Every finding on record at Health Central Park

Based on interview, and record review, the facility failed to provide activities in resident rooms on the weekends for 3 of 4 residents reviewed for activities, of a total sample of 53 residents, (#142, #65, #66). Findings: The care plan for resident #142 revised on 3/12/25 revealed the resident was unable to communicate and all needs were anticipated by staff. The goal indicated the resident would be encouraged to participate in activities that were meaningful to her. Review of the Recreation Therapy Services Attendance and Participation record for April and May 2025 showed the days that social visits were conducted in the resident's room. Social visits were not conducted on Saturday or Sunday. The care plan for resident #65 revised on 3/05/25 revealed the resident wanted staff to invite and encourage him to participate in programs and events. The goal indicated the resident wanted to be invited and assisted to programs. Review of the Recreation Therapy Services Attendance and Participation record for March 2025, April 2025, and May 2025 showed the days that social visits were conducted in the resident's room and attendance to other events. Social visits were not conducted on Saturday or Sunday during the three month timeframe from March 2025 to May 2025. The care plan for resident #66 revised on 3/12/25 revealed the resident needed help with all tasks and wanted staff to visit with her. The goal indicated the resident wanted to be invited and encouraged to attend programs and events. Review of the Recreation Therapy Services Attendance and Participation record for May 2025 showed the days that social visits were conducted in the resident's room. Social visits were not conducted on Saturday or Sunday for the month of May 2025. On 5/21/25 at 11:15 AM, Activities staff R discussed activities provided in the residents' rooms for residents # 142, #65, and #66. She explained social visits were approximately 10-15 minutes in length and the type of activity was documented on the Attendance and Participation record. Activities staff R explained activity was not offered on the days where nothing was documented. She said they had six staff available to provide activities/recreational therapy, two were assigned to the memory care unit and four staff were available for the rest of the facility. Activities staff R conveyed on the weekend, there was one activities/recreational therapy staff person to provide activities for the entire facility and in-room visits did not occur. On 5/19/25 there were 188 residents in the facility.

Based on observation, interview, and record review, the facility failed to offer hand hygiene prior to meals for 35 residents, at 3 different dining locations and failed to follow evidence based practice for implementation of enhanced barrier precautions for 1 of 1 residents reviewed for enhanced barrier precautions, (#65); of a total sample of 53 residents. Findings: 1. On 5/19/25 at 11:30 AM, 25 residents were observed as they prepared to eat lunch in the main dining room. Hand hygiene for residents was not offered by staff or observed as performed. On 5/20/25 at 11:55 AM, 28 residents were observed as they prepared and ate their lunch in the main dining room. Hand hygiene for residents was not offered by staff or observed as performed. On 5/22/25 at 12:00 PM, 29 residents were observed as they prepared and ate their lunch in the main dining room. Hand hygiene for residents was not offered by staff or observed as performed. On 5/19/25 at 11:30 AM, resident #597 was wheeled into the dining room at 11:34 AM, by Physical Therapy Technician B who stated the resident came directly from working out in rehabilitation and did not use the restroom after working out. Resident #597 was not offered hand hygiene prior to eating his lunch. On 5/20/25 at 11:57 AM resident #597 was wheeled into the dining room by Physical Therapy Assistant A, who stated the resident came directly from doing physical therapy exercises and did not use the restroom after exercising. Resident #597 was not offered hand hygiene prior to eating his meal. On 5/21/25 at 12:48 PM, resident #597 was observed eating lunch in his room. He stated he washed his hands after physical therapy today because he came back to his room. He added, on Monday and Tuesday he went straight from physical therapy into the dining room and wasn't offered a way to wash his hands before eating. He stated it would have been nice to have had that offered by staff. On 5/22/25 at 12:04 PM, resident #77 stated she went on a field trip on the bus that morning. She added, staff asked them if they needed to use the restroom before lunch, but she didn't need to go. Resident #77 stated she went straight to the dining room from the bus and was not offered her a way to clean her hands. She explained she had hand wipes in her room, but she didn't go to her room and would like staff to offer her a way to clean her hands before she ate her food. On 5/22/25 at 12:13 PM, resident #88 stated she went to all the activities and this morning the residents took turns reading paragraphs of a story out loud. Resident #88 stated she came straight to the dining room from the activity and was not offered a way to clean her hands before eating. She added, months ago they used to provide hand wipes prior to eating and was not sure why they stopped doing that. On 5/22/25 at 12:55 PM, Case Manager C was assisting with meal service in the main dining room and explained she was assigned to the facility's all-hands-on-deck duties from 11:15 AM to 1:30 PM, once or twice per week. She confirmed hand hygiene was not offered to the residents prior to eating their lunch today. The Case Manager explained she had not seen hand hygiene being offered recently, but remembered it was done in the past when they offered wipes or hand sanitizer gel prior to meals. Case Manager C stated it was important for both staff and residents to wash/sanitize hands prior to meals to limit the spread of germs, and for dignity. She added it was one of the most important things. 2. On 5/19/25 at 1:00 PM, four residents were seated in the 300's unit dining room waiting for their lunch. A few minutes later at 1:13 PM, the meal cart arrived and by 1:38 PM all of the residents were observed eating. During that time no hand hygiene was offered or given for the residents prior to eating. On 5/19/25 at 5:44 PM, the 300's Unit Manager (UM) stated some of the residents who ate in the 300's unit dining area came there straight from activities and added, if they need to use the toilet, staff take them to their room and then bring them back to the dining room. On 5/20/25 at 1:25 PM, in the 300's unit dining area, four residents were observed eating lunch in the dining area but no offering of hand hygiene was observed prior to the meal. On 5/22/25 at 1:29 PM, residents #139, #103, #14, and #84 were observed dining in the 300's unit dining room. None of the residents were offered hand hygiene by the staff prior to eating. Resident #84 was observed being assisted with his lunch meal by the 300's UM, who cleaned her own hands but did not offer hand hygiene to the resident before the meal. On 5/22/25 at 1:34 PM, Registered Nurse (RN) E stated she thought resident #103 didn't need her hands washed before the meal because the resident had received a shower earlier in the day. RN E acknowledged the facility may have failed to do offer hand hygiene to the residents this week, and explained it was important to offer hand washing as it was the best tool to prevent infection. 3. On 5/22/25 at 1:00 PM , Certified Nursing Assistant (CNA) D delivered a lunch meal tray to resident #134 who was resting in bed but was not offered hand washing prior to the meal. CNA D stated she did not offer hand hygiene to resident #134 before lunch because she washed the hands of this resident earlier in the morning before breakfast, so she knew it had already been done. On 5/22/25 at 1:05 PM, resident #126 stated he routinely got up at 7:00 AM, needed help to use the bathroom, brush his teeth, shave and wash his hands. He added, later in the mornings, he walked with therapy down the hall and then went back to sit on his bed. Resident #126 stated he had not washed his hands since his morning routine and was not offered hand hygiene by staff prior to the meal. On 5/22/25 at 1:40 PM, the Director of Nursing stated it was important to wash everyone's hands before meals to get rid of microorganisms. She added, it was very important for residents who resided in such close quarters to perform hand hygiene in order to prevent the spread of illnesses among them. The facility's policy entitled hand hygiene, dated May 2022, indicated the purpose of the guidelines was to promote hand hygiene as an essential element of patient safety to reduce health care associated infections. 14730 4. Review of the Minimum Data Set assessment dated [DATE] for resident #65 revealed he had an indwelling urinary catheter. The facility policy and procedure with revision date of September 2024 indicated Enhanced Barrier Precautions applied to residents with indwelling medical devices (e.g. urinary catheters). The procedure section instructed staff to perform hand hygiene and don gown and gloves for high-contact care activities and for device care. On 5/19/25 at 10:45 AM, observation of resident #65's room revealed a purple magnet on the door frame that listed EBP for enhanced barrier precautions. A container with gowns and gloves was hanging on the back of the door. On 5/22/25 at 9:45 AM, resident #65's door into the room was closed. The purple EBP magnet was on the door frame. After knocking and gaining permission to open the door, CNA O was seen bathing and dressing resident #65, without a gown on. The CNA was wearing gloves, but not a gown, and said, I forgot, as to why she was not wearing the gown. On 5/22/25 at 10:20 AM, the Infection Preventionist confirmed that residents with indwelling urinary catheters required staff use of gloves and gown for high-contact care activities.

Based on interview, and record review, the facility failed to timely accommodate a resident's preference to obtain individualized diabetic shoes for 1 of 1 residents sampled for specialized durable medical equipment, of a total sample of 53 residents, (#46). Findings: Resident #46 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy (nerve pain), unspecified. His Quarterly Minimum Data Set assessment dated [DATE], indicated he had intact cognitive function. On 5/19/25 at 10:32 AM, resident #46 explained he would like new specialized diabetic footwear. He said he was told by his insurance company that he was allowed a new pair of diabetic specialty shoes every year. He said he had previously spoken with a Podiatrist who provided him care in the facility about the new diabetic specialty shoes. Review of resident #46's medical record revealed a podiatry visit note dated 3/19/25 which indicated resident #46 inquired about receiving his yearly diabetic specialty shoes. Podiatrist G's note detailed the provider of the specialized diabetic footwear company was waiting on the facility to submit forms in order to move forward in the process. On 5/22/25 at 9:20 AM, Unit Secretary F, and the Director of Social Services, concurrently reviewed the Standard Written Order signed by a physician and dated 3/28/25, from the diabetic footwear company which detailed supplying and fitting inserts and shoes for persons with diabetes. Unit Secretary F said she helped facilitate getting the diabetic shoes order signed by a physician of resident #46's primary physician group. Unit Secretary F said that she had done no additional follow-up with the diabetic footwear provider to see what the delay was in providing the shoes. The Director of Social Services explained they had received no follow-up regarding resident #46's diabetic specialty shoes from the company-55 days after the signed order had been obtained. The Director of Social Services acknowledged it was the facility's responsibility to reach out to the company in order to facilitate resident #46's choice to get specialty diabetic shoes and follow up on the physician's orders. On 5/22/25 at 11:56 AM, Podiatrist G stated the specialty footwear company involved with resident #46's footwear showed a lack of timeliness in providing the ordered shoes and verified facility staff were expected to follow-up timely so that resident #46's could receive his choice of specialty diabetic footwear.

Based on observation, interview, and record review, the facility failed to monitor implementation of a fall prevention intervention for 1 of 1 residents sampled regarding fall care plan interventions, of a total sample of 53 residents, (#95). Findings: Resident #95 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia- unspecified severity with other behavioral disturbance, primary open-angle glaucoma (eye condition), bilateral, stage unspecific. His Quarterly Minimum Data Set assessment dated [DATE], indicated he had moderate cognitive impairment. Review of resident #95's medical record revealed a change in condition note dated 3/28/25 which indicated resident #95 was found on the floor. On 3/31/25 an interdisciplinary team (IDT) note indicated the team met to review resident #95's plan of care and fall risk after he was observed on the floor of his room next to his bed. The IDT note described resident #95 stated he had gone to sleep in his bed and woke up suddenly when he fell to the floor. The team noted resident #95 had an increased risk for falls due to impaired vision and a behavior of sleeping with his head at the foot of the bed and his legs at the head of the bed. The fall intervention put into place by the IDT team was a scoop mattress so that resident #95 had borders at the foot of the bed. Review of resident #95's care plan revealed the resident was identified as at risk for falls and injuries related to his impaired vision/blindness, glaucoma, dementia with an initiation date of 4/25/23 and a revision date of 12/04/24. The intervention for the scoop mattress to bed to maintain border of bed was dated 3/28/25. On 5/19/25 at 4:02 PM, resident #95 was lying on his bed in his room. The mattress was standard, flat mattress. He did not have a scoop mattress on his bed. On 5/20/25 at 8:47 AM, resident #95 was lying in bed in his room. A standard mattress was present. On 5/21/25 at 12:34 PM, resident #95 was again lying on a standard mattress with his head at the foot of the bed and his legs at the head of his bed. On 5/21/25 at 2:17 PM, resident #95 was seated on his bed, Certified Nursing Assistant (CNA) M verified resident #95 had a regular mattress on his bed. On 5/21/25 at 5:03 PM, Registered Nurse (RN) L verified resident #95 has a regular mattress on his bed. Resident #95 was seated on his bed. She verified that his care plan indicated that he should have a scoop mattress. On 5/21/25 at 5:26 PM, the Director of Nursing (DON) reviewed resident #95's care plan and verified he should have a scoop mattress on his bed. She explained the intervention was put in place after he was found on the floor on 3/28/25. The DON stated she recalled resident #95 had a scoop mattress on his bed and he had not refused its use. She recalled that RN J assisted with obtaining the scoop mattress for resident #95 and updating resident #95's care plan. She said she and the Assistant Director of Nursing (ADON) did rounds on the residents to check for safety items and additional care items. The DON could not explain when the scoop mattress had been removed from resident #95's bed and replaced with a regular mattress. On 5/22/25 at 10:00 AM, RN J recalled resident #95 had been found on the floor after he rolled out of his bed in March 2025. She recalled a scoop mattress was placed on resident #95's bed after that time. RN J could not say what happened to resident #95's scoop mattress or why it was not currently on his bed. She acknowledged the facility had no system to track mattresses to indicate when the scoop mattress was added or removed from resident #95's bed. On 5/22/25 at 10:09 AM, the Environmental Director said he did not recall removing or changing resident #95's mattress. He confirmed the facility has no record keeping for when a mattress was changed for a resident, and could not say if the scoop mattress was ever placed on resident #95's bed, or when it was removed. Review of the Fall Prevention and Reduction policy with an issue date of 9/25/24 indicated after a fall nursing staff were to monitor and document the resident's response to interventions, implement change(s) if indicated, and notify the provider.

Based on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADLs) were maintained for nail care of 1 of 1 residents reviewed for ADLs, of a total sample of 53 residents, (#141) . Findings: Resident #141 was admitted to the facility on [DATE] with hemiparesis (one sided muscle weakness) to the left side of his body. His minimum data set quarterly assessment dated [DATE] indicated the resident had impairment to his upper and lower extremities on one side. The assessment revealed resident #141 was dependent upon staff for shower and bathing, and had no behaviors, including rejection of ADLs exhibited. The assessment indicated he had mild cognitive impairment, was usually understood and usually understood others. On Tuesday, 5/20/25 at 1:27 PM, an observation of the resident #141's fingernails showed they were approximately 5 millimeters beyond the quick. A dark-colored substance was observed under the length of the fingernails with a small sliver of white nail, approximately 1 millimeter, visible. A review of the Certified Nursing Assistant (CNA) care assignment list showed the resident was scheduled to receive showers on Mondays and Thursdays on the 7:00 AM to 3:00 PM shift and fingernails were to be cleaned and trimmed on shower days. The care plan for ADL self care performance related to impaired mobility listed a goal that the resident will continue to have ADL needs anticipated and met. The intervention for bathing/showering showed the resident required assistance. The intervention also included check nail length, trim and clean on bath day and as necessary. On Thursday, 5/22/25 at 9:23 AM, observation showed resident #142's fingernails were in the same condition as on 5/20/25. His nails were not trimmed and dark-colored substance remained under the nails. At that time the resident stated he wished they would trim and clean his nails. Review of the CNA assignment for Monday, 5/19/25 revealed CNA O was assigned to care for resident #141 that day. In an interview with CNA O on 5/22/25 at 9:50 AM, she stated she gave the resident a bed bath on 5/19/25. She said she did not trim his nails that day, and did not give an explanation why.

Based on observation, interview, and record review the facility failed to provide services to prevent reduction in range of motion by failing to apply bilateral palm guards per the plan of care for 1 of 1 residents reviewed for positioning, of a total sample of 53 residents, (#66). Findings: Resident #66's Minimum Data Set assessment dated [DATE] indicated the staff assessed her cognition as severely impaired. She had a diagnosis of cerebral palsy and impaired functional limitation in range of motion for both upper and lower extremities. The assessment indicated resident #66 was dependent upon staff for all activities of daily living. A care plan revised on 3/12/25 indicated she had bilateral contractions and required the use of bilateral hand splints/palm guards. On 5/19/25 at 12:15 PM, the resident was not wearing palm guards on either hand. An interview with the resident's representative at that time revealed the palm guards had not been on her hands for approximately a week. On 5/20/25 at 10:00 AM, resident #66 did not have palm guards on either hand. On 5/21/25 at 9:30 AM, the resident had a palm guard only on her left hand. On 5/22/25 at 9:15 AM, assigned Licensed Practical Nurse P could not say why the palm guard had not been applied to the resident's right hand. The nurse looked in the resident's drawers but could not locate the palm guard. On 5/22/25 at 12:25 PM, the Rehabilitation Director confirmed the resident required bilateral palm guards daily to prevent a loss of range of motion.

Based on observation, interview, and record review, the facility failed to provide the appropriate assistive device for fluids (two-handled cup) during the lunch meal for 1 of 2 residents reviewed for assistive devices while dining on the 500 unit, of a total sample of 53 residents, (#128). Findings: On 5/19/25 at 12:30 PM, during an observation during the lunch meal, resident # 128 was observed with a standard, clear cup with no handles on his lunch tray. The resident had a paper meal ticket that indicated he required adaptive equipment including a two-handle cup. An interview with Licensed Practical Nurse Q at that time, confirmed the resident required a two-handled cup to be able to drink independently. The Minimum Data Set assessment dated [DATE] revealed an impaired functional limitation in range of motion for resident #128's upper and lower extremities on both sides. Review of a care plan revised 4/30/25 for self-care performance deficit listed the goal as the resident would continue to have activities of daily living needs anticipated and met by staff. The intervention for eating detailed resident #128 required one staff to set up for eating, and included use of a cup with handles. On 5/22/25 at 12:25 PM, the Rehabilitation Director stated the resident had a therapy screen in March 2025 which indicated resident #128 continued to require the use of a two-handled cup for fluids. (Photographic evidence obtained)

Based on interview, and record review, the facility failed to maintain an accurate medical record for 1 of 2 residents reviewed for respiratory care, of a total sample of 53 residents, (#107). Findings: Resident #107 had physician orders dated 3/06/25 for BiPap (Bilevel positive airway pressure) for sleep apnea. The orders included directions for staff to change the BiPap mask and tubing every month. Review of the treatment administration record for April 2025 and May 2025 revealed staff documented with their initials that the BiPap mask and tubing were changed every day. The treatment records also showed similar orders for a CPAP (continuous positive airway pressure) care and tubing changes initialed by nurses as completed. On 5/22/25 at 1:50 PM, assigned Licensed Practical Nurse (LPN) P verified her initials were listed as having changed the BiPap mask and tubing 12 times in May, although the order indicated them to be changed monthly. She was unsure why the treatment record contained orders for BiPAP care and for CPAP care. The LPN stated maybe the orders were entered incorrectly into the computer. On 5/22/25 at 3:30 PM, the Minimum Data Set Coordinator confirmed the orders and treatment records were inaccurate and the resident did not use a CPAP. He stated the order for the tubing change was entered into the system incorrectly and should have listed one day a week for the tubing changes.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide care and maintenance for a central line intravenous catheter (CVC) per standards of care for 1 of 1 resident reviewed for CVCs, of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on 11/15/22 with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and readmitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalization s and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the surveyor, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. The facility's failure to identify and provide necessary care and services for maintenance of the central line intravenous catheter contributed to the hospitalization of resident #65 and placed all residents who were admitted /readmitted with medical devices including CVCs at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 12/22/22 and was removed on 9/23/23. Findings: Cross reference F684 and F726. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to his abdomen and severe malnutrition. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. Review of the Admission Screening dated 11/15/22 revealed the nurse documented an IV/Sub q/Implanted Port to resident #65's right chest. The screening document was marked, Treatment ordered or required, under the skin assessment section, and indicated Advanced Practice Registered Nurse (APRN) I was notified of the admission and medications were confirmed. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C, lowered the resident's hospital gown to reveal a central venous intravenous catheter under a worn dressing dated in large black marker, 5/15/23. The clear CVC dressing was dirty, lifting up on the sides, and had dried blood at the insertion site. A few minutes later at 1:19 PM, Licensed Practical Nurse (LPN) A confirmed the dressing covering resident #65's CVC was dated 5/15/23, and agreed the dressing needed to be changed. She explained that although LPNs like herself could and should check the dressing site, they were not able to care for a CVC, only a Registered Nurse (RN) could do that. LPN A stated she had not looked at the CVC dressing since last week and could not say why she had not notified the Unit Manager (UM) or a physician to question the presence of the line or for orders to care for the line. Review of the undated Policy and Procedure for Abuse and Neglect revealed the definition of neglect as, .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy statement included residents had the right to be free from neglect, and the interpretation included the administration would develop and implement policies and procedures to aid in preventing neglect of residents. Signs of actual neglect are described in the document as, Inadequate provision of care and Caregiver indifference to resident's personal care and needs. In interviews on 9/18/23 at 1:45 PM and on 9/20/23 at 2:18 PM, the [NAME] Garden LPN Unit Manager (UM) described the facility process for admissions utilized an admission checklist. She described the process for the admitting nurse to assess the resident and the admission paperwork and complete the checklist. She noted within the first business day, the checklist was reviewed during the morning clinical meeting by a supervisor or manager who would often work together to double check the checklist completed by the nurse. She described a section on the checklist for devices such as IVs or urinary catheters which listed all of the orders required for the device. The [NAME] Garden UM described the last piece of the admission checklist was to develop the baseline care plan which included skin assessment which was then reviewed by the clinical team. She detailed her next step after the checklist was completed at the meeting was to meet the resident. The [NAME] Garden UM explained the UMs were responsible for entering any additional care plans based on progress notes, changes in condition or any new orders. She confirmed although she was a LPN she was IV certified, but said she was not aware of resident #65's CVC until it was brought to her attention by the surveyor on 9/18/23. The [NAME] Garden UM stated she rounded with APRN B weekly on resident #65 but said they usually only looked at the wound to his abdomen. She explained she expected the nurses and CNAs to look at the resident's skin and notify her if there were any impairments including an IV dressing. The [NAME] Garden UM stated she didn't know how the nurses missed the CVC dressing on resident #65's chest or notify anyone about the central line. She explained she thought staff saw it but since it had been there for so long they didn't say anything about it. Review of the medical record revealed resident #65 went to the hospital and readmitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On each of the Admission Screening forms nurses documented a full head-to-toe skin assessment was completed as well as auscultation and inspection of the chest and lungs. Four of the admission screenings, the first two (11/15/22 and 11/18/22) and the last two (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but only a single order for weekly dressing changes was ever placed. This order was made on 11/21/22 for 21 days and was discontinued on 12/09/22. Review of the medical record revealed between 11/15/22 and 9/18/23 resident #65 was seen by Physician Q four times, the Medical Director three times and by APRN I 11 times. The providers' documentation included mention of the CVC by the Medical Director on 11/18/22, by Physician Q on 6/20/23, 6/27/23 and 7/06/23, and by APRN I on 12/22/22, 6/14/23 and 6/26/23, but none of the documentation addressed maintenance care, infection prevention or any other orders for the IV. Review of the medical record and documentation provided by the facility revealed during the approximate nine-month period between 12/01/22 and 9/18/23, 99 different licensed nurses were assigned to care for resident #65. Review of nursing progress notes from 11/15/22 to 9/18/23 revealed resident #65's CVC was identified and mentioned only four times by LPN H, RN O and agency RN P. There was no documentation to indicate any of the 99 nurses queried or reported the absence of physician orders or a care plan for resident #65's CVC. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and 9/22/23 at 12:16 PM, the Director of Nursing (DON) explained neglect was failure to provide the needed services or care to a resident. She described her conclusion from her investigation so far was that staff thought someone else was taking care of resident #65's CVC, and no one took ownership of it. She found that some of the admission checklists were incomplete or had not addressed the CVC. The DON explained the licensed nurses, the nursing managers and the supervisors were all part of the check they had in place to ensure admission orders were in place, but somehow the CVC was still missed. The DON acknowledged she had not realized she did not receive some of the admission checklists that UMs were supposed to submit to her for review including for resident #65. The DON explained the assigned licensed nurse was assigned to complete head-to-toe skin checks weekly and also upon admission to the facility. She further detailed the nurse was supposed to get orders for maintenance and care of the CVC but acknowledged that had not been done during the time resident #65 had the CVC from November 2022 to the present. The DON explained resident #65 had been ordered to be sent to the hospital on 9/18/23 and needed to be evaluated by Interventional Radiology to determine the plan for his CVC. The DON stated she reviewed resident #65's medical record from 11/15/22 to 9/18/23 and could not find documentation that showed any of the 13 nurses who performed the weekly skin assessments identified, queried or reported the CVC or absence of any physician orders for the CVC. The DON confirmed all of the nurses in the facility except LPN H were IV certified, and although the LPNs were not supposed to push IV medications they were able to change the CVC dressing and check the site for signs and symptoms of complications. She stated even if the licensed nurse was uncomfortable with a CVC they should ask the RN, supervisor or a UM for help. In an interview on 9/21/23 at 11:49 AM, APRN I explained she was required to do a physical exam or focused assessment when a resident came back from the hospital based on their concerns at the time. She said part of the physical exam included listening to the heart and lungs, but explained she would ask the nurse if the resident had any wounds as part of the skin assessment. The APRN described when a resident was admitted with a device such as a CVC she would see the resident in person and provide orders for their care. She explained she did her best to review all of the orders by utilizing the information in the medical record and any hospital paperwork. The APRN stated the last time she was aware of resident #65's CVC was this past June, but explained she figured it had been removed and did not question whether there were physician orders for it. APRN I could not give a reason why she had not entered orders for resident #65's CVC herself, as she had noted it on some of her documentation. She only explained APRN B usually handled the batch orders. She said she thought it was pretty bad when she learned resident #65 had received only 3 dressing changes since he had been admitted [DATE] with the CVC. The APRN explained she was gravely concerned licensed nurses did not recognize resident #65 had a CVC and had no maintenance orders for it since December 2022. In interviews on 9/18/23 at 3:49 PM and on 9/21/23 at 12:17 PM, APRN B stated she did weekly wound rounds at the facility and regularly saw resident #65. She confirmed she did not know until 9/18/23 that resident #65 still had the CVC in his right chest and assumed it had been removed at some point. APRN B explained care for a central line would include the nurse assessing the site every shift for signs and symptoms of infection, drainage, swelling, or redness. She said other required orders for care would include flushing the line frequently and changing the dressing and accessing the port regularly and as needed to prevent infection, blood stream infection, or blood clots. APRN B stated she expected at the minimum, nurses would have seen the CVC when they performed the weekly skin checks and notify her if he didn't have any orders. On 9/21/23 at 1:46 PM, the Medical Director stated he was familiar with resident #65 and confirmed he was one of his providers. The Medical Director explained he learned of the concerns about resident #65's CVC on 9/19/23. He stated the providers should do a hands-on examination of the residents and then enter orders as required. The Medical Director indicated he felt communication was very important to prevent things like this from happening again. He said it was disappointing that would believe some part of a resident's care was not part of their job. He continued that nurses needed to communicate effectively what they saw and to notify their superiors if there was something going on or to seek guidance if they did not know something. Review of the facility's undated Facility Assessment revealed they provided care for residents with common diseases, conditions, and physical and cognitive disabilities that require complex medical care and management. The policy and procedure indicated if a resident's care was not one of the listed diagnoses, the nursing team was consulted to determine if the resident's care needs could be met. The document detailed that nurse leaders including the DON, and APRNs were consulted to review the resident's medical records to determine what skills were required by nursing staff to care for the resident and to identify any special equipment needed including educational materials. The document further detailed a relationship between itself and the hospital system that made resources readily available and accessed, including education. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: On 9/18/23, central line orders were obtained for resident #65. A dressing change completed. Assessed by nurse practitioner for medical necessity of central line. New order to evaluate line removal at hospital, resident sent via medical ambulance to hospital. *On 9/18/23, an audit was completed by Director of Nursing for all resident records in electronic medical record for orders for IV lines. Orders in place for three residents, however not all appropriately scheduled. Orders were corrected. * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of QAPI admission tool. 100% of nurses scheduled for that day and 65% of C.N.A.s received in-person education. *On 9/18/23, a whole house skin audit was initiated by Director of Nursing and unit managers. *On 9/19/23, skin audit completed on all residents in facility. No IV lines identified other than the three residents already identified from initial audit. * On 9/19/23, A physical assessment of current IV lines in facility by Director of Nursing with no issues found. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 CNAs. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. * On 9/20/23, education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. *On 9/20/23 an Ad-Hoc QAPI meeting was held including Medical Director. * On 9/20/23, 100% of nurses received education on central line policies, skin checks and admission process. Out of 35 staff nurses, 18 completed education in person and 17 received education through email and responded in writing via email understanding of education. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on abuse and neglect. In person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/20/23, DCF and 1 Day AHCA report made by Risk Manager. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 via email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility. The sample was expanded to include 3 other residents identified with IV catheters. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.

Based on observation, interview, and record review the facility failed to provide care and assessment of a central line intravenous catheter (CVC) for 1 of 1 resident reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on 11/15/22 with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and readmitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalization s and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the surveyor, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. These failures placed resident #65 at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #1 could have developed severe infection, blood clots, vascular damage or bled to death. The facility's failure to obtain appropriate admission orders for central line catheter care, and failure to provide assessments and care to prevent serious adverse outcomes resulted in Immediate Jeopardy starting on 12/22/22. The Immediate Jeopardy was removed on 9/23/23. Findings: Cross reference to F600 and F726 Resident #65, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to the stomach and severe malnutrition. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed resident #65 had moderately impaired cognition, clear speech, and adequate vision. The assessment indicated resident #65 was totally dependent on more than two staff for transfers, bed mobility and toilet use, and totally dependent on one staff for eating, bathing and personal hygiene. The assessment revealed he did not refuse care in the look back period and had received no intravenous medications. On 9/18/23 at 11:24 AM, resident #65 was observed in bed, alert and oriented to self, location, and time. The corner of a worn-looking dressing on his right chest could be seen from the top of his hospital gown. Resident #65 acknowledged the dressing was for an Intravenous catheter (IV) but could not recall when he got it or why he had it. He indicated the facility had inserted another IV in his left arm not long ago for some medications. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C confirmed resident #65 had an IV dressing to his right chest and said she did not recall seeing anyone use it recently. After asking resident #65's permission, she lowered his hospital gown to reveal a central line IV catheter under a worn dressing dated more than four months ago, 5/15/23 in large black marker. The clear CVC dressing was dirty, lifting up on the sides, and had dried blood near the insertion site. A central line venous catheter is an indwelling device inserted into a large central vein like the internal jugular and advanced until part of it rests inside a chamber of the heart or inside the large vein entering the heart. This device is often used for administration of certain medications, hemodialysis or a specific type of nutrition that bypasses the digestive system. After placement of a CVC, nurses must maintain and monitor the line for possible serious complications like bleeding, infection and clots. The nurse and physician should be aware of and keep track of when the line was placed as complication rates increase the longer the line is left in (retrieved from www ncbi.nlm.nih.gov on 9/25/23). On 9/18/23 at 1:19 PM, the assigned Licensed Practical Nurse (LPN) A said she was aware resident #65 had a CVC to his right chest and explained it was to draw blood from occasionally as he was a hard stick. LPN A observed the CVC dressing to the resident's right chest and acknowledged the dressing was dirty, loose, with dried blood under the dressing and the antiseptic foam disc used to help prevent infection floated freely under the clear film. She confirmed the date on the dressing clearly marked in black was 5/15/23. LPN A explained central lines should have orders to assess the IV site every shift, flushes, and dressing changes for maintenance of the line. After returning to the nurses' station LPN A reviewed resident #65's physician orders and said there were no orders for resident #65's CVC. LPN A stated she was unable to provide care for a CVC and explained only a Registered Nurse (RN) could change the dressing or flush the line. She noted even if a LPN could not provide care to a CVC, they could observe the site and should report to a Registered Nurse (RN) if the dressing was old or needed to be changed. She revealed she had not looked at resident #65's CVC dressing since last week and could not explain why she had not questioned why there were no orders for it nor why she did not report it to her supervisor. On 9/18/23 at 1:45 PM, the [NAME] Garden Unit Manager (UM) confirmed resident #65's CVC dressing was dated 5/15/23. She stated she thought resident #65 was admitted to the facility with the CVC. She was unsure how long the line had been there, when it had been placed or the reason for the CVC. The UM explained the protocol for CVCs was to obtain physician orders to assess it regularly, flush it every shift, and change the dressing per orders. She explained a RN could provide care to a CVC, but LPNs were able to assess the site. The [NAME] Garden UM said regular care was important to prevent infection since the intravenous line went right to the heart. She reviewed the physician orders and said although the resident had a midline IV placed in August those orders had been discontinued. She explained she was unable to identify any physician orders for the care of resident #65's CVC. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. The hospital After Visit Summary printed 11/15/22 revealed a hand written, unsigned note on the second page that declared he had a right chest CVC line and a request for the Advanced Practice Registered Nurse (APRN) to please check the orders. The Admission Screening dated 11/15/22 indicated resident #65 had a, IV/Sub q(subcutaneous)/Implanted Port to the right chest, and the document indicated treatment was ordered or required. The admission document also detailed APRN I and the physician were notified of the admission and the medications were verified. Review of resident #65's medical record revealed no orders were placed upon admission on 11/15/22 for resident #65's CVC, nor were any care plans initiated. On 11/16/22, resident #65 was sent back to the hospital for low hemoglobin and returned on 11/18/22. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/18/22 did not include the CVC on resident #65's right chest on the document, nor did the After Visit Summary dated 11/18/22. Although the hospital paperwork did not show the right chest CVC, in the Admission Screening Rev 6 dated 11/18/22 the nurse documented the CVC at the right chest and again checked the box, Treatment ordered or required. The nurse also documented on the admission form that APRN B and the physician were notified and that medications were verified. Review of the Order Listing Report for 11/15/22 to 9/20/23 revealed no orders were obtained upon admission for the CVC, and no care plan was initiated. Review of the Order Listing Report for 11/15/22 to 9/20/23 revealed the only orders for the care of resident #65's CVC was a single order placed by APRN B on 11/21/22 for a weekly dressing change, Wednesdays on day shifts for 21 days. The document showed the dressing change order was discontinued on 12/09/22, and never re-ordered. There was an additional IV medication order during the 10-month time period for 60 cubic centimeters of normal saline every shift for abnormal labs for 2 days times 2 liters on 12/20/22 and ending on 12/22/22. Review of the medical record revealed no care plan ever initiated for resident #65's CVC. The medical record indicated resident #65 went to the hospital and readmitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On the Admission Screening form, nurses documented a full head to toe skin assessment as well as auscultation and inspection of the chest and lungs. Only the first two admission screenings (11/15/22 and 11/18/22) and the last two admission screenings (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but no orders were placed for care of resident #65's CVC except the one order for 3 weeks of dressing changes on 11/21/22. Review of resident #65's medical record revealed the resident was assessed at least 18 times by his attending physician, or APRN I from his re-admission on 11/15/22 to 8/16/23. The first assessment since resident #65 was readmitted with the CVC, by APRN I on 11/16/22, a physical exam was documented including heart and lung sounds and skin assessment, but no mention of the CVC was made. On 11/18/22, the physician documented the CVC in resident #65's right chest was intact with no redness, swelling or pain to the surrounding tissue, but no orders for CVC care was mentioned or ordered. The CVC was noted present only 8 of the 18 times, but there were no orders placed or any plan for care mentioned. Review of the medical record revealed resident #65 had physician orders for a weekly skin assessment. The medical record showed no documentation of the CVC by 13 different nurses who were assigned the weekly skin assessment over 41 and a half weeks from 11/25/22 until 9/11/23. On 9/19/23 at 9:46 AM, resident #65's assigned LPN D stated she knew resident #65 and had cared for him as recently as the past weekend. LPN D stated caring for the CVC was an RN's job even though she confirmed she was IV certified before she came to the facility. She explained the only education she received at the facility about what she could do regarding CVCs or IVs was learned from other staff she trained with. She stated she was told LPNs could not flush CVCs, could not do dressing changes nor could they assess them. LPN D recalled doing a skin assessment for resident #65 in the past several weeks. She recalled he had the CVC dressing on his chest but was told to only document anything new. She recalled asking the [NAME] Garden UM what the dressing was to resident #65's chest when she started working there in June and was told it was a port. LPN D explained the UM acted like it had been there a while so she didn't think anything of it after that. On 9/20/23 at 12:30 PM, LPN E stated he usually worked on the [NAME] Garden unit and was familiar with resident #65. LPN E explained when a resident was readmitted to the facility the assigned nurse is responsible to assess the resident, review the hospital paperwork and call the physician to give report including any IVs or other devices. He spoke about a set of orders to be used upon admission for IVs that included regular flushes, dressing changes and assessment of the site for maintenance. He confirmed he was IV certified and said he could perform dressing changes on a CVC but was unsure if an LPN was allowed to flush a CVC. LPN E recalled resident #65 came back from the hospital with the CVC a while ago, and he himself had readmitted him from the hospital on occasion. He recalled doing the weekly skin assessment for resident #65 but said he couldn't remember if he ever checked to see if there were any orders to care for the CVC. LPN E described care for the IV site which included assessing for drainage, swelling or infection and said the dressing should be changed if it was soiled or if it was time for it to be changed. He said there was no excuse to not change it. He could not recall if he ever looked at the date on resident #65's CVC dressing, and explained nurses should not have to look at the date on the dressing as they should trust staff did what they were supposed to do. Review of the document, Nurses with Skin Checks with dates from 11/25/22 to 9/11/23 provided by the facility revealed LPN E documented weekly skin assessments on resident #65 4 times during this time period, 7/3/23, 7/17/23, 8/28/23 and 9/11/23. LPN E also documented an Admission Screening Rev 7 on 6/19/23 in which he detailed the IV/Sub q/Implanted Port to resident #65's chest, and indicated treatment was ordered or required. He documented on the screening form that medications were verified and APRN I was notified of the admission, but no orders were obtained for resident #65's CVC by LPN E. In a telephone interview on 9/21/23 at 9:11 AM, LPN H confirmed she was IV certified in another state and was not allowed to technically touch an IV. She stated she could look at an IV, assess it and know something needed to be done, but was not supposed to do it herself. LPN H stated she got a mixed message on whether nurses were supposed to document an IV like a CVC dressing on the weekly skin assessment. LPN H recounted resident #65 came back with the CVC from the hospital a while ago. She explained she often cared for resident #65 and looked at his skin frequently, noting she had seen the CVC but did not look closely at it. She did not recall noticing the date 5/15/23 on the dressing, and said it never crossed her mind why she had not seen orders to care for the line. LPN H could not say why she had not asked another nurse to change the CVC dressing. Review of the document, Nurses with Skin Checks with dates from 11/25/22 to 9/11/23, revealed LPN H documented weekly skin assessments on resident #65 11 times, on 12/02/22, 12/20/22, 1/02/23, 1/17/23, 1/31/23, 2/14/23, 2/28/23, 7/10/23, 7/24/23, 8/21/23 and 9/4/23. She did not document presence of the CVC on these assessments. LPN H also documented an Admission Screening Rev 7 on 6/12/23 in which she detailed the IV/Sub q/Implanted Port to resident #65's chest, and indicated treatment was ordered or required. She also documented on the screening form that medications were verified and APRN I was notified of the admission, but no orders were obtained for resident #65's CVC by LPN H. On 9/21/23 at 11:49 AM, APRN I stated she was very familiar with resident #65, and recalled in June she and APRN B discussed his CVC. She explained she did her best to review all of the residents' orders but said she didn't look at any orders for resident #65's central line. APRN I stated she figured resident #65's CVC had been removed and did not look at the date on the CVC dressing when she examined him this past June and in August. APRN I could not say why she had not put orders in for resident #65's CVC when she had examined him multiple times during his stay including in June. She said she thought APRN B usually put in the orders. She noted it was a grave concern that for almost 9 months nurses had not recognized he had a CVC and there were no orders for care. In interviews on 9/18/23 at 3:49 PM and 9/21/23 at 12:17 PM, APRN B stated she assessed wounds in the facility weekly including for resident #65. She recalled speaking to APRN I in June about resident #65's CVC but did not realize until now that it was still there. APRN B explained she did not usually have anything to do with entering orders unless someone asked her for help. She was unable to say why resident #65 did not have orders to care for the CVC other than the dressing change order that had been discontinued after 3 weeks in December. APRN B stated she was not sure why only the one order for dressing changes was placed and not other care orders like flushes and assessment of the site. She said she assumed his CVC being addressed and that facility nurses would have told her if there were no orders for it. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and on 9/22/23 at 12:16 PM, the Director of Nursing (DON) confirmed resident #65 was sent to the hospital on the evening of 9/18/23 by physician order for evaluation for removal of his CVC. She explained the CVC would have to be removed by Interventional Radiology at the hospital and she was unsure when resident #65 would return. The DON stated nurses were supposed to get orders for the care of the CVC from the physician upon re-admission to the facility. The DON confirmed all nurses working in the facility were IV certified except one, and they were expected to assess the site, change the dressing and flush the line per the physician orders. She explained licensed nurses should have noted resident #65's CVC in their weekly skin assessment, but she found that none of the nurses who performed them had noted his CVC. The DON acknowledged there were major concerns that no care was provided for resident #65's CVC, that there were no orders beyond the one that was discontinued in December and that none of the nurses who cared for him after his re-admission in May noticed his CVC dressing needed to be changed until brought to their attention by the surveyor. She stated she concluded that everyone thought someone else was taking care of it and no one took ownership of it. The policy and procedure document, Central Line Dressing Change dated June 2016, described the purpose was to reduce infections and minimize contamination of the catheter. The policy included the transparent dressing should be changed every 7 days or as needed if soiled or loose, if there was drainage or bleeding from the site the transparent sterile dressing should be changed every 48 hours if dry, the needleless connector attached to the lumen should be changed every 7 days and after every lab draw. The policy also included the insertion site should be monitored at a frequency determined by the symptoms, type of therapy, access type or by facility policy and during dressing change the site should be observed for signs and symptoms of complications and the length of the catheter should be measured. The procedure described the sterile dressing change which included the nurse to observe the insertion site for redness, swelling or drainage, to label the dressing with the date and initials of the nurse who changed the dressing and to document on the medication administration record and the resident's medical record. The undated Facility Assessment indicated the facility cared for residents that required complex medical care and management. The facility assessment also noted the facility was able to meet varied resident care needs which included medications administered by different routes including intravenous central lines. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 9/18/23, central line orders were obtained for resident #65. A dressing change was completed. The resident was assessed by nurse practitioner for medical necessity of central line. A new physician order was obtained to evaluate CVC line removal at the hospital. The resident was sent via medical ambulance to hospital. *On 9/18/23, an audit was completed by Director of Nursing for all residents' electronic medical record for orders for IV lines. Orders were in place for three residents, however not all orders were appropriately scheduled. The orders were corrected. * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool. 100% of nurses scheduled for that day and 65% of CNAs received in-person education. *On 9/18/23, a whole house skin audit was initiated by Director of Nursing and unit managers. *On 9/19/23, skin audits completed on all residents in the facility. No IV lines identified other than the three residents already identified from initial audit. * On 9/19/23, a physical assessment of current IV lines in facility conducted by Director of Nursing with no issues found. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of QAPI admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 CNAs. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. * On 9/20/23, education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23, education packet sent to two agencies that facility currently used for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. *On 9/20/23 an Ad-Hoc QAPI meeting was held that included the Medical Director. * On 9/20/23, 100% of nurses received education on central line policies, skin checks and admission process. Out of 35 staff nurses, 18 completed education in person and 17 received education through email and responded in writing via email understanding of education. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/20/23, Department of Children and Families and 1 Day Agency for Health Care Administration (AHCA) report made by Risk Manager * On 9/200/23, in person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 via email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility including skin assessments, central line education for nurses and admission assessments. The sample was expanded to include 3 other residents identified with IV lines. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services for a central line intravenous catheter (CVC) for 1 of 1 residents reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on 11/15/22 with a CVC to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and readmitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalization s and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the survey team, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. These failures placed resident #65 at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #1 could have developed severe infection, blood clots, vascular damage or bled to death. The facility's failure to obtain appropriate admission orders for central line catheter care, and failure to provide assessments and care to prevent serious adverse outcomes resulted in Immediate Jeopardy starting on 12/22/22. The Immediate Jeopardy was removed on 9/23/23. Findings: Cross reference F600 and F684 Resident #65, a [AGE] year-old man was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to the stomach and severe malnutrition. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. A Progress Note dated 11/15/22 at 7:24 PM, by Licensed Practical Nurse (LPN) H indicated resident #65 was alert and oriented when he returned from the hospital for rehabilitation. LPN H documented that she notified Advanced Practice Registered Nurse (APRN) I of the admission and resident #65's medications were confirmed. Review of the Admission Screening dated 11/15/22 revealed the nurse documented an IV/Sub q (subcutaneous)/Implanted Port to resident #65's right chest. The screening document was marked, Treatment ordered or required, under the section, skin assessment. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C, lowered the resident's hospital gown to reveal a central venous intravenous catheter under a worn dressing dated in large black marker, 5/15/23. The clear CVC dressing was dingy, lifting up on the sides, and had dried blood under it near the insertion site. A few minutes later at 1:19 PM, Licensed Practical Nurse, (LPN) A confirmed the dressing covering resident #65's CVC was dated 5/15/23, and agreed the dressing needed to be changed. She explained that although LPNs like herself could and should check the dressing site, they were not able to care for a CVC, only a Registered Nurse (RN) could do that. LPN A stated she had not looked at the CVC dressing since last week and could not say why she had not notified the Unit Manager (UM) or a physician to question the presence of the line or for orders to care for the line. In interviews on 9/18/23 at 1:45 PM, and on 9/20/23 at 2:18 PM, the [NAME] Garden LPN Unit Manager (UM) confirmed the worn dressing to resident #65's right chest was dated 5/15/23. She stated that although she thought resident #65 came from the hospital with the IV, she was unsure how long he had it, why he had it, or what type of IV it was. She was not sure if there were any orders associated with it, and after reviewing the electronic orders, she stated she could not find any. She described the process for admissions via utilization of an admission checklist by the admitting nurse. First, to assess the resident, then in combination with the admission paperwork to complete the checklist. She continued that within the first business day the checklist was reviewed during the morning clinical meeting by a supervisor or manager who would often work in collaboration to double check the checklist completed by the nurse. She described a section on the checklist for devices such as IVs or urinary catheters which listed all of the orders required for the device. The [NAME] Garden UM described the last piece of the admission checklist was to develop the baseline care plan which included skin assessment, then it was reviewed by the clinical team as they reviewed the chart and discussed the resident. She detailed her next step after the checklist was completed at the meeting was to meet the resident herself. The [NAME] Garden UM explained the UMs were responsible for entering any additional care plans based on progress notes, changes in condition or any new orders. She confirmed she was IV certified, but said she was not aware of resident #65's CVC until it was brought to her attention by the surveyor on 9/18/23. The [NAME] Garden UM stated she rounded with APRN B weekly on resident #65 but said they usually only looked at the wound to his abdomen. She explained she expected the nurses and CNAs to look at the resident's skin and notify her if there were any impairments including an IV dressing. She could not explain how the nurses missed the CVC dressing on resident #65's chest or notify anyone about the central line. She explained she thought staff saw it but since it had been there for so long they didn't say anything about it. Review of the job description, Nursing Manager dated 9/20/17 revealed the position functioned as a clinical generalist and was responsible for providing, managing, and coordinating the comprehensive care to their designated group of residents. Essential functions included assesses to anticipate risk, designs and implements plans of care and provides oversight of the care delivery of their specific group of residents. They also had clinical responsibility accountability and authority for implementing and collaborating the needs of residents to effectively manage their clinical outcome goals. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and 9/22/23 at 12:16 PM, the Director of Nursing (DON) explained the assigned licensed nurse was assigned to complete a head-to-toe skin check weekly and also upon each admission to the facility. The DON acknowledged she was unsure how long resident #65 had the IV or exactly what type of IV it was when it was brought to her attention on 9/18/23. She confirmed the seriousness of the concerns regarding the lack of care for resident #65's CVC since November of the past year. The DON explained the nurse who completed the admission assessments only recognized and documented resident #65's CVC on four of the seven admissions he had to the facility since he returned with it on 11/15/22. The DON stated the nurses entered the admission assessment electronically but failed to obtain the proper orders for care of the CVC such as assessments of the site every shift, flushes of the line every shift, and weekly and as needed dressing changes. She stated nurses should have recognized the CVC and called the physician for orders. The DON stated she reviewed resident #65's medical record and found no documentation from 11/15/22 to 9/18/23 that showed any of the 13 nurses who performed the weekly skin assessments identified, queried or reported the CVC nor the absence of any physician orders for the line. The DON confirmed all nurses in the facility except LPN H were IV certified, and although LPNs were not supposed to push IV medications they were able to change the CVC dressing and assess the site for signs and symptoms of complications. She stated even if the nurse was uncomfortable with a CVC they should know to ask a RN, supervisor, or UM for help. The DON stated she also found some of the admission checklists were incomplete or had not addressed the CVC. She explained the licensed nurses, the nurse managers and the supervisors were all part of the check they had in place to ensure admission orders were in place, but somehow it was still missed. The DON acknowledged she had not realized she did not receive some of the admission checklists that UMs were supposed to submit to her for review including for resident #65. Review of the medical record revealed resident #65 went to the hospital and readmitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On each of the Admission Screening forms nurses documented a full head-to-toe skin assessment as well as auscultation and inspection of the chest and lungs. Four of the admission screenings, the first two (11/15/22 and 11/18/22) and the last two (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but only a single order for weekly dressing changes was ever placed. This order was made on 11/21/22 for 21 days and was discontinued on 12/09/22. Further review of resident #65's medical record revealed no current orders for care or maintenance for the CVC. In an interview on 9/21/23 at 11:49 AM, APRN I explained she was required to do a physical exam or focused assessment when a resident came back from the hospital based on their concerns at the time. She said part of the physical exam included listening to the heart and lungs, but explained she would ask the nurse if the resident had any wounds as part of the skin assessment. The APRN described the admission process for a resident with a CVC. She stated the process was to assess the resident, and provide orders for care of the CVC. She explained she did her best to review all of the orders by utilizing the information in the medical record and any hospital paperwork. The APRN stated the last time she was aware of resident #65's CVC was this past June, but explained she figured it had been removed and did not question whether there were physician orders for care. APRN I could not give a reason why she had not entered orders for resident #65's CVC herself, as she had noted the CVC in her documentation. She only explained APRN B usually handled the batch orders. She said she thought it was pretty bad when she learned resident #65 had received only 3 dressing changes since he had been admitted on [DATE] with the CVC. The APRN explained she was gravely concerned licensed nurses did not recognize resident #65 had a CVC and had no maintenance orders for it since December 2022. Review of the medical record revealed between 11/15/22 and 9/18/23 resident #65 was seen 11 times by APRN I. Her documentation included mention of the CVC on 12/22/22, 6/14/23 and 6/26/23, but none of her documentation addressed maintenance care, infection prevention or any other orders for the IV. In interviews on 9/18/23 at 3:49 PM and on 9/21/23 at 12:17 PM, APRN B stated she did weekly wound rounds at the facility and regularly saw resident #65. She confirmed she did not know until 9/18/23 that resident #65 still had the CVC in his right chest and assumed it had been removed previously. APRN B explained care for a central line would include the nurse's assessment of the site every shift for signs and symptoms of infection, redness, drainage, or swelling. She explained required orders for care included flushing the line frequently and changing the dressing. She noted the line would need to be accessed regularly to prevent infection, including blood stream infection, or blood clots. APRN B noted she expected nurses would have seen the CVC when they performed the weekly skin checks and notify her if they did not have any orders for care. The job description, Nurse Practitioner dated 10/02/17 summarized the Advance Practice Registered Nurse helped with all aspects of resident care, including diagnoses, treatments and consultations. Essential functions of the position included assessment of the physical status of residents through interview, health history and physical exam, and recognition of deviations from normal in the physical examination to formulate treatment plans. Other functions included initiation of appropriate actions to facilitate the implementation of therapeutic plans consistent with continuing healthcare needs of the residents, and communication of appropriate information with the physician and other members of the healthcare team regarding the resident's condition. Further review of the medical record and documentation provided by the facility revealed during the approximate nine-month period between 12/01/22 and 9/18/23, 99 different licensed nurses were assigned to care for resident #65. Review of nursing progress notes from 11/15/22 to 9/18/23 revealed resident #65's CVC was identified and mentioned only four times by only three nurses, LPN H, RN O and agency RN P. There was no documentation to indicate any of the 99 nurses queried or reported the absence of physician orders or a care plan for resident #65's CVC. On 9/21/23 at 11:11 AM, LPN A explained only new skin impairments were documented on the weekly skin assessment. She stated since resident #65's CVC dressing was not a new impairment she did not document it. She stated she was IV certified in school and was told at that time it was not in her scope of practice to do central line dressing changes or flushes. LPN A explained she had not received education from the facility about what LPNs were or were not allowed to do with IVs or CVCs. She confirmed she was taught to look at the date on any dressing but said she did not look at the date on resident #65's dressing because she thought only the RN could do it. LPN A explained with new admission, one nurse did the assessment and the other nurse entered the orders. She said she did not understand how nurses who readmitted resident #65 missed telling the physician about the CVC or obtain orders for the care of the line. On 9/19/23 at 9:46 AM, LPN D stated she recalled resident #65 having the CVC since she started there in May. LPN D stated she did not remember receiving any education on IVs or specifically central lines since she had been at the facility. She explained she was IV certified from her previous job and understood care for central lines was done by RNs. She stated LPNs were not supposed to assess or change CVC dressings, instead she would have to ask a RN to do it. LPN D recalled she completed a weekly skin assessment on resident #65 recently but did not document the CVC as it had been there previously. She had asked the [NAME] Garden UM about resident #65's CVC, but said they acted like it had been there awhile and were not too concerned. On 9/20/23 at 12:30 PM, LPN E stated he had worked on the [NAME] Garden unit for about 6 years. He said at admission, the resident would be assessed, then the orders would be checked and verified with the physician. He explained there was an order set for IVs that included dressing changes, site assessment and flushes. LPN E recalled he had readmitted resident #65 from the hospital at least once and was aware of the CVC. He said he was IV certified and was allowed to care for CVCs including dressing changes but was unsure whether he was allowed to flush a CVC. LPN E could not recall ever checking to see if there were any orders for resident #65's CVC and said he did not recall documenting it under the weekly skin assessment because it was not a new variance. He recalled doing the weekly skin assessment but did not recall looking at the dressing or the date on it, and explained there was no excuse to not change the dressing if it was dirty or old. LPN E stated he should not have to check the date on the dressing because other staff should be doing what they were supposed to be do. In a telephone interview on 9/21/23 at 9:11 AM, LPN H confirmed she often cared for resident #65 on the 3 PM-11 PM shift. She stated she had IV certification from another state, but the facility did not accept it. LPN H explained she knew about IVs but technically she was not allowed to touch them, so if something needed to be done she would have to ask another IV certified nurse for help. She recalled resident #65 had a lot of frequent issues with his feeding tube in his stomach and then he came back with the CVC from the hospital with it a while ago. LPN H stated she looked at resident #65's skin all the time and had seen the CVC dressing but did not look at it closely. She described collaborating with LPN E often on admissions and said the APRN usually reviewed the orders and made any adjustments as needed when they came to assess the residents themselves. LPN H stated it never crossed her mind why she had never seen any orders for the care of resident #65's CVC and she could not say why she had never looked at the date on his dressing or asked someone to change it. Review of the job description, LPN dated 11/12/18 revealed the LPN provided and documented individualized resident care including evaluation, education, medication administration, IV therapy, treatments under the supervision of the RN. Some essential functions of the LPN included competency in nursing skills, communication of appropriate information regarding the resident's condition to the physician and other members of the healthcare team and assumed an active role in keeping informed about changes in facility policy and procedures. Review of the job description, RN Staff dated 10/02/17 revealed the RN provided and documented individualized resident care to include evaluation, education, medication administration, IV therapy, and treatments. Essential functions included competency in nursing skills as defined by unit specific skills, communication of appropriate information regarding the resident's condition to the physician and other members of the healthcare team and assumed an active role in keeping informed about changes in facility policy and procedures. Finally the RN should demonstrate the knowledge and skill necessary to provide appropriate care. In interviews on 9/20/23 at 4:54 PM, and on 9/21/23 at 5:38 PM, the Clinical Educator stated all staff complete orientation and computer-based learning for resident rights, abuse/neglect, infection control, dementia care, incidents and accidents. She noted after the education, staff worked on the floor with a preceptor based on their experience level. The Clinical Educator explained the nursing staff completed a checklist with their preceptor over the first month or so that included a section on wounds for nurses and on skin checks for CNAs. She explained although IV medications were included on the checklist, care of IVs or specifically CVCs were not part of the checklist. The Clinical Educator stated if the licensed nurse had IV certification, it was expected they would have knowledge of how to care for a CVC or IV. She stated she expected nurses would notify her if they felt uncomfortable or lacked the knowledge to care for a CVC and would receive education. She was unable to provide LPN D's nor LPN E's orientation packet as they could not find it. The Clinical Educator confirmed nurses should document any skin impairments in the nurses note until they were resolved, including IVs. She stated she was surprised to learn resident #65 had not had a dressing change to his CVC nor had any orders for care since December of last year. The undated and untitled packet provided by the facility to agency nurses was reviewed. Policy and procedures for topics such as abuse, neglect and resident rights were included and staff were required to acknowledge their receipt. IVs, CVCs, weekly skin assessments or admission process were not included in the packet. Review of the 2023 Education Calendar revealed topics in the monthly education included basic nursing skills, abuse and neglect, skin and wound management, and effective communication. Review of the undated LPN Competency Skills Check Off and the undated RN Competency Skills Check Off revealed objectives included evaluate resident for potential safety problems, report safety problems to appropriate person in timely manner, review infection control policies and procedures, communicate effectively in professional relationships, complete an admission process, and provide nursing care for wound evaluation including clean dressing change. Additionally, competency section 5 required nurses to identify and utilize the admission checklist, complete admission orders, skin and wound protocols, care plans, knowledge of unit routine including IVs, admission, physician notification and physician orders. Review of nurse education for LPNs D, E and K revealed computer-based learning completed but no Competency Check Off for these LPNs were provided after upon request made to facility. Per the DON and Clinical Educator on 9/21/23, the facility was unable to find the packets for LPN E and LPN D. On 9/21/23 at 1:46 PM, the Medical Director explained he learned of the concerns about resident #65's CVC on 9/19/23. The Medical Director indicated he felt communication from nursing staff was very important to prevent things like this from happening again. He said it was disappointing that staff would believe some part of a resident's care was not part of their job. The Medical Director explained nurses needed to communicate effectively about what they saw and notify their superiors if something was going on. He said nurses should seek guidance if they did not know something. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool. 100% of nurses scheduled for that day and 65% of C.N.A.s received in-person education. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of QAPI admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 C.N.A.s. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. *On 9/20/23 an Ad-Hoc QAPI meeting was held that included the Medical Director. * On 9/20/23, 100% of nurses completed education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23 additional education developed with QAPI team for nurses on Central lines to include identification of different types of possible lines with a written competency, and ongoing education that included skills competency checks following written competency. *On 9/20/23, education packet sent to two agencies that facility currently used for supplemental nursing coverage. Agency was to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure agency nurses received education at start of shift. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on abuse and neglect. In person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 by email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility. The sample was expanded to include 3 other residents identified with IV catheters. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.

Based on interview, and record review, the facility failed to timely follow procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and available to nursing staff, and failed to honor an advance directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident reviewed for Death, of a total sample of 42 residents, (#108). These failures contributed to resident #108 receiving CPR against her explicit wish for a natural, dignified death. There was likelihood resident #108 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On Friday, [DATE], at approximately 2:00 PM, resident #108 and her physician signed a Do Not Resuscitate Order (DNRO) form. The Social Services Assistant scanned the completed form to the Electronic Medical Record (EMR) and placed the document in her office. The Social Services Assistant continued her workday until 5:00 PM then left for the weekend. The Social Services Assistant failed to provide a copy of the DNRO to the nursing staff, before she left for the weekend. Upon receipt of the DNR form, the nursing staff, per policy, would have updated the EMR from Full Code status to DNR status. Nursing staff would have also placed the canary yellow DNR form in front of the resident's chart to allow for staff to quickly identify the code status during an emergency. On Sunday, [DATE], at approximately 5:20 AM, resident #108 became unresponsive, was not breathing, and had no pulse. Nurses checked the resident's EMR and paper binder chart and found a physician's order for Full Code status. Nurses determined resident #108 was Full Code status and initiated CPR. Facility staff called 911 at 5:24 AM, and when Emergency Medical Services (EMS) personnel arrived at the resident's bedside, they continued CPR from the resident's room to the ambulance. Resident #108 suffered aggressive resuscitation measures on the way to the hospital and in the Emergency Department (ED) until she was pronounced dead on [DATE] at 6:32 AM. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a DNRO advanced directive at risk for serious psychosocial harm, physical trauma, and a prolonged undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Review of the medical record revealed resident #108, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included metastatic (spread from origin to a distant part of the body) melanoma (deadly skin cancer), chronic congestive heart failure, aortic (heart) valve stenosis (narrowing), complete atrioventricular (heart chamber) block, oxygen dependence, acute respiratory failure, chronic obstructive lung disease, heart disease, cardiac rhythm (heartbeat) dysfunction with pacemaker, chronic peripheral (limb) venous insufficiency (blood flow), intestinal obstruction (blockage), stage 3 chronic kidney disease, type 2 diabetes mellitus, sleep apnea (breathing pause or stop), repeated falls, need for assistance with personal care, and depression. The Minimum Data Set (MDS) Death In Facility tracking assessment with an Assessment Reference Date (ARD) of [DATE] noted resident #108 was discharged from the facility to the hospital. The MDS quarterly assessment with an ARD of [DATE] noted resident #108 had a Brief Interview for Mental Status score of 11 out of 15 which indicated moderate cognitive impairment. The assessment showed the resident had no indicators of psychosis, behavioral symptoms, or rejections of evaluation or care, required extensive assistance from staff to complete her Activities of Daily Living, walked once in her room with staff assistance, did not walk outside of her room, was incontinent of bladder and bowel functions, experienced moderate pain, shortness of breath, and she required supplemental oxygen. For 7 out of 7 days during the look back period, she received injectable insulin, and antidepressant (depression), anticoagulant (blood thinner), diuretic (fluid retention), and opioid (narcotic pain) medications. The Florida Agency for Health Care Administration Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA ,d+[DATE]) dated [DATE] revealed resident #108 did not require a surrogate to make healthcare decisions. The Readmission Agreement between the resident and the facility was signed by resident #108 on [DATE] that indicated she made her own medical and financial decisions. The medical record did not include any requests for a capacity evaluation nor a physician's determination of incapacity. The Order Listing Report showed physicians orders dated [DATE] that read, Resident is a Full Code, and [DATE] that read, Transfer to ER. The Comprehensive Care Plan included focus for self-performance care deficits, dependence on staff to complete daily living activities, infections, multiple chronic medical conditions of the heart, lungs, kidneys, muscles, and bones, diabetes with insulin dependence, abdominal surgery, skin injuries, repeated falls, adverse medication effects, depression, anxiety, risk for nutritional and hydration problems, supplemental oxygen dependence, and pain. The care plan did not include a focus for advanced directives or code status. The Psych (Psychiatric) Health Associates progress notes dated [DATE] noted resident #108 was assessed by the Psychiatric Advanced Practice Nurse Practitioner (APRN) who wrote, Thought association is intact, insight and judgement are adequate. Thought process is linear (logical and sequential), . Denies depression or anxiety noted. Denies any suicidal ideation. Patient is adjusting emotionally well to the stressful change the patient is undergoing. On [DATE] at 4:45 PM, during an interview, the Social Services Assistant said she handled most of the facility's code status changes from a full code to Do Not Resuscitate (DNR). She explained the process included her evaluation and determination of residents' cognition, the ability to make their own decisions, and she ensured they understood the full meaning of a DNRO. She stated residents who were not determined by a physician to be incapacitated signed their own DNRO, and it was valid with a physician's signature. She recalled on [DATE] at approximately 2:00 PM, resident #108 was cognitively intact and wished for DNR as part of her treatment plan when she signed the yellow DNRO form. She said the physician was in the facility, and he signed the form immediately after the resident did. She explained it was Friday when she scanned the form into the Electronic Medical Record (EMR) and decided to keep the form in her office until she returned to work on Monday. She explained she planned to give it to nurses on Monday so they could change the order and put the form in the resident's chart. She said she left work that Friday at 5:00 PM and when she returned to work on Monday [DATE], she learned the resident had died . She conveyed she told her supervisor, the Social Services Director about the DNRO and gave the form to the Unit Secretary. She said, I dropped the ball. Review of the State of Florida DO NOT RESUSCITATE ORDER form revealed both resident #108 and her physician signed the form on [DATE]. On [DATE] at 11:28 AM, in a telephone interview, resident #108's son said his mother's health had declined and she was recently diagnosed with cancer. He recalled about a week prior to [DATE] they had conversations about her code status, and she had decided she did not want to be resuscitated. He said on [DATE], the Social Services Assistant was reminded by his husband to have the DNR implemented but he wasn't aware his mother had signed it until about a week after she passed. He said no one from the facility called him, but rather sent messages through his husband. He stated it was very disappointing that no one reached out to him personally. He explained the facility communicated everything through his husband and told him everything was being handled. He spoke about the deep sorrow and anguish he felt because he knew his mother's spiritual beliefs and wishes very well as they were extremely close. He stated he was most affected when he envisioned his mother, over her body looking down and saying to herself, what are you doing to me? That's not what I asked for. On [DATE] at 4:11 PM, the Unit 300 Unit Manager explained when nurses were given a completed DNRO form for a code status change, the process included a revision of the Full Code order in the EMR to DNR and the form placed in front of the resident's paper chart kept at the nurses' station. She stated nurses depended on the EMR and paper chart for a current and accurate code status to initiate or withhold CPR when emergencies arose. On [DATE] at 4:21 PM, the Director of Nursing (DON) said all resident's code status were entered into the EMR as a physician's order and DNRO forms were kept on top in the paper binder/charts kept at the nurse's station. She explained when emergencies with cardiac and respiratory arrest occurred, nurses checked the EMR and paper chart for code status and proceeded with CPR for full code and did not proceed with a DNRO. She stated when staff other than nursing completed a DNRO with a resident who wanted to change their status, the form was given to nurses for order transcription and placement of the form onto the front of the paper chart so it was easily accessible by direct care staff. She referred to residents' wishes to change their full code status to DNR and said, it's a big deal. Review of the Change in Condition progress note dated [DATE] at 5:30 AM revealed Registered Nurse (RN) L assessed resident #108 as unresponsive, pale, and without breathing or a pulse. The note showed nurses checked the resident's records, determined the code status was Full Code, and initiated CPR until EMS personnel arrived and transported her to the hospital, on active CPR. On [DATE] at 12:37 PM, and [DATE] at 9:49 AM, unsuccessful attempts were made to interview RN L by telephone. In a telephone interview on [DATE] at 12:45 PM, the Nurse Night Shift Supervisor described the sequence of events on [DATE], the day resident #108 received CPR. She recalled RN L had called a Code Blue. She explained she entered resident #108's room and observed RN L took vital signs, and told her the resident wasn't breathing. She said nurses verified the code status in the EMR and paper chart and determined the resident was a full code. She stated she told RN L to start CPR, she called 911, and returned to assist nurses with chest compressions and oxygen ventilations via Bag Valve Mask (ambu bag) until EMS arrived and took over. She said facility management never informed her after the incident that resident #108 was a DNR. On [DATE] at 10:12 AM, in a telephone interview, Licensed Practical Nurse (LPN) M recalled resident #108's Code Blue and CPR on [DATE]. She explained when she arrived in the room, she observed that RN L obtained vital signs and initiated CPR. She stated nurses provided 2 rounds of CPR with chest compressions and ventilations by ambu bag until Law Enforcement and EMS personnel arrived. She said she heard from other staff days later there was a DNRO for resident #108. She explained nurses would have known about the DNR if the Social Services Assistant had given them the form to place in front of the medical record. On [DATE] at 10:39 AM, RN N recalled on [DATE], she observed CPR was in progress by nurses for resident #108. She said she assisted them with chest compressions and the ambu bag until EMS personnel transitioned and continued resuscitative measures. On [DATE] at 4:11 PM, the Unit 300 Unit Manager said resident #108's DNRO form was not provided to nurses after the resident and the physician signed it. She said if nurses had received the DNRO on [DATE], they would have withheld CPR. On [DATE] at 10:57 AM, the APRN said resident #108 had multiple chronic conditions, her health had declined, and she had a diagnosis of melanoma in previous months. She recalled she had discussions with resident #108 and her family about a week prior to [DATE], and the resident did not want resuscitation measures. She said resident #108 was able to make her own decisions as she only had mild cognitive impairment. The APRN explained she was upset about the CPR incident as it was preventable, and had the resident survived it likely would have been a bad outcome for her as her quality of life, could have been so much worse. On [DATE] at 2:04 PM, the Medical Director said on [DATE] around 2:00 PM he signed the DNRO yellow form for resident #108 after she had signed it with the Social Services Assistant. He explained his expectation was that the DNRO was an active physician's order that was in effect immediately after he signed it. He recalled resident #108 had good cognition and was able to make the decision to change her code status to DNR. He stated a DNRO was a very important plan of treatment to honor one's wishes. He said he was informed in the weeks after the incident, the facility completed an investigation and determined the Social Services Assistant didn't follow their process. He stated the incident could have been avoided, and had the resident survived, she likely would have suffered a very poor quality of life. He said he was disappointed it happened and accounted the event as, devastating and heartbreaking. On [DATE] at 5:32 PM, resident #108's son-in law said he and his mother-in-law had a very close relationship. He recalled on [DATE] at around 1:30 PM, he reminded the Social Services Assistant that his mother-in-law still wanted to be a DNR. He explained he was not aware she had signed the form until about 10 days after she died . He stated about a week prior to [DATE], the resident and family had discussions about a DNRO, as her health had declined, and he was confident she fully understood that the order meant there would be no CPR. Tearfully, he recalled when his mother-in-law verbalized to him and her son jointly, I definitely want it; once I'm in God's arms I don't want to come back. Review of the Fire Rescue Department Report showed on [DATE] at 5:36 AM, EMS personnel arrived at resident #108's bedside and found her unresponsive while facility staff provided CPR. While CPR continued, EMS transferred the resident to a stretcher and into an ambulance. The report revealed during emergency transport, aggressive Advanced Life Support (ALS) measures were provided that included CPR with orotracheal intubation (tube inserted into the throat to maintain an airway and provide oxygen to the lungs). ALS medications and fluids were administered through an intraosseous (directly through bone into bone marrow) and intravenous (into a vein) infusions. EMS arrived at the hospital emergency room (ER) at 6:20 AM where efforts continued while the resident was transferred from the ambulance into the ER. The ER Provider Notes showed at 6:23 AM on [DATE], EMS arrived in the ER with resident #108 while they provided CPR. Aggressive efforts continued in the ER until she was pronounced dead at 6:32 AM, one hour after CPR was initiated at the facility. On [DATE] at 5:07 PM, the Social Services Director said the Social Services Assistant reported to her and was primarily responsible for processing resident's change of code status and DNROs. She recalled on Monday [DATE], the Social Services Assistant told her that on [DATE] resident #108's completed DNRO was left in her office over the weekend, and she had not provided it to nurses. She stated the Social Services Assistant dropped the ball. On [DATE] at 4:35 PM, the Nursing Home Administrator (NHA) recalled on [DATE], he was notified by the Social Services Director that in the late afternoon on [DATE], the Social Services Assistant assisted resident #108 to complete a DNRO that was signed by the physician the same day. He said the document remained in the Social Services office over the weekend and was not provided to the nurses. He said on [DATE], two days later, the facility discussed the incident at their weekly Risk Meeting with the Risk Manager, and they completed their investigation. He explained there was no incident report completed or adverse event reported to the state agency because nurses followed the code status policy and the team felt they had resolved the issue. On [DATE] at 6:34 PM, the DON said the facility investigated the incident and determined resident #108's DNRO form was never provided to nursing staff and the nurses followed the process. On [DATE] at 2:29 PM, the Risk Manager recalled on [DATE], two weeks after resident #108 died , she was at the facility to investigate an unrelated issue. She said she investigated resident #108's CPR event at that time because there had been an internal corporate complaint related to family dissatisfaction with management communication, and an internal tracking report variance for a resident hospital transfer with CPR. She stated her expectation was that on [DATE], when the NHA learned resident #108 had a DNRO and nurses provided CPR, he should have notified her immediately. She explained the facility had not completed an incident report, and it was concluded that no reportable adverse event had occurred because the DNRO wasn't considered a physician's order, and nurses followed the code status procedure. On [DATE] at 5:31 PM, the Medical Records Coordinator said on [DATE] during a routine check, she found 2 errors with resident's code status orders in medical records that were subsequently corrected by the Unit Manager. She said she informed the DON of her findings and the DON directed that Medical Records was to continue with chart audits monthly. She could not recall if she had completed audits in August or [DATE]. She said she did not recall seeing resident #108's DNRO form when she processed the closed paper medical record after she died . On [DATE] at 9:49 AM, the DON said Medical Records did not complete advanced directive audits in August or [DATE]. She stated additional audits were completed by the Social Services Director on [DATE], and Unit Managers on [DATE]. On [DATE] at 1:09 PM, the Risk Manager said monthly Quality Assurance Performance Improvement (QAPI) meetings included reviews of policies and procedures, variances, regulatory compliance, incidents, and accidents. The NHA, DON, and Risk Manager could not recall any discussions during their last monthly QAPI meeting in [DATE] about resident #108's CPR with a DNRO incident. The Risk Manager checked the meeting minutes record, and confirmed the incident was not discussed. The Risk Manager said regulatory non-compliance related to the incident was not identified or acknowledged by the facility until [DATE], after surveyors investigated resident #108's death. Review of the undated facility Policy and Procedure titled Advanced Directives, read, . 8. All residents have the right to review and revise his/her advanced directives. 9. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 10. b. Nursing staff and/or the social worker will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 12. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. 13. A resident will not be treated against his or her own wishes. 17. our facility has defined advanced directives as preferences regarding treatment options and include . c. Do Not Resuscitate---indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: * On [DATE] the Social Services Director and NHA met with the Social Services Assistant responsible for initiating advanced directives and education was provided on resident rights. * On [DATE] the Social Services Director conducted audits of all residents' medical records to verify the DNRO yellow form and the physician's order was correct and included in the EMR. * On [DATE] additional education of the Advanced Directive policy, Resident Rights, and timeliness was provided to the Social Services Assistant with disciplinary action. * On [DATE] resident #108's CPR event was discussed in the weekly QAPI Risk meeting. * On [DATE] a follow up meeting was conducted with the Social Services Assistant utilizing an audit tool to evaluate her understanding of advanced directives and resident rights. * From [DATE] to [DATE] the Social Services Director conducted weekly follow up and check-in meetings with the Social Services Assistant to review education and process adherence on any new code status changes. * On [DATE] the facility held an Ad-Hoc QAPI meeting that included the Medical Director. * On [DATE] the QAPI team developed licensed nurses and Certified Nursing Assistant (CNA) education that addressed their roles in Advanced Directive policies. * On [DATE] an audit plan was developed for code status verification upon admission to ensure the EMR and paper binder/chart matched. * On [DATE] an audit of all resident's code status was completed by nursing staff and medical records to ensure the EMR and chart/binder paper chart matched. * On [DATE] a plan was developed to complete weekly code status audits for 12 weeks by nursing leadership to ensure orders in the EMR and hard binder/chart matched with findings reported to QAPI. * On [DATE] education for nurses and CNAs began for advanced directives that utilized scenarios with emphasis on timeliness of orders and placement of the DNRO in the chart. * At the end of the day on [DATE], 39% of nurses and 39% of CNAs had received in person education on advanced directives. * On [DATE] the facility's plan for advanced directive education continued utilizing email to staff not scheduled with required return acknowledgement. * On [DATE] nurses and CNAs were required to complete advanced directive education prior to working their next scheduled shift. If education was not completed staff were to be removed from the schedule until their education and acknowledgement was completed. * On [DATE] education materials were sent to the two staffing agencies utilized by the facility for distribution to nurses scheduled to work at the facility that required return acknowledgement prior to working. The schedules were highlighted for any scheduled agency nurses to ensure supervisors provided education prior to working a shift. * On [DATE] at 12:17 PM, 54% of nurses and 54% of CNAs had received in person education. Education included scenarios and emphasis on timeliness of the full completion process to ensure current and correct advanced directives and DNROs were included on the EMR and paper binder/chart to ensure direct care staff had readily available access. Remaining nurses or CNAs were required to receive the education prior to working a shift. Between [DATE] and [DATE], interviews were conducted with one APRN, two RNs, five LPNs, eleven CNAs, one Speech Language Pathologist, the Social Services Assistant, and the Social Services Director regarding the facility's Immediate Jeopardy removal plans and in-service education for Advanced Directives/DNR. Eight of thirty-four nurses, eleven of eighty-four CNAs, and other staff that covered all shifts verbalized their understanding of the education provided. The resident sample was expanded to include six additional residents who died at the facility. Five residents elected DNR status and one elected Full Code status. Interviews and record reviews revealed no concerns for residents #510, #511, #512, #513, #514, and #515 related to advanced directives.

Based on observation, interview, and record review, the facility failed to ensure Oxygen (O2) therapy was administered as per physician's order for 1 of 38 total residents sampled, (#3). Findings: Resident #3 was admitted to the facility on [DATE], with diagnoses of cerebral infarct, end stage renal disease, cerebral palsy, dementia, and dependence on supplemental oxygen. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was mildly impaired and he required oxygen therapy. A physician's order dated 4/06/22, noted Oxygen (O2) 2 liters per minutes continuously every shift for shortness of breath (SOB). Observations on 12/06/22 at 9:42 AM, and on 12/06/22 at 2:55 PM, showed the resident received O2 therapy via nasal cannula, infusing at 4 liters per minute (LPM). Resident #3 stated he used oxygen 24/7 but could not say what the rate of O2 was. On 12/06/22 at 2:57 PM, the resident's oxygen settings were observed with Licensed Practical Nurse (LPN) A. She acknowledge the resident's O2 settings was at 4 LPM. The resident's physician's orders were reviewed with LPN A, and she verbalized the resident's order was for O2 at 2 LPM. LPN A explained oxygen was a medication that required a physician's order for administration and should be checked by the nurse daily. LPN A stated she did not check the resident's O2 at the beginning of her shift. On 12/06/22 at 3:00 PM, the LPN Nurse Manager was made aware of the findings, and she stated that O2 was a medication that required a physician's order, and nurses should be checking on the resident's O2 every shift. On 12/06/22 at 3:15 PM the Director of Nursing (DON) stated O2 was considered a medication that required a physician order for administration, and nurses should be checking the O2 according to physicians order every shift. The resident's care plan, has oxygen therapy ordered r/t (related) shortness of breath, comfort initiated on 10/18/20 and revised on 9/21/22 included, O2 via nasal cannula for SOB, comfort as order. A review of the Policy and procedure on Oxygen Administration not dated, indicated that under Preparation #1 read, Verify that there is a physician's order. Review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to maintain sufficient nurse staffing on the night shift to promote the highest practicable level of well-being for residents on 2 of 2 units; and failed to provide necessary care and services and ensure safety according to the plans of care for 7 of 16 residents reviewed for staffing concerns, (#2, #3, #10, #12, #45, #62, and #79). Findings: On 2/21/22 at 10:18 AM and 2/22/22 at 1:31 PM, resident #45, the Resident Council President, voiced a concern about the skeleton crew on the night shift. She explained there were nights when only 2 nurses and 2 Certified Nursing Assistants (CNAs) were assigned to take care of over 80 residents in the building. She explained that number of staff was not able to adequately care for everyone. She recalled residents' complaints regarding being left on the toilet too long. She expressed fear of fire or other emergency situations that would require staff to assist residents to evacuate their rooms or the building. The Resident Council President was particularly concerned about residents who were bed bound or required extensive assistance for mobility. She confirmed she had spoken to the facility's Administrator about staffing concerns on the night shift and was told the facility had a back-up plan and could call in staff when needed. On 2/21/22 at 12:34 PM, resident #10 stated the facility was short staffed and CNAs were overburdened. She explained she has a urinary catheter preferred to use a small drainage bag strapped to her leg. She stated staff replaced the small bag with a large drainage bag to cut down on the number of times needed to empty the leg bag. Review of resident #10's medical record revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10's Minimum Data Set (MDS) Significant Change in Status assessment dated [DATE] revealed she was cognitively intact and did not resist care. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 had an indwelling urinary catheter. On 2/23/22 at 10:00 AM during a Resident Council group meeting, the Resident Council President reiterated the facility had a staffing issue on the night shift. She stated she had used this forum in the past to encourage resident to express their concerns about staffing and how it affected them. She explained during the last scheduled meeting of the Resident Council on 2/16/22, the group requested a meeting with the facility Administrator, Director of Nursing (DON) and the company's Chief Executive Officer (CEO) in order to address their concerns regarding staffing. The following residents expressed specific concerns related to staffing: On 2/23/22 at approximately 10:20 AM, resident #2 stated the facility is often short-staffed, especially on the night shift. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed she required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. The resident did not walk and had impairments of both upper extremities. On 2/23/22 at approximately 10:25 AM, resident #79 recalled nights when she did not receive care for the entire night shift. She said, I got changed on the 3-11 shift and went through the night shift without being changed. Resident #79 explained she wore an incontinence brief, and not being changed regularly increased her risk for bedsores especially since she had them in the past. Review of resident #79's medical record revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #79's MDS Significant Change in Status assessment dated [DATE] revealed she was cognitively intact, did not reject care and required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and personal hygiene. The resident was totally dependent on two staff for toilet use. She had impaired range of motion in one upper extremity, used a wheelchair for mobility and was always incontinent of bowel and bladder. Resident #79 had a care plan for activities of daily living (ADL) self-care performance deficit dated 2/22/21. The interventions included check for incontinence with routine care and provide incontinence care as indicated. A care plan for risk for pressure injury and other skin impairment dated 2/22/21 had a goal initiated on 2/09/22 related to moisture associated skin damage on resident #79's sacrum. The interventions included assist resident to turn and reposition frequently, keep skin clean and dry and provide perineal care after each incontinent episode. On 2/23/22 at approximately 10:30 AM, resident #12 stated night shift staff did not have time to provide a thorough bath or incontinence care. She said, They hurry through and do not take their time. Review of resident #12's medical record, revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS Quarterly assessment dated [DATE] revealed the resident was cognitively intact and did not reject care. She required extensive assistance of two staff for bed mobility, transfer and toilet use and extensive assistance of one staff for personal hygiene and dressing. She had impaired range of motion in one upper and one lower extremity and used a wheelchair for mobility. She was always incontinent of bladder and frequently incontinent of bowel. Resident #12 had a care plan for ADL self-care performance deficit revised on 9/21/21. Interventions included provide sponge bath when a full bath cannot be tolerated, and resident requires extensive assistance of two staff to turn and reposition in bed. Document revealed resident #12 had 42-inch bed and needed assistance with proper positioning in the center of the bed. A care plan for risk for pressure injury and other skin impairment revised on 9/24/21 directed staff to assist resident to turn and reposition frequently and keep skin clean and dry. A care plan for oxygen therapy related to decreased oxygen level when sleeping at night directed nursing staff to monitor for signs and symptoms of respiratory distress. The care plan directed CNAs to prevent abdominal compression and respiratory compromise by routinely checking the resident's position to ensure she did not slide down in bed. On 2/23/22 at approximately 10:35 AM, resident #62 said, Sometimes you ring the bell needing to go to the bathroom or get changed and they do not respond. I laid there all night one night. Review of resident's medical record revealed she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Significant Change in Status assessment dated [DATE] revealed the resident was cognitively intact and did not reject care. She required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She used a wheelchair for mobility and was frequently incontinent of bowel and bladder. Resident #62 had a care plan for ADL self-care performance deficit dated 5/19/21. An intervention directed CNAs to assist with toileting as the resident was frequently incontinent. A care plan for risk for pressure injury and other skin impairment dated 1/17/22 had interventions including keep skin clean and dry and observe for changes in skin status with routine care. On 2/23/22 at 11:44 AM following the Resident Council meeting, the Director of Recreation stated he was responsible for arranging resident council meetings and recording minutes. He confirmed the Resident Council members voiced concerns regarding night shift staffing during the last meeting. He stated he informed the Administrator and DON of the Resident Council's request for a meeting with them and the CEO to discuss their concerns. On 2/21/22, the Staffing Coordinator (SC) stated she facility often did not meet the State minimum staffing requirements. She confirmed that State required staffing ratios were not met for night shift nurses and/or CNAs on 13 of 14 days from 2/06/22 to 2/19/22. She stated the actual number of staff on the night shift on those days was disturbing. On 2/22/22 at 11:38 AM, the facility Director of Nursing (DON) was informed of staffing concerns on the night shift related to two to four scheduled CNAs instead of the minimum of five recommended according to the census. She acknowledged she had received complaints from staff regarding their workload on the night shift. When asked if two CNAs could adequately care for 81 residents, the DON did not have an answer. The DON from a sister facility, DON C, explained the facility was currently on a self-imposed moratorium and had not admitted new residents for over a month as it was unable to maintain and adequate number of staff. DON C acknowledged staffing on the night shift was a problem and stated she could not guarantee the residents were receiving adequate care with current staffing levels on the night shift. She confirmed the facility had not initiated the Personal Care Attendant (PCA) program to improve staff ratios on the night shift. The PCA program permits a nursing home to employ PCAs who are participating in a training program to perform designated duties in a limited scope of practice under direct supervision of licensed nursing staff and in collaboration with CNAs. Each PCA may work within a facility for up to 4 months before becoming a CNA. The purpose of this program was to provide additional staff to meet resident care needs during the Corona Virus-19 State of Emergency (retrieved on 3/03/22 from www.fhca.org). On 2/22/22 at 11:46 AM, the Administrator validated residents may not have received good care due to low staffing on the night shift. He confirmed the facility had not implemented a PCA program to supplement staffing. On 2/22/22 at 3:54 PM, CNA G stated she worked on both the evening and night shift. She said, The night shift can be vicious. She explained that on Monday night, 2/21/22, there were four CNAs assigned to care for all residents in the building, but one CNA worked only half a shift. She stated on the nights when there were only 2 CNAs, each CNA was assigned to twenty-two residents. CNA G explained in addition to a heavy assignment there was one resident, resident #3, who required assistance from three staff to turn and reposition her. CNA G felt she did not provide good patient care under those circumstances because she could not get all her assigned tasks done. She said, It takes a miracle to finish a shift. Review of resident #3's medical record revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's MDS Annual assessment dated [DATE] revealed the resident required extensive assistance of two or more staff for bed mobility and personal hygiene and was totally dependent on two or more staff for toilet use. She had impaired range of motion in both upper and lower extremities and was always incontinent of bowel and bladder. Resident #3 had a care plan for ADL self-care performance deficit initiated 5/03/17. The interventions included three to four staff to assist with bathing, bed mobility, dressing, toilet use and transfers. A care plan for risk for falls initiated on 3/25/19 included interventions for bariatric bed for bed mobility, encourage and remind resident to call for assistance and use a slide sheet for bed mobility. A care plan for risk for pressure injury and other skin injury dated 5/03/17 included interventions to provide perineal care after each incontinent episode, reposition in bed as needed and support with pillows due to frequent leaning to one side and pull up in bed with sliding lift sheet. Resident #3's Kardex or CNA care plan reflected interventions including assistance of three to four staff for bed mobility, dressing, transfers, and toilet use. On 2/22/22 at 4:26 PM, CNA H stated she normally worked on the 500 unit on the evening shift but occasionally picked up extra shifts on the night shift. She confirmed sometimes there were only two CNAs for the entire facility on the night shift. She described the situation as rough. She explained most residents needed assistance and with that many residents she could not check on each on every two hours as required. She said, I cannot provide all the care needed. On 2/22/22 at 11:38 PM, in a telephone interview, CNA J stated she normally worked on the night shift and was frequently one of two CNAs on the 500 unit. She explained with two CNAs, they would have to divide the 45 residents between them and was only able to make rounds twice for the shift rather than every two hours. She acknowledged CNAs should check and reposition residents at least every two hours. CNA J said, It is absolutely not possible. We cannot give the proper care like that. I would go in there more often if we had enough CNAs. On 2/22/22 at 11:51 PM, in a telephone interview, Licensed Practical Nurse (LPN) K stated the facility has been short-staffed for the last 6 months. She recalled two nights recently when she worked the 400 unit with only one CNA. She acknowledged it was not appropriate for one CNA to care for almost 40 residents. She explained on those nights the CNA was not able to check and change the residents every two hours. On 2/23/22 at 12:04 AM, in a telephone interview, Registered Nurse (RN) L stated he was usually assigned to the 500 unit with a census of over forty residents. He explained there was usually only one nurse assigned to that unit. He confirmed there were often only two CNAs on the unit for the night and there were occasions when there was only one CNA assigned to the residents. He explained when the staffing was this low, the CNAs had to prioritize because there were too many residents to do everything necessary. He agreed the residents should be checked every two hours but said, It is not possible if one CNA has the unit. On 2/23/22 at 12:10 AM, in a telephone interview, CNA M stated there had been a staff shortage on the night shift for last couple of months. She said, I often work alone on this unit for the whole night shift. I cannot check my residents every two hours if I am alone. When asked how she cared for 44 residents, she said, I know who needs to be changed and who is usually soiled. But you cannot change people every two hours. She stated the facility's management knew there was a problem, but she did not see anything changing. On 2/23/22 at 9:17 AM, CNA F stated although she usually worked the day shift, she was aware of staffing concerns on the night shift. She explained at the start of her shift, she sometimes found residents heavily saturated with urine if there were one or two CNAs working on the night shift. CNA F confirmed resident #3 required three to four staff to care for her and one or two CNAs on the night shift could not adequately care for her. The facility's Policy and Procedure for Staffing revised in April 2007 included the statement, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident services. The Facility assessment dated [DATE] included a staffing plan to ensure a sufficient number of qualified staff were available to meet each resident's needs.

Based on interview and record review, the facility failed to utilize its resources effectively to develop and implement a plan that ensured sufficient staffing on the night shift to meet residents' care needs. Findings: On 2/21/22 at 11:19 AM during a review of State staffing calculation forms with the Staffing Coordinator (SC), she stated she was aware the facility did not meet minimum State staffing requirements on a few days. She was informed minimum staffing requirements were not met on a significant number of days, 13 of the 14 nights shifts on the days reviewed. She stated the supervisor or manager on duty should have handled call-offs or openings in the schedule by attempting to call staff or a staffing agency to fill those slots. The SC stated she notified the Administrator whenever staffing was not sufficient. She was unable to confirm whether the supervisor or manager on duty attempted to utilize other licensed or certified staff from other departments on the dates when staffing was insufficient. On 2/22/22 at 11:38 AM, the Director of Nursing (DON) from a sister facility, DON C, stated the facility was currently on a self-imposed moratorium and had not admitted any new residents for over a month because they had been unable to maintain an adequate number of staff. DON C acknowledged staffing on the night shift was a problem. She confirmed the facility had never initiated the Personal Care Attendant (PCA) program to supplement staffing on the night shift. On 2/22/22 at 11:46 AM, during review of the State staffing calculation with the Administrator, he was informed on some nights there were only 2 CNAs in the building caring for over 80 residents and there were frequently two nurses with no nursing supervisor assigned to care for all residents. He stated he was not aware of the extent of the staffing concern on the night shift. He explained he was not responsible for hiring nursing staff. The Administrator stated he had informed his direct supervisor of the facility's staffing issues and discussed the possibility of implementing the PCA program; but at this point it had not been authorized. The PCA program permits a nursing home to employ PCAs who are participating in a training program to perform designated duties in a limited scope of practice under direct supervision of licensed nursing staff and in collaboration with CNAs. Each PCA may work within a facility for up to 4 months before becoming a CNA. The purpose of this program was to provide additional staff to meet resident care needs during the Corona Virus-19 State of Emergency, (retrieved on 3/03/22 from www.fhca.org). On 2/24/22 at 11:36 AM, the Administrator stated staffing was reviewed daily for compliance with State-mandated ratios and direct patient care hours. He explained the facility used agency to help fill openings on shifts. He stated the facility had discharged some patients to a sister facility; but said, It is hard to find other facilities who will take Medicaid patients. The Administrator clarified he understood what need to be done under regular circumstances, but this was a public health crisis. He could not elaborate on why the corporation had not implemented the PCA program which was designed to mitigate staffing shortages in this crisis. On 2/24/22 at 11:36 AM, the Administrator stated he was aware the facility had significant staffing concerns. He confirmed the facility had an emergency staffing plan but could not give specifics. He acknowledged staffing requirements had to be met under regular circumstances; but stated the facility was impacted by the current public health crisis. The Administrator could not explain why the corporation had not implemented the PCA program in the almost two years the program had been in existence. He verbalized understanding the PCA program was designed to mitigate staffing shortages in this crisis. When asked what census the facility's current staffing could accommodate, the Administrator responded he was not certain and would have to calculate. DON C stated the current availability of night shift CNAs would support a census of 50 to 60 residents. The Facility assessment dated [DATE] included a staffing plan to ensure a sufficient number of qualified staff were available to meet the resident's needs. Review of the job description for the Staffing Coordinator revised on 10/06/17 revealed he/she was responsible for ensuring nursing units were adequately staffed. Essential functions included accommodating unplanned staffing variances and communicating with staff on duty or making calls to off duty personnel to adjust staffing as necessary. Review of the job description for the facility's Nursing Director revised 9/20/17 revealed he/she would plan, organize, develop and direct the operations of the nursing department. The document indicated the DON ensures a sufficient number of nursing staff is assigned daily to meet the total nursing needs of the residents. Review of the job description for the facility's Administrator revised on 3/10/20 revealed he/she was responsible for directing day-to-day functions of the facility in accordance with regulations. Essential functions included managing human resources functions such as hiring and work assignments and ensuring there was an adequate number of staff on duty at all times to meet residents' needs.

Based on observation, interview and record review, the facility failed to maintain oxygen flow rate as ordered by the physician for 1 resident (#60); and failed to ensure oxygen concentrators were in clean and safe condition for 6 residents (#60, #83, #49, #32, #13, and #83), out of 7 residents reviewed for respiratory care, of 16 residents receiving oxygen therapy. Findings: 1. Resident #60 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/21/22 at 12:05 PM, resident #60 was observed in bed. She did not have oxygen applied as the nasal cannula (NC) was draped over the left bed rail. The tubing was attached to a dirty oxygen concentrator. The rear vents of the concentrator were covered in a thick layer of gray dust particles. The oxygen flow rate was set at 3 liters per minute (LPM). A review of physician orders dated 10/15/20 noted oxygen at 2 LPM via NC as needed (PRN) for shortness of breath. An order directed nurses to change the oxygen tubing weekly and PRN, label, and date on each change every night shift on Sundays, to start on 10/18/20. Resident #60 had care plan, revised on 1/18/22, for oxygen therapy related to respiratory illness, history of COVID-19 including interventions for, Oxygen Settings: O2 via nasal prongs at 2L. On 2/21/22 at 3:00 PM, resident #60 wore the NC and received oxygen via the concentrator which was set to deliver a low rate of 3.5 LPM. The rear vents of concentrator were still covered with thick gray dust particles. On 2/21/22 at 3:08 PM, Licensed Practical Nurse (LPN) D stated she was assigned to resident #60 on the 7 AM to 3 PM shift. LPN D checked the electronic medical record (EMR) and confirmed the resident was to have her oxygen concentrator set at 2 LPM. LPN D checked the setting on resident #60's oxygen concentrator and verified it was set at 3.5 LPM. She said she had not checked the oxygen setting until prompted and acknowledged the resident was not receiving oxygen as ordered by the physician. LPN D added she thought that since the tubing was changed earlier that morning on the 11 PM to 7 AM shift, the nurse would have checked the setting then. LPN D did not notice that the thick layer of gray dust on the rear vents of the oxygen concentrator. On 2/22/22 at 10:02 AM and 2:05 PM, resident #60 wore the NC which was attached to the concentrator at bedside. The rear vents of the machine were unchanged. On 2/22/22 at 2:25 PM, LPN A and housekeeper B acknowledged resident #60's oxygen concentrator was dusty and dirty. Neither LPN A nor housekeeper B knew whether nursing or housekeeping staff were responsible for cleaning the oxygen concentrators. They did not know any details of the facility's policy related to cleaning and maintenance of oxygen concentrators. On 2/22/22 at 2:42 PM, the Environmental Services Supervisor said, Housekeeping staff do not clean or touch any of the oxygen concentrators when the residents are using them. They will clean them when the resident is finished using or when instructed by the nurse. On 2/23/22 at 3:00 PM, the Director of Nursing (DON) stated nurses were expected to check concentrator settings at least every shift to ensure oxygen infused at the prescribed flow rate. She explained residents with [CONDITION(S)] could get carbon [MEDICATION(S)] overloaded and make their condition worse if they got too much oxygen. The DON stated cleaning of concentrators was a new issue for the facility, and confirmed staff required further education regarding the concern. Review of the policies and procedures revised October 2010 titled, Oxygen Administration read, Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders. 2. Review of resident #83's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had moderate cognitive impairment and had been on oxygen therapy. Review of the plan of care dated 9/17/21 revealed the resident required oxygen therapy related to [CONDITION(S)] and shortness of breath. Goals included monitor for respiratory distress, oxygen via nasal cannula at 2 to 4 liters LPM continuously. Review of the physician's orders documented oxygen at 2 to 4 LPM minute with humidifier via nasal cannula continuously for shortness of breath / [CONDITION(S)]. The orders indicated nurses could remove oxygen for short periods as tolerated, oxygen tubing was to be changed weekly and as needed, and stored in a labeled and dated bag. On 2/21/22 at 11:39 AM; 2/22/22 at 9:19 AM, 2:38 PM and 4:06 PM; and 2/23/22 at 9:26 AM resident #83's oxygen concentrator was noted to have no external filter. There was gray dust built up on the inlet area where the room air entered the oxygen concentrator. On 2/22/22 at 2:38 PM, LPN E observed resident #83's oxygen concentrator and said, There is no external filter in the concentrator. There should be a filter to filter the air from the room. LPN E confirmed gray dust had built up in the space where the external filter should have been located. LPN E explained resident #83 was on oxygen all the time and was therefore inhaling unfiltered air. On 2/22/22 at 5:14 PM, the DON confirmed resident #83's oxygen concentrator did not have an external filter. The DON said, There should have been a filter on the concentrator to filter the room air. 3. Review of resident #49's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and had been on oxygen therapy. Review of resident #49's plan of care dated 4/04/2016 and revised on 1/18/22, documented the resident sometimes had difficulty breathing related to her [CONDITION(S)], may need to use oxygen, and would use oxygen at bedtime. Interventions included physician ordered oxygen via nasal cannula at 2 LPM at bedtime. The goal was for resident #49 to have no complications related to shortness of breath. Review of the medical record revealed a physician's orders for oxygen at 2 LPM via nasal cannula due to low oxygen saturation levels during the night. On 2/21/22 at 10:54 AM and 2:40 PM, and on 2/22/22 at 9:27 AM and 1:45 PM, the filter on resident #49's oxygen concentrator was noted to be completely covered with a gray dust-like substance. On 2/22/22 at 2:38 PM, LPN E stated resident #49 wore her oxygen at night because her oxygen levels went down. LPN E observed the concentrator's external filter and confirmed it was completely covered with gray dust. LPN E then peeled the layer of dust from the external filter. She explained the external filter was used to clean the air from the room and in order for the oxygen concentrator to function properly the filter should be clean. She said, If the filter is not cleaned it becomes clogged and the resident may not receive the correct percentage of oxygen ordered by the physician. LPN E stated she was not aware who was responsible for checking and cleaning the external filters. On 02/23/22 at 9:41 AM, the Director of Nursing (DON) stated there should be an clean external filter on the oxygen concentrators. The purpose of the filter was to filter/clean the room air before concentrating and providing the percentage of oxygen per physician order to the resident. The DON explained the nurses were not aware they were responsible for checking and cleaning the filters. The licensed nursing orientation did not include oxygen concentrator filter training. Review of the Invacare Perfecto2 V Oxygen Concentrator User Manual, dated 2016, read, . 1.2 The intended use of the oxygen concentrator is to provide supplemental oxygen to patients with respiratory disorders, by separating nitrogen from room air, by way a a molecular sieve . 7.3 Cleaning the Cabinet Filter . Do Not operate the concentrator without the filter installed or with a dirty filter. There is one cabinet filter located on the back of the cabinet. 1. Remove the filter and clean as needed . 2. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent (such a Dawn) and water. Rinse thoroughly. 3. Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found . 7.6 Preventive Maintenance Checklist On Each Inspection . Clean Cabinet Filter . During Preventive Maintenance Schedule, Or Between Patients every 3 years of continuous use (Equivalent to 26,280 hours) . Clean/Replace Cabinet filters . Review of the Facility Assessment revealed the facility was capable of caring for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Respiratory treatments would include oxygen therapy, suctioning, [CONDITION(S)] care and ventilator or respirator. The document indicated the facility would determine the skills, education, and equipment necessary to meet the needs of the residents. Staff competencies would be based on the resident's needs and staff were expected to demonstrate competency during orientation, class room instruction, videos, computer-based instruction and skill's fairs. 4. Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record included physician orders for oxygen at 2 LPM via nasal cannula at night and PRN for shortness of breath and admit to hospice for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] indicated the resident's health conditions included shortness of breath. The assessment showed she used oxygen and received hospice services. Resident #32 had a care plan for oxygen related to end stage respiratory failure, and [CONDITION(S)]. On 2/21/22 at 10:12 AM, an oxygen concentrator was noted next to resident #32's bed. The nasal canula tubing was dated 2/07/22 and it was in a plastic bag, also dated 2/07/22. The tubing was connected to the oxygen concentrator that had an external filter covered in a thick gray dust-like substance. Additional observations on 2/21/22 at 1:54 PM and 3:14 PM, and on 2/22/22 at 8:48 AM revealed no change in the condition of the filter. On 2/22/22 at 1:39 PM, the Unit Manger (UM) stated resident #32 used oxygen at night and as needed during the day. She validated the oxygen tubing and nasal cannula should be changed every Sunday night and confirmed the resident's tubing was dated 2/07/22, two weeks ago. The UM confirmed the external filter was covered with thick, gray dust-like material and stated she was unsure who was responsible for cleaning the filter. 5. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS assessment dated [DATE] indicated the resident used oxygen. A physician order directed nurses to apply oxygen at 2 LPM via nasal canula as needed for shortness of breath. Resident #13 had a care plan for use of oxygen due to respiratory illness, [CONDITION(S)] and acute respiratory failure. On 2/21/22 at 10:41 AM, resident #13's oxygen concentrator was noted to have no external filter on the back of the machine. On 2/22/22 at 9:00 AM, the oxygen concentrator still did not have a filter. On 2/22/22 at 1:41 PM, the UM validated the oxygen concentrator had no external filter. She confirmed oxygen concentrators should always have a filter. On 2/23/22 at 3:00 PM, the DON stated she was not sure who was responsible for cleaning the external filters on the oxygen concentrators. She stated this is a new issue that was brought to her attention by the survey team. 6. Resident # 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician order dated 10/26/20 for oxygen at 2 LPM via nasal cannula as needed for shortness of breath while awake. Review of the resident's Quarterly Minimum Data Set (MDS) assessment with assessment reference date of 12/15/21 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment indicated the resident had shortness of breath or trouble breathing with exertion. On 2/21/22 at 3:03 PM, resident #20 was in bed. An oxygen concentrator to the left of his bed did not have an external filter. On 2/22/22 at 2:48 PM, LPN A stated the resident had physician's order for oxygen at 2 LPM as needed. During observation of the resident's oxygen concentrator with LPN A, he confirmed the machine did not have an external filter. He explained the maintenance department was responsible for replacing the filter. On 2/22/22 at 2:55 PM, the DON confirmed the oxygen concentrator did not have an external filter. She stated the maintenance department was responsible for replacing these filters. On 2/23/22 at 10:01 AM, Registered Nurse (RN) D stated the resident had orders for oxygen as needed. RN D checked the resident's oxygen concentrator and confirmed there was no external filter in place. RN D stated even if oxygen was ordered only as needed, and the resident was not currently connected to the machine, the filter should be in place. On 2/23/22 at 10:03 AM, Maintenance Assistant V stated maintenance staff check and replace the external filters on the oxygen concentrators monthly, and after resident use of the machine was completed. Maintenance Assistant V stated he did not know when the external filter for resident #20's oxygen concentrator was last changed. He verbalized the external filter was missing and stated he recently replaced it. The resident's care plan for oxygen therapy related to ineffective gas exchange and [CONDITION(S)], initiated on 10/26/20 and revised on 12/26/21 read, O2 via nasal prongs @ 2L PRN while awake and connected to C-pap at night. The facility's policy Oxygen Administration revised October 2010 read, Check the mask, tank, humidifying jar etc., to be sure they are in good working order.

Based on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 1 of 2 nutrition rooms, (400-unit). Findings: On 2/24/22 at 9:40 AM, during a tour of the 400-unit nutrition room / pantry with the Unit Manager (UM), undated food items observed inside the refrigerator included: bag labeled room 421 with a large bucket of fried chicken with 3 biscuits, bag with 1 box onion rings, box containing fish/shrimp/French fries, box with biscuit and shrimp, bag with 2 containers of Cole slaw, 2 slices of cheesecake, and 64 ounces vanilla creamer which was almost empty. Food particles and trash were observed on the cabinet shelves and inside drawers. The cabinets were disorganized and there were miscellaneous condiments, nut mixture and cereal noted in the drawers as well as the cabinets. The upper cabinet adjacent to the coffee supplies had an undated bagel wrapped in tinfoil. The upper right cabinet had a bag containing 4 bottles of various vitamins and supplements and a bruised red apple was left on the countertop. The UM said, Whoever puts items into the refrigerator needs to date them and the night staff are to throw out the outdated food. The UM acknowledged the cabinets, drawers, and refrigerator were dirty, disorganized, and had outdated or undated food items present. She said, I wound not want my house kept like this. On 2/24/22 at 10:30 AM, the Food Service Director was interviewed regarding concerns identified on the 400-unit nutrition room. He said, Food brought from the outside to the panty and nutrition rooms must be thrown out after 3 days. Anyone can clean the pantries. He explained nursing staff were responsible for throwing out the outdated food and the kitchen staff should rotate items such as milk and juice. On 2/24/22 at 12:30 PM, the Food Service Director stated since nursing staff checked the refrigerator temperatures in the pantries, they would be responsible for cleaning up and throwing out outdated food. He explained Environmental Services staff cleaned the panty and nursing staff were assigned on all shifts to clean the refrigerator and throw out outdated items. The Food Service Director stated when family members provide food for the residents, nursing staff should put the residents' room number and current date on the item(s). Review of the facility policy for, Food from Family, Visitor, Community read, Food stored for resident should be labeled and dated appropriately and discarded per safe food storage guidelines. Review of the facility policy and procedure dated 2016 for, Handling Leftover Food read, Leftover food stored in the refrigerator shall bed wrapped dated, labeled with a use by date that is no more than 72 hours from the time of first use. Refrigerated leftovers stored beyond 72 hours shall be discarded.

Based on interview and record review, the facility failed to provide showers according to preferences for 3 of 8 residents reviewed for choices of a total sample of 54 residents, (#20, #65, #75). Findings: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 9/22/21 revealed resident #20 felt it was very important to choose between a tub bath, shower, bed bath or sponge bath. The Quarterly MDS assessment with Assessment Reference Date (ARD) of 12/15/21 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 12/15. The assessment indicated the resident required extensive assistance from one person for dressing and personal hygiene, and extensive assistance from two persons for transfers. She was totally dependent on staff for bathing and had functional limitation in range of motion of his bilateral upper extremities. The resident's Task: ADL (Activities of Daily Living) - Daily Bathing Showers form revealed he was scheduled for showers on Monday and Thursday on the 7 AM to 3 PM shift. Review of the document for the period 1/25/22 to 2/23/22 showed check marks in the column for one-person physical assist but there was no documentation to indicate the type of bath or shower the resident received. On 2/21/22 at 3:03 PM, resident #20 stated he had only received one shower since his admission to the facility, and verbalized he had no idea why never received any additional showers. Resident #20 stated staff used a mechanical lift to transfer him, and he was left in bed all the time. On 2/22/22 at 3:07 PM, Certified Nursing Assistant (CNA) S stated resident #20's showers were scheduled for the 3 PM to 11 PM shift. However, she explained the resident received only bed baths . CNA S verbalized the resident required a mechanical lift for transfers, and the facility did not have a shower stretcher to transport him to the shower room. On 2/22/22 at 4:24 PM, the Director of Nursing (DON) stated the facility did not have a shower bed / stretcher, but residents were given the option of a tub bath, since there was a tub on the 400 Unit. In additional interviews with the DON on 2/23/22 at 1:12 PM and 3:01 PM, she stated the facility had a reclining shower chair that would enable staff to provide the resident with showers. The DON was not sure where provision of showers would be documented in the electronic medical record. The resident's Task form was reviewed with the DON, and she validated there was documentation to show some type of bed bath was given. She confirmed there was no documentation to indicate resident #20 received showers according to his expressed preference on scheduled shower days. The resident's care plan for ADL self-care performance deficits, initiated on 3/02/20 with revision on 12/26/21 read, Bathing/showering: the resident requires assistance by (1) staff with bathing/showering and as necessary. 2. Resident #65 was admitted to the facility on [DATE] with her most recent readmission on 9/15/20. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment with ARD of 8/05/21 revealed resident #65 felt it was very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's Quarterly MDS assessment with ARD of 1/20/22 revealed the residents' cognition was intact with a BIMS score of 14/15. Resident #65 required extensive assistance from two people for most of her ADLs and she was totally dependent on staff for bathing. She had functional limitation in range of motion was impairments on both sides of her upper and lower extremities. Review of the resident's Task form showed she was scheduled for daily bathing/showers on Monday and Thursday on the 7 AM to 3 PM shift. For the period 1/26/22 to 2/23/22 there was no documentation to indicate resident #65 received showers as scheduled. On 2/21/22 at 3:20 PM, resident #65 stated she had neither received a shower nor been taken out of bed for one year. The resident stated staff told her it took too long to give her a shower since they had to transfer her from the bed to a wheelchair, then from the wheelchair to the shower chair. She verbalized she was told it was too much. Resident #65 stated she got partial or half bed baths, and verbalized she told staff she was not being cleaned properly. On 2/22/22 at 3:33 PM, CNA P confirmed resident #65 required a mechanical lift for transfers into the wheelchair and then to the shower chair. The CNA stated the resident was paralyzed from her waist down and could not lift her feet up during transfers. CNA P explained the facility did not have a shower bed or stretcher, and a shower bed would not fit in the shower room. She confirmed she had been giving the resident bed baths instead of showers. On 2/23/22 at 10:50 AM, Registered Nurse (RN) R stated resident #65 used to receive showers in the past but had not been showered for approximately one year. RN R explained the DON at that time did not want the resident to be placed in the shower chair due to the resident's risk for falls. She stated the resident received bed baths as the facility did not have a shower bed / stretcher. On 2/23/22 at 1:12 PM, the DON stated the facility had a reclining shower chair, but this device was not rated for transport. She explained staff would have to transfer the resident to a wheelchair, transport her to the shower room and then transfer her again into the reclining shower chair. The DON stated she was aware of discussions related to the facility acquiring a shower bed, but she was not certain of the outcome. On 2/23/22 at 3:01 PM, the resident's Task: ADL-Daily Bathing Showers form for the period 1/26/22 to 2/23/22 was reviewed with the DON. She stated there was documentation to show the type of bed bath provided and verbalized there was no additional documentation to indicate the resident received showers. An intervention on the resident's care plan for ADL self-care performance deficits, initiated on 4/10/14 with revision on 1/26/22 read, The resident is totally dependent on staff to provide bath. 3. Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment with ARD of 8/15/21 revealed resident #75 felt it was very important to choose between a tub bath, shower, bed bath or sponge bath. The Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 which indicated he was cognitively intact. Resident #75 required extensive assistance from one person for personal hygiene. He was totally dependent on two staff for transfers and totally dependent on one staff for bathing. On 2/21/22 at 3:05 PM, the resident stated he had not received a shower since he was admitted to the facility. He stated staff gave him a bed bath, If that is what you want to call it. Resident #75 explained although he preferred showers, staff gave him bed baths as he required use of a mechanical lift and assistance from two people to get out of bed. Review of the medical record revealed resident #75 had a care plan for bathing/showering initiated on 8/10/21 and revised on 11/10/21. The document indicated the resident required assistance of two staff with bathing/showering and a sponge bath should be given when a full bath or shower could not be tolerated. The care plan indicated the resident required a mechanical lift for transfers. On 2/23/22 at 1:59 PM, CNA O stated resident #75 received bed baths because in order to have a shower he would have to be transferred via a mechanical lift to a wheelchair, taken to the shower room and again transferred with the mechanical lift to the shower chair. She explained after his shower, the resident would have to be put back to bed to have some areas of his body washed. CNA O stated this was necessary because the shower chair did not recline enough to allow access to all areas of the resident's body. She stated a shower bed would be ideal for residents who were unable to stand, and she was not sure why the facility did not have this equipment. On 2/23/22 at 3:12 PM, the DON stated she was not aware of the problem of residents being showered according to their preferences. She confirmed residents should be able to receive showers if that was their preference. The DON could not explain why the facility did not have a shower bed.

Based on interview and record review, the facility failed to develop an individualized care plan for 1 of 5 residents reviewed for oxygen therapy of a total sample of 54 residents, (#51). Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #51's care plans revealed there was no specific care plan for oxygen therapy, and this intervention was not listed in any other care plan. On 2/24/22 at 2:30 PM, the Minimum Data Set (MDS) Coordinator stated if there was an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator reviewed all of resident #51's care plans and confirmed there was no active care plan to address the resident's oxygen use.

Based on observation, interview, and record review, the facility failed to provide non-surgical site treatment according to a physician's order for 1 of 2 residents reviewed for non-pressure skin condition out of a sampled of 54 residents, (#83). Findings: Review of resident #83's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment dated [DATE] documented she had moderate cognitive impairment, required extensive assistance with activities of daily living and had a surgical wound and wound care / non-surgical dressings. Review of #83's medical record revealed physician orders dated 2/11/22 to observe the right [MEDICATION(S)] area status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed nurses to change dry sterile gauze and secure with tape daily and as needed if soiled or dislodged, until healed. Observations conducted on 2/21/22 at 11:35 AM, and 2/22/22 at 9:19 AM, 4:06 PM, and 5:13 PM revealed the dressing to resident #83's right upper chest area was dated 2/19/22. Review of the Treatment Administration Record (TAR) revealed the physician's order was transcribed correctly to reflect observation for signs and symptoms of infection and to complete a daily dressing change until the wound as healed. The TAR was initialed by nurses to verify the treatment was completed on 2/20/22 and 2/21/22. On 2/22/22 at 5:13 PM, the Director of Nursing (DON) confirmed the dressing on #83's right upper chest was dated 2/19/22. The DON stated the physician's order was written to observe for signs and symptoms of infection and to change the dressing daily and as needed. The DON explained the nurses' initials on the TAR indicated they completed the dressing change daily on 2/20/22 and 2/21/22. The DON said, Since the dressing was dated 2/19/22, the daily dressing change had not been completed as ordered by her physician. Review of the facility's policy Dressings, Dry/Clean Procedure, revised September 2013, read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: 1. Verify that there is a physician's order . check the treatment record . Steps in the Procedure: . 17. Apply the ordered dressing and secure with tape or border dressing per order. Label with date and initials to the top of the dressing . Documentation: 1. The date and time the dressing was changed . 9. The signature and initials of the person recording the data .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and a safe environment for 1 of 5 residents reviewed for elopement risk (#21). Resident #21 exited a secured locked unit and then proceeded to exit through a rear door of the facility to the employee parking lot without any staff awareness. The resident was attempting to get into a parked car when he was observed by a staff member who was leaving for the day. The failure to provide adequate supervision to prevent elopement of an elderly, vulnerable resident with dementia who had a known elopement risk and could not self-sustain, resulted in immediate jeopardy that occurred on 4/20/17. The facility implemented corrective measures to address the risk for residents assessed to require supervision based on the exit seeking evaluation and they achieved substantial compliance on 5/26/17. Findings: Resident #21 was admitted to the facility 7/17/13, with [DIAGNOSES REDACTED]. The admission history documented his family member reported that he resided in several other long term care facilities and had a history of [REDACTED]. Review of a State Required Report dated 5/4/17, indicated Resident #21 had eloped form the Dementia Special Care Unit on 4/20/17 around 7 PM, and was observed by therapy staff who were leaving the facility at the end of shift. Review of Resident #21's Annual Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) indicated the resident's cognition was moderately impaired. There was no change in the residents' mental status from his baseline. Resident #21 required limited staff assistance for transfers from bed, chair and standing. He walked with the aid of a walker. He was independent to walk in his room and on the unit and needed supervision when off the unit related to his history of wandering and poor safety awareness. Resident #21 was incontinent of bowel and bladder and had exhibited a wandering behavior 1 to 3 days of the MDS assessment. The impact of the resident's wandering, does the wandering place the resident at significant risk of getting into a potentially dangerous place (e.g. outside of the facility) was listed as no. The resident was found outside the facility within 16 days of this assessment. Review of Resident #21's Care Plan for Elopement dated 3/12/14, indicated he was at risk related to impaired safety awareness, impulsiveness, poor decision making, history of attempts to leave the facility unattended and a [DIAGNOSES REDACTED]. Interventions were to distract resident from wandering by offering pleasant diversions (structured activities, food and conversation), identify patterns of wandering (purposeful, aimless or escapist), have resident reside in room that looks out to courtyard not parking lot and resident to reside on secure unit. The Elopement Care Plan interventions did not include individualized interventions for supervision while on the secured unit and did not include any details pertinent to resident #21 regarding type of activity, food, or conversation. The care plan did not address resident #21's pattern of wandering. Review of the quarterly Exit Seeking Evaluation dated 10/07/16, reflected the following for Resident #21: 1. Is the resident mobile either by ambulation or by wheelchair? YES 2. Is the resident resistant to being in the facility? YES 3. Does the resident have a history of exit seeking behavior? YES 4. Are there any indications psychosis, hallucination, delusions or BIMS score of 12 or less? YES 5. Does the resident appear younger than stated age? YES 6. Recent personal tragedy, rec'd upsetting news or change in environment? NO ACTION: 1=YES-2=NO If score is greater than 4, a note is required for a security bracelet (a bracelet that alarms when resident approaches the exit door of the secured unit) determination. Resident #21's note indicated: To be implemented-Resident does not have security bracelet will be re-evaluated at end of the quarter for bracelet placement. Review of the annual Exit Seeking Evaluation dated 1/04/17, reflected a change to question #5 (does the resident appear younger than stated age) of an answer being NO. Resident #21's note indicated: Not to be implemented-Resident unable to leave facility unattended and will not be placed with bracelet at this time-will evaluate at end of quarter (bracelet not in place). Review of the quarterly Exit Seeking Evaluation dated 2/11/17, reflected no changes to the above answers. Resident #21's note indicated: Not to be implemented-Resident is unable to leave the facility unattended and will not be placed with bracelet at this time-will continue to monitor (bracelet not in place). Review of the status change Exit Seeking Evaluation dated 4/21/17, the day after resident #21 eloped from the secured unit and the building, reflected no changes to the above answers. Resident #21's note indicated: To be implemented-Resident has shown new exit seeking behaviors. These behaviors have not been observed by staff in over six months. Security bracelet added to walker and wrist. On 10/26/17 at 10:50 AM, the Director of Nursing (DON) stated the Exit Seeking Evaluation is based on the primary mode of ambulation, if a resident can ambulate with a walker or wheelchair independently. The DON was unable to explain why the resident (#21) was not considered an elopement risk based on his past history of elopements. When asked about Resident is unable to leave the facility unattended, the DON said the resident is in a secured unit and has no way to leave unless accompanied by staff. She said they did not consider how a resident could possibly leave the unit without staff. The DON's could not explain how a determination was made for Resident #21 to wear, or not wear, a bracelet. Review of a State required report dated 5/04/17, indicated Resident #21 had eloped from the Dementia Special Care Unit on 4/20/17 around 7 PM, and was observed by therapy staff who were leaving the facility at the end of shift. The resident (#21) was brought back into the facility and had no injuries. Analysis of the incident included the following: Resident (#21) is independent with ambulation using a walker. He tends to spend most of his time in his room, but will present to the dining area on the unit for meals. The entry/exit for the unit is secured with a keypad exit. The code for the exit is provided to team members that require access to the unit to full fill their job duties. The resident's exit from the unit was not witnessed by team members. On 10/26/17 at 4:20 PM, the Risk Manager (RM) indicated Resident was in a unit that was secured by a key pad code at the door. Staff and visitors had to know the code to exit the unit and it was very possible that visitors had the code. Around the time of the elopement (4/20/17 at 7 PM), both visitors and dietary staff had left the unit allowing the resident to follow behind. Once outside the secured unit, the resident was able to leave the facility via the rear exit door and was found by therapy staff leaving for the day on 4/20/17 at 7 PM. Upon review of the rear door camera video and staff interviews, the RM was able to establish the following time line: 4/20/17 at 6:36 PM, Resident #21 last seen by a Certified Nursing Assist (CNA) sitting at the table finishing dinner. 4/20/17 at 6:39 PM, Resident left the unit, out the rear door of the facility and into the parking lot. The resident was checking for open doors on cars in the parking lot. 4/20/17 at 7 PM, Resident was found by a Physical Therapist Assistant (PTA) who was leaving work for the day. 4/20/17 at 7:06 PM, Resident brought in facility by nursing and therapy staff. The RM also indicated family members had visited on 4/20/17 around 6:39 PM, the same time the resident had eloped. Dietary staff had exited the unit around 6:36 PM. The facility concluded the resident might have followed visitors or dietary staff out of the unit without any other staff realizing he had left or been missing. Resident #21 was found by a PTA B staff leaving work for the day on 4/20/17 at 7 PM. PTA B called the therapy department and spoke with another PT therapist who verified the resident and notified staff on the Dementia Specialty Care Unit. The PTA B remained with the resident until nursing arrived to escort the resident back to the unit. PTA B was told by the resident that he wanted to go home. At the time of the elopement, Resident #21 was not wearing a security bracelet. Review of an Interdisciplinary Therapy Screening Tool dated 4/5/17, indicated, Nursing reports no change in cognition, communication or swallowing. On 10/26/17 at 9:47 AM, PTA A indicated PTA B called the therapy department to ensure Resident #21 was a resident at the facility. PT A called Resident #21's unit to inform staff that Resident #21 was out in the employee parking lot. PTA B learned that Resident #21 was trying to go home and had observed the resident trying to climb into the driver's side seat of a black jeep. During the same interview, PTA A indicated that Resident #21, who was now wearing a security bracelet on his right ankle, was well dressed and appeared to walk well with his walker from his room to the common/dining area. PTA A said the resident could have easily passed for one of the outpatient therapy patients that come to the facility for physical therapy. On 10/26/17 at 11 AM, PTA B stated she was on her way out the door to head home and saw a man with a walker that was trying to get into the driver's side of a black jeep. She believed him to be a resident in the facility and called her therapy department to have someone assist her with identifying him. While she waited for assistance she, asked the resident why he was in the parking lot. Resident #21 stated he was going home. On 10/26/17 at 3:20 PM, Resident #21 was observed walking with his walker without assistance from his room to a table in the dining/common area. The resident was well groomed wearing a Navy baseball hat sitting with several other residents. On 10/27/17 at 2:17 PM, the Unit Manager (UM) of the Dementia Special Care Unit indicated there were 6 CNA's, 2 nurses and a house supervisor on duty for the 3 to 11 shift on 4/20/17, the afternoon of the elopement. When staff was interviewed, a CNA stated he had seen the resident (#21) sitting at the table around 6:35 PM. Staff at that time would have been cleaning, toileting residents and providing additional care. No one was assigned to watch the door and it was understood that staff was monitoring to make sure they knew where their assigned residents were at any time during the shift. The means of exit at that time would have been a code. Staff and family members had the code access and there were no witnesses to how the resident (#21) got out of the secured unit. Since the resident was not wearing a security bracelet, when the resident reached the back door of the facility, there would not have been an alarm sounding to alert staff that the resident was leaving the facility. The location of that door leads to the employee parking lot and is located near the therapy department. Therapy staff is behind closed doors which makes it difficult for them to see who is coming and going out that door. At that time, 7 PM, most the therapy staff would have left for the day. An observation of the parking lot 10/27/17 at 2:14 PM, revealed a gravel lot with multiple uneven surfaces, 2 lane roads and medians with step ups/downs. The parking lot gave access to employee parking for many cars. On 10/27/17 at 3:05 PM, CNA C indicated that Resident #21 had been assigned to her on 4/20/17, the day of the elopement. Her routine during the shift was to find each resident on her assignment, get report on each resident, gather supplies for the shift and get the residents ready for supper. After supper the routine was to clean up supper, give showers and get resident ready for bed. Resident #21 had a routine of spending most of his time in his room and would only come out of room for meals. Once finishing his meal, the resident would return to his room. I was not aware the resident (#21) had left the unit. On 10/27/17 at 4:35 PM, Register Nurse (RN) Supervisor indicated she received a call from a nurse on the Dementia Special Care Unit that the resident (#21) was found in the employee parking lot on 4/20/17 around 7 PM. I immediately went to that unit to assess the resident. He seemed OKAY. I called the Unit Manager and the DON to make them aware. A wander guard bracelet was immediately placed on the resident's right ankle. I remember the Resident (#21) sometimes wandering too close to the exit door of the secured unit with his walker. I never remember him trying to get out. Review of the policy regarding Safety and Security of Resident reviewed 7/17/15, states the facility strives to make the environment free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. System Approach to Safety 1. Facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 4/20/17 and removed 5/26/17, before exit. The facility implemented the following measures to address the immediacy and achieve substantial compliance as follows: On 4/20/17, the access code to the key pad was changed by the supervisor. After this change, the code was changed every other Friday by the Unit Manager. The codes were recorded on a log that was kept by the Unit Manager. The dates were placed on a Microsoft Outlook calendar for the DON and the Unit Manager. Staff members were educated to keep the code confidential from visitors and residents. Staff were educated about watching for resident exiting behind them. Every other Friday, the DON went to the unit to verify that the key pad code had been changed. On 4/23/17, the team members of the Dementia Special Care Unit and dietary were given education on identifying exit seeking behaviors beginning immediately following the event by the Unit Manager and the Dietary Manager. On 6/12/17 and 6/13/17, the staff of the Dementia Specialty Care Unit to include nurses, CNA's, housekeeping , unit secretary and other staff from around the building, attended a dementia training that focused on learning about dementia and behaviors that helped staff understand and identify behaviors, including exit seeking behaviors. The training increased the awareness of elopement and what to observe. On 5/03/17, residents of the Dementia Special Care Unit were re-assessed by the DON and the Unit Manager for elopement risk to determine ambulatory status. The audit evaluated whether the residents were independently ambulatory or mobile in their wheelchair based on observation and the medical record. Residents continue to be evaluated for ambulatory status in the exit seeking evaluation according to the Resident Assessment Instrument schedule, at a minimum of quarterly and as necessary. On 5/26/17, the Exit Seeking Tool was reviewed by nurse leadership to ensure that the evaluation included all questions necessary to make an appropriate determination of a security bracelet. A meeting was conducted with nursing leadership to evaluate effectiveness of tool in 3 months, July 2017, and they determined no adjustments to the tool were needed at that time. On 7/03/17, a badge system became required for both entrance and exit to the Dementia Specialty Care Unit. Changing the key pad access code was no longer required. Staff members had to physically go to the door and swipe their badge to allow anyone to enter or exit the unit. A camera is located on the edge of the counter near the entrance inside the unit to allow staff to monitor who is outside the entrance requesting access to the unit. A voice request by name is also in place to request entry to the unit. An electronic signaling device to include a security bracelet as part of a new wander management system was initiated based on the resident ambulatory evaluations. The electronic signaling device is a transponder that can be put on a resident's body, such as a wrist or ankle or a resident asset such as a walker, wheelchair or purse. Residents that had been identified as ambulatory of independently mobile in a wheelchair received the electronic signaling device. The residents' physicians were notified and orders were placed on each residents' chart to check for placement of the device every shift by the Unit Manager. Per manufacturer's specifications, the signaling device can be placed on a wheelchair, walker or person's body. On 8/31/17, the new wander management system was initiated. The new system included the resident's picture and name of the resident associated with the transponder. New transponders were placed on each resident that had previously had a bracelet under the previous system. The wander management system is a self-monitoring system that will alert via message on the screen on the centralized monitor on 100 and 300 units. Staff were given education on elopement and the new wander alert system during the week of 8/22/17, up until the initiation date of 8/31/17, by Information Technology and the Assistant DON/nurse educator. On 10/27/17, all 5 sampled residents #258, 307, 312, 314, and 21, were observed to be wearing security bracelets and ambulating with the use of their walkers. The residents security bracelets were verified to be working and were being checked every shift as evidenced by nursing signatures on the treatment record. On 10/26/17 and 10/27/17, designated staff of the Dementia Special Care Unit were observed to be strategically stationed directly facing the locked exit door of the unit to monitor who enters and exits the locked unit. A sign was observed outside above the call monitoring unit provided for anyone wishing to enter the unit. The sign indicated: For the Safety of Our Residents, Please Do Not Permit Anyone to Enter With You or Follow Behind You. On 10/27/17 at 1:07 PM, the Dementia Special Care Unit Manager provided a schedule of times/staff assigned to monitor the exit door and stressed the importance of monitoring during shift change and high traffic times. On 10/27/17 at 1:17 PM, CNA I was interviewed and stated staff is assigned to monitor the exit door of the Dementia Special Care Dementia Unit. The elopement care plans for all sampled residents were updated to reflect a designated staff to monitor the exit door to the secured unit during high traffic times of the day (i.e. many visitors, shift change). On 10/27/17 at 9:37 AM, The DON and Risk Manager indicated the topic of elopement and wandering has been a special focus of the QA committee since the elopement of Resident #1. Elopement is reviewed during weekly meetings. The QA Committee reviews all interventions to develop and/or revise individualized interventions to prevent future elopements. They have not had any residents elope since the elopement on 4/20/17.

Based on record review and interview, the facility failed to provide adequate supervision to prevent falls for 1 of 3 sampled residents reviewed for accidents (#230). The facility's failure to provide adequate supervision to prevent an avoidable fall resulted in actual harm. Resident #230 fell and sustained a fracture of the left femoral neck (left hip fracture) and the resident required surgical intervention. When the resident was readmitted to the facility after surgery, new fall prevention interventions were not initiated at that time. Findings: Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the New Admission Report Sheet for resident #230 dated 10/31/16 at 4:25 PM revealed information provided to the facility by the hospital nurse prior to admission. This form included documentation of resident #230's [DIAGNOSES REDACTED]. Hospital Admission Record dated 10/26/16, included resident #230 [DIAGNOSES REDACTED]. The hospital History and Physical revealed resident #230 was admitted on [DATE] after repeated falls with a compression fracture of the 4th thoracic vertebra located in the upper back. She had end-stage dementia and toxic, metabolic [DIAGNOSES REDACTED], acute onset confusion or delirium secondary to a UTI (<http://www.uptodate.com/contents/acute-toxic-metabolic-[DIAGNOSES REDACTED]-in-adults>). A Consultation Report dated 10/27/16 revealed resident #230 had 2 falls at home within the previous 4 days and she was taken to the hospital emergency room for evaluation. She was admitted after a computed tomography (CT) scan showed a thoracic fracture. A CT scan is an imaging method that uses x-rays to create pictures of cross-sections of the body (<https://medlineplus.gov/ency/article/ 0/htm>). The consultant physician report indicated resident #230 was not a candidate for surgery and she had a [DIAGNOSES REDACTED]. Kyphosis is an exaggerated curvature of the spine. (http://www.mayoclinic.org/diseases-conditions/kyphosis/basics/complications/con- 732). Review of the Patient Transfer Form used to communicate resident information upon transfer from one institution to another revealed a primary [DIAGNOSES REDACTED]. The form listed the reason for transfer as rehab, and falls was checked in the patient risk alerts section. Resident #230's Admission Screening,dated 10/31/16 at 11:09 PM, revealed Reason for admission from paperwork: Fall. The relevant history and [DIAGNOSES REDACTED].#230 had unsteady gait and confusion, but her history of falling or recent falls was omitted. The section for activities of daily living (ADLs) indicated resident #230 required assistance of staff for bed mobility, transfers, walking, toilet use and bathing. She was listed as independent with dressing, eating and personal hygiene. The mobility device listed was a walker, but the resident used a wheelchair and it was omitted. Other relevant [DIAGNOSES REDACTED]. Review of the facility's Fall Risk Evaluation, dated 10/31/16 at 9:11 PM revealed documentation of a fall in the month prior to admission. The fall was documented as .minor injury. The category of a minor injury included skin tears, abrasions, laceration, superficial bruises, hematomas or sprains. However, resident #230's admission paperwork from the hospital supported the category of major injury which included fractures. Resident #230's cognitive status was documented as moderately impaired, Frequently confused and disoriented; decisions poor; requires cues and supervision. Physical performance limitations indicated gait problems, but omitted musculoskeletal problems such as kyphosis. Internal risk factors omitted from the Fall Risk Assessment were anemia, visual impairment, cognitive impairment, other dementia and infection. Additional documentation regarding this resident's history of falling included information that she slipped and fell at home, sustaining a back injury when she attempted to get out of bed to go to the bathroom. The admission nurse recorded information received from resident #230's daughter regarding her mother's usual routine of getting up to go to the bathroom at 10:00 PM and 5:00 AM. As a result of this screening tool, resident #230 received a fall risk evaluation score of 21. A score of 0-12 is low risk, 13-19 is moderate risk and greater than (>) 20 is high risk for falls. The Minimum Data Set (MDS) 5-day scheduled assessment dated [DATE] revealed resident #230 had short-term and long-term memory problems. She had moderately impaired cognitive skills for daily decision making, made poor decisions and required cues and supervision. Resident #230 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. She was not steady during transitions and walking and was only able to stabilize with staff assistance. Admission performance of functional abilities and goals revealed resident #230 did not attempt walking .due to medical condition or safety concern. She did not have a toileting program and was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS admission assessment dated [DATE] revealed resident #230 had a Brief Interview of Mental Status score of 5, which indicated severe cognitive impairment. She now required extensive assistance of two people with transfers, was not steady during transitions, did not walk and had impaired range of motion of one leg. Resident #230's care plan read, I had a fall with minor injury, poor balance, poor communication / comprehension, psychoactive drug use, impulsive, confused was initiated on admission on 10/31/16. Interventions implemented on that date included Continue interventions on the at-risk plan .For no apparent injury, determine and address causative factors of the fall .Provide activities that promote exercise and strength building where possible. Provide one to one activities if bedbound .physical therapy (PT) consult for strength and mobility .Vital signs (every shift). On 11/02/16, the day resident #230 fell , the intervention Continuous Comfort rounds was added to the fall care plan, and the use of a walker was not addressed. The care plan I have impaired cognitive function/dementia or impaired thought processes related to Alzheimer ' s, Dementia was initiated on 10/31/16. Interventions on that date included Cue, reorient and supervise as needed .resident needs supervision/assistance with all decision making. On 12/08/16 at 10:32 AM, the director of nursing (DON) stated all newly admitted residents receive hourly monitoring for a 72-hour period during Comfort Rounds, regardless of a resident ' s level of risk for falls. Staff members document residents' activities and location on a form. She confirmed resident #230 scored >20 on the facility's fall evaluation tool, which deemed her at high risk for falls. The DON stated residents at high risk should receive constant monitoring but she could not provide any details regarding how resident #230 received constant monitoring. When asked how the data gathered to determine the level of risk was used, the DON responded the level of monitoring associated with the level of fall risk is not defined. The DON could not provide the specific items included in the falls care plan instruction to continue interventions on the at-risk plan. She stated resident #230 did not meet criteria for the higher risk plan anyway because she had a prior fall with minor injury. The DON stated documentation of prior fall with major injury would have triggered a more detailed care plan. She failed to acknowledge the thoracic fracture as a major injury. Review of the Physical Therapy Plan of Care revealed resident #230 was evaluated and treated by a physical therapist (PT) on admission to the facility on [DATE]. The initial assessment findings indicated resident #230 needed moderate assistance with bed mobility, transfers and positioning. She could walk 50 feet with a 4-wheeled walker with minimal, or 25%, physical assistance. Underlying impairments included resident #230 was unable to maintain balance while turning head/trunk, was 4 times more likely to fall and had moderate kyphosis. The treatment [DIAGNOSES REDACTED]. The plan of care developed by the PT included Gait training .for balance safety throughout the gait cycle. Review of the Occupational Therapy Plan of Care revealed resident #230 was evaluated on 11/01/16. The Initial Assessment indicated she needed moderate, or 26-75%. physical assistance with transfers and moderate assistance of 2 people for sitting to standing mobility. Resident #230's underlying impairments included severe, cognitive impairment. In an interview on 12/06/16 at 4:07 PM, resident #230's daughter stated her mother was admitted to the facility on [DATE] for rehabilitation. The daughter said she was informed on 11/02/16 that her mother fell , was having knee pain and x-rays were ordered. The x-rays revealed a left hip fracture and the resident was transferred to the hospital for surgery. Resident #230's daughter stated the assistant director of nursing (ADON) informed her that her mother was left unattended in her room after PT. The daughter stated on admission she shared some specific details about her mother ' s habits with the admission nurse and the assigned 3:00 PM - 11:00 PM shift nurse that her mother needed to be toileted at night before bed and again early in the morning. She also emphasized that her mother had dementia, probably would not use the call light before attempting to get up or go to the bathroom. The daughter explained the medical record from the hospital included her mother's history of dementia, UTI and her falls at home. On 12/07/16 at 2:20 PM the ADON stated on 11/02/16 she observed resident #230 in the hallway, coming around the corner with a 4-wheeled walker without staff assistance. In the interview ADON stated the time might have been 11:45 AM, but she was unsure of the time. She fell about 20-25 feet from her room door. The resident asked her for directions to the salida or exit. The ADON stated she did not know if the person was a resident or a visitor and signaled to the nurses at the end of the hallway for information. The ADON stated her back was to the resident and when she turned around she observed resident #230 on the floor. She said the resident was approximately 20-25 feet from her room. The ADON explained that residents do not have interim care plans, rather, the facility opens full care plans on admission. She said these initial care plans are standardized for all residents at risk for falls and are reviewed, updated, and individualized after monitoring is completed. In an interview on 12/07/16 at 2:39 PM licensed practical nurse (LPN) F stated she was the assigned nurse for resident #230 on the day she fell and fractured her hip, 11/02/16. LPN F stated someone told her resident #230 was a fall risk, but she couldn't recall who gave her the information. LPN F stated she did not have a chance to review the care plan before attending to resident #230. In change of shift report on 11/02/16 she was told resident #230 was ambulatory, but had not been assessed by therapy yet although PT documentation revealed resident #230 was evaluated on 10/31/16. LPN F stated resident #230 should not have been up walking since staff would not know the level of assistance needed for safe transfer and ambulation with the walker. LPN F stated resident #230 was in bed at the start of the shift, and when she saw her on the floor at the end of the hallway, her first thought was Where did she get the walker? LPN F stated resident #230 should not have been walking without staff assistance. On 12/07/16 at 2:50 PM certified nursing assistant (CNA) G, resident #230's 7:00 AM to 3:00 PM shift caregiver stated she received information on new residents in verbal report from other CNAs and nurses. In addition to verbal report, she said that there is a CNA care plan or Kardex. CNA G stated she was not told resident #230 was at risk for falls when she was assigned to care for resident #230 on 11/01/16 or 11/02/16. CNA G stated she did not check the Kardex to access information and instructions on this resident's needs on either 11/01/16 or 11/02/16 when she was assigned to care for resident #230. CNA G stated she checked resident #230 for Comfort rounds and documented her activity and location on the checklist. She recalled resident #230 remained in bed for most of her first morning in the facility. She explained resident #230 was very weak and needed max assist for transfers. CNA G stated she gave report to the on-coming shift CNA that resident #230 could stand and transfer. She did not tell the on-coming CNA that this resident was a fall risk. CNA G shared on the morning of 11/02/16 resident #230 attempted to get out of bed without assistance, so she got her cleaned up, dressed and put her in the wheelchair and left her in the room. CNA G stated she saw the physical therapy assistant (PTA) leaving the unit with resident #230 but could not recall the time. CNA G stated she did not know what time the resident came back to her room or who delivered her lunch tray in her room. CNA G stated she returned from her lunch break after 1:00 PM and was told that resident #230 fell . On 12/07/16 at 5:35 PM CNA H stated she was assigned to care for resident #230 on admission. CNA H stated resident's daughter was present and explained her mother was confused, so the CNA decided to implement the intervention of bed in low position although she was not instructed to do so by a nurse. CNA H stated she did not usually check the Kardex for care instructions and precautions, rather depended on nurses to provide necessary information. CNA H stated she felt residents at risk for falls should be in the day room until bedtime so that they could be supervised closely. On 12/07/16 at 3:06 PM, the unit manager (UM) stated the admission assessments done by nurses included a fall risk evaluation for every resident. Information is passed on in verbal and written forms, and her expectation is that nurses review care plans and CNAs review Kardexes prior to working with newly admitted residents. The UM said all residents received comfort rounds or hourly monitoring for 72 hours after admission, regardless of fall risk. She said comfort rounds consisted of staff members checking where residents were and what they were doing, for example, eating, participating in therapy, offered toileting, or sleeping. She explained there were no specific interventions for residents assessed to be at high risk for falls, but she verbalized participation in group activities or staying by the nurses ' station would be encouraged during daytime hours to promote safety. Review of the Comfort Rounds Checklist for resident #230 revealed documentation was incomplete and inaccurate. There was no documentation of hourly rounds during the 11:00 PM - 7:00 AM shifts on 10/31/16 and 11/01/16. Comparison of the Comfort Rounds Checklist with Daily Interaction Form for OT and PT revealed documentation on 11/01/16 by CNA for therapy activity at 4:00 PM and 5:00 PM, but OT documentation revealed resident #230 received services from 6:19 PM to 6:33 PM. Comfort rounds documentation by CNA E for 11/02/16 revealed resident #230 was in bed at 7:00 AM, eating and offered toileting at 8:00 AM and in the chair at 9:00 AM. However, Physical Therapy documentation revealed resident #230 was off the unit and receiving therapy services from 7:10 AM to 8:26 AM. In addition, resident #230's activity was listed as IC (in chair) and T (therapy) at approximately 1:00 PM when UM reported resident was in her room and CNA E stated she was on her lunch break. On 12/07/16 at 5:47 PM, registered nurse (RN) I stated she did the admission screening for resident #230. RN I explained that she gathered data from verbal report from the hospital nurse, interview with the family, the Patient Transfer Form, the history and physical and other documents received from the hospital at the time of transfer. She confirmed the fall risk evaluation should have reflected resident #230 had a fall with major injury, instead of minor injury as indicated. Further interview with RN I on 12/08/16 at 3:37 PM revealed she received information from resident #230's daughter regarding her mother's confusion and pattern of getting out of bed at night. RN I stated she initiated the care plan for falls on 10/31/16 and gave verbal report to the assigned 3:00 PM - 11:00 PM CNA and nurse, and the on-coming 11:00 PM - 7:00 PM night supervisor. She informed them resident #230 needed to be offered toileting at 10:00 PM and 5:00 AM. RN I confirmed this information was not on the nursing care plan and therefore was not transferred to the CNA Kardex. On 12/08/16 at 9:14 AM, RN J stated resident #230 was assigned to her on admission, but the evening supervisor did the admission assessment. RN J stated she usually reads the Patient Transfer Form for information on new residents, and if she has time, she reviews assessments. RN J did not recall resident #230 getting a PT evaluation, nor did she recall any conversation with a therapist on 10/31/16. She stated she was aware the resident was at high risk for falls due to dementia and taking an antipsychotic medication, Seroquel. She said that resident #230's daughter explained her mother was confused and would get up at 3 or 4 in the morning to go to the restroom, and asked her to pass it on to the night shift. RN J stated whenever she had a resident at risk for falls she would keep him or her at the nurses' station or have alternating CNAs sit with the resident until the resident was sleepy or ready to go to bed. RN J stated she was not aware of any individualized interventions used by the facility for residents assessed to be at high risk for falls. An interview with the PT on 12/08/16 at 8:59 AM revealed resident #230 was evaluated within an hour after initial admission. The PT determined resident #230 was a fall risk and documented this on her therapy plan of care under precautions. The PT explained resident #230 was admitted status [REDACTED]. During the evaluation resident #230's daughter was present, and the resident followed commands with the daughter cueing and providing visual demonstration. The resident ambulated 50 feet with the walker as the PT was holding the gait belt and pulling the wheelchair behind her. She did not ambulate independently at this time. Upon returning to the resident's room, the PT said she told the CNA that resident #230 needed moderate assistance with transfers. She said she did not discuss the resident's care with any other caregivers at that time. The PT stated she would not leave the resident alone because she was at high risk for falls and was not safe walking with the walker without staff assistance. When asked if she would leave the resident alone in a room during therapy, the PT stated she would not take her eyes off resident #230 because she could attempt to ambulate or transfer without assistance and fall. On 12/08/16 at 8:42 AM, the PT Assistant (PTA) stated she worked with resident #230 on 11/01/16 and 11/02/16. The PTA explained she followed the therapy plan of care which included fall precautions. She stated resident #230 was unsteady and required hands-on assistance when ambulating, so a gait belt and wheelchair were used. On the morning of 11/02/16, the PTA said she told the nurses she wanted to take resident #230 for therapy. She stated this is done by all therapists to verify if residents were clear to leave the unit and that all medications were given. After therapy, the PTA returned resident #230 to her room and she said she informed a CNA of the resident ' s return to her room, but she could not identify the CNA. The PTA was unable to give the time, but stated this was way before lunch time. Review of nurses' progress notes revealed on 11/01/16 at 3:00 AM, resident #230 was trying to get out of bed, and taken to sit in the television room with staff. The documentation did not include any toileting at that time. Change of Condition note dated 11/02/16 at 1:30 PM revealed resident #230 had a change of condition at 1:10 PM, She was walking down the hall with the walker, unsteady gait and unable to use walker independently. She fell and complained of left hip and knee pain. The note indicated staff involved was a nurse and there were no witnesses. On 11/02/16 at 8:22 PM x-ray results showed a possible femur (hip) fracture. physician's orders [REDACTED]. The facility's Transfer/Discharge Report documented the chief complaint as suspicion for a distal femoral fracture. Review of progress notes revealed resident #230 was re-admitted to the facility on [DATE] at 3:45 PM with a [DIAGNOSES REDACTED]. Review of the fall care plan on re-admission after the fall with major injury revealed no new interventions were initiated for this resident from readmission between 11/07/16 and 11/14/16. On 11/13/16 at 8:35 PM, resident #230's daughter informed staff her mother and her mother's roommate reported the resident fell on the previous weekend. A change in condition note dated 11/14/16 at 11:37 AM revealed roommate observed resident #230 get out of bed and slid to the floor when trying to go to the bathroom on Friday or Saturday night. On 11/14/16 a 3-day bowel and bladder program was documented on the care plan. Ten days later, on 11/24/16, the care plan for falls included instructions for nursing staff to Toilet resident as needed during the day, at bedtime, 10PM and 5AM. Review of the CNA Kardex Task List Report revealed interventions initiated on 11/24/16 to toilet resident as needed during the day, 10PM and 5PM and Monitor-safety check every hour. This information on resident #230's toileting needs was provided by the daughter on initial admission on 10/31/16, and documented on the fall risk assessment. However, it was not included as an intervention on an individualized care plan or implemented to meet resident #230 ' s toileting needs until after the report of a second fall. On 12/07/16 at 8:54 AM, CNA E, who was currently assigned to care for resident #230 that day, stated resident #230 was confused and staff had to keep an eye on her because she will try to get up. She stated the resident had to stay in the wheelchair. CNA E explained she never left resident #230 in her room alone because she may get out of the wheelchair and fall. She said resident should stay in common areas or hallways during the day. Review of facility policy and procedure for Care Plans-Preliminary revealed 1 to assure that the resident's immediate care needs are met and maintained, a preliminary care plan is developed upon admission. 2. The interdisciplinary team reviews the attending physician's order [REDACTED]., diet, medications, treatment, etc), and implements a nursing care plan to meet the resident ' s immediate care needs Review of the facility ' s policy and procedure for Fall Management updated 11/14/2012, read Residents are evaluated for fall risk and when indicated, fall reduction measures are initiated Residents will be evaluated upon admission for fall risk. Residents found to be at risk, will have appropriate interventions initiated Post Fall Evaluation will be completed after each fall incident, with appropriate interventions implemented as indicated. Review of the interventions on the facility's High Risk Plan revealed comfort rounds for 3 days to determine behavior patterns and individual needs for all new residents, regardless of the level of fall risk. The High Risk Plan's Additional Fall Intervention List revealed detailed instructions and approaches to ensure residents' safety and decrease the potential for falls. The list included monitoring toileting needs, behaviors, need for activities, activities of daily living schedule, out of bed schedule, providing low bed, assisted devices e.g. wedge cushion and monitoring assistive devices used. Review of the fall reduction program called Falling Leaf Program revealed high risk residents were identified by a leaf outside the room or on assistive devices, and staff were educated to ensure residents did not attempt to stand or transfer by themselves. Criteria for inclusion in that program was identification as at high risk for falls with major injury on the admission fall assessment and/or having a new fall with additional medical concerns such as osteoporosis, osteopenia or anticoagulant therapy. Review of the medication administration report (MAR) for November 2016 revealed resident #230 was readmitted after her hip fracture with orders for Alendronate Sodium 70 milligrams (mg) once weekly and Rivaroxaban 10mg once daily. Alendronate is a drug used to treat osteoporosis and Rivaroxaban is an anticoagulant or blood thinner (www.drugs.com <http://www.drugs.com>). Resident #230 was not placed on the Falling Leaf Program on initial admission or after readmission on 11/07/16 after the hip fracture. Despite the facility's fall evaluation finding that resident #230 was at high risk for falls, detailed information provided by her daughter, and numerous references were present in the medical records regarding [DIAGNOSES REDACTED].#230's individualized needs and risk factors on initial admission and re-admission.

Based on interview and record review, the facility failed to monitor and manage behaviors for 1 of 4 residents reviewed with behaviors of 38 sampled residents (#81). Resident #81's behavior was not addressed and resulted in angry and violent behavior in which he received injuries to his arms as he had to be placed in handcuffs and taken out of the facility by police. The failure to address resident #81's behavior led to an escalation of behaviors that resulted in a resident to resident altercation, in which resident #81 and his roommate, resident #73 required transfer out of the facility. Findings: Cross reference to F250 1. Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE] assessed the resident on cognition on the brief interview for mental status (BIMS) score as 5 on a total score 0-15. A score of 5 indicates severe cognitive impairment. The resident was assessed with [REDACTED]. There was no behavior or mood care plans since there was no mood or behaviors identified on the initial assessment period. The resident was ordered on the following medications: [REDACTED]. 1 capsule daily ordered on [DATE]. Both of the medications are for dementia. The other medication was [MEDICATION NAME] 10 mg. 1 tablet daily ordered on [DATE] for depression. A review of the nurses' notes dated 6/24/14 revealed; "the resident was extremely aggressive and violent tonight. I was alerted by staff and other residents that the resident was fighting with roommate, resident #73, I went into there and the resident was upset and then began trying to chase me and hit me with his cane. Another female resident tried to tell me what happened during the initial confrontation and then he charged at her and I had to restrain him from hitting her. He then charged at several certified nursing assistants (CNAs) and tried to hit them with his cane as well. He threatened that he would kill his roommate later tonight. I phoned the nurse supervisor and she told me to let him calm down somewhere. I told her that I did not think it would work and feared for everybody's safety over here and suggested to her that his room be changed. I moved him to room [ROOM NUMBER] with another resident for that night and she advised that they would deal with him tomorrow." On the next 2 days, 6/25/14 and 6/26/14, there was no documentation that the resident ' s behavior was monitored or reported to the unit manager, social worker, or risk manager/abuse coordinator. There was no documentation of why the resident #81 made the statement about his roommate, resident #73. The physician was not notified of the incident and the sudden change of behavior when it occurred. There was no assessment conducted or investigation to find out the root cause of the outburst and implement a new plan of care to ensure the behavior did not escalate again. The next entry in the nurses ' notes was dated 6/27/14, documented by the same nurse who documented on 6/24/14, revealed "I came in today and noticed resident #81 was put back in his room with resident #73 even after they were involved in a fight on Tuesday. Around 7:15 p.m. the CNA yelled for me that he was attacking resident #73 again in the room. I went in to find both men sitting on their bed breathing hard and obviously agitated. I asked resident #73 what was going on and he told me that resident #81 had whacked him several times with the cane. The CNA was unable to remove the cane from resident 81. . . " In an interview with the ADON on 7/02/14 at 3:15 p.m., she clarified that a CNA was in the room with both residents and attempted to get the cane away from resident #81, but was unsuccessful. Nurses notes from 6/27/14 indicated the police were called via 911. When they arrived, resident #81 began fighting with the police. He raised his fist to strike the police and he was placed in handcuffs and was taken to the hospital for involuntary examination of his mental status. Review of the report of the law enforcement initiating involuntary examination indicated the resident battered another resident, referring to resident #73. During the altercation with the police, resident #81 sustained bruises and skin tears on bilateral arms and wrists. In an interview with the SW on 7/02/1`4 at 2:30 p.m. she stated that she decided to transfer the resident on 6/23/14 from a locked unit, wing 200 dementia unit, because he was not showing behaviors that required him to stay on the dementia specialty unit at that time. The resident was transferred from room the 200 wing to the 100 wing on 6/23/14 at 3:00 p.m. The SW stated her decision to transfer resident #81 off the 200 wing was due to the resident being agitated because he was in a room with three other residents and a female resident wanders into his room and lies on his bed. The SW said, on the locked unit, he had no exit seeking behavior, he prefers to stay in bed in his room, and he was more appropriate for a calmer unit. The SW decided that resident #73 was the most appropriate room mate because he had no behaviors and was pleasantly confused. The decision to transfer the resident was made by the SW without an assessment from the interdisciplinary care team to determine if he was appropriate to have a room change and to be placed on wing 100. On 6/23/14 the SW documented on the "room change documentation" form that the resident will be transferred from a room on the 200 wing to the 100 wing on this date as resident not showing behaviors which requires the dementia specialty unit. Contrary to what the SW stated and documented for the reasons of transfer to the 100 wing, the following documentation was found in the nurses' progress notes when he was in the locked unit 200 wing: Nurses' notes dated 4/18/14 described the resident as alert with confusion. Observed crying and upset about not being able to go home. The resident was redirected several times to his room. On 5/20/14, "Resident had 2 episodes of anxiety, once with therapy and with restorative staff, refused to go with them and he threw his cane." On 5/28/14 the resident became agitated when his room was being cleaned and when was not able to lay down, he started to yell. When the nurse talked to him, he started to swing his cane, spit, and used profanity. On 6/20/14 the resident became agitated and had an altercation , staff failed to document description of incident. On 6/22/14, "the resident suddenly became angry throwing his cane- he then started swinging cane after picking it up-this happened twice- and he stated, I am going to get a gun and shoot myself- I am nothing but trouble." In an interview conducted with the social worker (SW) and the risk manager (RM) on 7/02/14 at 2:30 p.m., they both indicated they were not aware of the first incident of aggression by resident #81 on 6/24/14. They said they only found out about it on 6/30/14, after the resident was sent out to the hospital on [DATE] when he was taken by the police for involuntary examination. In an interview on 7/02/14 at 3:00 p.m. with administrator, DON, ADON, RM/abuse coordinator, unit manager for wing 100, and the CNA who witnessed the aggressive behavior of resident #81 on 6/24/14 they confirmed the events of 6/24 and 6/27/14. The confirmed the facility had not initiated an investigation or assessment of resident #81 ' s behaviors due to the fact the events were not reported until 6/30/14 to the administrator , abuse coordinator, or the physician, instead of when they occurred. Facility staff were aware of the resident ' s aggressive behavior staring on 4/18/14 and did not implement measures to prevent the continued behavior and escalation of behavior that required the resident to become upset and aggressive and he had be removed from the facility in handcuffs.