19) of 4 residents sampled resulting in decreased physical and psychosocial stimulants for the residents which a potential to cause a decline in both physical and mental abilities of the residents. The findings included: Review of the facility Policy NO: 10.01 for activities showed the policy was adopted 1/81, and was revised on 2/20/18, and, 10/23/19. The policy stated The facility will provide an ongoing program to support residents in their choices of activities, both group and independent, designed to meet the interests of, and support the physical, mental, and psychosocial wellbeing of each resident, encouraging both independence and interaction. Under the Procedure heading the policy lists the following interventions: 1. Residents shall be assessed at the time of admission for individual activity interests, hobbies and cultural preferences, which will be incorporated into the resident's plan of care. 2. An activity calendar shall be developed to create opportunities for each resident to enhance his/her sense of wellbeing . 1. Resident #24 was an [AGE] year-old resident who was admitted to the facility on [DATE] with a fractured left wrist and radius. She was assessed by the facility to have a brief interview for mental status score (BIMS) of 12 which idicates resident has good cognition. On 10/27/20 at 9:02 a.m., in an interview when Resident #24 was asked about her activities at the facility, she stated, All I do is watch TV and wiggle my toes. She said she never left her room and staff did not bring her any activities. The resident said she liked puzzle books. She said staff would come in and talk with her for about five minutes, but they had never brought her books or puzzle books. On 10/27/20 at 3:15 p.m., in an interview the Activities Director (AD) said he would have to locate Resident #24's activity visits documentation. The AD said residents have been encouraged to stay in their rooms since March of 2020. He said he had two activity staff members who made visits with the residents daily. They documented when they visited each resident. The AD said he would assess the resident for their activity's preferences 5 to 7 days after they were admitted because he liked to wait for the social services assessment to be completed prior to doing his assessment so he could compare their findings with his. On 10/27/20 at 3:45 p.m., in an interview Activities Assistant Staff K said the AD did not provide an activities program for each resident. She said she would go in and ask the resident what they liked to do and spent 5 to 10 minutes with each resident talking or playing music. She said they had a cart with books and activities that they brought around to residents on some days and they sometimes brought a snack cart around to the residents. Staff K said a confused resident like Resident #24 would be asked to fold towels. She said Resident #24 would fold one or two towels before stopping. On 10/27/20 at 4:00 p.m., in an interview the AD verified he could not find documentation of the initial activities observation he had completed for Resident #24. Review of the Activity Charting-Restricted Activities showed documentation of daily room visits. Activities documented provided for Resident #24 were resting, watching tv, snack cart, and folding towels. On 10/28/20 at approximately 11:00 a.m., in an interview the Director of Nursing and Administrator verified they were not aware of the Memorandum provided by Centers for Medicare and Medicaid dated 9/17/20 that allowed for communal activities of residents with social distancing, hand washing and face coverings. The Administrator said she had just started working at the facility and had not yet had time to review the activities program. On 10/29/20 at 12:30 p.m., in an interview Resident #24 said they still had not brought her any puzzle books. She said she did not read because of her eye site. She said she had some reading glasses but was not able to locate them at that time. On 10/29/20 at 2:30 p.m., in and interview the AD verified there were no structured activities for Resident #24. He said he was working on putting together group activities for the residents at this time. 2. Resident #127 was an [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #127's BIMS from his 5-day assessment shows his score as 00. This would show him to be severely confused. On 10/26/20 at 8:40 a.m., Resident #127 was observed sleeping in a recliner next to his bed. On 10/28/20 at 10:40 a.m., Resident #127 was observed in a recliner next to his bed. He was alert but unable to answer yes and no questions due to confusion. On 10/28/20 at 1:00 p.m., in an interview the AD verified he could not find documentation that he had completed an observation of activities for Resident #127. On 10/28/20 at 2:00 p.m., in an interview the AD said he had completed the activities observation on 10/28/20 by asking Resident #127 his likes and dislikes. He verified at that time resident #127 had a BIMS of 00. On 10/28/20 at 2:28 p.m., in an interview Activities Assistant, Staff L said she visited the resident daily for 5 to 10 minutes and he colored with [MEDICATION NAME], listened to music, and did puzzles. Staff L verified she had not documented these activities with Resident #127. Review of Resident #127's care plans showed no care plan for activities. On 10/29/20 at 2:00 p.m., in an interview the AD verified Resident #127 did not have a care plan for activities. 3. 10/26/20 at 9:24 a.m., in interview Resident #19 said she feels that it has been too long with being made to stay in the rooms. she said that it has been over 8 months. It seems like a person can go crazy in the room. She said, I use to go out on to the patio and just enjoy the sunshine and fresh air, now they will not let us go out. She said she did not feel that it should be a problem with us going out there. there are not many things to help life be interesting we have to stay in our rooms for so many months. She said she lays in bed all day, eats in her room and there are very few things to make life interesting anymore. On 10/27/20 at 10:38 a.m., observed Resident #19 laying in her bed appeared to be sleeping. Dressed appropriate for the day. On 10/27/20 at 1:49 p.m., in interview Certified Nursing Assistant (CNA) Staff N she said the managers say the residents must stay in their rooms. On 10/27/20 at 2:17 p.m., in an interview RN Staff M, said that the residents were encouraged to stay in their room and were not allowed out on the porch or outside. She said they pretty much did not have any activities and they just stay in their rooms and watch television, read, or sleep. On 10/28/20 at 2:24 p.m., observed Resident #19 in her room laying in her bed in her room. Review of Resident #19's activity care plan dated 3/17/20, documented the resident would have a current focus of programming including independent activities due to temporary group activity being prohibited related to COVID-19 virus. Approaches: 1. resident will keep in touch with family. 2. provide resident with independent activity supplies. 3. provide room visits and socialization.

Based on record review and interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal elimination function as possible for 1 (Resident #29) of 1 resident with the identified problem of a decline in bladder incontinence. The findings included: The facility's policy Incontinence (Bowel and Bladder) revised on 7/2005; indicated residents were to be evaluated for continence on admission and a monitoring record in place to assess elimination patterns. Each resident on the monitoring program would have individual plans and goals established by the care plan team to assist the resident in acquiring lost functions or to maintain present function. All incontinent residents would be further re-assessed on a quarterly basis using the Incontinence Re-assessment form. Licensed staff would review the last full incontinence assessment at that time. If there were no changes and current bladder plan of care was effective, continued current plan. If there were changes that did affect resident's plan of care, a new 3-day tracking and incontinence assessment would be completed. Then individualized plans and goals would be developed. Resident #29's clinical record revealed a [DIAGNOSES REDACTED]. An Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE], indicated the resident was always continent of bladder and required staff assistance with toileting. A Quarterly MDS dated [DATE], indicated the resident was occasionally incontinent of bladder. On 8/21/20 a quarterly MDS was completed and indicated the resident was now always incontinent of bladder and required extensive assist from staff with toileting. An Incontinence Assessment was completed on 6/3/20 and 8/16/20. The assessments indicated Resident #29 was continent at least once a day and no interventions to promote continence were in place (prompted voiding, scheduled voiding, adaptive equipment, habit training, etc.). The certified nursing assistant documentation for bladder function was reviewed from 7/26/20 through 10/27/20 and there was no evidence of any tracking being done to establish a pattern of continence/incontinence to include time of episode, and how many times the resident was continent or incontinent during the shift. On 10/27/20 at 9:05 a.m., in an interview Resident #29 said regarding toileting she didn't drink anymore so she didn't have to go to the bathroom. On 10/27/20 at 1:54 p.m., in an interview Certified Nursing Assistant (CNA) Staff F said Resident #29 was usually incontinent of bladder since she broke her hip a couple months ago. Staff F thought the resident was aware of the need to urinate, but when Staff F found her in the bathroom already, she had been incontinent. Staff F said the resident used to love coffee but no longer drinks it. The resident was not on any toileting program but tried to take her after meals. On 10/27/20 at 2:21 p.m., in an interview Licensed Practical Nurse Staff G said since Resident #29 was incontinent at times, had some control of bladder but was not on any toileting program that he knew of. On 10/28/20, Resident #29's care plan was reviewed. Under the problem Urinary Incontinence, dated 8/17/20, the goal was to keep the resident clean and dry to prevent skin damage. The approaches were to check frequently and provide care after each incontinent episode. No care plan had been developed to include a measurable goal and approaches to help the resident maintain her highest level of continence and to prevent decline. There were no interventions in place for CNA staff to use to assist the resident in being continent to include a scheduled or prompted toileting plan based on the resident's voiding pattern. On 10/28/20 at 12:52 p.m., in an interview Registered Nurse Staff D confirmed there had been no care plan developed to address Resident #29's decline in continence to include a specific goal and individualized approaches to improve or maintain the resident's urinary function.

Based on medical record review, facility policy review, room observation, and interview, the facility failed to ensure 2 (Residents #2 and #3) of the 6 sampled residents who had falls, had a revised plan of care noting preventive measures. The facility failed to evaluate and put preventive measures in place leaving residents potentially vulnerable and at risk of negative outcomes. The findings included: Review of policy #3.06 (FL) Area: Nursing, Subject: Emergencies (Revised 4/3/18) found under A. Falls: 8. If head injury has occurred, notify physician and monitor vital signs and neuro checks at least every four (4) hours for twenty-four (24) hours, or until stable, or as otherwise ordered by physician. 9. If a fall is unwitnessed, notify physician and initiate neuro checks at least four (4) hours for twenty-four (24) hours, or until stable, or as otherwise ordered by physician. 1. Review of Resident #2's medical record revealed a fall on 2/14/20, noting her left ring finger twisted and a knot on the left side of her forehead. The resident was sent to the emergency room (ER) and returned to the facility. Neither the [DATE] plan of care, nor the medical record provided a post-fall evaluation and the implementation of preventive measures. The care plan post-fall revisions were not evident. 2. Review of Resident #3's medical record revealed falls on 1/15/20, 1/26/20, 2/10/20, 2/10/20, and 2/15/20. On 2/10/20, the resident was taken to the ER; the progress note at 2:04 p.m. documented the resident said he hit his head and was observed rubbing the back of his head. Vital signs were taken at that time, but not repeated every 4 hours for 24 hours as part of neuro checks. Neither the current plan of care, nor the medical record provided a post-fall evaluation with preventive measures. On 2/18/20 at 2:30 p.m., room observations of Resident #2 and #3's room were done, with no signs of preventive measures such as, lower bed position or mats on the floor around the bed. On 2/18/20 at 3:08 p.m., during an interview, the Director of Nursing said, We don't have an internal investigation (of those falls). We use the Event Assessments form in each resident's medical record. In reviewing the Residents #2 and #3's care plan, I do not see where they were updated, and no documentation of interventions implemented post fall.

Based on medical record review, facility policy review, and administrative interviews, the facility failed to ensure 3 (Resident #1, #2, #3) of 6 residents' medical records reviewed for falls had accurate and systematic documentation. The facility failed to ensure the medical record had a complete investigation of the incident, the residents' post-fall evaluations documenting vital signs and neuro checks. The findings included: Review of policy #3.06 (FL) Area: Nursing, Subject: Emergencies (Revised 4/3/18) found in section A. Falls: 8. If head injury has occurred, notify physician and monitor vital signs and neuro checks at least every four (4) hours for twenty-four (24) hours, or until stable, or as otherwise ordered by physician. 9. If a fall is unwitnessed, notify physician and initiate neuro checks at least four (4) hours for twenty-four (24) hours, or until stable, or as otherwise ordered by physician. 1. A review of Resident #1's medical records revealed an admission date of [DATE], the plan of care, dated [DATE], revealed he was a fall risk. The noted approach was to instruct the resident to call for assistance before getting out of bed or transferring; encourage him to stand slowly; orientate him to the room, surrounding areas, and use of call light system. Review of the medical record and the Minimum Data Set (MDS) assessment, the resident was assessed as having a fall 6 months prior to his admission. The resident's [DIAGNOSES REDACTED]. The plan of care dated [DATE] failed to include the implementing physical fall prevention measures such as lowering the bed or putting mats beside the bed. The medical record revealed the resident fell on [DATE] at 11:53 p.m. Review of the progress notes failed to provide evidence the patient's vital signs were checked. The records did not include a fall event sheet. The medical record noted at 11:55 p.m., the resident's family was at the resident's bedside. The family was requesting an emergency room (ER)evaluation. The resident was transferred to theER on [DATE], at 12:45 a.m. The resident's medical record did not have a fall event assessment. 2. A review of Residents #2's medical record revealed she had a fall on 2/14/20. The progress note for 2/14/20 at 7:16 p.m. documented the resident was sitting upright on the floor in her room. The resident's left-hand ring finger was twisted out and there was a knot to the left side of her forehead. An order noted neuro checks every 4 hours for 3 days. The resident's medical record failed to document vital signs as noted on the facility's fall policy with head injury. The resident was transferred to the ER. The resident was not admitted to the hospital and was returned to the facility. The plan of care post-fall did not provide evidence of preventive measures such as low bed position, mats beside bed, or bed alarms. 3. A review of Resident #3's medical record revealed falls on 1/15/20, 1/26/20, 2/10/20, 2/10/20, and 2/15/20. On 2/10/20, the resident was taken to the ER. The progress note of 2/10/20 at 2:04 p.m. documented the resident said he hit his head and was observed rubbing the back of his head. Vital signs were taken at that time, but not repeated every 4 hours for 24 hours as part of the neuro check. Neither the current plan of care, nor the medical record provided a post-fall evaluation with preventive measures. During an interview on 2/18/20 at 1:32 p.m., the Director of Nursing said regarding Residents #1, #2, and #3, I can't find vitals checks for their fall occurrences. I have been looking and looking, I will be honest, I can't find them. (Resident #1) was discharged to the hospital right after the fall and was admitted . He did not return.

Based on record review and staff interview, the facility failed to provide and document a discharge summary with the necessary information about the resident's care needs to ensure a safe and orderly transfer from the facility for 1 (Resident #3) of 3 residents who were transferred or discharged from the facility. The findings included: The facility policy titled Transfer of a Resident initiated 12/89 and revised 2/15/18 instructed, upon transfer of the resident, the facility shall send the transfer form to the receiving facility, along with appropriate resident documents including special instructions (as appropriate), the residents comprehensive care plan and a copy of the resident's discharge summary. On 7/1/19, a review of Resident #3's medical record revealed the resident was discharged from the facility to another skilled nursing facility on 6/7/19. A nursing progress note dated 6/7/19 at 3:14 p.m., documented Resident #3 was discharged to the skilled nursing facility without discharge paperwork at 11:30 a.m. The Social Worker documented on 6/7/19 at 11:30 a.m., she contacted the Admission Director of the skilled nursing facility and left a message regarding Resident #3's transfer. The Social Worker also documented she faxed the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (a form used to determine medical eligibility for Medicaid Waiver programs) to the skilled nursing facility. The transfer form indicated it was faxed to the skilled nursing facility on 6/7/19 at 2:42 p.m. Resident #3's medical record did not show documentation the facility staff provided a discharge summary or appropriate information necessary to provide care to Resident #3, to the staff of the skilled nursing facility. On 7/2/19 at 9:12 a.m., the Director of Nursing (DON) confirmed the discharge summary for Resident #3 was not completed when the resident transferred to the skilled nursing facility. The DON said no discharge planning was completed when the resident transferred to the skilled nursing facility.

Based on interview, and record review the facility failed to follow the professional standard of following the physician's orders for 2 (Residents #2 and #3) of 6 residents surveyed resulting in a potential for skin deterioration (Resident #2) due to not following skin care orders, and a potential for urinary tract infection from not changing the Foley catheter as prescribed by the physician (Resident #3). The findings included: 1. Resident #2 was admitted to the facility with a stage 2 pressure ulcer to his sacrum. A physician's order dated 6/8/19 read Buttocks: cleanse with ns (normal saline) apply skin prep to periwound cover with foam dressing change every three days. On 6/22/19 at 9:34 a.m., Registered Nurse (RN) Staff H documented the wound was 100% epithelized, blanchable redness. A physician's order dated 6/22/18 read, Buttock/Sacrum cleanse with soap and water, apply barrier cream QS (every shift) and as needed after incontinence. On 7/2/19 at 10:30 a.m., Resident #2's spouse said she was in the resident's room and observed a dressing on the resident's backside near his belt line dated 6/23/18. Review of Resident #2's medical record showed no documentation a dressing was placed on the resident on 6/23/18. The Treatment Administration Record (TAR) shows nursing staff documented they were cleansing Resident #2's sacrum/buttocks area with soap and water and applying a barrier cream to the area from 6/23/19 to 7/5/19. On 6/29/19, Licensed Practical Nurse, Staff G documented on the TAR he had completed a weekly skin sweep of Resident #2. On 7/2/19 at 10:45 p.m., Staff G said he would have checked the resident from head to toe and removed any dressings to check under them during his weekly skin check. He said he would have documented his observations in a progress note. Review of Resident #2's progress notes show no documentation Staff G made any observations on 6/29/19. On 7/2/19 at 1:30 p.m., RN Staff H said she could not explain how the treatments were documented as being completed on Resident #2 when he had a dressing on his sacrum area. She said staff could have removed the dressing for 2 to 3 days and reapplied the dressing, but they could not have done this for twelve days. 2. Review of Resident #3's medical record indicated the resident had a [DIAGNOSES REDACTED]. The resident required an indwelling catheter (a tube inserted into the bladder and drains urine). Resident #3's medical record contained a physician order dated 11/29/18 specifying to change the urinary catheter every month on the 16th. The resident's TAR for March, April, (MONTH) and (MONTH) 2019 indicated the catheter was changed on 3/16/19, 5/16/19 and 6/16/19. The TAR lacked documentation the resident's catheter was changed as per the physician's order on 4/16/19. On 7/1/19 at 2:51 p.m., the DON confirmed the resident did not have the catheter changed on (MONTH) 16, 2019 as ordered and confirmed there was no documentation by staff for the reason the catheter was not changed. **Photo on File**

Based on record review and staff and resident interview, the facility failed to provide adequate services to maintain personal hygiene for 3 (Resident #3, #4 and #5) of 5 residents identified with limitations in their ability to perform activities of daily living. This had the potential to affect a resident's ability to maintain the highest practicable physical, mental and psychosocial well-being. The findings included: Review of the facilities job description for Certified Nurse's Aide (CNA), Specific Duties initiated 8/2000 and revised 4/30/18, instructed for the CNA to start showers/baths as assigned per the resident Care Information Sheets (instructions on bathing and hygiene assistance for the resident). 1) Resident #3's medical record revealed the resident had muscle weakness, cognitive loss and required assistance with his activities of daily living (ADLS). Resident #3's care plan (instructions on the type of care a resident requires) initiated 10/23/18 and revised on 6/7/19, instructed the CNA to provide showers two times a week as requested by the resident. Resident #3 was scheduled to receive his showers on Tuesday and Friday on the morning shift as ordered by the physician. A review of the facility ADL care history revealed documentation Resident #3 had received one shower from 5/1/19 through his discharge from the facility on 6/7/19. On 7/2/19 at 3:00 p.m., the Director of Nursing (DON) confirmed Resident #3 did not receive showers as ordered by the physician and as directed on the facility CNA care information sheets. 2) A review of Resident #4's medical record on 7/2/19 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #4's care plan initiated on 6/20/19 instructed the CNA was to provide bathing assistance with shower or bed bath two times a week. A physician order [REDACTED]. On 7/2/19 at 11:11 a.m., CNA Staff D said Resident #4 was scheduled to receive a shower on Monday and Thursdays on the 2-10 pm shift. CNA Staff D said, I get her up in the morning and take her to the bathroom sink and help her to wash up and clean her mouth. Staff D said Resident #4 is confused and needs assistance with all of her care. Staff D said the resident has never refused care when with her. Staff D said a partial bed bath is when you wash their face, hands and private area only. On 7/2/19 at 11:25 a.m., the Licensed Practical Nurse (LPN) Staff C, said if a resident refused a shower the aides are to notify the nurse and the nurse will try other interventions to get the resident to bathe. LPN Staff C said she works from 6a.m., to 6 p.m., and the evening shift CNA's had not reported that Resident #4 was not receiving showers or bed baths. On 7/2/19 at 11:30 a.m., Resident #4 said she did not know if she received her showers or if she had been bathed by the staff. On 7/2/19, a review of Resident #4's CNA care history lacked documentation of Resident #3 receiving a shower since her admission to the facility on [DATE]. Resident #4's care history documented Resident #4 had received three partial bed baths and one complete bed bath from 6/19/19 through 7/2/19. On 7/2/19 at 11:40 a.m., the DON confirmed Resident #4 had not received showers or bed baths 2 x's a week as ordered by the physician. 3) A review of Resident #5's medical record revealed the care plan initiated on 4/27/19 and revised on 5/21/19 instructed the resident required assistance with activities of daily living and was to have a shower twice a week. A physician order [REDACTED]. On 7/2/19 at 9:45 a.m., Resident #5 said he was unsure when he was showered. The resident said, the aides clean me up and get me dressed. The resident said, I would like a shower if they give them to me, but I don't know that they have. On 7/2/19 at 12:00 p.m., CNA Staff [NAME] said, Resident #5 got his showers on the 2 p.m. -10 p.m. shift. CNA Staff [NAME] said she had showered the resident once when she worked on the evening shift but when she had him during the day, she washed him up. On 7/2/19 at 12:10 p.m., LPN Staff F said she worked 6 a.m.-6 p.m., and was not aware that Resident #5 was not receiving his showers. A review of Resident #5's CNA care history on 7/2/19 revealed the resident had received one shower from 6/1/19 through 7/2/19. The resident received a partial bed bath 11 times and one complete bed bath. On 7/2/19 at 2:30 p.m., the DON confirmed Resident #5 did not receive his showers as ordered by the physician.

Based on record review, staff, resident and family interview, the facility failed to provide restorative nursing care per the resident's care plan for 4 (Residents #8, #21, #36, and #51) of 4 residents surveyed of 35 residents recommended to receive restorative care from the therapy department having a potential for the residents not receiving services to decline both mentally and physically from a lack of regular restorative care. The findings included: 1. Review of Resident #8's restorative nursing care plan dated 12/20/18 showed the resident was to receive active range of motion exercises on bilateral lower extremities as tolerated in the sitting or supine position. There was no documented number of days the restorative care was to be provided by nursing staff. Review of the Point of Care History Restorative Nursing Number of Minutes for Active Range of Motion revealed from 12/30/18 to 3/30/19 Resident #8 only had restorative nursing care on 2/20/19. On 3/19/19 at 4:45 p.m., the Director of Nursing (DON) verified the point of care documentation was correct and the reason Resident #8 had not been receiving restorative care was there had been staffing issues since (MONTH) of 2019. She said restorative aides have had to work the floor because of a lack of staffing to provide certified nursing assistance to the residents of the facility. The DON said she and the Administrator had tried to hold staff accountable, had them work every other weekend. Several staff members became upset and left employment at the facility. On 3/20/19 at approximately 9:30 a.m., the Director of Physical Therapy (DPT) verified his department had recommended to the nursing department that Resident #8 should receive active range of motion exercises. He said the reason was to prevent the resident from declining physically. The DPT verified active range of motion exercises would benefit the resident both physically and mentally. He said his department did not recommend how many times a week the resident should receive the exercises. The DPT said he would expect Resident #8 would receive active range of motion exercises three times weekly to prevent decline. 2. On 3/19/19 at 3:36 p.m., Resident #21 said they were supposed to walk with me. I'm supposed to be walked to and from dining three times daily. Resident #21 said they had not been doing this for some time before she was placed on Isolation. Review of Resident #21's restorative care plan read, Staff will assist her to WALK TO DINE using 4 wheel walker or rolling walker with minimal assist. Review of The Point of Care Restorative Nursing Number of Minutes Walked from 1/1/19 to 3/20/19 documentation verified staff ambulated with Resident #21 once (1/25/19) from 1/1/19 to 3/20/19. On 3/19/19 at 4:15 p.m., Restorative Aide Staff HH verified residents in the facility were not receiving restorative care because restorative staff were being pulled to work assignments on the floor. Staff HH said she had been pulled to the floor every weekend for the last month. On 3/19/19 at 4:15 p.m., Restorative Aide Staff P verified she was the aide that had walked with Resident #21 on 1/25/19. Staff P verified it would be possible for Resident #21 to receive restorative ambulation exercise in her room while on isolation. Staff P verified Resident #21 had not been receiving restorative care because of a lack of staffing. Staff P verified she was working an assignment at the present time and not providing restorative care to residents. On 3/19/19 at 4:45 p.m., the DON verified Resident #21 had not been receiving restorative ambulation due to a lack of staffing. She said the restorative aides were being pulled to the floor to work assignments. On 3/20/19 at approximately 9:30 a.m., the DPT verified his department had recommended to the nursing department that Resident #21 be walked to and from dining to prevent decline. The DPT verified Resident #21 could receive periods of ambulation in her room while on isolation which could substitute for walk to dine. 3. On 3/19/19 at 11:33 a.m., Resident #51's spouse said she was upset and angry because her husband had not received restorative care for over a month. She was upset because administration moved the restorative aides around and they did not have enough people to provide restorative care for her husband. She said she had complained to the DON. She said nothing ever got done about this. She said she would like her husband to get stronger so she could take him home. She said she was concerned he would not get stronger without his restorative care. The restorative nursing care plan for Resident #51 read, Start Date: 07/13/2018 (Include on Profile) APPROACH: AMBULATION PROGRAM: 1. Set up devices for ambulation. 2. Instruct/Encourage (Resident #51) to push off from chair or edge of bed and reach out for Rolling Walker 3. Instruct/Encourage (Resident #51) to walk with an upright stance looking forward using rolling walker. 4. Instruct/Encourage Resident #51 to rest if becomes tired or short of breath. 5. (Resident #51) will ambulate with Rolling Walker and CGA 10-15 feet and staff to follow with a WC, immediately sit if necessary. Active Range of Motion on Bilateral LE (lower extremities) while observing posterior hip precautions on Right LE APPROACH: sit - to - stand with rolling walker with Contact Guard Assist, observe hip precautions RLE. Review of the Point of Care Restorative Nursing Care Number of Minutes for Active Range of Motion showed from 12/31/18 to 3/19/19 Resident #51 had restorative nursing exercise nine times. The last time the resident had received restorative exercises was on 2/20/19. On 3/19/19 at 4:15 p.m., Restorative Aide Staff P verified Resident #51 was assigned to her to do restorative care. She said she really liked doing it when he was able to. Staff P said Resident #51 had not received restorative nursing since (MONTH) of 2019 due to a lack of staffing. Staff P said she was taken off restorative every weekend and given a resident assignment on the floor due to call offs of staff. Staff P verified Staff P's spouse had been upset and complained to the DON. Staff P said she considered it a lucky day if she got to provide restorative care to the nine patients she was assigned to do restorative care for. On 3/19/19 at 4:45 p.m., the DON verified Resident #51's wife had mentioned to her on two occasions on the prior month her husband was not receiving restorative care. The DON said she had told the residents spouse she and the Administrator were looking at the entire restorative program. The DON verified Resident #51 had not received restorative care due to a staffing issue since (MONTH) of 2019. 4. On 3/18/19 at 2:03 p.m., in an interview, Resident #36 said staff were supposed to be walking her. She said they had not done it for a long time and added Even a little walking is better than nothing. On 3/18/19, record review revealed a physician's orders [REDACTED]. Further review revealed a therapy recommendation to nursing dated 8/7/18 for active range of motion to bilateral lower extremities, sit to stand and pivot transfers and ambulation with rolling walker with contact guard assist (hands on body to help steady your body or help with balance) 30-50 feet or as tolerated. On 3/18/19, further record review revealed the last recorded restorative nursing minutes received by Resident #36 was 1/24/19. On 3/20/19 at 8:21 a.m., in an interview, Restorative Aide Staff P said Quite frankly we have not been doing restorative because we are assigned other duties by management like transporting residents to therapy, obtaining weights, or being pulled to the floor. For example, today the other restorative aide has been pulled to the floor. On 3/20/19 at 9:02 a.m., in an interview, Restorative Aide Staff Q said, I cannot remember the last time I walked her. I have other jobs, monthly and weekly weights to do and working on the floor. On 3/21/19 at 4:11 p.m., the DON confirmed Resident #36 had not received restorative service since 1/24/19. She said restorative services all stopped because of staffing issues.

Based on record review and staff interview, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 (Resident #4) of 3 residents reviewed for appropriate emergency care. The facility neglected the resident's needs for emergency care allowing her to expire. At the time of the survey, the facility had 55 residents who did not have a physician's order for or consented to withholding CPR. The facility's allowing staff to withhold CPR without a current Do Not Resuscitate Order (DNRO) put 55 residents in immediate jeopardy. Prior to exit on [DATE], the survey team verified the allegation of compliance reducing the scope and severity to D. The findings included: Review of the facility Policy #1.13(FL) Abuse Prohibition (revised [DATE]) revealed The resident has the right to be free from mistreatment, neglect and misappropriation of property. The policy addresses prevention of abuse, neglect, and exploitation. The policy included tips for prevention such as Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect. The facility's failure to document rescind a previous DNRO and to look for a current valid DNRO resulted in a terminal neglect. The face sheet showed Resident #4 was first admitted to the facility on [DATE]. The resident had a Do Not Resuscitate Order (DNRO) completed that same day. Medical records showed on [DATE] she hospitalized . She was readmitted to the facility on [DATE] and with a DNRO. The [DATE] Progress Note reported her physician had spoken to the resident's husband and the husband wanted his wife to be a full code. Full code meant a resident would be provided emergency care including CPR if needed. The Progress Note documented the DNRO was rescinded. The resident's face sheet was updated with the change of status to indicate full code status. The electronic medical record of [DATE] contained the physician's order for Resident #4's DNRO to be discontinued, making her a full code status. The resident was briefly hospitalized again. The [DATE] Progress Note documented Resident #4 had returned to the facility on [DATE]. This time Resident #4 returned under hospice care but continued with full code status. The Social Service Director (SSD) was to review the code status with spouse due to new hospice services. The [DATE] Social Service Progress Note documented the SSD reviewed code status with spouse and noted he would like for her to remain full code at this time. The [DATE] Progress Note documented hospice nurse in to see resident. The note reported hospice staff spoke to the husband at length regarding Resident #4's code status. He was aware that resident was a full code. He answered all questions related to DNRO paperwork necessary. He said he would sign DNRO paperwork tomorrow ([DATE]). The [DATE] Progress Note documented the SSD met with spouse on [DATE] and reviewed code status. He took a copy of a rescinded DNRO and said that he would take it home to discuss with his family and would let SSD know their decision. The Progress Note documented the husband was aware the resident remained full code status. On [DATE] at 2:00 p.m., RN Staff B said on [DATE] Licensed Practical Nurse (LPN) Staff C had called a code blue for Resident #4. Staff B responded and when she got to the room Staff C had just arrived with the crash cart. When she got there the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the SSD were there. The SSD had a yellow DNRO form in her hand. The DON called off the code blue. The DON requested RN Staff A and RN Staff B to pronounce the resident dead. The [DATE] Registered Nurse (RN) Progress Note documented that at 12:12 p.m. RN Staff A responded to a code blue for Resident #4. It noted various staff including the DON rushed to the room. The SSD had a signed DNRO in her hand. (This was the rescinded DNRO dated [DATE]). CPR was not started at this time. On [DATE] at 2:30 p.m., LPN Staff C said she came to work on [DATE] and realized Resident #4 was not doing well. She said she called the husband that morning to talk to him about a DNRO. He told her he thought his wife had a DNRO. Staff C said she tried to contact the SSD several times that morning and could not reach her. Staff C said shortly after noon the resident was found unresponsive. LPN Staff C said she knew the resident was a full code. At the time of her death, the electronic record indicated she was full code. That was why she called code blue and proceeded to prepare the crash cart. She was preparing to resuscitate the resident when the DON, ADON, and the SSD came into the room. The SSD had a yellow DNRO in hand and the DON terminated the code blue. She said there was no discussion concerning the DNRO or the resident being full code according to the record. Emergency Medical Services (EMS/[DATE]) was not called. On [DATE] at 2:45 p.m., the SSD said she had talked to Resident #4's husband and he had expressed a desire to have a DNRO completed for his wife. She had no documentation of this. The SSD said that on [DATE] she provided a blank DNRO for him to take home discuss with his daughter. The SSD admitted the husband did not sign a new DNRO form. She said she thought the old DNRO (from [DATE]) could be reinstated. The SSD said when she found out LPN Staff C was trying to contact her the morning of [DATE], she took the (rescinded) DNRO up to her. She just happened to arrive at the resident's room with the DNRO in hand when staff were gathering to start code blue. She said there was no discussion about the DNRO being rescinded. She acknowledged she had not contacted the physician of the husband's wish to have a new DNRO for his wife. On [DATE] at 10:15 a.m., Resident #4's physician said when the resident returned to the facility in November, he spoke to the husband about living wills and DNRO. It was at that time the husband no longer wished for his wife to be under a DNRO. He thought the resident may have had a new DNRO initiated when she was admitted to hospice service. He did not speak to the facility related to this matter prior to the resident's death on [DATE]. On [DATE] at 11:20 a.m., the DON said that at the time of the incident Resident #4's electronic record listed the resident as full code. He said that each unit had a DNRO book. When a resident needs emergency care, the first nurse to arrive at the scene would check the record or the book to verify the code status of the resident. The record showed Resident #4 was a full code at the time of the event. He said the SSD came into the room with the DNRO in hand and said I have her DNRO. He said he did not question the fact that the floor nurse (LPN Staff C who knew the resident well) who had checked the resident's record knew the resident was a full code. He said once he saw the yellow DNRO, he called the code blue off. The DON acknowledged that after the resident expired, he changed her electronic record to show that she was a DNRO. On [DATE] at 12:18 p.m., the Administrator said he heard the SSD speaking with Resident #4's husband. He felt the husband's wishes was for the wife to have a DNRO. He said the SSD did a monthly audit to ensure residents were coded correctly. The [DATE] audit showed Resident #4 was a full code. He said after her death, they added a space on the form used for the morning stand-up meeting. This space was to list new residents and their code status. If there was an issue, there was a place to add the resident for follow up. He confirmed they had not completed any new in-services after the event with Resident #4. On [DATE] at 3:30 p.m., the Hospice Nurse said she remembered speaking to Resident #4's daughter on [DATE] concerning the resident's code status. The resident was a full code. She provided a blank DNRO with the resident's name on it for the husband to take home to the family. On [DATE] at 4:30 p.m., the Hospice Clinical Director confirmed Resident #4 was on hospice services with a full code status. On [DATE] Hospice staff had discussed DNRO with the spouse and daughter. They were going to discuss the issue with the family. On [DATE] at 5:33 p.m., the Administrator, DON and the ADON were informed of the determination of immediate jeopardy for failing to provide CPR at the time of the emergency to a resident with full code status. The facility did not have current a DNRO with the husband's consent or a physician's signature. The facility failed to identify this deficient practice or take any corrective action to ensure other residents were not affected. The facility initiated a procedure that a DNRO that is rescinded/deactivated/revoked will be removed from the DNRO binder on the resident's neighborhood. The DNRO will be labeled as void and dated, then scanned and uploaded into the electronic medical record. The non-voided DNRO will be removed from the electronic medical record. The facility audited the resident charts for DNROs to ensure they were properly executed. The facility audited the charts of residents who had expired to determine if there were other residents that might have been effected by improper procedure and found none. On [DATE] the facility brought in a consultant who provided in-services on providing CPR, recognizing a valid and properly executed DNRO, and on the new protocol for DNROs that are rescinded to nursing staff and department heads present. The facility developed a plan and schedule for training staff not present prior to starting their shift. The facility will audit charts weekly and report to Risk Management. The Administrator submitted an allegation of compliance documenting these actions and plans. The facility provided in-service materials and the in-service sign-in sheets. The survey team reviewed the sign-in sheets and interviewed 6 floor nurses, the RN Supervisor, and 2 MDS (Minimum Data Set assessment) nurses. The nurses confirmed receiving the in-service training. They each were able to describe the new protocol and how to verify code status in the electronic system, by a physician signed DNRO, and in the advance directive book. By the time of the exit on [DATE] at 4:37 p.m., the survey team was able to verify the facility's actions to remove the Immediate Jeopardy had been implemented.

Based on record review and hospice and facility staff interview, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 (Resident #4) of 3 residents reviewed for appropriate emergency care. The facility failed to obtain a physician order [REDACTED].#4. The facility failed to meet the resident's needs for emergency care allowing her to expire. At the time of the survey, the facility had 55 residents who did not have a physician's orders [REDACTED]. The facility's allowing staff to withhold CPR without a current Do Not Resuscitate Order (DNRO) put 55 residents in immediate jeopardy. Prior to exit on [DATE], the survey team verified the allegation of compliance reducing the scope and severity to D. The findings included: Records showed Resident #4 was originally admitted to the facility on [DATE]. The resident had a Do Not Resuscitate Order (DNRO) completed on [DATE]. She was transferred to the hospital on [DATE]. She was readmitted to the facility on [DATE] and with a DNRO. The Progress Note dated [DATE] reported her physician had spoken to the resident's husband and the husband wanted his wife to be a full code. Full code meant a resident would be provided emergency care including CPR if needed. The Progress Note documented the DNRO was rescinded. The resident's face sheet was updated with the change of status to full code. The electronic medical record dated [DATE] contained the physician's orders [REDACTED]. The resident was briefly hospitalized again. The Progress Note dated [DATE] noted Resident #4 returned to the facility on [DATE]. This time Resident #4 returned under hospice care but continued full code status. The Social Service Director (SSD) was to review the code status with spouse due to new hospice services. Social Service Progress Note dated [DATE] documented the SSD reviewed code status with spouse and noted he would like for her to remain full code at this time. Progress Note dated [DATE] noted hospice nurse in to see resident. The note reported hospice staff spoke to the husband at length regarding Resident #4's code status. He was aware that resident was a full code. He answered all questions related to DNRO paperwork necessary. He stated he would sign DNRO paperwork tomorrow [DATE]. Progress Note dated [DATE] noted SSD met with spouse on [DATE] and reviewed code status. He took a copy of a rescinded DNRO and said that he would take it home to discuss with his family and would let SSD know of their decision. The Progress Note noted the husband was aware the resident remained full code status. The Registered Nurse (RN) Progress Note dated [DATE] documented that at 12:12 p.m. RN Staff A responded to a code blue for Resident #4. It noted various staff including the DON rushed to the room. The SSD had a signed DNRO in her hand. (This was the rescinded DNRO dated [DATE]). CPR was not started at this time. On [DATE] at 2:00 p.m., RN Staff B said on [DATE] Licensed Practical Nurse (LPN) Staff C had called a code blue for Resident #4. Staff B responded and when she got to the room Staff C had just arrived with the crash cart. When she got there the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the SSD were there. The SSD had a yellow DNRO form in her hand. The DON called off the code blue. The DON requested RN Staff A and RN Staff B to pronounce the resident dead. On [DATE] at 2:30 p.m., LPN Staff C said she came to work on [DATE] and realized Resident #4 was not doing well. She said she called the husband that morning to talk to him about a DNRO. He told her he thought his wife had a DNRO. Staff C said she tried to contact the SSD several times that morning and could not reach her. Staff C said shortly after noon the resident was found unresponsive. LPN Staff C said she knew the resident was a full code. At the time of her death, the electronic record indicated she was full code. That was why she called code blue and proceeded to prepare the crash cart. She was preparing to resuscitate the resident when the DON, ADON, and the SSD came into the room. The SSD had a yellow DNRO in hand and the DON terminated the code blue. She said there was no discussion concerning the DNRO or the resident being full code according to the record. Emergency Medical Services (EMS/911) was not called. On [DATE] at 2:45 p.m., the SSD said she had talked to Resident #4's husband and he had expressed a desire to have a DNRO completed for his wife. She had no documentation of this. The SSD said that on [DATE] she provided a blank DNRO for him to take home discuss with his daughter. The SSD acknowledged he did not sign a new DNRO. She said she thought the old DNRO (dated [DATE]) could be reinstated. She felt the husband did not want his wife to be resuscitated. The SSD said when she found out LPN Staff C was trying to contact her the morning of [DATE], she took the rescinded DNRO up to her. She just happened to arrive at the resident's room with the DNRO in hand when staff were gathering to start code blue. She said there was no discussion about the DNRO being rescinded. She said she had not contacted the physician about the husband's wish to have a new DNRO for his wife. On [DATE] at 11:20 a.m., the DON said that at the time of the incident Resident #4's electronic record listed the resident as full code. He said that each unit had a DNRO book. When a resident needs emergency care, the first nurse to arrive at the scene would check the record or the book to verify the code status of the resident. The record showed Resident #4 was a full code at the time of the event. He said the SSD came into the room with the DNRO in hand and said I have her DNRO. He said he did not question the fact that the floor nurse (LPN Staff C who knew the resident well) who had checked the resident's record knew the resident was a full code. He said once he saw the yellow DNRO, he called the code blue off. The DON acknowledged that after the resident expired, he changed her electronic record to show that she was a DNRO. On [DATE] at 10:15 a.m., Resident #4's physician said when the resident returned to the facility in November, he spoke to the husband about living wills and DNRO. It was at that time the husband no longer wished for his wife to be under a DNRO. He thought the resident may have had a new DNRO initiated when she was admitted to hospice service. He did not speak to the facility related to this matter prior to the resident's death on [DATE]. On [DATE] at 12:18 p.m., the Administrator said he heard the SSD speaking with Resident #4's husband. He felt the husband's wishes was for the wife to have a DNRO. He said the SSD did a monthly audit to ensure residents were coded correctly. The audit completed on [DATE] showed the resident was a full code. He said after the death of Resident #4, they added a space on the form used for the morning stand up meeting. This space was to list new residents and the code status. If there was an issue it had a place to add the resident for follow up. He said they had not completed any new in-services after the event with Resident #4. He felt honoring the family's verbal wishes was the correct thing. On [DATE] at 3:30 p.m., the Hospice Nurse said she remembered speaking to Resident #4's daughter on [DATE] concerning the resident's code status. The resident was a full code. She provided a blank DNRO with the resident's name on it for the husband to take home to the family. On [DATE] at 4:30 p.m., the Hospice Clinical Director confirmed Resident #4 was on hospice services and was full code status. Hospice staff had discussed DNRO with the spouse and daughter on [DATE]. They were going to discuss the issue with the family. On [DATE] at 5:33 p.m., the Administrator, DON and the ADON were informed of the determination of immediate jeopardy for failing to provide CPR to a resident with full code status. The facility did not have current a DNRO with the husband's signature or a physician's orders [REDACTED]. The facility initiated a procedure that a DNRO that is rescinded/deactivated/revoked will be removed from the DNRO binder on the resident's neighborhood. The DNRO will be labeled as void and dated, then scanned and uploaded into the electronic medical record. The non-voided DNRO will be removed from the electronic medical record. The facility audited the resident charts for DNROs to ensure they were properly executed. The facility audited the charts of residents who had expired to determine if there were other residents that might have been effected by improper procedure and found none. On [DATE] the facility brought in a consultant who provided in-services on providing CPR, recognizing a valid and properly executed DNRO, and on the new protocol for DNROs that are rescinded to nursing staff and department heads present. The facility developed a plan and schedule for training staff not present prior to starting their shift. The facility will audit charts weekly and report to Risk Management. The Administrator submitted an allegation of compliance documenting these actions and plans. The facility provided in-service materials and the in-service sign-in sheets. The survey team reviewed the sign-in sheets and interviewed 6 floor nurses, the RN Supervisor, and 2 MDS (Minimum Data Set assessment) nurses. The nurses confirmed receiving the in-service training. They each were able to describe the new protocol and how to verify code status in the electronic system, by a physician signed DNRO, and in the advance directive book. By the time of the exit on [DATE] at 4:37 p.m., the survey team was able to verify the facility's actions to remove the Immediate Jeopardy had been implemented.

Based on record review and staff interview, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to Resident #4 when she became nonresponsive. The facility had failed to obtain family consent or a physician order [REDACTED]. Nonetheless CPR was withheld allowing her to expire. At the time of the survey, the facility had failed to review the incident for quality assurance. Without plans or actions to identify and correct the deficiency, the 55 residents who did not have a physician's orders [REDACTED]. Prior to exit on [DATE], the survey team verified the allegation of compliance reducing the scope and severity to D. (Cross reference to F600 and F678) The findings included: Records showed Resident #4 was admitted to the facility on [DATE] and a Do Not Resuscitate Order (DNRO) completed that same day. On [DATE] she hospitalized . On [DATE] Resident #4 was readmitted to the facility and with a DNRO. The [DATE] Progress Note reported her physician had spoken to the resident's husband and the husband wanted his wife to be a full code. Full code meant a resident would be provided emergency care including CPR if needed. The Progress Note then noted the DNRO was rescinded. The resident's face sheet was updated with the change to indicate full code status. The electronic medical record of [DATE] contained the physician's orders [REDACTED]. The resident was briefly hospitalized again. The [DATE] Progress Note documented Resident #4 had returned to the facility on [DATE]. Resident #4 returned under hospice care but continued with full code status. The Social Service Director (SSD) was to review the code status with spouse due to new hospice services. The [DATE] Social Service Progress Note documented the SSD reviewed code status with spouse and noted he would like for her to remain full code at this time. The [DATE] Progress Note documented hospice nurse was in to see the resident. The note reported hospice staff spoke to the husband at length regarding his wife's code status. He was aware that resident was a full code. He said he would sign DNRO paperwork tomorrow ([DATE]). The [DATE] Progress Note documented SSD met with spouse on [DATE] and reviewed code status. He took a copy of a rescinded DNRO and said that he would take it home to discuss with his family and would let SSD know their decision. The Progress Note documented the husband was aware the resident remained with a full code status. The [DATE] Registered Nurse (RN) Progress Note documented that at 12:12 p.m. RN Staff A responded to a code blue for Resident #4. It noted various staff including the DON rushed to the room. The SSD had a signed DNRO in her hand. (This was the rescinded DNRO dated [DATE]). CPR was not started. On [DATE] at 2:00 p.m., RN Staff B said on [DATE] Licensed Practical Nurse (LPN) Staff C had called a code blue for Resident #4. Staff B responded and when she got to the room Staff C had just arrived with the crash cart. When she got there the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the SSD were there. The SSD had a yellow DNRO form in her hand. The DON called off the code blue. RN Staff A and RN Staff B pronounced the resident dead. On [DATE] at 2:30 p.m., LPN Staff C said she came to work on [DATE] and realized Resident #4 was not doing well. She said she called the husband that morning to talk to him about a DNRO. He told her he thought his wife had a DNRO. Staff C said she tried to contact the SSD several times that morning and could not reach her. Staff C said shortly after noon the resident was found unresponsive. LPN Staff C said she knew the resident was a full code. Staff C said at the time of her death, the electronic record indicated she was full code. That was why she called code blue and proceeded to prepare the crash cart. She was preparing to resuscitate the resident when the DON, ADON, and the SSD came into the room. The SSD had a yellow DNRO in hand and the DON terminated the code blue. She said there was no discussion concerning the DNRO or the resident being full code in the record. Emergency Medical Services (EMS/911) was not called. On [DATE] at 2:45 p.m., the SSD said she had talked to Resident #4's husband and he had expressed a desire to have a DNRO completed for his wife. She had no documentation of this. The SSD said that on [DATE] she provided a blank DNRO for him to take home discuss with his daughter. The SSD admitted the husband did not sign a new DNRO form. She said she thought the old DNRO (from [DATE]) could be reinstated. The SSD said when she found out LPN Staff C was trying to contact her the morning of [DATE], she took the (rescinded) DNRO up to her. She just happened to arrive at the resident's room with the DNRO in hand when staff were gathering to start code blue. She said there was no discussion about the DNRO being rescinded. She acknowledged she had not contacted the physician of the husband's wish to have a new DNRO for his wife. On [DATE] at 10:15 a.m., Resident #4's physician said when the resident returned to the facility in November, he spoke to the husband about living wills and DNRO. It was at that time the husband no longer wished for his wife to be under a DNRO. He thought the resident may have had a new DNRO initiated when she was admitted to hospice service. He did not speak to the facility related to this matter again prior to the resident's death on [DATE]. On [DATE] at 11:20 a.m., the DON said that at the time of the incident Resident #4's electronic record listed the resident as full code. He said that each unit had a DNRO book. When a resident needs emergency care, the first nurse to arrive at the scene would check the record or the book to verify the code status of the resident. The record showed Resident #4 was a full code at the time of the event. The DON said when the SSD came into the room with the DNRO in hand he did not question the fact that the floor nurse (LPN Staff C who knew the resident well) had checked the resident's record and knew the resident was a full code. He said when he saw the yellow DNRO form, he called the code blue off. The DON said that after the resident expired, he changed her electronic record to show that she was a DNRO. On [DATE] at 12:18 p.m., the Administrator said the SSD did a monthly audit to ensure residents were coded correctly. The [DATE] audit showed Resident #4 was a full code. He said after her death, they added a space on the form used for the morning stand-up meeting. This space was to list new residents and their code status. If there was an issue, there was a place to add the resident for follow up. He confirmed they had not completed any new in-services after the event with Resident #4. On [DATE] at 4:30 p.m., the Hospice Clinical Director confirmed Resident #4 was on hospice services with a full code status. On [DATE] hospice staff had discussed DNRO with the spouse and daughter. They were going to discuss the issue with the family. On [DATE] at 5:33 p.m., the Administrator, DON and the ADON were informed of the determination of immediate jeopardy for failing to provide CPR at the time of the emergency to a resident with full code status. The facility did not have current a DNRO with the husband's consent or a physician's signature. The facility failed to conduct any quality assessment and assurance review to identify this deficient practice. They failed to develop or take any corrective action to ensure no other residents would be affected. Review of prior survey history revealed the facility had been cited on [DATE] at scope and severity J for failure to provide CPR to a full code resident. The facility initiated a procedure that a DNRO that is rescinded/deactivated/revoked will be removed from the DNRO binder on the resident's neighborhood. The DNRO will be labeled as void and dated, then scanned and uploaded into the electronic medical record. The non-voided DNRO will be removed from the electronic medical record. The facility audited the resident charts for DNROs to ensure they were properly executed. The facility audited the charts of residents who had expired to determine if there were other residents that might have been effected by improper procedure and found none. On [DATE] the facility brought in a consultant who provided in-services on providing CPR, recognizing a valid and properly executed DNRO, and on the new protocol for DNROs that are rescinded to nursing staff and department heads present. The facility developed a plan and schedule for training staff not present prior to starting their shift. The facility will audit charts weekly and report to Risk Management. The Administrator submitted an allegation of compliance documenting these actions and plans. The facility provided in-service materials and the in-service sign-in sheets. The survey team reviewed the sign-in sheets and interviewed 6 floor nurses, the RN Supervisor, and 2 MDS (Minimum Data Set assessment) nurses. The nurses confirmed receiving the in-service training. They each were able to describe the new protocol and how to verify code status in the electronic system, by a physician signed DNRO, and in the advance directive book. By the time of the exit on [DATE] at 4:37 p.m., the survey team was able to verify the facility's actions to remove the Immediate Jeopardy had been implemented.

Based on record review and interview, the facility failed to provide adequate supervision to prevent the wandering into a hazardous environment by 1 (Resident #4) of 3 residents reviewed for elopement risk. Resident #4 was known to have impaired decision making. On 5/14/17 around 2:35 p.m., the resident was discovered missing from the facility. She was discovered walking near a busy intersection nearly a mile from the facility and was returned to the facility unharmed. She had the potential to be seriously injured or killed. The facility staff failed to supervise the resident's whereabouts. Staff failed to respond appropriately when they were notified of the resident's absence from the facility. The elopement rose to the severity level of isolated immediate jeopardy (IJ). After the resident's return, the facility's Quality Assurance (QA) Committee addressed the issue and initiated a corrective action plan that was completed on 5/19/17 when staff completed elopement training and drills. The deficiency was corrected and was identified as past non-compliance IJ. The nursing home administrator was notified of was notified of past noncompliance immediate jeopardy on 6/8/17. The findings included: Record review revealed Resident #4 had a primary [DIAGNOSES REDACTED]. At that time the resident was assessed as an elopement risk. Resident #4 had a physician order [REDACTED]. Observation Reports dated 1/6/17 noted Resident #4 was a high fall risk and had moderately impaired decision making. The facility did not develop a comprehensive care plan to ensure resident #4 was properly supervised and her safety devices (wander bracelet) were monitored for her elopement risk. Review of the statement dated 5/14/17 written by Activity Staff A revealed around 2:35 p.m. on that day she was in route to the facility when she observed Resident #4 walking north on Honore Avenue in Sarasota, Florida and was almost to the corner of University Parkway and Honore (This a busy intersection; University Parkway is a main east-west route from the Interstate into Sarasota). She parked her vehicle and proceeded to catch up with the resident who continued to walk towards University Parkway. She was able to catch up with the resident and stop her from continuing. Staff A noted she called the facility around 2:37 p.m. to request help to return Resident #4 to the facility. The statement from the Activity Director dated 5/14/17 noted Activity Staff A had reported to him that she found the resident walking on Honore. She reported that she called the facility for assistance twice. The second time Staff A called, she was informed that they went out front of the facility but did not see anything, so they went back inside. A statement by the receptionist dated 5/14/17 noted two female staff from the Independence unit walked through the front door and asked about a resident who had supposedly walked out the door without being noticed. The receptionist said she had just come back from lunch and was not sure that anyone had left. One of the women said Resident #4 was supposedly outside by University and Honore (1.4 miles from the facility). The women said they did not see anything. The receptionist asked them what they were going to do. They said they were going to go back to the Independence unit and find out what their next orders were. The receptionist said they walked to the elevator and met a third person who notified them that Resident #4 was never missing in the first place. She (the resident) was upstairs in the Media Center. They went upstairs. A few minutes after they walked away, she received a call from a wireless caller, screaming for a nurse supervisor. She said there was a resident walking outside on Honore. The receptionist said she immediately notified the caller that two women had gone outside and did not see anything. The caller said the resident was standing in front of her. The receptionist said she saw a nurse walking towards Bounce Back Lane (a rehab unit) and told her that someone on the phone reported that Resident #4 was on Honore near University parkway. Everyone kept saying the resident was in the Media Center. The receptionist told the nurse supervisor that the caller originally called Independence and they were of no help to her. The nurse took over the phone call and said she was coming right away. The receptionist said shortly after the phone call one of the women who had gone outside and came back in was informed about the second phone call. The woman said once again they never saw anyone outside and wondered how Resident #4 escaped out of the facility in the first place. Licensed Practical Nurse (LPN) Staff B from Bounce Back Lane said they had Resident #4 and that she was extremely warm. The nurse said it could have been a lot worse if no one would have been able to locate her. There was a written statement from LPN Staff B dated 5/14/17 which said she was on her way to physical therapy when the receptionist yelled for her and said there was a resident on Honore Avenue that needed help. LPN Staff B spoke with Activity Staff A via phone and immediately went to help. She met Staff A and Resident #4 on Honore Avenue and walked the resident to a shaded area. In an interview on 6/7/17 at 9:50 a.m., the Acting Regional Nurse Director said she was first notified of this event on the day it happened. When she came to the facility, the first thing she felt they needed to do was to assess the resident. They then checked all the wander bracelets and the system to ensure they were functioning as intended. The system was functioning. Staff reported the alarm went off when they brought Resident #4 back into the building. When a wander bracelet approaches the exit area, an alarm sounds. There is a wander bracelet panel that tells staff where the alarm was activated. Video of the back exit did not show the resident leaving by that exit. They thought she must have left through the front door. The alarm activates once a wander bracelet gets within proximity of the exit and will shut off once the wander bracelet is out of the area. The alarm does not need to be shut off by staff. The Acting Regional Nurse Director said when the resident got on the elevator the alarm should have sounded. When the doors to the elevator closed, the alarm should have stopped. When the resident got off the elevator, the alarm should have sounded a second time. When she walked away from the elevator, the alarm should have stopped a second time. When she exited the front door, the alarm should have sounded a third time and stopped when she was out of the exit zone. Staff were not aware of her being gone. She said the resident must have left through the front doors when the receptionist was at lunch. In an interview on 6/12/17 at 11:00 a.m., Staff C said she was the Certified Nursing Assistant (CNA) that provided care for Resident #4. She came to work on 5/14/17 at 2:00 p.m. and did not see Resident #4. She said that after a search of the 2nd floor she returned to the unit, and Resident #4 was in the TV room with a nurse. In an interview on 6/12/17 at 11:10 a.m., LPN Staff D said he had gone to lunch. When he came back, CNA Staff C told him she could not find Resident #4. They were searching the 2nd floor when LPN Staff B brought Resident #4 back to the unit. Review of Resident #4's care plan showed Problem: Resident at risk for elopement and tends to wander. Problem start date 5/15/17. Approaches included apply wander bracelet and monitor every shift; ensure photographs of resident who wander are maintained in accessible but secure location; and 1:1 supervision 5/14/17. The resident being out of the facility in an unsafe area and staff not aware of where the resident was and not responding to the missing resident constituted an Immediate Jeopardy situation. The facility abated the jeopardy that day by instituting an investigation. They initiated an intervention of staffing the front desk at all times. They inserviced staff on elopement procedures. By 5/19/17 the inserviced staff were aware of procedures to initiate when a resident is missing. Review of Missing Person Elopement protocol (revised 5/15/17) revealed multiple steps including: Check chart to see if signed out; call family to notify; page CODE YELLOW for missing person over intercom/walkie-talkie; notify staff and rest of campus; and conduct a head count. Review of the Wander bracelet Routine Maintenance Program revealed the device check is to be completed each night between midnight and 3 a.m. Review of incident reporting documentation noted corrective action included evaluation of all residents identified as a wander risk was completed 5/14/17. Resident #4 was placed on 1-to-1 supervision for 24 hours. All wander bracelet protected doors were tested . Most staff were inserviced within 48 hours. Review of QA records revealed documented elopement inservices for staff conducted on 5/15/17 (96 staff), on 5/16/17 (34 staff), on 5/19/17 (18 staff), on 5/20/17 (35 staff), on 5/21/17 (10 staff), on 5/24-26/17 (13 staff), on 5/30/17 (22 staff), on 5/31/17 (13 staff), on 6/1/17 (13 staff), and on 6/2/17 (14 staff). The records documented elopement drills were conducted on 5/16/17 (21 staff), on 5/29/17 (15 staff), and on 6/1/17 (31 staff). In an interview on 6/12/17 at 11:10 a.m., LPN Staff D said if a resident is determined to be missing, a code yellow is to be imitated. In an interview on 6/12/17 at 5:00 p.m., CNA Staff G said they have been inserviced about elopement. If someone calls code yellow for a missing resident, everyone is to stop what they are doing and help locate the resident. She said they have completed several elopement drills. On 6/12/17 at 5:10 p.m., the Assistant Director of Nursing said they have been doing 2 unannounced elopement drills each week and will continue to do that for a month. As the facility investigated the incident and initiated intervention to ensure the safety of residents, the Immediate Jeopardy was removed as of 5/20/17 when the majority of staff were inserviced at least once. The staff training was documented and verified by interviews. The facility implemented a new requirement that the front desk be staff at all times. When staff is not at the front desk, the doors are to be locked. The staff check the residents' wander bracelets daily. The facility exits are checked and documented daily. The plan of action was developed and implemented beginning the day of the elopement (5/14/17) with the formal staff training completed on 6/2/17. The facility correction date of the deficient practice was 6/2/17.

Based on record review and family and staff interview, the facility failed to initiate cardiopulmonary resuscitation (CPR) for 1 (Resident #437) of 3 residents sampled. This failure was to honor the resident's right to have emergency measures with a potential to prolong life. Failing to provide CPR, when a resident is a full code places that resident and has the potential to place all residents who wish to be resuscitated in immediate jeopardy. The IJ began on [DATE] and was removed on [DATE], lowering the scoope and severity to D. (Refer to F223, F309 and F514) The findings included: Resident #437 was admitted on [DATE] with chronic [MEDICAL CONDITION], pneumonia, and muscle weakness. There was no noted psychological or dementia issues on admission. The hospital Patient Transfer Form (#,[DATE]) showed Resident #437 to be, alert, oriented and follows instructions. There was no documentation for advanced directive planning for the resident listed on the form. On admission Resident #437 was on 4 liters of continuous oxygen. Resident #437 had two sons involved with the resident's care (Son #1 and #2). The facility provided documents that Son #1 had her legal power of attorney (POA). A Physician's progress note dated [DATE] documented Resident #437 had [MEDICAL CONDITION] with deconditioning. Nurse's progress note on [DATE] documented Resident #437 was making decisions, refusing and giving consents for vaccines. On [DATE] at 12:05 p.m., the Assistant Director of Nursing (ADON) said she did not explain to the resident what a do not resuscitate (DNR) was. She said she assumed the physician had done this. On [DATE] at 12:45 p.m., the progress note shows the resident is making her needs known to the nurse and telling her she is having diarrhea, she thinks she has a UTI, and she has not slept for 4 days. On [DATE] at 10:44 p.m. a Progress Note documented, Called to room by son (Son #2) saying his mother was not breathing. On entering room it was noted patient had no respirations. Unable to obtain (vital signs)-sternal rub ineffective as son continued to yell 'check her again she cannot be dead.' Dr. (primary physician) and on call person notified. Patients (sic) son says he does not want CPR performed. Funeral home in Wisconsin notified by son and arrangements made. On [DATE] at 11:45 a.m., Son #2 said he was with his mother on [DATE] from 5:30 p.m. until she had passed away. He said no one had informed him his mother was going to pass away. He said his mother was in pain and was having a hard time breathing the whole day while he was with her. He said he could not believe the hospital had sent her to the facility in the shape she was in. He said he asked a staff member if there was something they could put in her airway to assist her breathing and he was told they don't do that in the facility. He was told by a staff member the physician was doing rounds and he would be by to see his mother, but he never came. He said when his mother stopped breathing, he ran to the nurse's station to get assistance. He said the nurse came into the room and put her hand on his mother's chest and said, She's gone. He said he did not tell any staff member not to do CPR on his mother. He said his mother's father had been placed on a ventilator before he died and she had let the family know she did not want to be placed on a ventilator. Son #2 said if there was any chance his mother could have survived she would have wanted to survive. He said no staff member had explained DNR (do not resuscitate) to him. On [DATE] at 3:14 p.m., Licensed Practical Nurse (LPN) Staff C said she was busy with another resident when she was told the a family member was saying his mother was not breathing. She said she checked the chart and there was no DNR form in the chart. She said she brought the crash cart to the room for that reason. She said the Policy of the facility is if there is no yellow DNR form in the chart, the resident is a full code. A State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] was reviewed. The patient's signature was not signed by the resident or family member. The form noted the signature obtained by verbal consent given by son (Son #1). It was signed by two nurses. The physician's statement was signed by a physician and dated [DATE] (the date was identical to the nurses' script style) In an interview on [DATE] at 12:25 p.m., Son #1 said he had left the faciity on [DATE] at 3:00 p.m. He said he told his mother she was going to get better and kissed her on the forehead and said he would see her later. He said he left the facility and got on a plane to go to Texas. He said no one from the facility had called him on [DATE] to obtain a DNR. He said if someone would have told him his mother was declining, he would never have gotten on the plane on [DATE] at 4:20 p.m.; he would have turned around and gone back to the facility. On [DATE] at 12:05 p.m., the ADON said the physician had called her and he told her the resident was declining and she needed to obtain a DNRO. The ADON said she called the DON and was told she could obtain a telephone DNR consent. The ADON said she and Registered Nurse (RN) Staff A called Son #1 between 4 p.m. and 5 p.m. on [DATE]. She said the Son #1 told her per phone call she could make his mother a DNR. On [DATE] at 9:45 a.m., the ADON said she had called the physician when she was told by various staff members that the resident was declining. She did not remember when she called the physician. She did not remember who the staff members were that reported the resident was declining. The ADON said there was a blank white copy of the DNRO in the chart that had the physician's signature on it. She said she was not sure if she used the pre-signed copy of the DNRO or not. The ADON verified she never attempted to get consent from the resident herself. She said she was going off what various unknown staff was telling her about the resident. The ADON did not remember if she placed the completed form in the resident's chart. On [DATE] at 12:05 p.m., RN Staff A verified she was the nurse who signed with the ADON on the DNR order. She said she did not actually speak to the son to verify he wanted his mother to be a DNR. On [DATE] at 10:08 a.m., RN Staff A said there was a white copy of the DNRO form that had the physician's signature on it before she and the ADON went to obtain the telephone consent. She said the ADON had used a pre-signed white copy of the DNRO to obtain the verbal consent from Son #1. When questioned about getting telephone consent on a blank document with a physician's signature, in the presence of the Administrator, RN Staff A said, I refuse to answer. On [DATE] at 1:05 p.m., the DON verified she was called by the ADON and that she had told the ADON to obtain telephone consent for the DNR for Resident #437. The DON was not able to say when she was called. She said she was called sometime in the afternoon. On [DATE] at 3:47 p.m., RN Staff B said she was doing rounds when the resident's son came out asking for assistance because his mother was not breathing. Staff B said the son told her not to do CPR. She said the facility's policy is to honor the resident's and family's wishes, even if there is not a yellow DNRO copy in the chart. RN Staff B said she never saw or looked for the yellow DNRO form or a physician's orders [REDACTED]. On [DATE] at 4:11 p.m., LPN Staff D verified she was the nurse who was assigned to the resident during the day on [DATE]. She said she left after 7:00 p.m. and the resident was alert and oriented during her shift. LPN Staff D said Resident #437 was able to sign consents. LPN Staff D said she had obtained consents for vaccines from the resident. On [DATE] at 10:48 a.m., the Social Service Director (SSD) said they have 7 days to do an assessment after the resident is admitted . She said if the resident starts to decline they speed the process up. She said they were never notified by nursing the resident was declining. The SSD said Resident #437 was not deemed incapacitated and would have been able to make her own decisions. The SSD said the resident was a full code until there was a completed yellow DNRO form on the chart. The SSD said she had never seen a DNRO obtained by telephone consent. On [DATE] at 11:15 a.m., the primary physician said he could not have signed the DNR form on [DATE] as he was not in the facility on that day. He said he talked to a family member on [DATE] but did not know which family member he had spoken with. The primary physician verified he had not made a progress note of this conversation. He said he did not tell the nurses to obtain a DNRO from the family member. He said he thought the resident was a DNRO on [DATE]. The primary physician said he did not sign a blank DNRO and leave it in Resident #437's chart. On [DATE] at 10:45 a.m., the Medical Director said the resident should have been sent to the hospital if she was having dehydration with active diarrhea, heart rate variations, and oxygen saturation dropping below 90. He said the resident should never been sent to the facility in the first place. He said he had never heard of a 7-day period to obtain resident's advanced directive information. The Medical Director said if the staff had followed the facility policy of prior to or upon admission, asking the resident or family about the existence of advanced directive we would not be here right now. The Medical Director said policies should be implemented and staff should be educated to understand when and when not to perform CPR on a resident. He said he would have that policy in place within an hour. He said he had been [MEDICATION NAME] medicine for over [AGE] years and he had never seen anything like this before. On [DATE] at 2:30 p.m. the Administrator and the DON provided documentation they had reviewed the deaths in the facility over the last 6 months and there were no further issues noted with a lack of CPR not being provided to a resident. The facility initiated new policies regarding advance directives. They in-serviced the staff on the new policies for advanced directives, and they reviewed the code status of all resident's in the facility to ensure their choices for advanced directives were being honored. The Administrator was informed of the immediate jeopardy (IJ) on [DATE] at 2:33 p.m. The IJ began [DATE]. Based on surveyor verification of corrective measures in place, the IJ was removed on [DATE] at 3:05 p.m., lowering the scope and severity to D.

Based on record review, and interview, the facility failed to develop policies and procedures for identification and implementation of Do Not Resesutate Orders to prevent the neglect of 1 (Resident #437) of 3 residents sampled. Resident #437 did not have a properly executed do not resuscitate order (DNRO). The facility neglected to provide emergency treatment to this resident when she stopped breathing and died . (refer to F155, F309 and F514) The findings included: Resident #437 was admitted on [DATE] with chronic [MEDICAL CONDITION], pneumonia, and muscle weakness. There was no noted psychological or dementia issues on admission. The hospital Patient Transfer Form (#,[DATE]) showed Resident #437 to be, alert, oriented and follows instructions. There was no documentation for advanced directive planning for the resident listed on the form. There was no documentation in the medical record that showed the resident was incapacitated on admission. A progress note dated [DATE] at 5:27 p.m. shows Resident #437 refused a flu vaccine and signed the appropriate form. The resident also signed a consent for an antidepressant on the same date. On [DATE] at 10:44 p.m. a Progress Note documented, Called to room by son (Son #2) saying his mother was not breathing. On entering room it was noted patient had no respirations. Unable to obtain (vital signs)-sternal rub ineffective as son continued to yell 'check her again she cannot be dead.' Dr. (primary physician) and on call person notified. Patients (sic) son says he does not want CPR performed. Funeral home in Wisconsin notified by son and arrangements made. On [DATE] at 11:45 a.m., Son #2 said he was with his mother on [DATE] from 5:30 p.m. until she had passed away. He said no one had informed him his mother was going to pass away. He said his mother was in pain and was having a hard time breathing the whole day while he was with her. He said he could not believe the hospital had sent her to the facility in the shape she was in. He said he asked a staff member if there was something they could put in her airway to assist her breathing and he was told they don't do that in the facility. He was told by the unknown staff member the physician was doing rounds and he would be by to see his mother, but he never came. He said when his mother stopped breathing, he ran to the nurse's station to get assistance. He said the nurse came into the room and put her hand on his mother's chest and said, She's gone. He said he did not tell any staff member not to do CPR on his mother. He said his mother's father had been placed on a ventilator before he died and she had let the family know she did not want to be placed on a ventilator. Son #2 said if there was any chance his mother could have survived she would have wanted to survive. He said no staff member had explained DNR (do not resuscitate) to him. On [DATE] at 3:14 p.m., Licensed Practical Nurse (LPN) Staff C said she was busy with another resident when she was told the resident was saying his mother was not breathing. She said she checked the chart and there was no DNRO form in the chart. She said she brought the crash cart to the room for that reason. She said the Policy of the facility is if there is no yellow DNR form in the chart the resident is a full code. A state of Florida Do Not Resuscitate Order (DNRO) dated [DATE] and obtained as verbal consent by two nurses and signed by a physician on the same date was provided by the facility. The person listed as not being able to sign the form was Son #1. On [DATE] at 12:25 p.m., Son #1 said he had left the facility at 3:00 p.m. on [DATE]. He said he told his mother she was going to get better and kissed her on the forehead and said he would see her later. He said he went and got on a plane to go to Texas. He said no one had called him from the facility had called him on [DATE] to obtain a DNR. He said if someone would have told him his mother was declining he would never have gotten on the plane at 4:20 p.m. on [DATE]; he would have turned around and gone back to the facility. On [DATE] at 1:17 p.m., the Director of Nursing (DON) verified she had told the ADON that she could obtain a telephone consent form the POA. The DON could not remember when this conversation occurred. The DON said she did not have a policy for obtaining telephone consents for DNRs. The DON was unable to provide a policy for staff obtaining telephone consents. On [DATE] at approximately 2:00 p.m., The DON verified there was no current written policy to show how the facility determined what forms on the chart staff would look for to determine what made a resident a DNR. The DON said the resident would be a DNR if they had a written order for a DNR or a yellow DNR order form. The DON said it was not necessary to have a Yellow DNR order on the chart for the facility to honor a DNR. 64J-2.018(B)(a) Florida State law requires: (2) The Do Not Resuscitate Order: (a) Form shall be printed on yellow paper and have the words DO NOT RESUSCITATE ORDER printed in black and displayed across the top of the form. DH Form 1896 may be duplicated, provided that the content of the form is unaltered, the reproduction is of good quality, and it is duplicated on yellow paper. The shade of yellow does not have to be an exact duplicate. (3) The DNRO form and patient identification device must be signed by the patient's physician. In addition, the patient, or, if the patient is incapable of providing informed consent, the patient's health care surrogate or proxy as defined in Section 765.101, F.S., or court appointed guardian or person acting pursuant to a durable power of attorney established pursuant to Section 709.08, F.S., must sign the form and the patient identification device in order for them to be valid. On [DATE] at approximately 2:30 p.m., the Regional Nurse said the yellow DNRO form was for emergency medical services (EMS) staff alone. She said if a physician wrote a DNRO on a napkin, the facility would honor the order. The Regional Nurse was asked how the facility would identify the resident had consented to being a DNR but never answered the question. On [DATE] at 3:47 p.m., RN Staff B said she was doing rounds when the resident's son came out asking for assistance because his mother was not breathing. Staff B said the son told her not to do CPR. She said the facility's policy is to honor the resident's and family's wishes, even if there is not a yellow DNRO copy in the chart. RN Staff B said she never saw or looked for the yellow DNRO form or a physician's orders [REDACTED].>On [DATE] at 10:48 a.m., the Social Service Director (SSD) said they have 7 days to do an assessment after the resident is admitted . She said if the resident starts to decline they speed the process up. She said they were never notified by nursing the resident was declining. The SSD said Resident #437 was not deemed incapacitated and would have been able to make her own decisions. The SSD said the resident was a full code until there was a completed yellow DNRO form on the chart. The SSD said she had never seen a DNRO obtained by telephone consent. On [DATE] at 10:45 a.m., the Medical Director said the resident should have been sent to the hospital if she was having dehydration with active diarrhea, heart rate variations, and oxygen saturation dropping below 90. He said the resident should never been sent to the facility in the first place. He said he had never heard of a 7-day period to obtain resident's advanced directive information. The Medical Director said if the staff had followed the facility policy of prior to or upon admission, asking the resident or family about the existence of advanced directive we would not be here right now. The Medical Director said policies should be implemented and staff should be educated to understand when and when not to perform CPR on a resident. He said he would have that policy in place within an hour. He said he had been [MEDICATION NAME] medicine for over [AGE] years and he had never seen anything like this before. On [DATE] the Administrator and the DON provided documentation that all staff members were receiving education in honoring advanced directives for all residents. The education included, The yellow Florida DNRO must be signed by the physician and the person who has the authority to make medical decisions. It is not valid until it has both signatures. The Administrator provided an updated policy for advanced directives to include, If applicable additional advanced directives education will be provided as deemed necessary per the facility.

Based on record review and family and staff interview, the facility failed to provide emergency care to 1 (Resident #437) of 3 residents sampled. The facility failed to honor the resident's right to have emergency measures with a potential to prolong life when a resident was a full code. The findings included: Resident #437 was admitted on [DATE] with chronic [MEDICAL CONDITION], pneumonia, and muscle weakness. There was no noted psychological or dementia issues on admission. The hospital Patient Transfer Form (#,[DATE]) showed Resident #437 to be, alert, oriented and follows instructions. There was no documentation for advanced directive planning for the resident listed on the form. On admission Resident #437 was on 4 liters of continuous oxygen. Resident #437 had two sons involved with her care (Son #1 and #2). The facility provided documents that only Son #1 had her legal power of attorney (POA). A Physician's progress note dated [DATE] shows Resident #437 had [MEDICAL CONDITION] with deconditioning. Nurse's progress notes shows on [DATE] the resident was making decisions refusing and giving consents for vaccines. On [DATE] at 12:45 p.m., the progress note shows the resident is making her needs known to the nurse and telling her she was having diarrhea, thought she had a UTI, and had not slept for 4 days. On [DATE] at 10:44 p.m. a Progress Note documented, Called to room by son (Son #2) saying his mother was not breathing. On entering room it was noted patient had no respirations. Unable to obtain (vital signs)-sternal rub ineffective as son continued to yell 'check her again she cannot be dead.' Dr. (primary physician) and on call person notified. Patients (sic) son says he does not want CPR performed . On [DATE] at 11:45 a.m., Son #2 said he was with his mother on [DATE] from 5:30 p.m. until she had passed away. He said no one had informed him his mother was going to pass away. He said his mother was in pain and was having a hard time breathing the whole day while he was with her. He said he could not believe the hospital had sent her to the facility in the shape she was in. He said he asked a staff member if there was something they could put in her airway to assist her breathing and he was told they don't do that in the facility. He was told by the unknown staff member the physician was doing rounds and he would be by to see his mother, but he never came. He said when his mother stopped breathing, he ran to the nurse's station to get assistance. He said the nurse came into the room and put her hand on his mother's chest and said, She's gone. He said he did not tell any staff member not to do CPR on his mother. He said his mother's father had been placed on a ventilator before he died and she had let the family know she did not want to be placed on a ventilator. Son #2 said if there was any chance his mother could have survived she would have wanted to survive. He said no staff member had explained DNR (do not resuscitate) to him. On [DATE] at 3:14 p.m., Licensed Practical Nurse (LPN) Staff C said she was busy with another resident when she was told the resident was saying his mother was not breathing. She said she checked the chart and there was no DNR form in the chart. She said she brought the crash cart to the room for that reason. She said the Policy of the facility was if there is no yellow DNR form in the chart, the resident is a full code. A State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] was reviewed. The patient's signature was not signed by the resident or family member. The form noted the signature obtained by verbal consent given by son (Son #1). It was signed by two nurses. The physician's statement was signed by a physician and dated [DATE]. On [DATE] at 12:25 p.m., Son #1 said he had left the facility at 3:00 p.m. on [DATE]. He said he told his mother she was going to get better and kissed her on the forehead and said he would see her later. He said he went and got on a plane to go to Texas. He said no one had called him from the facility had called him on [DATE] to obtain a DNR. He said if someone would have told him his mother was declining he would never have gotten on the plane at 4:20 p.m. on [DATE]; he would have turned around and gone back to the facility. On [DATE] at 12:05 p.m., the ADON said the physician had called her and he told her the resident was declining and she needed to obtain a DNRO. The ADON said she called the DON and was told she could obtain a telephone DNR consent. The ADON said she and Registered Nurse (RN) Staff A called Son #1 between 4 p.m. and 5 p.m. on [DATE]. She said the Son #1 told her per phone call she could make his mother a DNR. On [DATE] at 9:45 a.m., the ADON said she had called the physician when she was told by various staff members that the resident was declining. She did not remember when she called the physician. She did not remember who the staff members were that reported the resident was declining. The ADON said there was a blank white copy of the DNRO in the chart that had the physician's signature on it. She said she was not sure if she used the pre-signed copy of the DNRO. The ADON verified she never attempted to get consent from the resident herself. She said she was going off what various staff had told her about the resident. The ADON did not remember if she placed the completed form in the resident's chart. The ADON said she had never seen a DNRO obtained by telephone before and she had never completed a DNRO by telephone in the past. On [DATE] at 12:05 p.m., RN Staff A verified she was the nurse who signed with the ADON on the DNR order. She admitted she did not actually speak to the son to verify he wanted his mother to be a DNR. On [DATE] at 10:08 a.m., RN Staff A said there was a white copy of the DNRO form that had the physician's signature on it before she and the ADON went to obtain the telephone consent. She said the ADON had used a pre-signed white copy of the DNRO to obtain the verbal consent from Son #1. When questioned about getting telephone consent on a blank document with a physician's signature, in the presence of the Administrator, RN Staff A said, I refuse to answer. Staff A said she does not know what happened to the form after it had been completed. Staff A said she had never seen a DNRO obtained by telephone before and she had never completed a DNRO by telephone in the past. On [DATE] at 1:05 p.m., the DON verified she was called by the ADON and that she had told the ADON to obtain telephone consent for the DNR for Resident #437. The DON was not able to say when she was called on [DATE]. She said she was called sometime in the afternoon. On [DATE] at 3:47 p.m., RN Staff B said she was doing rounds when the resident's son came out asking for assistance because his mother was not breathing. RN Staff B said the son told her not to do CPR. She said the facility's policy was to honor the resident's and family's wishes even, if there is not a yellow DNRO copy in the chart. RN Staff B said she never saw or looked for the yellow DNRO form or a physician's orders [REDACTED]. On [DATE] at 4:11 p.m., LPN Staff D verified she was the nurse who was assigned to the resident during the day on [DATE]. She said she left after 7:00 p.m. and the resident was alert and orient during her shift. LPN Staff D said Resident #437 was able to sign consents. LPN Staff D said she had obtained consents for vaccines from the resident. Staff D said she had called the physician regarding the resident refusing to go to therapy due to diarrhea and her complaints of having a possible urinary tract infection. She said she had informed the physician that resident's heart rate was running from 45 to 125 beat per minute. The nurse said the resident's oxygen saturation (sats) kept dropping to 88 to 89% and she would remind the resident to breath through her nose. Review of Resident #437's record shows one oxygen sat was completed on [DATE] and documented on the treatment record, on exertion with oxygen, sats ,[DATE]%, patient continually breathing through mouth, needed constant reminder to take slow breaths through nose. Review of the Subsequent Visit form completed by LPN Staff C on [DATE] at 7:45 p.m. showed no documentation the physician was notified that Resident #437's oxygen sats were below 90%. On [DATE] at 10:48 a.m., the Social Service Director (SSD) said they have 7 days to do an assessment after the resident is admitted . She said if the resident starts to decline they speed the process up. She said they were never notified by nursing the resident was declining. The SSD said Resident #437 was not deemed incapacitated and would have been able to make her own decisions. The SSD said Resident #437 was a full code until there was a completed yellow DNRO form on the chart. The SSD said she had never seen a DNRO obtained by telephone consent. On [DATE] at 11:15 a.m., the primary physician said he could not have signed the DNR form on [DATE] as he was not in the facility on [DATE]. He said he talked to a family member on [DATE] but did not know which family member he had spoken with. The primary physician verified he had not made a progress note of this conversation. He said he did not tell the nurses to obtain a DNRO from the family member. He said he thought the resident was a DNRO on [DATE]. The primary physician said he did not sign a blank DNRO and leave it in Resident #437's chart. On [DATE] at 10:45 a.m., the Medical Director said the resident should have been sent to the hospital if she was having dehydration with active diarrhea, heart rate variations, and oxygen saturation dropping below 90. He said the resident should never been sent to the facility in the first place. He said he had never heard of a 7-day period to obtain resident's advanced directive information. The Medical Director said if the staff had followed the facility policy of prior to or upon admission, asking the resident or family about the existence of advanced directive we would not be here right now. The Medical Director said policies should be implemented and staff should be educated to understand when and when not to perform CPR on a resident. He said he would have that policy in place within an hour. He said he had been [MEDICATION NAME] medicine for over [AGE] years and he had never seen anything like this before. At 2:30 p.m. the Administrator and the DON provided documentation they had reviewed the deaths in the facility over the last 6 months and there were no further issues noted with a lack of CPR not being provided to a resident. They had initiated new policies regarding advance directives. They had in serviced the staff on the new policies for advanced directives, and they had reviewed the code status of all resident's in the facility to ensure their choices for advanced directives were being honored. The Administrator was informed of the immediate jeopardy on [DATE] at 2:33 p.m. The immediate jeopardy started [DATE] and was removed on [DATE] at 3:05 p.m. after the surveyor verified the corrective action, lowering the scope and severity to D.