Every finding on record at Johnson County Health and Rehab, LLC

Based on record review and interview, it was determined that the facility failed to ensure staff followed a care planned intervention while performing a transfer for one (Resident #113) of six residents reviewed.The findings include:A review of an admission Record revealed the facility admitted Resident #113 on 06/30/2025 with diagnoses which included acute and chronic respiratory failure, damaged or enlarged air sacs in the lungs, lung disease that blocks air flow making it difficult to breathe, urinary tract infection, and disorders of the skin and subcutaneous tissue.A review of an admission Minimum Data Set (MDS) with Assessment Reference Date of 07/06/2025, revealed Resident #113 had a Brief Interview for Mental Status score of 12, which indicated Resident #113 had moderate cognitive impairment. The MDS also revealed Resident #113 required substantial or maximum assistance with transfers.A review of a Care Plan with initiation date of 07/08/2025, indicated Resident #113 required a mechanical lift for all transfers. The Care Plan also revealed Resident #113 was to be evaluated and treated by Physical and Occupational Therapy per Physician Orders.A review of Physician Orders with an order date of 07/03/2025 revealed Resident #113 was to have a mechanical lift for all transfers.A review of an Incident and Accident (I&A) Report dated 07/29/2025 at 3:31 PM, revealed two Medication Aides (MA-C), MA-C #1 and MA-C #2, reported to the nurse that they went to obtain a weight on Resident #113, did not read the Care Plan, and did not use the mechanical lift for the transfer. The I&A indicated that the MA-Cs had to lower the resident to the floor and that the resident did not sustain any injuries. The I&A also indicated vital signs were obtained, the resident's family and the Advanced Practice Registered Nurse (APRN) were notified of the incident.A review of a Progress Note dated 07/29/2025 at 7:13 PM, revealed Resident #113 was transferred by MA-C #1 and MA-C #2, without using a mechanical lift, the resident was unable to help with the transfer, and was lowered to the floor. The progress note revealed that the MA-Cs did not review the Closet Care Plan prior to the transfer and the resident had recently been changed from two-person assistance to a mechanical lift for all transfers.A review of an I&A follow up progress note completed by the Director of Nursing (DON) dated 08/06/2025 at 8:54 AM, revealed that MA-C #1 and MA-C #2, were attempting to obtain a weight on Resident #113. The two MA-Cs attempted to transfer Resident #113 by two-person assistance and had to lower the resident to the floor. The progress note revealed MA-C #1 and MA-C #2 did not review the Care Plan prior to the incident.During an interview on 08/05/2025 at 8:15 AM, Resident #113 stated they had been transferred without the mechanical lift and fell. Resident #113 reported they were sore, but no injuries were sustained.During an interview on 08/06/2025 at 10:12 AM, Physical Therapist #3 revealed Resident #113 did not have the strength and was too weak to stand at that time but was receiving therapy for strengthening.During an interview on 08/06/2025 at 1:05 PM, MA-C #1 revealed that she and MA-C #2 had not reviewed the Care Plan prior to transferring Resident #113. She reported she had recently transferred Resident #113 prior to this incident and the resident was not lifted with a mechanical lift, she was unable to give the exact date of transfer at that time. MA-C #1 reported, she and MA-C #2 sat Resident #113 up on the side of the bed and stood Resident #113 to turn them to the wheelchair. The resident was unable to pivot, and they lowered the resident to the floor. MA-C #1 revealed they did not use a gait belt, and that they placed one arm under each of the resident's arms to transfer them. MA-C #1 also revealed that the nurse was immediately notified of the incident and no injuries were observed. MA-C #1 also reported that she did not have a gait belt, because she did not transfer that often. MA-C #1 revealed that it was important to review the Closet Care Plan prior to providing care because the Care Plan indicated how to transfer, toilet, and take care of the resident. She also revealed that she had an in-service about Closet Care Plans and received a verbal warning for not reviewing the Care Plan prior to transferring Resident #113.During an interview on 08/06/2025 at 1:14 PM, MA-C #2 reported to this surveyor, that was the first time providing any type of care to Resident #113 besides giving them medications. MA-C #2 revealed that she did not look at the Closet Care Plan prior to the transfer of Resident #113. MA-C #2 reported that she relied on MA-C #1's guidance on how to transfer the resident. MA-C #2 revealed they did not use a mechanical lift for the transfer. She reported that they under armed Resident #113 and did not use a gait belt. The resident's legs started to give out and they lowered the resident to their knees. No other part of the resident touched the floor. MA-C #2 revealed that the nurse was immediately notified and there were no injuries observed. MA-C #2 revealed that she received a verbal in-service from the DON to check the Closet Care Plan prior to providing care to a resident. MA-C #2 also revealed that it was important to review the Closet Care Plan prior to providing care because it provided information regarding resident safety, information to help avoid falls and indicated how to care for the resident.During an interview on 08/06/2026 at 1:57 PM, the DON revealed that no in-service documentation could be found about the change in Resident #113's transfer status.During an interview on 08/06/2025 at 1:59 PM, the MDS Coordinator revealed that she normally put out an in-service when there was a transfer status change in the Certified Nursing Assistant (CNA) book to update the staff. She revealed that she could not find the in-service. She also revealed the proper way to transfer a resident was to use a gait belt. The MDS Coordinator stated she updated the Closet Care Plans and Care Plans sometimes daily and that they were constantly changing. The MDS Coordinator revealed that she was the one responsible for the changes. The MDS Coordinator stated she kept a master copy and put a copy of the Closet Care Plan out for the staff to review which was in the closet of each resident's room. The MDS Coordinator also indicated Resident #113 was changed to a mechanical lift for all transfers, and a lift Sling Size Assessment was completed on 07/03/2025.During an interview on 08/06/2025 at 3:06 PM, the DON revealed that staff should always review the Closet Care Plan prior to providing care. She also revealed that the MA-Cs should have used a mechanical lift for the transfer and to obtain the resident's weight. She stated, it is important for the Care Plan to be reviewed to ensure resident safety. During an interview on 08/07/2025 at 8:55 AM, Medical Records, who was filling in as the Administrator, revealed that the Closet Care Plan should be reviewed prior to care being provided. She stated that it was important to review the Care Plan because they could change daily and the staff were responsible for providing care according to the Care Plan. She also stated that if the staff did not follow the Care Plan or Closet Care Plan it could result in a fall or a major injury.

Based on observation, record review, and interviews, the facility failed to ensure residents were free from elopement for 1 (Resident #1) of 3 sampled residents reviewed for elopement risks. Specifically, Resident #1 was admitted on [DATE] with diagnoses of dementia and psychotic disorder and was severely cognitively impaired. When the resident exited the facility an alarm sounded, and within one minute, an office aide turned the alarm off. The office aide did not notify any other staff that the alarm had sounded and continued working. On 02/28/2025 at 08:06AM, staff confirmed Resident #1 eloped by video, called a Code Green, and notified the Administrator. At 08:26AM the Certified Nursing Assistant (CNA) Supervisor located Resident #1 at a park, 1.25 miles away, and returned Resident #1 to the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 at a scope and severity of J. The IJ began on 02/28/2025 at 07:38AM, when Resident #1 eloped from the facility, and an office aide turned the alarm off and did not notify any other staff that the alarm had sounded. The Administrator was notified of the past noncompliance (PNC) IJ on 03/12/2025 at 1:46 PM. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey, thus it was determined to be a Past Noncompliance citation. Findings include: Review of a policy titled, Elopement and Wandering, revised 11/12/2017, revealed all employees are trained about elopement on hire and annually, and all employees were responsible for immediately reporting any suspicion or attempt of resident elopement to the charge nurse or Director of Nursing (DON). Review of the admission Record revealed Resident #1 admitted to the facility on [DATE] with diagnoses of dementia, delirium, and brief psychotic disorder. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/2024 revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Review of the Order Summary Report indicated on 11/01/2024 Resident #1 had an order for an antipsychotic 25mg (milligrams) tablet twice a day. On 01/08/2025, the antipsychotic was reduced to 25mg at bedtime, reduced to 25mg, 0.5 tablet on 01/20/2025, and discontinued on 01/27/2025. Review of Resident #1's Care Plan, dated 11/19/2024, revealed Resident #1 was at risk for elopement, with interventions to offer pleasant diversions, food, activities, television, and conversation. Resident #1 was at risk for falls, and on 12/23/24 had an unwitnessed fall, with an intervention to toilet every two hours. A review of the Nursing Admit Readmit Quarterly Assessment, dated 02/06/2025, section M2, revealed Resident #1 had a diagnosis of dementia, did not wander, and was able to follow direction. An elopement risk assessment for Resident #1 revealed a score of 9, indicating the resident was at risk to wander. A review of the Nursing Elopement Risk with Care Plan revealed on 02/28/2025 Resident #1 had a history of wandering, a diagnosis of dementia, had eloped from the facility, and had an elopement risk assessment score of 13, which indicated the resident was at high risk for elopement. A review of the Soc/Act Social Services Resident Room Change, effective date 2/20/2025, indicated on 02/20/2025 Resident #1 was moved from the closed unit to 100 [NAME] Hall. On 02/28/2025 at 07:38 AM, a facility video of the front door showed Resident #1 approaching the door, pressing the release bar of the door until the door opened, setting off an alarm. Resident #1 was visible on video exiting the front door. On 02/28/2025 at 07:39 AM, the Office Aide was seen on video walking to the front door, turning off the alarm, and glancing out the front door through the glass before walking to the front desk, sitting down, and picking up a cellphone. On 02/28/2025 at 07:41 AM, the Office Aide took a telephone call on the facility phone, with the call ending at 07:42 AM. The Office Aide walked from behind the desk and to the window on the right side of the lobby. On 02/28/2028 at 07:42 AM, the Office Aide walked to the front entrance and exited the building. On 02/28/2025 at 07:43:59 AM, the Office Aide walked back into the building and sat at the front desk. On 02/28/2025 at 07:44 AM, the Office Aide picked up a cell phone and looked toward the front entrance. Review of the (named area) Communications dispatch call log showed on 02/28/2025 at 08:23:36 AM, a call was received from Licensed Practical Nurse (LPN) #3 reporting an older resident (Resident #1) had gotten out of the facility and was walking toward the hospital, description given. Resident #1 left the facility at 07:38 AM. At 08:26:30 AM, LPN #3 advised the dispatcher Resident #1 had been found. At 08:27 AM, police units were advised Resident #1 had been found. In an interview on 03/10/2025 at 04:49 PM, Resident #1 confirmed the resident left the facility unsupervised, but did not remember when or why the resident left. Resident #1 reported the resident just went for a long walk. On 03/11/2025 at 08:30 AM, the Maintenance Director provided Weekly Exit Door Inspections since January and indicated the front door was in good working condition. He revealed that the front door would open if the door bar was held down for 15 seconds. In an interview on 03/11/2025 at 10:35 AM, the Office Aide stated on 2/28/2025 she rushed from the bathroom because she heard the front door alarm, turned off the door alarm, looked out the windows, the side first then the front windows, and did not see any residents, went to the desk and answered the facility phone. The Office Aide said that she failed to tell staff the door alarm went off so they could count residents and failed to notify the Director of Nursing (DON) or Administrator right away. The Office Aide revealed a family member had previously informed her Resident #1 was a wanderer. The Office Aide revealed she was in-serviced on elopement when she was hired, and with yearly competencies. In an interview on 03/11/2025 at 11:00 AM, the CNA Supervisor stated on 2/28/2025 Resident #1 left the building without supervision. CNA #8 told the CNA Supervisor Resident #1 could not be located. The CNA Supervisor and CNA #8 searched 100-Hall, East and [NAME] side of the building, and were unable to locate Resident #1. The CNA Supervisor notified the DON and called a Code Green for elopement. The CNA Supervisor stated she got into her car and drove away from the facility to search for Resident #1 and located Resident #1 walking near the ballfields at (specific location) Park, approximately 1.25 miles away from the facility. The CNA Supervisor described Resident #1 as being exhausted, dragging, and easily directed into her car to return to the facility. The CNA Supervisor said facility policy was not followed, when the alarm was turned off and no notification was made to other staff in the building so all residents could be accounted for. On 03/11/2025 at 12:45 PM, the surveyor reviewed front door video with the Administrator. The Administrator identified Resident #1, wearing a red beanie, pressed down on the bar of the door until it opened, and the alarm sounded. The Administrator identified the Office Aide, who walked to the front door and turned the alarm off, returned to the desk, picked up her cellphone, and answered the facility phone. The Administrator stated when she pulled up to facility at 08:06 AM and staff called and told her Resident #1 had left the building, she immediately searched the grounds, and went to the back of the facility because there is a large drop off to the rear of the building and she wanted to check for herself that Resident #1 had not fallen at the drop off. The Administrator stated the facility failed when the Office Aide turned off the alarm and did not physically go outside and look immediately to see if a resident went out the front door. The Administrator revealed walking down the road between the facility and (the park where Resident #1 was found) was a concern because of traffic. The Administrator was not sure if any waterways were between the facility and (the park), and confirmed staff were in-serviced for elopement on hire, and with a yearly in-service. During a second interview on 03/11/2025 at 1:15 PM, the Office Aide said that it took her about one minute to get to the front door, and if someone was at the nurse's station it would show them what door was alarming. I glanced out the front glass doors and did not see anyone. The Office Aide stated that after talking on the phone she thought two minutes had passed and went outside to check more thoroughly. The Office Aide did not see anyone and came back inside the facility. The Office Aide did not notify the staff, charge nurse, DON, or Administrator of the alarm sounding. In an interview on 03/11/2025 at 01:30 PM, LPN #3 confirmed Resident #1 resided on [NAME] Hall, and stated she was notified by CNA #8 that Resident #1 could not be located. LPN #3 checked around the building, could not find Resident #1, and called the police. LPN #3 stated the [NAME] nurse ' s station panel did not have an indicator for the front door alarm. LPN #3 stated if an alarm was heard, LPN #3 would check the panel to see what door it was and would turn off the alarm if a resident was not observed outside the facility glass door. LPN #3 stated she would not go outside to check because in the past staff set the alarms off taking too long to put in the code, or when taking residents out to smoke. The surveyor asked LPN #3 to confirm when an alarm went off, she would turn it off and would not have gone outside to look around because staff were setting off alarms taking too long to put in the code, and when taking residents out to smoke, which LPN #3 confirmed. LPN #3 stated training was provided yearly on elopement. In an interview on 03/11/2025 at 01:49 PM, LPN #7 stated the front door alarm sounded on the East panel and confirmed Resident #1 left the building unsupervised on 02/28/2025, that she did not hear the alarm sound, but may not have been at the nurse's station to hear the alarm. In a phone interview on 03/11/2025 at 04:18PM, CNA #8 revealed that she was familiar with Resident #1 and confirmed the resident eloped on 02/28/2025. CNA #8 said that Resident #1 was a good eater and the morning of 02/28/2025 she noted that Resident #1's breakfast tray was still on the rack. She looked in the bathroom and started searching for the resident. Resident #1 was not in the dining room, and she became concerned and started asking everyone to please help her look for him. Housekeepers #9 and #10 thought Resident #1 had gone to smoke. We looked everywhere, and a Housekeeper and I went out the front door and split up and ran around the building, but did not find (Resident #1). I heard someone call Code Green, and it was not long after Resident #1 was found and returned to the facility. Resident #1 was described as very tired when (the resident) came back, walking slower than usual, and staff got a wheelchair and took Resident #1 to the locked unit. On 03/12/2025 at 08:27AM, Housekeeper #9 said she was aware Resident #1 left the building without supervision. She said Resident #1 left (the resident's) room that morning and said (the resident) was leaving and would see us later, I assumed (pronoun) went outside to smoke. Housekeeper #9 said she was in-serviced on elopement a few weeks ago when she was hired, and after the incident. In an interview on 03/12/2025 at 08:29AM, Housekeeper #10 revealed she was training Housekeeper #9 on 2/28/25 and saw Resident #1 come out of the resident's room and was given permission to clean resident's room. Resident #1 said (the resident) was leaving and I assumed (pronoun) was eating breakfast or smoking. Had the resident said (the resident) was leaving the facility Housekeeper #10 said she would have notified the nurse. Housekeeper #10 confirmed everyone was in-serviced about elopement on hire, after the incident, and with yearly competencies. On 03/12/2025 at 11:40 AM, the Administrator provided a missing in-service signature sheet dated 2/28/2025. The Administrator said that she and nursing immediately started educating everyone in the facility, the morning of 02/28/2025 and calling staff to come be in-serviced. She revealed that signatures were done over second and third shift with the help of nursing services, suggesting an end date of 03/01/2025. The Administrator provided a copy of in-services on Code Green dated 02/28/2025. On 3/12/2025, the route Resident #1 followed to travel from the facility to the park where the resident was found was examined by the surveyor. Resident #1 would have traveled approximately 3,588 feet westward on Arkansas Highway 123, passing a densely wooded plot of land on the left. Resident #1 then turned north on a local street, traveling approximately 1500 feet. On this street the resident would have transversed a bridge spanning a creek before arriving at the park.

Based on observations, interview and manufacturer guidelines, the facility failed to ensure two (300 Hall and 600 Hall) of six medication carts assessed had medication properly labeled with an open date. The findings are: On 04/11/2024 at 10:04 AM, the Surveyor observed an open bottle of eye drops on the 300 Hall medication cart with no open date. The medication was received from the pharmacy with a date of 02/28/2024. On 04/11/2024 at 10:33 AM, the Surveyor observed (1) an open bottle of eye drops on the 600 Hall medication cart with no open dated. The medication was received from the pharmacy on 02/09/2024. (2) An open inhaler with no open date or received date from pharmacy. (3) A second open bottle of eye drops with no open date. The medication was received from the pharmacy on 02/22/2024. On 04/11/2024 at 10:39 AM, Registered Nurse (RN) #4 confirmed there were no open dates on the inhaler or eye drops located on the 600 Hall medication cart. On 04/11/2024 at 10:05 AM, the Surveyor asked the Director of Nursing (DON), Should there be an open date on eye drops and inhalers? The DON stated, If there is not an open date wrote on the medication when it is opened then we go by the pharmacy received date on the package. The DON confirmed there was not an open date on the Latanoprost eye drop bottle located on the 300 Hall medication cart. A document received by the DON on 04/12/2024 at 08:49 AM titled, [named brand] Olopatadine Ophthalmic Solution 0.2% showed, .discard 4 weeks after opening . A document received by the DON on 04/12/2024 at 08:49 AM titled, [named brand] Inhalation Aerosol Approval 2020 showed, .throw away your inhaler in household trash .3 months after your inhaler has been removed from the foil pouch . A document received by the DON on 04/12/2024 at 08:49 AM titled, [named brand of eye drops] (Latanoprost Ophthalmic solution) Package Insert showed, .once a bottle is open for use, it may be store at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks . On 04/12/2024 at 09:33 AM, the DON confirmed the package inserts for each of the three identified medications showed discard instructions that had not been followed.

Based on observation, interview and record review, the facility failed to ensure food items were sealed or covered during meal preparation; and failed to ensure equipment was cleaned, rinsed, and sanitized to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 104 residents who received meals from the 1 of 1 affected kitchen. The findings are: A facility policy titled Safe Food handling Practices,dated 02/25/2029, specified, All food is purchased, stored, prepared and distributed in clean safe sanitary manner promoting safe food handling and compliance with state and federal guidelines. To minimize contamination and bacteria while providing nutritious meals. All working surfaces and equipment are clean and sanitized after each use. On 04/10/2024 at 09:45 AM, Dietary Aid #1 was observed using a food processor to puree chili. On 04/10/2024 at 09:53 AM, Dietary Aid #1 placed the food processor into the metal sink with other dirty utensils that was attached to the metal table in the middle of the kitchen. On 04/10/2024 at 09:57 AM, Dietary Aid #1 hand washed the food processor and attachments with dishwashing liquid and rinsed the food processor and attachments under running water. There were bubbles/soap residue on the food processor bowl/container handle. Dietary Aid #1 set the food processor bowl on the edge of the metal table near the sink. Dietary Aid #1 did not sanitize the food processor bowl/container or the attachments. On 04/10/2024 at 09:58 AM, Dietary Aid #1 assembled the food processor attachments to the bowl and placed the food processor bowl on its stand. On 04/10/2024 at 10:01 AM, Dietary Aid #1 removed 14 - 4 oz scoops of cooked green beans from a metal pan and placed them into the unsanitized food processor bowl. On 04/11/2024 at 11:00 AM, Surveyor entered the kitchen and observed a large metal bowl with apple slices covered with sugar. The metal bowl of apples was uncovered and not contained, 3 bowels of vegetable soup observed sitting on a tray near the microwave, uncovered and not contained. Two metal pans of biscuits containing 54 biscuits each, was observed on the metal table uncovered and not contained. On 04/11/2024 at 11:08 AM, 3 bowls of vegetable soup were observed near the microwave uncovered and not contained. On 04/11/2024 at 11:09 AM, Dietary Aid #2 placed two pans of biscuits in the oven. On 04/11/2024 at 11:27 AM, 3 bowls of vegetable soup and 3 bowls of chicken noodle soup were observed near the microwave uncovered and not contained. On 04/11/2024 at 11:28 AM, Dietary Aid #3 was asked who the bowls of soup were for. Dietary Aid #3 replied, It's for residents whoever requested soup. Dietary Aid #3 confirmed there were 3 bowls of vegetable and 3 bowls of chicken noodle soup. Dietary Aid #3 was asked why the soup was uncovered. Dietary Aid #3 stated, I think [Dietary Aid #2] is supposed to microwave it, then she covers it. On 04/11/2024 at 11:30 AM, Dietary Aid #2 was asked why should food be covered while it's sitting out? Dietary Aid #2 stated, So no bugs get in it or it stays at a certain temperature. Dietary Aid #2 was asked, are the bowels of soup supposed to be covered while sitting out? Dietary Aid #2 stated, Yes, I'm supposed to cover it while it's sitting out. On 04/12/2024 at 07:45 AM, The Dietary Manager (DM) was asked what is the cleaning process for the food processor bowl and attachments after preparing pureed food. The DM stated, Wash it out in the sink, rinse it well; after the meal, they put it through the dishwasher. The DM was asked when the food processor bowel was sanitized. The DM stated, After the end of the meal. The DM was asked why equipment used for preparing food should be cleaned, rinsed, sanitized, and be free of soap residue/bubbles? The DM stated, Cleaned, rinsed, and sanitized to prevent any cross contamination and we don't want soap in our food. The DM was asked what the process was for food sitting out during meal preparation. The DM stated, I recommend the food be covered. The DM was asked why food items should be covered during meal preparation. The DM stated, To prevent flies from getting in it, or anything else.

Based on observation and interview, the facility failed to ensure residents who reside on the secure unit were fed in a manner that provided dignity to each resident. This failed practice had the ability to effect 28 residents residing on the secured unit. The findings are: a. On 04/09/2024 at 12:23 PM, Certified Nursing Assistant (CNA) #2 was providing feeding assistance to a resident in the secure unit while standing over them. b. On 04/09/2024 at 12:27 PM, CNA #3 was standing while providing feeding assistance to a resident in the secure unit. c. On 04/09/2024 at 12:29 PM, CNA #1 was standing while providing feeding assistance to a resident in the secure unit. d. On 04/09/2024 at 12:33 PM, CNA #1 was asked, How do you feed residents that need help with dining? She said, We offer them food and drinks. e. On 04/09/2024 at 12:44 PM, CNA #2 was asked, When helping more than one resident to eat what should you do between residents? She said, We make sure the residents are ok. f. On 04/09/2024 at 12:52 PM, CNA#3 was asked, When in the dining room helping feed residents why do we perform hand hygiene? She said, To keep from transferring germs, cross contamination. g. On 04/09/2024 at 01:07 PM, Licensed Practical Nurse (LPN) #1 was asked, When feeding a resident should we be standing or sitting? LPN #1 said, Most likely sitting to be eye level with the residents, but there are too many of them. h. On 04/11/2024 at 03:59 PM, the Administer provided a document titled, Residents Rights that included the excerpt, .Each resident has the right to be treated with consideration, respect, and full recognition of dignity and individuality .

Based on observation, and interview, the facility failed to ensure dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and baking products were dated when received to assure first in first out usage to prevent potential for food borne illness. These failed practices had the potential to affect 104 residents who received meals from the kitchen (total census: 106) as documented on a list provided by the Dietary Supervisor on 03/23/23 at 3:02 PM. The findings are: a. On 03/22/23 at 9:18 AM, Dietary Employee (DE) #1 removed a bag of chopped lettuce and loose fresh tomatoes from the walk-in refrigerator and placed them on the counter. He opened a bag of chopped lettuce, a bag of shredded carrots and emptied them into a bowl. Without washing his hands, he placed gloves on his hands, contaminating the gloves. He rinsed the tomatoes and placed them on the cutting board and sliced them. He placed the sliced tomatoes on the mixture of chopped lettuce and shredded carrots. He mixed them with his contaminated gloved hands and placed them on a shelf in the walk-in refrigerator to be served to the residents who received regular and mechanical soft diets for lunch. b. On 03/22/23 at 9:36 AM, there were 2 bottles of Sorghum Molasses on a shelf in the refrigerator in the Hydration Room on the 200 Hall (Unit). The bottles were not dated when received. c. On 03/22/23 at 10:23 AM, DE #6 pushed a cart that contained bowls of soup towards the counter. Without washing her hands, she picked up a plate and a bowl from the clean rack and placed them on the cart with her fingers inside of them. At 10:26 AM, she placed 2 pieces of breaded fish on a plate, transferred them into a baking pan and placed them in the oven. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. d. On 03/22/23 at 11:00 AM, DE #3 carried a container full of utensils with gloves on his hands. He placed it on the counter, contaminating the gloves. Without changing gloves and washing his hands, he picked up the utensils at the tips that go into the mouth, placed them on napkins and wrapped them for the residents to use when eating their lunch meal. At 12:05 PM, the Surveyor asked DE #3, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have removed the gloves and washed my hands. e. On 03/22/23 at 11:01 AM, DE #1 picked up a bottle of cooking spray and sprayed inside the pans. He picked up a container of thickener from under the food preparation counter and placed it on the counter. He removed a pan of cut green beans from the food warmer and placed it on the counter. Without washing his hands, he attached a clean blade to the base of the blender and pureed food to be served to the residents for lunch. f. On 03/22/23 at 11:06 AM, DE #4 was wearing gloves on her hands, she untied a bread bag, contaminating the gloves. Without changing gloves and washing her hands, she removed slices of bread from the bag and placed them on the tray to be used for making peanut butter and jelly sandwiches. The Surveyor asked, What should you have done after touching dirty objects and before handling food? She stated, Washed my hands before using gloves. g. On 03/22/23 at 11:16 AM, DE #1 squeezed out a rag that was used to wash the blender bowl. Without washing his hands, he picked up a clean blade and attached to the base of the blender to puree food items to be served to the residents who required pureed diets. When he started to put the food in the blender to puree, the Surveyor immediately stopped him and asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. h. On 03/22/23 at 12:03 PM, DE #5 pushed a cart that contained cartons of cultured butter milk, and cartons of 2% [percent] milk from the walk-in refrigerator towards the counter where clean glasses were stored. She placed gloves on her hands, contaminating the gloves. She used her contaminated gloved hands to pick up glasses that contained beverages by the rims and wrote the date on each lid. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. i. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 03/23/23 at 3:02 PM documented, .After engaging in other activities that contaminates the hands .

Based on observation and interview, the facility failed to ensure 2 of 2 ice machines and dietary equipment were maintained in a clean and sanitary manner and failed to ensure food was properly stored in a sanitary manner to prevent the potential of food borne illness. The failed practices had the potential to affect 100 residents who received ice and meals from the kitchen, and 100 residents who received ice from the ice machines, according to the list provided by the Dietary Manager on 7/6/2020. The findings are: 1. On 7/6/2020 at 11:20 a.m., an ice machine located in front of the kitchen was checked for cleanliness. The Dietary Manager used a white napkin and wiped the inside shield and the surrounding area of the ice machine. After wiping the ice machine, there was an unidentified black substance on the napkin. The Dietary Manager was asked what she saw. She stated, Black stuff. She was asked what she thought the substance could be. She stated, Sedimentation from the water. 2. On 7/6/2020 at 11:30 a.m., two opened 32-ounce cartons of tomato juice were on a shelf in the refrigerator. One carton had a received date of 6/18/2020 and the second carton had a received date of 6/4/2020. The cartons of tomato juice had no opened date. The Dietary Manager was asked what the shelf life of the tomato juice was once opened. She stated, 10 days. She was asked, Can the safety of the juice be determined without an opened date? She stated, No. 3. On 7/6/2020 at 11:35 a.m., the stand mixer had an unidentified dried substance on the underside where the beaters fit. The Dietary Manager was asked, What do you see? She stated, Dry splatter. They used it yesterday to mix a cake. 4. On 7/6/2020 at 11:38 a.m., an opened bottle of lemon juice was on a pantry shelf. The label on the bottle of lemon juice documented Refrigerate After Opening on the side of the bottle. The Dietary Manager was asked to look at the bottle. She stated, Oh, it says to refrigerate after opening. 5. On 7/6/2020 at 12:10 p.m., the ice machine on the 200 Hall was checked for cleanliness. The Dietary Manager took a white napkin and wiped the inside ice dispensing spout. When the napkin was removed from the dispensing spout, the napkin contained an unidentified black residue. The Dietary Manager was asked to describe what she saw. She stated, Blackish stuff.

Based on observation, record review, and interview, the facility failed to ensure Enteral Feeding bags / containers were labeled and dated when initiated, to prevent potential illness by facilitating staff's ability to promptly dispose of any remaining formula if the formula manufacturer's recommended hang time was exceeded for 3 (Residents #105, #7, and #5) of 3 sampled residents who had Physicians Orders for Enteral Feeding. This failed practice had the potential to affect 3 residents who required nutrition via an enteral feeding tube. The facility also failed to ensure enteral feedings were administered according to physician's orders [REDACTED].#105) of 3 (Residents #105, #7, and #5) sampled residents who had physician's orders [REDACTED]. 1. Resident #105 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 1/2/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 6/17/2020 documented the resident had a percutaneous endoscopic gastrostomy tube; received 51% or more of total calories via tube feeding; and received 501 cubic centimeters (cc's) of total fluid intake via tube feeding. a. A physician's orders [REDACTED].[MEDICATION NAME] 1.5 calories via (by) pump at 52 ml/hr (milliliter every hour) . b. The Plan of Care with a revised date of 1/28/19 documented, .[MEDICATION NAME] as ordered for Dysphagia . may remove for shower and reattach as ordered . Intake amount of PEG (Percutaneous Endoscopic Gastrostomy) Intake Amount of PEG Tube Feeding as ordered . Change Tubing Feeding, bag, bottle . Syringe as ordered . c. On 7/6/2020 at 11:10 a.m., the resident was receiving an enteral feeding of [MEDICATION NAME] 1.5 calories via pump at 55 cubic centimeters per hour (cc/hr). The enteral feeding formula bottle was not labeled or dated. The enteral feeding formula contained 600 cubic centimeters (cc's) of formula remaining in the bottle. d. On 7/6/2020 at 11:30 a.m., the Assistant Director of Nursing (ADON) was asked, Should tube feeding be labeled and dated? She stated, Yes. e. On 7/6/2020 at 1:30 p.m., the enteral tube feeding was hanging and contained no label or date. f. A physician's orders [REDACTED].[MEDICATION NAME] at 52 ml/hr (milliliters per hour) . g. A physician's orders [REDACTED].[MEDICATION NAME] at 55 ml/hr (milliliters per hour) . every shift for Dysphagia . h. A facility policy titled Enteral Feeding provided by the Director of Nursing on 7/6/2020 documented, .Label, date, time and initial . 2. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 6/29/2020 documented the resident scored 14 (13 to 15 indicates cognitively intact); on a Brief Interview for Mental Status, was totally dependent for eating; received Nothing By Mouth (NPO); received 51% or more of total calories daily via tube feeding; and received 501c cc's or more of fluid intake via tube feeding. a. The Comprehensive Care Plan with a revision dated of 9/30/19 documented, .Tube feeding as ordered . b. A Physicians Order dated 4/11/20 documented, .Two-Cal HN (High nitrogen) at 44 cc/hr (cubic centimeters) via (by) pump . c. On 7/6/2020 at 10:53 a.m., the resident was receiving a tube feeding of Two Cal (calorie) HN infusing at 44 cc/hr via pump. There were 750 cc's remaining in the enteral formula container. The enteral feeding container of formula was not labeled or dated, and the resident's container of water was not dated. The head of the resident's bed was up, but the resident was slid down in the center of the bed. d. On 7/6/2020 at 10:54 a.m., the Assistant Director of Nursing (ADON) was in the resident's room looking at the resident's oxygen. The ADON was asked, Should the tube feeding be labeled and dated? After looking at the tube feeding, she stated, It should be. I will take care of it e. On 7/6/2020 at 12:53 p.m., the resident's tube feeding was not labeled or dated. f. On 7/7/2020 at 10:00 a.m., the resident's tube feeding was labeled and dated. 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 4/2/2020 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent for nutrition; received 51% or more of total calories per tube feeding; and received 501 cubic centimeters (cc's) or more of total fluid intake per tube feeding. a. The Comprehensive Care Plan dated 1/3/2020 documented, .Tube Feeding (and) Flushes as ordered . b. A physician's orders [REDACTED].[MEDICATION NAME] 1.2 at 55 cc/hr (cubic centimeters per hour) via (by) Kangaroo pump . c. On 7/6/2020 at 10:42 a.m., the resident was receiving [MEDICATION NAME] 1.2 calories 55 cc/hr via feeding pump. The of the resident's water flush was hanging and was dated 7/6/2020. The tube feeding syringe was dated 7/6/2020. The resident's container of enteral formula of [MEDICATION NAME] 1.2 was not labeled or dated.

Based on observation and interview, the facility failed to ensure medication carts were kept locked while unattended for 1 (600 Hall) of 4 medication carts, and failed to ensure expired medications were removed from the Medication Cart and placed into an area for destruction to prevent potential administration to 1 (Resident #63) of 1 sampled resident who had physician's orders [REDACTED].#69) of 1 sampled resident who had physician's orders [REDACTED]. 1. On 7/8/2020 at 9:39 a.m., an unlocked Medication Cart was in the 600 Hall hallway in front of room [ROOM NUMBER]. (The Surveyor took a photograph of the Medication Cart at this time.) At 9:43 a.m., Registered Nurse (RN) #1 was asked if the Medication Cart was unlocked. She stated, Yes. I just locked it. She was asked, Where is the nurse who left the Medication Cart unlocked? She stated, She is in his room. She pointed to Resident #617's room. The door to the resident's room was partially closed. a. On 7/8/2020 at 9:47 a.m., Licensed Practical Nurse (LPN) #1 exited the resident's room with the Therapist. LPN #1 was asked where she was when she left her medication cart unlocked. She stated, I was in room [ROOM NUMBER]. I went in there and forgot my stuff, so came back to get a breathing treatment. I removed my PPE and unlocked the Medication Cart to get the breathing treatment and forgot to lock it back up when I went back in the room. She was asked, Should the Medication Cart have been left unlocked? She stated, No. b. On 7/8/2020 at 10:00 a.m., the Director of Nursing (DON) was asked if the Medication Carts should be left unlocked. She stated, No, not when they are outside of the line of site of the Medication Cart. She was asked, If the Nurse is inside a Resident's room and the Medication Cart is out in the hallway against the wall outside of his room, should the Medication Cart be unlocked? She stated, No, it should have been locked. 2. On 7/7/2020 at 10:25 a.m., the following observations were made in the Medication Cart on the 200 Hall with LPN #1: a. On 7/7/2020 at 10:26 a.m., one vial of Insulin [MEDICATION NAME] R (Regular) was stored in a drawer in the 200 Hall Medication Cart. The opened vial of insulin documented an opened date of 6/3/2020. LPN #1 was asked, Is this the insulin that you used for this resident? She stated, Yes. She was asked, Is the insulin in date? She stated, No. It should be replaced. It is only good for 28 days after it is opened. b. On 7/7/2020 at 10:27 a.m., one Medication Card containing [MEDICATION NAME] HCL ([MEDICATION NAME]) 4 milligrams (mg) was stored in the bottom drawer of the 200 Hall Medication Cart. The Medication Card of [MEDICATION NAME] HCL pharmacy label documented an expiration date of 5/25/2020. LPN #1 was asked, Is this medication expired? She stated, Yes. She was asked, Should it be on the Medication Cart? She stated, No.

Based on observation, record review, and interview, the facility failed to provide documentation of interventions implemented to ensure the resident could maintain adequate nutritional status while awaiting dental services for 1 (Resident #66) of 2 (Residents #21 and #66) sampled residents who had dentures. The findings are: 1. Resident #66 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 5/21/2020 documented the resident scored 8 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status; required limited assistance with meals; and had no natural teeth or teeth fragments. a. On 7/6/2020 at 9:31 a.m., the resident stated she had been without dentures for about 3 weeks and the facility had been giving her the same meals without changing her diet to soft foods. She stated she was having trouble chewing her food and she was eating a lot of soup. b. On 7/6/2020 at 12:40 p.m., the resident was eating lunch in her room. Her meal consisted of soft vegetables and an intact pork chop. The resident consumed approximately 2% of the pork chop and approximately 25% of the soft vegetables. c. On 7/9/2020 at 11:21 a.m., the Administrator was asked, Can you provide the facility's policy regarding when the facility will replace lost / damaged dentures? She stated, It talks about that in the Admission Packet, but I can tell you what the process is. When we are told that the dentures are lost or damaged, we look for them very thoroughly, and if we can't find them, then we immediately contact our dental provider. For (Resident #66), when we called the Mobile Dental Services, they were not able to come right away as they normally would due to COVID. She was asked, Can you tell me what the facility did to ensure the resident was able to continue to eat while awaiting dental services? She stated, I think the Dietary Manager spoke with the resident and she (the resident) didn't want to change anything. She was asked, Where is that conversation documented? She stated, I am not sure she did document that. She was asked, Where should it be documented? She stated, In the Progress Notes. d. On 7/9/2020 at 11:23 a.m., the Director of Nursing (DON) was asked, Can you provide documentation with the interventions initiated to ensure the resident was able to continue to eat while awaiting dental services for replacement dentures? She stated, I believe the Dietary Manager spoke with the resident around the time her dentures were lost, and the resident did not voice any difficulty with chewing her food. She was asked, Do you know when this conversation took place? She stated, No, but it was close to the time the dentures went missing. e. On 7/9/2020 at 12:02 p.m., the Dietary Manager was asked, Did you speak with the resident regarding her dentures being lost? She stated, Yes, and she told me she did not want to make any changes to her diet. f. On 7/9/2020 at 12:50 a.m., the Social Director was asked, When did the resident's dentures go missing? She stated, On May 19, 2020. She was asked to explain what actions were taken after the dentures were known to be lost. She stated, I get notified immediately and make the referral. I called the Mobile Dental company the same day (May 19, 2020) but they (Mobile Dental) were not able to come into the building due to COVID. She was asked if she knew the date the company planned to come to the facility. She stated, I believe it is going to be this week, but we had a positive (COVID-positive) resident in the facility for 3 weeks and that resident has had one negative test. g. As of 7/9/2020 at 12:55 a.m., the Medication Review Report with the date range of 6/1/2020 through 7/8/2020 documented, .Dietary Order Summary . Regular, NAS (no added sodium) diet . Regular texture . Regular consistency . Low fiber . No milk products . 2000 ml (milliliters) fluid restriction every 24 hours . Can have Regular fish . Fortified juice TID (three times a day) with meals . Order Date 9/23/2019 . Regular, NAS (no added sodium) Diet . Regular texture . Regular consistency . Low fiber . No milk products . 2000 ml (milliliters) fluid restriction every 24 hours . Can have Regular fish . Fortified juice TID (three times a day) with meals . Ground meat with meals . Order Date 7/9/2020 . h. On 7/10/2020 at 8:04 a.m., the Registered Dietician was asked, How are you made aware of issues regarding residents' nutritional status? She stated, I am reviewing the records off-site during COVID. She was asked, Were you aware (Resident #66) had lost her dentures on 5/19/2020? She stated, No. I was not informed. She was asked, Can you look at the documentation and tell me if it had been documented? She stated, It was not documented in any of the documents I review for off-site review. She was asked, Did anybody from the facility notify you that she had lost her dentures on 5/19/2020? She stated, No, not until yesterday. I spoke with (Dietary Manager) yesterday and she stated that when she spoke with the resident at the time the resident lost the dentures, the resident told her that she did not want to make any changes to her diet. She was asked, Do you know if anyone readdressed the issue at any time other than on 5/19/2020? She stated, She (Dietary Manager) did yesterday I believe. i. On 7/10/2020 at 10:00 a.m., the Dietary Manager was asked if she spoke with the resident again yesterday. She stated, Yes and she told me she has been having trouble chewing and wants a Mechanical Diet. j. The facility policy titled Dental Services provided by the Administrator on 7/9/2020 at 11:38 a.m., documented, .The facility will promptly refer a resident with lost or damaged dentures to a dentist . ' Prompt referral ' means, within reason, that an appointment will be made as soon as the dentures are lost or damaged. In the interim, the facility will document efforts to ensure the resident is able to adequately eat and drink while awaiting dental services and any extenuating circumstances leading to a delay in treatment .

Based on observation, record review, and interview, the facility failed to ensure staff followed isolation precautions, including the consistent appropriate disposal and handling of contaminated / soiled Personal Protective Equipment (PPE) and supplies, to prevent potential cross-contamination which could result in infection or other complications for 1 (Resident #256) of 1 sampled resident who had physician's orders [REDACTED]. These failed practices had the potential to affect 5 residents who required isolation, and 103 residents who resided in the facility, according to a list provided by the Administrator on 7/ at 8:35 a.m. The findings are: 1. Resident #256 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 7/2/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive two person assistance with transfers; required extensive one person assistance with personal hygiene; experienced shortness of breath with exertion and when lying flat; required oxygen therapy; and did not require isolation. a. On 7/6/2020 at 11:35 a.m., the resident was lying in bed and was receiving oxygen via a nasal cannula. Two isolation disposal barrels were in the resident's room. One isolation barrel was over-flowing and contaminated / soiled PPE was protruding from under the lid on top of the barrel. b. On 7/8/2020 at 9:47 a.m., Licensed Practical Nurse (LPN) #1 and the Therapist were in the resident's room. The resident was lying in bed. Both isolation barrels in the resident's room containing contaminated / soiled PPE which was over-flowing from under the closed lids on the barrels. c. On 7/8/2020 at 9:53 a.m., the Therapist exited the resident's room after disposing of her PPE in one of the overflowing barrels. LPN #1 also disposed of her PPE in the overflowing barrels. LPN #1 was asked if the isolation barrels had contaminated / soiled PPE overflowing from them. She stated, Oh, yes they do! (She looked at the barrels.) She was asked if they should have contaminated / soiled PPE overflowing. She stated, No, they shouldn't! She was asked, Who is responsible for making sure the barrels are emptied and disposed of properly? She stated, I think it is the aides (Certified Nursing Assistants) responsibility. d. On 7/8/2020 at 9:54 a.m., the Therapist, was replenishing the Isolation Three-Drawer Supply plastic bins outside of the resident's and other isolation rooms down the hallway. She stated, Those barrels are supposed to pulled by the CNAs (Certified Nursing Assistants) if full at the end of each shift and put it in the isolation barrel hopper rooms. She turned and instructed LPN #2, Make sure the resident's isolation barrels are taken care of immediately.! e. On 7/8/2020 at 10:00 a.m., the Director of Nursing (DON) was asked, Whose responsibility is it to ensure the isolation barrels are emptied and disposed of properly? She stated, They are pulled at the end of shift if full by the CNAs and put in the isolation barrel hopper rooms. 2. On 7/7/2020 at 10:10 a.m., Laundry Employee #1 was asked, How is clean linen transferred to the residents? She stated, Personal clothing is transferred in covered carts. We handle it so it doesn't touch our clothing. She was asked, How about linens, blankets, sheets, et cetera? She stated, It is put in a bin and taken to resident rooms or storage closets on the hall. She was asked, Is it covered? She stated, No. a. On 7/7/2020 at 10:15 a.m., the Housekeeping and Laundry Supervisor, was asked, How is the linen transferred to the halls? He stated, It is put in a bin and rolled down the halls. He was asked, Is it covered? He stated, No, should it be? b. On 7/8/2020 at 9:42 a.m., a bin containing linens, such as sheets, towels, and blankets, was being pushed down the 600 Hall, and was not covered.

Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within 14 days after a significant change of status to determine if any changes in care were necessary for 1 (Resident #51) of 25 Residents #51, #46, #66, #10, #56, #105, #5, #29, #7, #22, #256, #61, #71, #92, #31, #18, #98, #59, #50, #38, #34, #2, #11, #96, and #42) sampled residents whose MDS Assessments were reviewed. The findings are: 1. Resident #51 had a [DIAGNOSES REDACTED]. a. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/11/2020 documented the resident scored 9 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status; was totally dependent with one person assistance with locomotion on and off the unit and eating; and was totally dependent with one person assistance with eating. This indicated the resident had a decline in transfers, locomotion on and off the unit and eating, with the resident becoming totally dependent in these areas of activities of daily living. b. On 7/8/2020 at 11:27 a.m., the Minimum Data Set Coordinator was asked, Has there been a decline in activities of daily for (Resident #51)? She stated, Yes, there are changes in there. She was asked, Should a Significant Change of Condition have been completed? She stated, Yes, it was a decline in ADLs (activities of daily living). c. On 7/9/2020 at 10:30 a.m., the Restorative Nurse was asked if Resident #51 had received any Restorative Treatment. She stated, When she first got here, we noticed she was having trouble transferring. We decided it may have been positioning in the room on the side she was on. So, therapy looked at her. She was moved to another room and a raised toilet seat was tried. It was determined that she couldn't follow instructions, so we started using the lift. 2. The Centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual, Chapter 2, Section 03, Page 2 documented, .A 'Significant Change' is a major decline or improvement in a resident's status that . a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting' . b. Impacts more than one area of the residents' health status . and c. Requires Interdisciplinary Review and / or revision of the Care Plan .

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's current status to provide accurate information with which to develop a Care Plan to meet the resident's needs for 1 (Resident #105) of 1 sampled resident who had a [MEDICAL CONDITION] and required suctioning. The findings are: Resident #105 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 1/2/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 6/17/2020 documented the resident was totally dependent with two-person assistance with transfer, bed mobility, and personal hygiene; had limitation in range of motion on both sides of the upper and lower extremities; had no shortness of breath; required oxygen therapy; did not require suctioning; and required [MEDICAL CONDITION] care. a. A physician's orders [REDACTED].Change O2 (oxygen) canister / tubing on Sunday on 11-7 (11:00 p.m. to 7:00 a.m.) shift weekly . Every night shift . Every Sun (Sunday) for maintenance . b. A physician's orders [REDACTED].Deep Suction PRN (as needed) to keep airway patent, prevent choking, gagging and vomiting . c. A physician's orders [REDACTED].O2 (oxygen) (at) 2 l/min (liters per minute) [MEDICAL CONDITION] mask . May remove for ADLs (activities of daily living) . d. The Care Plan with a revised date of 6/30/2020 contained no documentation related to the resident's [MEDICAL CONDITION] care, suctioning, or oxygen therapy. e. On 7/6/2020 at 12:10 p.m., the resident was lying in bed and was receiving oxygen at 2 liters per minute via a [MEDICAL CONDITION] collar. The [MEDICAL CONDITION] collar was dated 6/29/2020. f. On 7/7/2020 at 10:38 a.m., the resident was lying in bed and was receiving oxygen at 2 liters per minute via a [MEDICAL CONDITION] collar. The [MEDICAL CONDITION] collar was dated 7/6/2020. g. On 7/8/2020 at 9:45 a.m., Licensed Practical Nurse (LPN) #2 was asked, Have you received any training for specific respiratory interventions or care, including oxygen and nebulizer treatment? She stated, No, not really. She was asked, You have an order to deep suction. Did you have any special instruction for that? She stated, No. I just suction what he coughs up. She was asked, Who is responsible to assure that machines or equipment used are working properly? She stated, I'm not sure. She was asked, What procedures are in place for power outages? She stated, The generator kicks in. She was asked, Will you describe infection control practices for respiratory care? She stated, We use clean gloves. h. On 7/9/2020 at 9:06 a.m., the Assistant Director of Nursing was asked, Who provides suctioning and emergency care? She stated, The nurses on the hall, and I do. She was asked, When and what type of training do you provide? She stated, The DON (Director of Nursing) checks them off. She was asked, How often are competencies assessed? She stated, Yearly. She was asked, Who is responsible to assure that machines or equipment used for respiratory care are properly working and maintained? She stated, I check them weekly.

Based on observation, record review, and interview, the facility failed to ensure 2 of 3 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services during the COVID-19 facility lockdown for 1 of 1 laundry room. This failed practice had the potential to affect all 110 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 5/26/2020. The findings are: On 5/26/2020 at 1:17 p.m., during the Infection Control tour with the Maintenance Director, the following observations were made: a. On 5/26/2020 at 1:17 p.m., 3 clothes dryers were in the clean area of the laundry room. Dryer #1 had a one-quarter inch build-up of lint on the lint screen. Laundry Aid #1 was asked, How often are the lint traps to be cleaned? Laundry Aid #1 stated, Every other load. b. On 5/26/2020 at 1:18 p.m., Dryer #2 had insulation on the side of the dryer and there were holes in the insulation. The Maintenance Director was asked, Could that affect the heating of the dryer or cause any problems? He stated, I don't know. It's from sweeping it all the time. The Maintenance Director was asked, Can you tell me what is in the lint door? He stated, Binder clip, food particles, and trash. He was asked, Should it be there? He stated, No. c. On 5/26/2020 at 1:20 p.m., Laundry Aid #1 was asked, How often should the lint trap be cleaned? She stated, Every other load. She was asked, When was it last cleaned? She stated, I'm not sure. She was asked, Have you been doing laundry today? She stated, Yes. d. On 5/26/2020 at 1:46 p.m., the Administrator was asked, How often should lint traps on the dryers be cleaned? The Administrator looked at the lint log and stated, I think that it is saying daily. She was asked, Do you have a policy for that? She stated, I will look. e. On 5/27/2020 at 2:30 p.m., the Laundry Supervisor was notified via telephone and was asked, How often are the lint traps to the dryers to be cleaned? He stated, Every three loads. The machine (dryer) has a sensor and will not turn on unless you clean it. He was asked, Does the staff know this? He stated, I think so. He was asked, How often are the staff supposed to initial that the dryer lint trap is cleaned? He stated, Every time it is done. He was asked, Should it have been initialed yesterday from 6:00 a.m. until 2:00 p.m.? He stated, Yes, it should have been. f. The facility policy titled Laundry provided by the Administrator on 5/27/2020 at 2:35 p.m., contained no documentation related to how often the dryer lint traps should be cleaned, and contained no documentation related to how often staff should initial indicating the dryer lint traps were cleaned.

Based on observation and interview, the facility failed to consistently implement appropriate policies for COVID-19 to prevent the potential exposure and spread of the Coronavirus to residents and staff by failure to ensure the clean area of laundry remained free of open drinks from staff; and, failure to ensure masks were worn by staff while in the facility. This failed practice had the potential to affect 110 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 5/26/2020. The findings are: On 5/26/2020 at 1:17 p.m., during the Infection Control tour with the Maintenance Director the following observations were made: a. On 5/26/20 at 1:20 p.m., Laundry Aid #2 was in the laundry room and had no mask on. Laundry Aid #2 was standing next to Laundry Aid #1. Laundry Aid #1 was asked, Are you supposed to be wearing a mask? He stated, I assume so. b. On 5/26/2020 at 1:22 p.m., a half-empty bottle of soda was on the shelf in the laundry room with the clean linen. The Maintenance Supervisor was asked if a bottle of soda was supposed to be with the clean linen. He stated, No. c. On 5/26/2020 at 1:24 p.m., a clothes rack with clean clothes hanging on the rack was in the laundry room. A small refrigerator was under the clothes rack and an opened cup of coffee was on the refrigerator. The Maintenance Supervisor was asked, Should that (cup of coffee) be with the clean clothes? He stated, No. d. On 5/26/2020 at 1:25 p.m., one opened can of Mountain Dew was on the folding table next to Multi- Purpose Disinfecting Wipes in the laundry room. The Maintenance Supervisor was asked, Should the opened drink be next to the disinfecting wipes, or should it be on the table with clean laundry? He stated, No, it should not be there at all. e. On 5/26/20 at 1:46 p.m., the Administrator was asked, Should laundry personnel wear face masks? She stated, If they are on the floor, or close to each other, yes. She was asked, Should laundry staff have opened drinks on the clean side of the laundry? She stated, No, that's why there is an office back there. f. On 5/27/2020 at 8:17 a.m., the Laundry Supervisor was asked, Are laundry staff supposed to wear face masks? He stated, Yes. He was asked, Should laundry staff have drinks on the clean side of laundry? He stated, No. They have an office.

Based on observation and interview, the facility failed to ensure the ice machine was maintained in clean condition, food items stored in the refrigerator or freezer were covered and sealed, and dietary staff washed their hands before handling clean equipment and between dirty and clean tasks to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. The facility also failed to ensure expired food and supplements were promptly discarded to prevent their potential use, which could result in illness for residents who received supplements from 1 (200 Hall nourishment room) of 2 nourishment rooms. These failed practices had the potential to affect 105 residents who received meals from the kitchen (total census: 108), as documented on a list provided by the Dietary Supervisor on [DATE], and 27 residents who received food or supplements from the 200 Hall nourishment room, as documented on the Midnight Census Report provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 11:05 a.m., the top interior surfaces of the ice machine panel had a black wet substance on it. The Food Service Supervisor (FSS) was asked to wipe the residue from the interior surfaces of the ice machine panel. When she did so, the black substance easily transferred to the paper towel. FSS stated, We just cleaned it last week. We missed that area. The FSS was asked, How often do you clean the ice machine? She stated, We clean it weekly. The FSS was asked who used the ice from the machine. She stated, That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms. 2. On [DATE] at 11:21 a.m., the following observations were made in the freezer: a. An open box of sausage was on a shelf in the freezer. The box was not covered or sealed. b. A 3-gallon carton of vanilla ice cream was on a shelf in the walk-in freezer. The box was not completely covered exposing the ice cream. c. A box of mixed vegetables was on a shelf in the freezer. The box was not covered and the bag was not completely sealed. 3. On [DATE] at 11:28 a.m., there were 2 half-gallon cartons of buttermilk on a shelf in the refrigerator. The label on one box documented an expiration date of [DATE]. The label on the second box documented an expiration date of [DATE]. The FSS was asked if the buttermilk was served to residents. She stated, We have a resident who likes buttermilk, but she passed away this year. They should not be in the refrigerator. 4. On [DATE] at 11:34 a.m., the following observations were made in the refrigerator in the unit on the 200 Hall: a. A carton of vanilla yogurt was on a shelf in the refrigerator. The label on one box documented an expiration date of [DATE]. b. There were 5 boxes of buddy fruit apple juice in a bag in the lower compartment of the refrigerator. The apple juice boxes were not labeled with a date or resident's name, and the manufacturer's labels on the boxes documented an expiration date of [DATE]. 5. On [DATE] at 12:15 p.m., Dietary Employee #2 was on the tray line assisting with the meal service. He was picking up cartons of health shakes and cartons of milk and placing them on trays, then without washing his hands, he began picking up glasses of ice by their rims. He poured tea into the glasses and placed the glasses on residents' meal trays. 6. On [DATE] at 4:12 p.m., Dietary Employee #3 was wearing gloves on both hands. She pushed a cart of trays that contained drinking glasses towards the ice machine and, without changing gloves and washing her hands, placed ice into the glasses, using her gloved hands to arrange and wedge the pieces of ice.

Based on observation, record review, and interview, the facility failed to ensure interventions were developed and implemented to assist a resident with maintaining proper body alignment while in a wheelchair, to maintain or improve the resident's mobility and level of independence with positioning for 1 (Resident #100) of 16 (Residents #1, #20, #21, #23, #37, #40, #45, #61, #66, #67, #70, #76, #79, #81, #91, #100) sampled residents who required assistance with positioning. The failed practice had the potential to affect 44 residents who required assistance with positioning, according to a list provided by the Administrator on 3/14/19 at 2:34 p.m. The findings are: Resident #100 had [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set with an Assessment Reference Date of 2/4/19 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status, required extensive physical assistance of 2-plus people for bed mobility, transfer, dressing, toilet use and bathing, was not steady, and only able to stabilize with staff assistance when moving from seated to standing position, walking with assistive device if used, turning around and facing the opposite direction while walking, moving on and off the toilet, and moving from surface to surface transfers and had no functional limitations in range of motion in the upper or lower extremities. The Care Area Assessment (CAA) sheet dated 2/4/19 documented Activities of Daily Living (ADL) Functional / Rehabilitation Potential triggered as an area for further assessment. a. The Care Plan dated 2/12/19 documented, Resident is at risk for falls due limited mobility, muscle weakness, history of a knee replacement . 1/2 side rails for mobility and positioning . The Care Plan did not address any need for assistance, cueing or devices related to the resident's positioning while sitting in a wheelchair. b. On 3/11/19 at 11:49 a.m., 12:07 p.m., and 12:27 p.m., the resident was sitting in a wheelchair with her head bent forward touching her chest, and her body was leaning at approximately a 30 degree angle over the left arm of the wheel chair. c. On 3/11/19 at 12:35 p.m., the resident was sitting in a wheelchair at a table in the dining room. The staff was entering and exiting the kitchen serving meal trays to the other residents in the dining room. The resident's body was leaning approximately 30 degrees to the left in the wheelchair, and she was attempting to feed herself using her left hand. The resident attempted to reach a bowl of cottage cheese that was on the meal tray, but could not reach it. Resident #410's family member positioned the tray to enable the resident to reach the bowl of cottage cheese. d. On 3/12/19 at 8:18 a.m., the resident was sitting in a wheelchair in her room. The resident's body leaned to the left in the wheelchair. At 8:33 a.m., the resident was in a wheelchair in the therapy room. The resident was leaning to the left while sitting in the wheelchair. e. On 3/14/19 at 9:45 a.m., the Occupational Therapist was asked, when did therapy start working with (Resident #100)? The Occupational Therapist stated, 1/29/19. The Occupational Therapist was asked, how often does the resident receive therapy? The Occupational Therapist stated, Every day. The Occupational Therapist was asked, what is therapy doing to address the resident's positioning concerns? The Occupational Therapist stated, We haven't done anything to address the leaning, other than verbal. The Occupational Therapist was asked, how much assistance does the resident need for positioning? The Occupational Therapist stated, Just verbal, minimal to moderate verbal cues. The Occupational Therapist was asked, what assistive devices does the resident use? The Occupational Therapist stated, A wheelchair and walker. The Occupational Therapist was asked if staff had been instructed on verbally cueing the resident to correct her body position and stated, No. f. On 3/14/19 at 9:51 a.m., the resident was in therapy, sitting in a wheelchair and leaning to the left. No verbal cues for positioning were given to the resident. g. On 3/14/19 at 10:08 a.m., Licensed Practical Nurse (LPN) # 5 was asked, who is responsible for ensuring the residents are properly positioned? LPN #5 stated, CNAs (Certified Nurse Assistants). LPN #5 was asked, what is being done to ensure (Resident #100) is positioned properly while sitting up in wheelchair. LPN #5 stated, Reposition her and she'll slump over every time. LPN #5 was asked if the resident had any equipment or devices for positioning and stated, No, I haven't noticed anything. LPN #5 was asked, did therapy give you any training on verbal cueing for (Resident #100)? LPN #5 stated, No. LPN #5 was asked, do you think (Resident #100) is positioned properly while sitting up in the wheelchair? LPN #5 stated, No I do not. h. On 3/14/19 at 10:16 a.m., Certified Nurse Assistant (CNA) #7 was asked, who is responsible for ensuring residents are properly positioned? CNA #7 stated, CNAs and staff. CNA #7 was asked, what is being done to ensure (Resident #100) is positioned properly while sitting in the wheelchair? CNA #7 stated, Sometimes, I put pillows under her arm to help with positioning. CNA #7 was asked if the resident had any equipment or devices for positioning and stated, I don't know; I have propped a pillow under the left arm to help her sit up. CNA #7 was asked, did therapy give you any training on verbal cueing for (Resident #100)? CNA #7 stated, I don't recall. CNA #7 was asked, do you think (Resident #100) is positioned properly while sitting in the wheelchair? CNA #7 stated, No, I do not. i. On 3/14/19 at 11:02 a.m., the Director of Nursing (DON) was asked, does ther facility use any devices for positioning of residents? The DON stated, Yes, we have different wedges. The DON was asked, who decides who needs positioning devices? The DON stated, Therapy, but not always; they will recommend a specialty device, but we have generic devices. The DON was asked, has therapy, specifically Occupational Therapy, trained staff on verbal cueing for positioning for (Resident #100)? The DON stated, No. The DON was asked, should it be care planned if a resident is to be verbally cued by staff for positioning? The DON stated, Yes, if they specifically require it. The DON was asked, should residents be properly positioned to encourage or maintain activities of daily living? The DON stated, Yes. j. The facility's policy and procedure titled, Rehabilitative Nursing Care, provided by the Administrator on 3/14/19 at 1:34 p.m., documented, The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence . Maintaining good body alignment and proper positioning .

Based on observation of the 12:00 p.m., 3:00 p.m. and 4:00/5:00 p.m. medication passes on 3/11/19, record review and interview, the facility failed to ensure physician orders [REDACTED].#46, #22 and #64) of 13 residents observed during the medication passes resulting in medication errors. Medication errors were made by 4 Licensed Practical Nurses (LPNs #1, #2, #3 and #4) of 8 LPNs who were observed administering medications in the facility. The failed practice had the potential to affect 59 residents who received medications administered from these Nurses, according to a list provided by the Administrator on 3/12/19. The medication error rate was 9.3%, based on observation of 43 medications administered and a total of 4 errors detected. The findings are: 1. Resident #46 had a [DIAGNOSES REDACTED]. On 3/11/19 at 1:05 p.m., LPN #1 administered Sennosides 8.6 mg (milligrams) instead of the ordered Sennosides-[MEDICATION NAME] Sodium Tablet 8.6-50 mg. 2. Resident #22 had a [DIAGNOSES REDACTED]. On 3/11/19 at 12:18 p.m., LPN #2 checked the resident's blood pressure and obtained a reading of 98/60. The LPN then stated, I am holding the [MEDICATION NAME] 25 mg due to the (systolic) blood pressure is less than 100. 3. Resident #64 had a [DIAGNOSES REDACTED]. A physician order [REDACTED]. On 3/11/19 at 4:09 p.m., LPN #3 administered [MEDICATION NAME] Aerosol 1 puff to the resident. At 4:10 p.m., LPN #3 was asked if the resident had received all of the ordered medication and stated, Yes. The second puff of [MEDICATION NAME] was not administered. 4. Resident #22 resided on 300 Hall and had a [DIAGNOSES REDACTED]. Check pulse prior to administration. Hold if pulse below 60. Give with food. a. On 3/11/19 at 4:23 p.m., LPN #4 administered the [MEDICATION NAME] 50 mg with water and no food. b. On 3/12/19 at 10:39 a.m., the Dietary Manager was asked about this resident's meal schedule and stated, She eats in her room. The trays for the 300 Hall go out at 5:45 p.m.

Based on observation, record review and interview, the facility failed to ensure a urinary catheter drainage bag with tubing was kept off of the floor and staff washed their hands and changed gloves prior to opening the closed urinary drainage system to change the bag / tubing, to prevent cross-contamination that could result in infection for 1 (Resident #1) of 3 (Residents #1, #40, and #61) sampled residents who had indwelling urinary catheters. The facility failed to ensure staff washed their hands/changed gloves during incontinent care to prevent the potential spread of infection for 1 (Resident #67) of 22 (Resident #1, #5, #20, #21, #23, #27, #34, #37, #40, #45, #51, #61, #66, #67, #68, # 70, #75, #76, #81, #87, #95, and #100) sampled residents who were dependent for incontinent care. The failed practices had the potential to affect 4 residents who had indwelling urinary catheters, and 56 residents who were incontinent and required assistance with incontinent care, as documented on a list provided by the Administrator on 3/14/19. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Comprehensive Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/7/19 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive physical assistance of 2-plus people for bed mobility, transfers, and toilet use, required extensive physical assistance of 1 person for personal hygiene, was occasionally incontinent of bowel and had an indwelling urinary catheter. a. On 3/11/19 at 12:47 p.m., 12:53 p.m., and 3:24 p.m., approximately 5 to 7 inches of the resident's indwelling urinary catheter tubing was lying on the floor underneath the resident's wheelchair. b. On 3/12/19 at 8:14 a.m. and 8:54 a.m., approximately 3 inches of the resident's indwelling urinary catheter tubing was lying on the floor underneath the resident's wheelchair. c. On 3/12/19 at 2:51 p.m., the resident was in the therapy room using an exercise machine. The resident's indwelling urinary catheter tubing was hanging underneath the wheelchair and rubbing against the rails of the exercise machine as the resident exercised. d. On 3/13/19 at 9:20 a.m., the resident was lying in bed. urinary catheter drainage bag was attached to the bedframe of the bed, uncovered, and was touching the floor. e. On 3/13/19 at 9:30 a.m., Licensed Practical Nurse (LPN) #5 entered the resident's room with a new urinary catheter drainage bag. The resident was lying in bed. The urinary catheter bag was on the floor. The floor around and underneath the drainage bag was is wet. LPN #5 stated, I need to get a few more things and left the room. f. At 9:36 a.m., LPN #5 returned to the resident's room with a biohazard bag and alcohol pads. LPN #5 put on clean gloves but did not wash her hands after entering the room and prior to putting on the gloves. LPN #5 removed the old catheter tubing, disconnecting it from the safe lock at the resident's right upper thigh, cleaned the port with an alcohol pad, used another alcohol wipe on the connection adaptor on the drainage bag tubing, then attached the new tubing to the catheter drainage bag. g. On 3/13/19 at 10:08 a.m., LPN #5 was asked, should you have washed your hands prior to changing the catheter bag for (Resident #1)? LPN #5 stated, Yes, I failed to wash my hands when I came back in the room. LPN #5 was asked, should catheter tubing and bag be on the floor? LPN #5 stated, No. LPN #5 was asked, would catheter bags and tubing on the floor be considered an infection control issue? LPN #5 stated, Yes. LPN #5 was asked, who is responsible for ensuring catheter bags and tubing are not on the floor? LPN #5 stated, Any of the staff. h. On 3/14/19 at 11:02 a.m., the Director of Nursing (DON) was asked, should catheter bags and tubing be on the floor? The DON stated, No. The DON was asked, would you say this is an infection control issue? The DON stated, Yes. 2. Resident #67 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/1/18 9 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS, required extensive physical assistance of 2 persons for 2 plus persons for bed mobility, total assistance of 2 plus persons for transfers and toilet use, extensive assistance of one person for personal hygiene and was incontinence of bowel and bladder a. On 3/12/19 at 9:05 a.m., CNA #1 and 2 provided incontinent care for the resident. CNA #1 cleansed urine from the resident's abdomen and front perineal area, and CNA #2 cleansed the buttocks and anal area. Without washing hands or changing gloves, CNA #2 placed a clean brief underneath resident and assisted the resident to turn onto her back, fastened the disposable brief, then covered the lower portion of the resident's body with the bed linens. CNA #1, who was still wearing the same gloves worn during incontinent care, placed the package of wipes and peri-wash in the top drawer of the resident's bedside table. CNA #2, still wearing the same gloves, retrieved a clean gown, and both CNAs assisted the resident to remove her shirt and put on the gown. They then assisted the resident to adjust her position in bed. Neither CNA changed gloves at any time during care. b. On 3/14/19 at 1:59 p.m., the Director of Nursing was asked, when should gloves be changed during peri-care? She stated, .when moving from one area to the next, when visibly soiled . from dirty to clean .

Based on observation, record review and interview, the facility failed to ensure a care planned fall prevention intervention was consistently implemented, as evidenced by failure to ensure the call light was kept within reach to enable the resident to call for assistance with transfers and minimize the potential for falls for 1 (Resident #79) of 35 (Residents # 37, 68, 14, 21, 40, 76, 71, 66, 75, 36, 48, 5, 81, 10, 27, 106, 23, 61, 20, 70, 43, 51, 34, 100, 91, 32, 62, 79, 88, 95, 107, 67, 1, 97 and 45) sampled residents who required assistance with transfers. This failed practice had the potential to affect 83 residents who required assistance with transfers, as documented on Residents Census and Conditions of Residents form dated 3/11/19. The findings are: Resident #79 had [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set with an Assessment Reference Date of 2/4/19 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, required extensive physical assistance of 2 persons for bed mobility, transfer, and toilet issue, and has had no falls since admission. a. The Care Plan with a revision date of 9/25/18 documented, .The resident is at risk for falls . Be sure the resident's call light is within reach . b. On 3/12/19 at 1:22 p.m., the resident was sitting in wheel chair in his room. The resident asked this surveyor, Are you going to put me to bed? The resident's call light was approximately 9 feet away, out of his reach. At 1:26 p.m., the resident stated, Put me to bed. Staff continued to walk past the opened doorway. c. On 3/12/19 at 1:29 p.m., Certified Nurse Assistant (CNA) #3 and CNA #4 entered the resident's room and were asked by the surveyor, can you tell me what that is on the floor on the other side of the bed? Both CNAs stated, His call light. The CNAs were asked, can the resident reach his call light? CNA #3 stated, He can't reach it. The CNAs were asked, should the call light be within reach? Both CNAs stated, It should be in reach. d. On 3/13/19 at 10:08 a.m., Licensed Practical Nurse (LPN) #5 was asked, should the call light be in reach of the resident for their use? LPN #5 stated, Yes. LPN #5 was asked, who is responsible for ensuring call lights are within reach? LPN #5 stated, Any of the staff. LPN #5 was asked, what could happen if a resident cannot reach their call light? LPN #5 stated, They might need something and they are just lying in there needing something. e. On 3/13/19 at 10:14 a.m., CNA #5 was asked, should call lights be within reach of residents for their use? CNA #5 stated, Yes. CNA #5 was asked, what could happen if the resident cannot reach their call light? CNA #5 stated, They try to get up and fall. CNA #5 was asked, who is responsible for ensuring call lights are within reach of residents? CNA #5 stated, CNAs and nurses. f. On 3/13/19 at 10:17 a.m., CNA #6 was asked, should call lights be within reach of residents for their use? CNA #6 stated, Yes. CNA #6 was asked, what could happen if a resident cannot reach their call light? CNA #6 stated, Scream and reach for it, fall and get hurt. CNA #6 was asked, who is responsible for ensuring call lights are within reach of residents? CNA #6 stated, CNAs and nurses and whoever provides care for them. g. On 3/14/19 at 11:02 a.m., the Director of Nursing (DON) was asked, what could happen if a resident didn't have or couldn't reach their call light? The DON stated, They are supposed to be put with the call light within reach; he wouldn't be able to call for help. The DON was asked, should call lights be within reach for residents' use? The DON stated, Yes.

Complaint # was substantiated, all or in part, with these findings. Based on interview and record review, the facility failed to ensure Resident #1 received the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well-being. The facility failed to ensure that Oxygen E-Cylinder Tanks were kept in good working order; that licensed staff were knowledgeable in the operation and set up of an Oxygen E-Cylinder Tank; and staff was aware where to locate the oxygen tanks in the event of an emergency to ensure prompt response for 1 of 1 (Resident #1) case mix resident who went into respiratory distress. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 1 who experienced respiratory distress, with an oxygen saturation rate of 55%, was unable to receive needed oxygen therapy until the emergency medical technicians arrived and transported the resident to the hospital and had the potential to cause more than minimal harm to 17 residents who had a change in condition since 4/1/14 according to a list provided by the Administrator on 6/18/14. The facility was notified of the Immediate Jeopardy condition on 6/17/14 at 4:00 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. No Minimum Data Set was available for review. a. On 6/17/14 at 9:10 a.m., CNA #1 stated, "I work 3:00 p.m. until 11:00 p.m. I worked with (Resident #1) (on 6/7/14). He had a blue buzzer and he pulled it and I went in. He said he was going to throw up. He lays flat in bed. I raised his head and gave him a bath basin. This was about 3:15 p.m. to 3:30 p.m. He threw up a little bit and choked a little. I pushed him forward and told him to keep coughing. He stopped coughing. (CNA #4) came in and she gave him a few drinks of water. I told the nurse (LPN #1) he was sick to his stomach and tried to throw up and was coughing. " On 6/17/14 at 2:15 p.m., a recorded video documented a visualization of Certified Nurse Assistant (CNA) #1 entering the resident ' s room on 6/7/14 at 3:49:01 p.m. On 6/17/14 at 1:00 p.m., (LPN #1) stated, "I work the 3:00 p.m. till 11:00 p.m. shift. (On 6/7/14) the CNA came and told me (Resident #1) was sick at his stomach. I went and saw (Resident #1) early on the shift. I went to his room and asked if he was o.k. He shook his head yes. " On 6/17/14 at 2:15 p.m., a recorded video documented a visualization of Licensed Practical Nurse (LPN) #1 (Licensed Practical Nurse #1) entering the resident ' s room on 6/7/14 at 4:12:16 p.m. and exiting the residents room at 4:13:11. As of 6/18/14, there was no documented assessment of the resident ' s condition at this time. b. A Nurse's Notes dated 6/7/14 at 4:15 p.m. documented, "Called to res (resident's) room per CNA. Res bluish in color. Unable to take deep breath. Could answer questions. pulse ox 55%. (Physician) here. Checked res. Orders to send to ER (emergency room ). Wife here. Left via ambulance at 4:40 p.m. DON (Director of Nursing) aware." As of 6/18/14, there were no Nurse's Notes found in the clinical record from the date of admission, on 6/2/14 until 6/7/14 that indicated the resident had any signs or symptoms of "nausea/vomiting, cyanosis, changes in lung sounds or decrease in oxygen saturation levels" prior to this time. On 6/18/14 at 10:21 a.m., the DON (Director of Nursing) was asked if there were other Nurse's Notes available for review. The DON stated, "No." 1) On 6/17/14 at 9:10 a.m., CNA #1 stated, "About 30-40 minutes later (after 3:15 - 3:30 p.m. complaint of nausea), I went and checked on him again. At that time he was purple in the face. He did not respond to me. (CNA#2) entered the room. I cranked his head to an upright position, told (CNA#2) to stay and went and got (LPN #1). I said (Resident #1) is purple and can't breathe. She went to the room and tried to talk to him. (LPN #1) told me to go get another nurse. I ran to get a nurse to come to his room. (LPN #2) was running toward the room. We both arrived at his room. One nurse stayed with (Resident #1). One nurse paged (Physician) who was in the facility. She paged (Physician) to his room STAT. (Physician) arrived within one minute. (Physician) listened to his lungs and did the pulse ox. His right hand was just laying there and his left hand was on his stomach. (Physician) asked him what was wrong and asked if he knew where he was. He would nod. After they assessed him, I said '(Resident #1) it is going to be o.k.' He said 'I hope so'. It was weak (his speech) but clear as day. (LPN #2) brought two oxygen tanks and both were not working. By that time the ambulance arrived and put a face mask on him with oxygen. (Physician) stayed with (Resident #1) the whole time. " On 6/17/14 at 2:15 p.m., a recorded video documented a visualization of Certified Nurse Assistant (CNA) #1 entering the resident ' s room on 6/7/14 at 4:36 p.m. 2) On 6/17/14 at 1:00 p.m., (LPN #1) stated, " Later, (CNA #1) came running and said (Resident #1) was blue. I went to his room. He had a bluish tint on his face. He was sweating. When I asked him if he had pain, he shook his head no. I washed his face. I sent for the other LPN. His face was then pale and he was sweating. (LPN #2) came and took his pulse ox. (Physician) was in the building and came right down to the room. She said 'send him to the ER.' I left (LPN #2) in the room and left to call the ambulance. LPN # 1 was asked what the facility policy was for a change of condition in a resident. LPN #1 stated, " Our policy for change of condition is to assess the resident, call the physician and transport if needed. I did not get vital signs. I did not do a pulse ox. I did not check his pulse. I did not listen to his breath sounds. With a change of condition we should take vital signs, get them stable and call the doctor. By the time I got the paper work done the ambulance was at the facility." On 6/17/14 at 2:15 p.m., a recorded video documented a visualization CNA #1 and LPN #1 entering the residents room at 4:37p.m. 3) On 6/17/14 at 1:30 p.m., (LPN #2) stated, "I was on the 3:00 p.m. till 11:00 p.m. (shift) that day (6/7/14). It was a little after 4:00 p.m. I heard a page for an LPN to come to A Hall. I was on B Hall. I took out to A Hall. I saw (LPN #1) walk in to (Resident #1's) room. (Resident #1) was sitting up with the bed at 90 degrees. I heard (LPN #1) say 'I don't know him. I don't know what's wrong with him'. I could tell (Resident #1) was in distress. His head was forward with his chin to his chest. His lips were cyanotic. His nail beds were cyanotic. He was sweating, clammy and very cold. I asked (LPN #1) if she had a pulse ox on her. She said it was on her cart. I left the room and paged (Physician) STAT to (Resident #1's) room. I ran back to the room and tried to get him to talk to me with the only response being 'huh'. At this point (Physician) entered and asked for the pulse ox. I got the pulse ox. The pulse ox was 52-53. (Physician) told (LPN #1) to get the ambulance and told me to get oxygen. I went and got a tank from B Hall oxygen storage room and ran it back to the room. It was leaking. I got the second oxygen tank from the oxygen storage room. It was leaking also. The EMT's (Emergency Medical Technicians) arrived. They put oxygen on him. We are supposed to evaluate the resident, check their vitals, check oxygen sats (saturation) and listen to the lungs. To my knowledge none of this was done. When I entered the room (LPN #1) was not doing anything. (CNA #1) was in the room. (LPN #1), (CNA #1) (Physician) and EMT's were in the room when I left." On 6/17/14 at 2:15 p.m., a recorded video documented a visualization of LPN #2 running to the resident ' s room followed by CNA #1. LPN #2 immediately leaves the room again and goes to the Nurse's Station and uses the phone at 4:39 p.m. c. The Physician's Clinical Encounter Summary dated 6/7/14 at 5:00 p.m. documented, " Chief Complaint ...breathing problems ...Dyspnea was reported by patient ...Pt (patient) was found in bed by an aide, who reported that he was 'purple'. The nurses were called to evaluate him and I was then called as well. Pt was able to answer questions appropriately, denied any pain or nausea. The nurses report that he was complaining of some nausea earlier, no emesis. O2 Sat (oxygen saturation) 59% room air at rest ... physical exam ...Lungs: Respiratory Effort-dyspneic. Auscultation-decreased breath sounds and wet rales/crackles. Cardiovascular: Heart Auscultation-RRR (regular rate and rhythm) and no murmurs. Extremities-cyanosis, Cyanosis of the fingertips/nail beds .... Assessment/Plan Aspiration pneumonia-I suspect that he has aspirated. We will put him on Oxygen and call EMS (emergency medical services). Pneumonitis due to inhalation of food or vomitus. Hypoxemia." On 6/17/14 at 3:00 p.m., (Physician) stated, "Vital signs were taken. The blood pressure was 140/90. I don't remember the pulse and respirations." On 6/17/14 at 2:15 p.m., a recorded video documented visualizations of the Physician entering the resident ' s room at 4:40 p.m.; LPN #1 coming to the Nurse's Station followed by the Physician at 4:43 p.m.; of the Physician re-entering the resident ' s room then leaving the room at 4:46 p.m.; of the Physician and LPN #2 entering the resident ' s room, LPN #2 has E-cylinder oxygen tank on a small cart. LPN #2 leaves room at 4:49 p.m.; of LPN #2 entering the resident ' s room carrying an E-cylinder oxygen tank at 4:52 p.m. d. The Emergency Medical Service Narrative dated 6/7/14 documented in part "Call received 1630 (4:30 p.m.) ...At Patient side 1635 ...Departed Scene 1645...Pt (patient) present with respiratory distress. O2 Sat (oxygen saturation) 45% on 5 LPM (liters per minute) at (Facility). Pt lungs wet. Possibly aspirated. Skin warm-moist...Place pt on 15 LPM NRB (non rebreathing mask)....O2 Sat on 15 LPM still only 70%....Assist ventilations via BVM (Bag Valve Mask). O2 Sat on BVM 90%. Transport pt to (Hospital). No complaints enroute. Pulse-120, Respirations-35 and Blood Pressure 169/76." On 6/17/14 at 2:15 p.m., a recorded video documented a visualization of an Emergency Medical Transport Personnel entering the resident ' s room with a stretcher and emergency equipment at 4:55 p.m. ant leaving the resident ' s room at 4:59 p.m. The hospital Emergency Department Triage Assessment documented, "Triage Time: Sat (Saturday) Jun (June) 07, 2014 1743 (5:43 p.m.) ...[DIAGNOSES REDACTED]. The wires of the false teeth were hooked to an area. Removed with forceps, then intubation started." e. The hospital Physician History and Physical documented, " admitted [DATE] ...Chief Complaint Respiratory Arrest ...Assessment: 1. Metabolic Acidosis that is uncompensated, probably related to underlying aspiration pneumonia 2. Elevated troponin levels which could be consistent with Acute [MEDICAL CONDITION] Infarction obviously 3. Cardiac arrhythmia 4. Systolic ejection murmur 5. Diabetes Mellitus 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION] Arthritis and 8. status [REDACTED]. f. The Nurse's Notes dated 6/7/14 at 9:30 p.m. and signed by LPN #1 documented, "Call to (hospital). Res admitted to ICU (Intensive Care Unit). Admin (Administrator) aware. 141/59-92-20-99.1" g. On 6/17/14 at 9:45 a.m., the Administrator, (LPN #3) and the surveyor went to the oxygen storage room. (LPN #3) attempted to set up the E-cylinder oxygen tank on the portable cart to deliver 6 liters per minute. There was no oxygen delivered from the port. (LPN #3) stated, " It does not work. " The Assistant Director of Nursing arrived and stated, "The oxygen cylinder on the cart would be the one to use." At 9:55 a.m., the Assistant Director of Nursing went to the crash cart and checked the oxygen E-cylinder. She turned the oxygen to 6 liters per minute and a burst of oxygen came through the port then quit. The Assistant Director of Nursing stated, "It is empty." The Administrator (also a nurse) opened the valve and the oxygen at 6 liters per minute came through the port, it was operational. h. On 6/17/14 at 3:55 p.m., the Administrator stated, "We do not have oxygen inservices available from 2013 through 2014" (for your review). i. On 6/18/14 at 10:21 a.m., the Director of Nursing was asked if the facility had a list of procedures that could be adequately performed by the professional staff such as a skills check list. The Director of Nursing stated, "No." At 10:55 a.m., the Director of Nursing was asked on 6/7/14 where the closest oxygen available to (Resident #1) would be located. The Director of Nursing stated, "It would have been on the crash cart." The Director of Nursing was asked where did (LPN #2) get the oxygen from on 6/7/14 for (Resident #1). The Director of Nursing stated, "The oxygen room." The Director of Nursing was asked how much further is the oxygen room from the placement of the crash cart on 6/7/14. The Director of Nursing stated, "Approximately 87 feet, The video showed that (LPN #2) made that trip twice being a total of 348 extra feet." The Director of Nursing was asked if the facility had provided an inservice related to change of condition recently. The Director of Nursing stated, "On 5/29/13, 5/31/13 and 5/22/14." The Director of Nursing was asked why (LPN #1) did not complete the assessment as required. The Director of Nursing stated, "I do not know why." The Director of Nursing stated "Our current assessment form is the Interact form which requires vital signs, oxygen sats, key clinical information, relevant [DIAGNOSES REDACTED]. (LPN #1) should have assessed the resident utilizing these tools." 2. The Immediate Jeopardy was removed on 6/17/14 at 11:00 p.m. and reduced to a scope/severity of "G" after the facility began implementation of the Plan of Removal as follows: a. On 6/17/14 at 4:20 p.m., the Administrator identified 73 residents per the facility census residing in the facility that did not have continuous O2 (Oxygen) orders as having potential to be affected by the deficient practice. By 11:00 p.m. on 6/17/14 the DON (Director of Nursing), ADON (Assistant Director of Nursing), LPN MDS (Licensed Practical Nurse Minimum Data Set) Coordinator and LPN medical records had assessed all 73 residents for adverse respiratory or cardiac symptoms by assessing breath sounds, heart rate, cyanosis, LOC (level of consciousness) and any dyspnea with no negative findings noted. b. On 6/17/14 at 10:20 a.m., the Administrator/LPN inserviced the ADON on utilization, contents, and location of the crash carts during change of condition for prompt access to O2 and suction if needed and proper utilization of O2 cylinder for use and how to turn one cylinder (O2 cylinder) with return demonstration. On 6/17/14 at 11:00 a.m., the ADON then began inservicing on-duty staff with return demonstration on turning one cylinder on crash cart with all on duty licensed staff inserviced and return demonstration received by 3:00 p.m. c. On 6/17/14 at 3:00 p.m., on duty licensed personnel and oncoming 3-11 licensed personnel inservicing was completed as well as the DON, ADON and office nurse staff on duty by the RN (Registered Nurse) Consultant on assessment of resident when change of condition is reported or noted, utilization, contents and location of crash carts during change of condition for prompt access to O2 and suction if needed and proper utilization of O2 cylinder and turning on for use and how to identify new sealed e cylinder. This inservice as well as return demonstration will be repeated on each shift with all licensed staff prior to providing resident care. d. Inservice with return demonstration will be conducted with any new hires or licensed staff on vacation or on sick leave before returning to work by the DON or ADON. e. Beginning 6/18/14 and to continue until compliance is achieved, DON, ADON and department head licensed nurses will conduct walking rounds throughout the entire facility every weekday morning and by the weekend RN and visualize all residents using a daily census to assure all are seen for any signs or symptoms of respiratory or cardiac distress. Any negative respiratory or cardiac signs or symptoms on visualization will be addressed immediately. f. Beginning 6/18/14, the DON/designee will bring to the every weekday morning meeting the 24 hour report from the previous 24 hour shifts as well as the weekend RN addressing the weekend 24 hour report to the every weekday morning meeting and the reports will be reviewed by the team for documentation of change on resident condition. The DON/designee will re-assess any resident with documentation change in condition and review the documentation in the nurses notes. Any negative findings will be addressed immediately by DON/designee. g. Beginning 6/18/14 the DON/designee will check each crash cart everyday to assure all items in place and that full cylinder with flow meter in place and ready to use on cart. Any negative findings will be corrected immediately by DON/designee. h. Beginning 6/18/14 the results of the monitoring will be added to the every weekday morning meeting agenda and discussed with any negative findings being reported to the MD (Medical Director) by the DON and new interventions or additional inservicing will be brought to the quarterly QA (Quality Assurance) meeting by the LPN/Administrator for review and additional inservicing or interventions will be implemented as needed.

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure pressure sores were reassessed at least weekly with the results documented to include the type/stage, measurements, condition of the surrounding tissue, presence or absence of drainage/odor in order to promptly identify healing or lack of healing to ensure prompt changes in treatment when needed; failed to ensure physician orders for wound care were consistently implemented; and failed to ensure changes in wound care orders were promptly implemented to promote healing for 1 (Resident #1) of 3 (Resident #1, 3 and #4) case mix residents with pressure sores. The failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury or death to Resident #1, who developed [MEDICAL CONDITION] to the left calf, required surgical debridement and hospitalization , and was likely to affect 4 residents who had pressure sores as identified by the Administrator on 3/14/12 at 8:10 a.m. The facility removed the Immediate Jeopardy as of 2/24/12 prior to the surveyor ' s entrance; however, the facility had not corrected the underlying deficient practices. On 3/14/12 at 11:51 a.m., the facility Administration was informed of the Immediate Jeopardy findings. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) with an Assessment Reference Date of 2/2/12 documented the resident scored 4 (0 - 7 indicates severely Impaired) on the Brief Interview for Mental Status (BIMS); required extensive assistance of 1 staff member for bed mobility and transfers and was totally dependent on 1 staff member for locomotion, dressing, toileting, personal hygiene and bathing; was at risk for developing pressure ulcers but had no unhealed pressure ulcer(s) at Stage I or higher, had no venous and arterial ulcers, was on a turning/repositioning program, received applications of nonsurgical dressings other than to feet, received application of ointments/medications other than to feet and received application of dressings to feet (with or without topical medications). a. The resident developed Pressure Ulcers on the Left Lower Extremity. 1) " Charge Nurse Skin Condition Assessment/Tracking " for the Left Lower Extremity from 10/7/11 - 1/13/12 documented: 10/7/11 Skin tear (ST) to left leg ....10/28/11 skin tear to lower extremity (no other description). The form contained no other documentation regarding the left leg until 11/18/11. 11/18/11 " LLE (left lower extremity) 2.2 cm (centimeters) x 2 cm skin tear " with 2nd entry dated 11/18/11 " ...ST LLE (outer) steri strips in place. " 11/23/11 " LLE Tx (treatment). " 11/29/11 " LLE s/t (skin tear) drsgs (dressings) D/I (dry/intact). " The forms contained no further documentation regarding the skin tears to the LLE or of the presence of pressure sores to the LLE. 2) A Nurses Note dated 11/29/11 at 10:40 a.m. documented, " ...2 cm (centimeter) x 1 cm skin tear back of LLL (left lower leg) ...red blood on sock... (Attending Physician) notified with new order received: [MEDICATION NAME] (and) dressing to skin tear posterior LLL (left lower leg) q (every) (day) x (times) 10 days ...At 11:05 a.m. (Power of Attorney) notified ... " 3) The November 2011 Treatment Administration Record (TAR) documented, " Cleanse LLE (with) wound cleanser approx (approximate) edges cover (with) bandaid wrap (with) kerlix secure (with) tape obs (observe) (and) change QD (every day) til healed 11/10/11. " ; " 11/18/11 [MEDICATION NAME] (and) dressing to LLE q (every) shift x 10 days. " ; and "11/29/11 [MEDICATION NAME] and dressing to skin tear back of LLL q day x 10 days. " The December 2011 TAR documented the STs to the LLE as healed 12/20/11. 4) Nurses Notes dated 12/26/12 at 6:00 a.m. documented, " 2 large hematomas back of (left) calf fluid filled ...protective drsg per (Doctor) - (family member) called. " The December 2011 did not document any treatment other than a protective dressing to back of left leg after 12/20/11. 5) A wound clinic assessment dated [DATE] documented, " ...Post (posterior) Lt (left) sup (superior) leg ...Decub (Decubitus) ulcer (stage) III ...1.7 (cm) x1 (cm) x 0.2 (cm) ...Lt. posterior leg ...Decub ulcer (stage) III ...3(cm) x 2.6 (cm) x 0.2 (cm) ...were debrided in clinic today ... " The assessment documented treatment for [REDACTED]. Nurses Notes from 12/27/12 until 1/13/12 occasionally note dressings to LLE dry/intact but do not describe wounds to left calf. Nurses Notes dated 1/13/12 document the resident was admitted to the hospital. 6) A telephone order dated 1/13/12 documented, " ...Cleanse wounds on back (left) calf (with) hibaclens apply [MEDICATION NAME] oint (ointment) cover (with) drsg QD. " 7) The January 2012 did not document any treatment to the Decubitus ulcers to the LLE until the resident ' s return from the hospital on [DATE]. b. The resident developed Pressure Ulcers on the left foot. 1) " Charge Nurse Skin Condition Assessment/Tracking " for the Left Foot from 10/7/11 - 1/13/12 documented: 11/2/11 open area left foot (no other description). There was no further documentation regarding the left foot on the forms. 2) A Nurses Note dated 11/30/12 at 2:00 p.m. documented, " Asked to assess resident ' s left foot. Noted to have a 1.0 cm x1 cm annular ulceration to left lateral foot. Unable to stage. Depth not visible d/t (due to) thick layer of scabbing. (Physician) made aware. New orders received to apply [MEDICATION NAME] (every) shift to ulcer on left lateral foot (and) pad (with) 4x4 ' s (and) wrap with [MEDICATION NAME] x 14 days then re-evaluate. " a) A Physicians Order dated 11/30/11 documented, " Apply [MEDICATION NAME] q shift to ulcer on left lateral foot and pad (with) 4x4 ' s (and) wrap with [MEDICATION NAME] x 14 days then re-evaluate. " b) The November 2011 and December 2011 Tar documented, " Apply [MEDICATION NAME] q shift to ulcer on left lateral foot and pad (with) 4x4 ' s (and) wrap with [MEDICATION NAME] x 14 days then re-evaluate. " The care was initiated on 11/30/11. The December 2011 TAR showed no documentation to indicate the wound care had been completed on the, night shift for 12/3/12, the evening and night shift for 12/8/11 and the evening shift for 12/9/11. The December MAR indicated [REDACTED]. There was no documentation to indicate wound care had been provided on the night shift on 12/14, 15, 17, 18, 19 or 20th. 3) The Wound Care Clinic assessment dated [DATE] documented, " A- left dorsal foot Decub (stage) I ...0.8 (cm) x 0.6 (cm) x ...B- left lat (lateral) foot decub (stage) III ...1.7(cm) x 1.5 (cm) x ...Wounds A, B debrided in clinic today ... " a) A Physician order dated 12/21/11 documented, " 1) D/C (Discontinue) current tx (treatment) (L) foot. 2) Cleanse wound (L) foot (with) normal saline, apply Santyl to wound bed. Apply [MEDICATION NAME] to peri wound tissue. Cover wound (with) bordered foam 3 X ' s (times) weekly. " b) The December 2011 TAR documented, " Cleanse wound(L) foot (with) NS (Normal Saline) apply Santyl to wound bed, [MEDICATION NAME] to peri wound cover (with) boarded (bordered) foam 3 X ' s weekly 12/21/11. " 4) A Body Audit Sheet with a start date from 1/2/12 through 1/13/12 documented: 1/2/12: (Left) Lateral (foot) 1 1/2 cm x 2 cm x1/4 cm (and) Top .5 scab 1/7/12: (Left) lateral (foot) 2x2x4 cm and (another area was identified by a dot on diagram) scabbed. 5) The Wound Care Clinic assessment dated [DATE] documented, " 1- left dorsal foot Decubitus Ulcer (stage) I ...0.6 (cm) x 0.4 (cm) x 0.2(cm) ...2- left lateral foot Decubitus Ulcer (stage) III ...2.2(cm) x 1.6 (cm) x .03 (cm) ...Wounds 1, 2 debrided in clinic today ... " The Wound Care Clinic assessment dated [DATE] documented, 1- left dorsal foot Decubitus Ulcer (stage) I ...0.7 (cm) x 0.5 (cm) x 0.1(cm) ...2- left lateral foot Decubitus Ulcer (stage) III ...2(cm) x 2 (cm) x .01 (cm) ...Wounds 1, 2 ... debrided in clinic today ... " The January 2012 TAR documented the order continued as indicated for the L foot wound. c. The resident developed Pressure Ulcers on the coccyx. " Charge Nurse Skin Condition Assessment/Tracking " for the coccyx from 9/28/11 - 1/13/12 documented: 9/28/11: Coccyx reddened (no other description) 9/29/11 Coccyx reddened (no other description) 10/1/11 Coccyx reddened (no other description) 10/2/11: Coccyx reddened closed (no other description) d. A Nurses Noted dated 1/13/12 documented, " admitted to Hot Springs Kidney Center called 2:10. " On 3/13/12 at 3:30 p.m., the Patient Care Coordinator stated when she (Resident) went (to hospital) on 1/13/12 she had gangrenous areas on the left lower leg. The Director of Nurses (DON) at the time talked to [MEDICAL TREATMENT] and they told her that the doctor was upset about the areas being gangrenous and (the resident) was sent directly from [MEDICAL TREATMENT] to the hospital. e. The History and Physical Admission Hospital Note dated 1/13/12 documented, " ...She had a Stage II decubitus ulcer, which is linear over the sacrum. The entire buttocks, sacrum and perianal are [DIAGNOSES REDACTED]tous and this is not blanching [DIAGNOSES REDACTED] comprising a Stage I decubitus ulcer. The patient has three or four ulcers with surrounding [DIAGNOSES REDACTED] involving the left calf. These appear to be either pressure ulcers or traumatic ulcers. She has two ulcers of the foot and these are dry eschars ... " f. The Hospital Surgical Report dated 1/14/12 documented: " ... Preoperative Diagnosis: [REDACTED]. 1: Left Calf Ulcers times four (please see dimensions below). 2. Left foot ulcers times two. 3. [MEDICAL CONDITION] of the left calf. Procedures Performed: 1. Excisional debridement of left lateral foot ulcer. This is over the lateral dorsal aspect of the midfoot; this is a dry eschar. The dimensions of the debridement, including margins, measured 2.4 x 2.3 cm. The debridement included debridement eschar, ligamentous tissue, as well as a little bit of bone. Clinically, the patient has osteo[DIAGNOSES REDACTED] at this site. ... 2. Excisional debridement of 4 mm (millimeter) x 3 mm ulcer over the dorsal aspect of the right midfoot overlying the first metatarsal .... 3. Excisional debridement of ulcer of the left calf. The debridement, including margins, measured 2.5 x 1.8 cm; this included skin, hematoma, as well as epidermis .... 4. Excisional debridement of left calf ulcer. The debridement measured 4.3 x 2.8 cm; this included skin as well as subcutaneous tissue. ... 5. Excisional debridement of left calf decubitus ulcer. The dimensions of the debridement, including margins, measure 1.2 x 1.0 cm; this included eschar. ... 6. Excisional debridement of left calf ulcer. The dimensions of the debridement, including margins, measured 3.2 x 2.0 cm; this included epidermis only. ... " g. A Hospital Physician Orders sheet dated 1/20/12 documented, "Ok to D/C (discharge) to (Nursing Home) (with) Hospice today with no [MEDICAL TREATMENT] ... " h. An Admission Nursing Assessment/Nurses Notes dated 1/20/12 at 5:30 p.m., documented, " " ... ...L (upper) arm is bruised (with) a 1x1 cm scabbed area, bruise 2x2 R (right) (upper) arm, has 0.24 cm open area (upper) spine (and) 0.5 cm open area below it on spine, 3x2 cm bruise above L elbow, 5 cm scratch across R (lower) back, 8x5 cm re sacrum, L (lower) leg posterior has 6x2 cm open area, L heel has 5x6 cm black area (with) a 1x1.25 cm black area (and) a 1 cm open area above heel on bottom of foot, L side of foot has 2x2 open area (with) black edges, top of L foot has 1x0.5 cm open area, R heel has 5x7 cm red mushy area. Lungs CTA (cleat to auscultation), bowel sound active. ... " i. A Body Audit Sheet with a start dated 1/21/12 through 1/26/12 documented: 1/21/12: left lateral calf 3 cmx 2cm; 1x1 cm;0.5 x 1cm. Left Heel - black 5 x6; (left) lateral (foot) 2x2cm. 1/23/12: Left lateral calf 3x2; 1x1; 0.45 x1 (with) reddened drainage. 1/24/12: Heel black 4x6; Open 6 x4 Foot 2x2 ? , ? surround white, leg 4 open areas; 31/2 x11/2; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]. (documentation does not identify an area on diagram; all information is documented on left side of diagram) 1/25/12: 3x2; 1x1; 0.5x1 reddened (with) odors; Dressing intact (l) foot; L ankle (and) heel reddened. 1/26/12: Reddened area Rt (right) heel 1 cm Ankle 0.5 cm; Drsg (dressing) intact L foot; 2x2 area L calf 2x2 cm. j. Charge Nurse Skin Condition Assessment/Tracking documented, " 2/16/12: L heel 6x2 eschar; Rt heel 1 cm; L lateral foot 3x4; top L foot 1 cm; L calf 4x4. " calf 4x4. " (no other k. Nurses Notes dated 2/17/12 at 2:45 p.m. documented, " Resident (without) v/s (vital signs) skin cold, color is cyanotic ... " 2. The facility removed the Immediate Jeopardy and reduced the scope/severity to " H " on 2/24/12 when the following corrective actions were taken: a. On 3/13/12 at 4:15 p.m., the Patient Care Coordinator stated the Director of Nursing was terminated at the end of February due to failure to follow thru on skin issues. She stated that the management staff is having weekly QA meetings regarding skin issues initiated 3/1/12. b. An Inservice Training reports were provided by the Administrator on 3/14/12 at 12:24 p.m. The Inservice Reports documented, " Date 2/24/12, Instructor: (Name) Brief outline. Skin (and) Body Audit Forms. " The Employee signature page was attached. " Date: 3/7/12 Instructor: (Name) Brief Outline: 3). Skin audit tablets (and) instructions. " c. The Policy and Procedure for Pressure Ulcer Prevention and Assessment (no date) received from the Administrator on 3/14/12 at 8:10 a.m. documented, " ...Policy: To promote healthy intact skin ...At risk patients will be identified by using Braden Scale and Clinical Assessment ...RN or Designated skin care provider may determine need for and implement appropriate skin care treatment ...Assessment: 1. Braden Scale completes by the 14th day of admission, quarterly and significant change in condition. 2. All residents will have a body audit completed weekly ...Interventions: ...6. CNA (Certified Nurses Assistant) to report any change in skin condition to LPN (Licensed Practical Nurse).

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the staff provided the necessary care and services to maintain the highest practicable physical well-being for Residents #1 and #2: A. The facility failed to ensure staff responded to a call light and repeated verbal requests for help for 1 (Residents #1) of 3 (Residents #1, #2 and #5) case mix residents who were totally dependent on staff for care. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who after turning on her call light, repeating verbal requests for help, was not ensured immediate assistance and was later found to be without vital signs. The failed practice had the potential to affect 43 residents who required total assistance from staff, according to a list provided by the Director of Nursing (DON) on [DATE] at 9:35 a.m. The facility was informed of the Immediate Jeopardy situation on [DATE] at 9:50 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 12 (,[DATE] moderately impaired) on the brief interview for mental status (BIMS), was totally dependent on staff for all activities of daily living except eating and had no behaviors. a. A Nurse's Note dated [DATE] at 4:08 p.m. and signed by Registered Nurse (RN) #1 documented, "Called to resident's room by CNA (Certified Nursing Assistant). Found resident pale, dusky color, agonal resp (respirations), HR (Heart Rate) 60, SpO2 (oxygen saturation measured by pulse oximetry) 62%, nonresponsive, diaphoretic, flaccid. O2 (oxygen) via NC (nasal cannula) at 2 L (Liter), pupils equal, sluggish. Ambulance called, O2 increased to 6 L, SpO2 73%, BP (Blood Pressure) ,[DATE], resp 16, HR 103, responsive to voice, slurred speech, unable to follow commands, flaccid... 4:20 p.m. - Ambulance here to transport..." b. A Hospital History and Physical dated [DATE] documented, "Impression: Florid [MEDICAL CONDITIONS] - this is a clinical diagnosis... Known [MEDICAL CONDITIONS] with previous [MEDICAL CONDITION] infarctions... History of [DIAGNOSES REDACTED]." c. A Hospital Discharge Instruction sheet dated [DATE] documented, "Discharge Diagnosis: [REDACTED]. d. A Nurse's Note dated [DATE] at 2245 (10:45 p.m.) and signed by Licensed Practical Nurse (LPN) #6 documented, "CNA (,[DATE]) (3:00 p.m. to 11:00 p.m. shift) reported to LPNs ((LPN #1) and myself) (resident) was complaining of SOB (shortness of breath). LPNs entered (resident) room and found resident cyanotic and unresponsive (with) pupils fixed (and) dilated. V/S (vital signs) B/P (blood pressure) ,[DATE], R (respirations) 26, P (pulse) 48, O2 (oxygen) 48%. Administered O2 via NC (nasal canula) at 6 L/M (liters per minute) (and) notified (hospital) for an ambulance. (Resident) became more responsive as O2 sat (saturation) increased to 84% prior to arrival of ambulance... Transferred to (hospital)... 2:10 a.m. Returned to (nursing home) via ambulance (with) Dx (diagnoses) of [MEDICAL CONDITIONS] / [MEDICAL CONDITION]. Received N.O. (New order) to (increase) [MEDICATION NAME] to 20 mg (milligram) BID (twice daily)..." On [DATE] at 2:53 p.m., LPN #2 stated, "A couple of weeks before (Resident #1) passed away ([DATE]), she had a bad episode where she was unresponsive. The CNAs called me down there." She was asked if she was the resident's nurse. She stated, "No." She was asked why the CNAs called her instead of the resident's nurse. She stated, "I don't know." She was asked who the resident's nurse was that evening. She stated, "(LPN #1). The resident was unresponsive. I put the O2 cannula in her mouth and did a sternal rub and she started coming around. I asked (LPN #1) specifically if she had called 911 and she said no, she's a DNR (Do Not Resuscitate). I said I don't give a damn, she's sick. You've got to call 911. For some reason she thinks you don't call 911 if someone's a DNR." e. A Physician order [REDACTED]." f. A Nurse's Note dated [DATE] at 10:25 p.m. and signed by LPN #1 documented, "Resident found by staff, unresponsive to verbal or tactile stimulus. This LPN notified by staff. 10:30 p.(m.) Assessment by this LPN found resident unresponsive to verbal, tactile and sternum rub stimulus. Resident was noted to be (without) a pulse for 1 minute by palpation of carotid and auscultation was also found (without) respirations by auscultation for a period of 1 minute... (Doctor) notified... Family notified... Funeral home notified... (Doctor) here to pronounce..." 1) Interview with CNAs on duty at the time of the incident: On [DATE] at 8:15 p.m., CNA #4, who was on duty the evening of [DATE], was asked about the incident involving Resident #1. She stated, "We had just taken her off the bed pan and (Housekeeping Supervisor) started waxing. I don't remember if her call light was on, but she started saying help, help, somebody come here. She said that maybe 3 times. (Housekeeping Supervisor) blocked off the hall and said don't go down there." The CNA was asked if LPN #1 heard the resident calling for help. She stated, "Yes she heard her and said she just probably wanted on the bedpan and said not to go down there. I should have just went down there. I blame myself. I could have at least held her hand." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "Maybe 30 minutes. I know (CNA #2) called (Administrator) and (Administrator) told her the resident could have passed at any time." On [DATE] at 12:25 p.m., CNA #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "Me and (CNA #4) was working old north. (Housekeeping Supervisor) said he came in to wax the floors and that he was going to block off the hall. He put wet floor signs across the hall and some blue tape on the floor. He told us to tell certain residents that we would not be able to answer their call lights for a while. I could hear (Resident #1) yelling even on old north where I was doing bed checks. Her call light had been going off probably 20 minutes. We asked (Housekeeping supervisor and LPN #1) if we could go down the hall and they said no. (LPN #1) said she just needed the pee pan. I was so upset I called (Administrator) and she said 'well she could have died at any time. She had a bad heart.' She's done this before but we get her on her oxygen and she'll be okay." The CNA was asked what happened when the resident was found without vital signs. She stated, "(Housekeeping Supervisor) was pretty calm and he just went and sat down and started watching TV. (LPN #1) asked for a stethoscope. (LPN #2) came over and said we need to go ahead and call an ambulance and (LPN #1) said no you don't have to, she's a DNR. We thought we could feel a pulse occasionally, but it went away. She was blue." The CNA was asked if the resident had her oxygen on that evening. She stated, "When I went into the room her O2 tubing was on the floor and the concentrator was off." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "At least 20 minutes. I blame myself. I should've done something different. Even if we couldn't have saved her, at least she wouldn't have died alone." The CNA was asked if the resident had a habit of yelling for staff. She stated, "I've not ever heard her yell. I made the comment to (Housekeeping Supervisor) to just do half the hall because how would we know, with the entire hall blocked off, that if someone's alarm was going off they hadn't fallen. So what if she'd just been yelling for a pee pan - we had gotten that woman to where she was continent, so yeah, I think that needing a pee pan is significant." On [DATE] at 3:20 p.m., CNA #3, who was assigned to Resident #1 on the evening of [DATE], was asked during an interview about the incident that evening. She stated, "(Housekeeping Supervisor) said he was going to do the floors. We did an in-between bed check because our next bed check wasn't really due until 10:00 p.m. We went down the hall and told specific residents who normally get on their call light that the floor was being done and we couldn't come through here for a little while. (Resident #1) was one of them." The CNA was asked if Resident #1 was able to understand or comprehend what she was telling her. She stated, "Oh yes. She understood. When I went in to (Resident #1's) room, she actually asked me if (Housekeeping Supervisor) had already started. So (Housekeeping Supervisor) started and we were all up there at the desk, and no sooner had he finished and her call light comes on. We had asked (Housekeeping Supervisor) before he started how long it would be and he said probably 45 minutes. She started hollering help, help me girls. She did that sometimes. We asked him again how long it was going to be before we could go and he said probably 30 minutes." The CNA was asked approximately how much time passed between the resident's call light being activated and when she was found without vital signs. She stated, "Probably at least 30 minutes, maybe a little longer." The CNA was asked if LPN #1 told anyone not to go down the hall during the resident's call for help. She stated, "Not that I know of." The CNA was asked if (Housekeeping Supervisor) told staff not to go down the hall and check on the resident. She stated, "He told us not to walk across the wax until it was dry. I asked him a long time ago why he couldn't wax one half of the hall so we could go and check on residents. He said because it leaves a seam down the middle." CNA #3 was asked if she could do anything differently from that night, what would it be. She stated, "I would definitely walk down that hall." 2) Interview with LPNs on duty at the time of the incident: On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked how long she had worked for the facility. She stated, "I've been here three different times, but the most recent is from May to now." She was asked if she had been terminated from the facility before. She stated, "Yes." She was asked why she was terminated. She stated, "Documentation." LPN #1 was asked about the incident involving Resident #1. She stated, "We were up on North. Around the time I was finishing my med (medication) pass, the floor on new north was being waxed. We had made our rounds, then the wax was put on the floor. The resident put on her call light. I was at my med cart, (Housekeeping Supervisor) was there with his equipment. Some of the girls were by the break area and they looked to see who had their light on. (Housekeeping Supervisor) said 'give me 5 minutes'. As soon as he moved his equipment he went down there and found her. Then he informed me that I needed to come down the hall now. (Resident #1) was unresponsive, no vital signs. We paged the other LPN and she also determined the resident had no vital signs. (Resident #1) had a similar incident not long before this. That time she came around." The LPN was asked if the resident was verbally asking for assistance. She stated, "Yes. She hollered 'girls come help me.' She did that on a regular basis." LPN #1 was asked approximately how much time passed between the resident activating her call light and when (Housekeeping Supervisor) found her without vital signs. She stated, "Maybe 10 minutes. Even if I went long, I would say no more than 15 minutes." The LPN was asked why someone did not go down the hall when the resident requested help. She stated, "She would call out to me or the other girls if she saw us going down the hall. She usually just wanted the bedpan or to be moved in bed. That's what her tone of voice sounded like that night." The LPN was asked how she would be able to determine if a resident was in distress by the tone of their voice. She stated, "I don't know how to even answer that. There's a different tone, a different pitch. I didn't determine there wasn't a problem. That's why I asked (Housekeeping supervisor) how long it was going to be before we could go down the hall. You just learn residents by the tone of their voice. She was up for supper just before that and didn't appear in any distress." The surveyor stated, "I guess in this case she was apparently in distress or in need of immediate assistance." LPN #1 stated, "I don't think so. I don't know that because she sounded like she wasn't in any distress." LPN #1 was asked if she told anyone not to go down the hall and check on the resident when she was asking for assistance. She stated, "No." She then stated, "I followed policy that night by calling (Administrator) about what happened." The LPN was asked if anyone from administration came to the facility that night because of the incident. She stated, "No one came out that night." On [DATE] at 2:53 p.m., LPN #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "I knew that (Housekeeping supervisor) had been cleaning the floors. I'm sorry, but if one of my residents needs me, I'm gonna step on his newly waxed floor. They called me over there for that one too, but she was already gone." LPN #2 was asked if she was aware that the resident had activated her call light and had also been verbally calling for help before she was found without vital signs. She stated, "I became aware after the fact that her call light was on and she was calling for help. CNAs told me that." LPN #2 was asked if she was aware of any occasions when CNAs had reported serious information about residents to LPN #1 and the LPN not responding to it. She stated, "My CNAs are my eyes and ears. If they tell me something, I'm going... Yes, I've personally seen CNAs report things to her that she just brushes off, and doesn't respond to whatever it is they've told her." 3) Interview with the Housekeeping Supervisor: On [DATE] at 8:35 a.m., the Housekeeping Supervisor was asked about the incident that occurred involving Resident #1 on the evening of [DATE]. He stated, "I had just got done with putting down a coat of wax. About 5 minutes after I finished the wax, her call light came on. I don't like for the call lights to be on too long, but it takes 30 minutes for a coat of wax to dry. From the end of the hall to where I was sitting, it for some reason doesn't take the floor that long to dry. About 2, 3, maybe 4 minutes after her call light came on, she said help. About 3 or 4 minutes after that, she hollered help again in the same tone of voice. Then I started checking the floor to see how dry it was and it was dry enough to walk on, so I proceeded to go down the hall and I got to her room and checked on her, then I came out and hollered for the nurse." He was asked why no one responded to the resident the first time she called for help. He stated, "I don't know. The aides and the nurse was sitting right there. But she's done this before just to get her TV turned on or a drink of water. No one acted like it was a big deal that she was calling for help." The Housekeeping Supervisor was asked if he told staff not to go down the hall when the resident was calling for help. He stated, "No, and I didn't hear anyone ask if they could go down the hall." He was asked approximately how much time passed between the resident activating her call light and when he found her without vital signs. He stated, "Ten to 12 minutes." He was asked if the LPN on duty, LPN #1, told any of the CNAs to go down the hall and check on the resident. He stated, "No." He was asked if anyone suggested doing just half of the hall at a time so staff could respond to calls. He stated, "No." He was asked if it was okay to not respond to a call light or a resident yelling for help because there is wet wax on the floor. He stated, "No. I feel terrible." 4) On [DATE] at 9:00 a.m., the Housekeeping supervisor showed the surveyor where he and other staff members were sitting when Resident #1 called out for help. It was approximately 56 feet from the nurse's station where he and others were sitting to the door of Resident #1's room, then another 9 feet inside the room to the head of her bed. g. On [DATE] at 8:15 p.m., CNA #4 was asked if she had been involved in any in-services since the incident concerning answering call lights or resident's requests for help. She stated, "We had a meeting, ,[DATE] shift, a little while later about not blaming people for someone dying. But we all felt bad and were blaming ourselves, not (Housekeeping Supervisor) or (LPN #1)." The CNA was asked if she had ever had any problems with reporting serious concerns to LPN #1 and her not responding. She stated, "We tell (LPN #1) stuff all the time and she just blows it off." The CNA was asked if she had ever reported this to anyone. She stated, "We've reported this to (Administrator). (LPN #1) has been fired from here before and they brought her back." h. On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked if she was in-serviced or educated soon after the incident to ensure she understood that staff was to respond to a resident's call for help. She stated, "Yes, a day or so after the incident." LPN #1 was shown the in-service sheet dated [DATE] (19 days after the incident) and she was asked to identify her signature indicating that she had attended the in-service. She looked at it and said, "My signature is not on there." LPN #1 was asked if she could change anything about the events of that evening, what would she change. She stated. "I did my job that night. I don't think anything I could've done would have made a difference." i. On [DATE] at 7:40 p.m., CNA #6, who was on duty the evening of [DATE], was asked if she had ever passed along resident information to LPN #1 and then LPN #1 not respond to it. She stated, "(LPN #1) just kind of blows you off. Now (LPN #2), if I tell her something, she checks on it right then." CNA #6 was asked if she had been in-serviced since the incident on responding to residents who call for help. She stated, "I don't remember an in-service, but we had a ,[DATE] meeting about gossiping." j. The facility's Policy and Procedure for Answering the Call Light documented, "The purpose of this procedure is to respond to the resident's requests and needs... Answer the resident's call as soon as possible..." On [DATE] at 11:00 p.m., the following addendum was added to the policy and procedure: "Time frame for answering resident call lights. Regular call light - Located in the resident's room. Usually a white light that comes on outside the door. EVERY resident is to have a call light in place. NO EXCEPTIONS! These lights are to be answered within ,[DATE] minutes..." k. On [DATE] at 9:17 p.m., the Administrator was asked what she knew about the incident on [DATE] involving Resident #1. She stated, "I got a call from (LPN #1) around 10:00 p.m. or 10:30 p.m. saying they had just found the resident without vital signs and that she was a DNR. After that I got a call from (CNA #2) saying she wanted me to look at the way we were waxing the floors... We interviewed (Housekeeping Supervisor) and he said he had waxed the hall after bed check. He was at the cart and two aides were at the new north table doing books, two were down old north. He said her call light came on and he heard her say girls, come help me. Probably 5 minutes went by and she said that again. He told (LPN #1) to wait until he got his stuff picked up, then (Housekeeping Supervisor) went down and checked on her and she was without vital signs. I interviewed (LPN #1). She heard her 1 or 2 times. I asked her if she sounded like she was in distress and she said no... The resident's roommate said the next morning that she yelled for someone to put her on the bedpan." (According to the facility's assessment, Resident #1's roommate had a BIMS score of 6 indicating a severely impaired cognitive status). The Administrator was asked if this incident was reported to local law enforcement and the Office of Long Term Care. She stated, "No." The Administrator was asked if she had a documented in-service where the staff members involved in the [DATE] incident had signed indicating they had attended and understood the in-service. She stated, "We did all of them one on one, then we did the rest of the building on [DATE]." The Administrator provided no documentation of a one on one in-service where the involved staff members were educated on preventing reoccurrences. The Administrator was asked if the incident was discussed and an action plan initiated in their Quality Assurance committee. She stated yes, but provided no documentation to show this occurred. l. On [DATE] at 11:15 a.m., the signature sheet for the in-service dated [DATE] was reviewed to ensure all staff had been in-serviced on responding to residents who call for help. According to the signature sheets provided and a list of current employees, at least 10 current employees had not been in-serviced on this. On [DATE] at 11:20 a.m., the DON was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She stated, "There's one or two on leave, but there's no reason why the rest shouldn't have been." On [DATE] at 11:40 a.m., LPN #3 was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She looked at the sign in sheet and stated, "It's not like they didn't have access to it. It's out there for 5 days." LPN #3 was asked if this was a formal in-service where everyone is gathered in a room, or was the in-service sheet placed at a location for staff to sign at their convenience. LPN #3 simply nodded her head. She was asked who was responsible for ensuring everyone signs and understands the content of the in-services. She stated, "I guess we're going to have to sit down and count signatures." m. The Immediate Jeopardy was removed on [DATE] at 10:03 p.m. and the scope and severity reduced to an "H", a pattern of actual harm, when the facility implemented the following plan of removal: 1) On [DATE] at 10:03 p.m., the LPN supervisor removed (LPN #1) from the floor and took charge of her hall. Her employment will be terminated by the Director of Nursing. 2) On [DATE], all nursing staff and maintenance/housekeeping on duty were in-serviced by the DON/LPN supervisor, and all on coming staff will be in-serviced regarding answering of call lights and/or calls for help within 5 minutes regardless of obstacles or floor situations, with all new hires being in-serviced immediately upon hire. 3) The DON/LPN supervisor will do daily audits every shift for four weeks, with all findings being corrected immediately and all information presented to the QA committee. 4) The facility is incorporating a new waxing system to allow waxing only to be done on one side of the hallway at a time completing 12 inch wide sections at a time to allow easy access over and into rooms if needed. 5) The QA committee meeting will be moved up to weekly for the duration of the audit. B. The facility failed to ensure necessary care and services were provided for 1 (Resident #2) of 4 (Residents #1, #2, #4 and #5) case mix residents who had a change in condition. The facility failed to ensure staff assessment and monitoring of a significant change in condition for 1 (Resident #2) of 4 (Residents #1, #2, #4 and #5) case mix residents who experienced a significant change in condition. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #2, who after Certified Nursing Assistants repeatedly reported change of condition to LPN #1, was not assessed and had to be sent to the hospital by the next shift where he expired approximately eight hours and 40 minutes later. The failed practices were likely to cause more than minimal harm for 35 residents in the facility who had a change in condition in the past 30 days, according to a list provided by the DON on [DATE] at 9:35 a.m. The facility was informed of the Immediate Jeopardy situation on [DATE] at 10:00 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (,[DATE] cognitively intact) on the brief interview for mental status (BIMS), had a feeding tube for nutrition and was totally dependent on staff for all activities of daily living. a. A Nurse's Note dated [DATE] (no time) and signed by Registered Nurse (RN) #1 documented, "Resident congested, wet, gurgling vocalization noted. Suctioned airway with 125 ml (milliliters) yellowish frothy drainage collected. Resident tolerated well. Resp (respirations) unlabored." b. A Nurse's Note dated [DATE] (7:00 a.m. to 3:00 p.m. shift) and signed by LPN #4 documented, "Resident has wet 'gurgling' cough, lung sounds congested, has productive cough with yellow/green sputum. (Physician) notified of same. Order received for [MEDICATION NAME] 875 mg pgt (per g tube) BID (twice daily) x (times) 10 days; portable chest x ray." c. A Nurse's Note dated [DATE] (3:00 p.m. to 11:00 p.m. shift) and signed by LPN #1 documented, "V/S (vital signs) - B/P ,[DATE], P 69, R 20, T 97.5. Congestion with productive cough noted. No distress noted. Will cont (continue) to monitor. 8:00 p.m. - [MEDICATION NAME] 875 mg initial dose given per tube. No s/s (signs or symptoms) adverse reaction noted." There were no further assessments documented during the 3:00 p.m. to 11:00 p.m. shift. 1) Interviews with CNAs: On [DATE] at 12:59 p.m., CNA #1, who was on duty and assigned to Resident #2 the evening of [DATE], was asked during an interview what occurred that evening. She stated, "I remember that day just fine. Me and (CNA #3) were working. I've been taking care of (Resident #2) for about a year. I knew him, and yeah, he'd make weird noises and stuff would bubble up in the back of his throat, but it wasn't normal for him to make sounds like he was making that day. We had been told already that he had to be suctioned earlier that day." The CNA was asked if it was normal for him to require suctioning. She stated, "I don't think so. Early in the shift, he was okay, but not long into the shift he was totally different. At one point I went in there and he looked kind of blue and was gurgling. I called (LPN #1) and she came down there and said 'roll him over and let that[***]run out of his mouth.' The suction machine was by the nurse's station, but it never moved during my shift. He just got worse and worse as the shift went on. Around 10:15 p.m., he was like foaming at the mouth. I hollered at (LPN #1) again and she said 'I'm going out to smoke.' So, I wound up talking to the 11 to 7 shift nurse, (LPN #5), about him. She sent him out and the next morning he was dead." CNA #1 was asked if she took the resident's vital signs during her shift. She stated, "Yes, they were okay, but that was around 3:15 p.m. I asked (LPN #1) later in the shift if I could take them again and she said he was okay, that there was no need to. Some time during the shift, I can't remember exactly when, but we went to a facility phone and called (LPN #2) on the other side of the building and asked her if she would come look at him. She told us we needed to talk to (LPN #1) since she was his nurse. We, at one point, saw (LPN #3) in the hall and asked her if (Resident #2) was okay. She said he was fine, but we knew something was wrong with him." On [DATE] at 3:20 p.m., CNA #3, who was on duty and assigned to Resident #2 on the evening of [DATE], was asked during an interview what occurred that evening. She stated, "We checked him around 3:30 p.m. or 4:00 p.m. because they said he wasn't doing well on day shift. He was sounding really bad, like he had aspirated or something. We told (LPN #1) we thought he needed to be suctioned." The CNA was asked what LPN #1 did. She stated, "I'm not sure she did anything. I was going down the hall and saw (LPN #3) and asked her if she knew if (LPN #1) ever went down and did anything with (Resident #1) and she said 'I believe she went down and suctioned him.' We kept going in and checking on him and kept reporting to (LPN #1). Our last bed check at 10:00 p.m., (CNA #1) called (LPN #2) from a facility phone and told her about it and (LPN #2) said to talk to (LPN #1). When 11 to 7 shift came on, (CNA #1) took me home, then came back up here and asked (LPN #5) to please check on him." CNA #3 was asked what type of changes Resident #2 had during the 3 to 11 shift that made her feel he had changed and was in need of immediate attention. She stated, "He at one point had bubbly stuff coming out of his mouth and he was real pale. Also, he was really limp. Normally his arms are stiff, like contracted, but he had gotten more limp. His eyes were kind of rolled back. He didn't urinate all shift. You could just tell from the beginning of the shift to the end, he progressively got worse." CNA #3 was asked approximately how many times did she and CNA #1 report this to LPN #1. She stated, "At least 4 times." 2) Interviews with LPNs: On [DATE] at 3:56 p.m., LPN #1 was interviewed concerning the evening of [DATE] and Resident #2. LPN #1 was asked if she recalled CNAs reporting to her numerous times that Resident #2 was extremely ill. She stated, "This has upset me so badly. I don't know how to answer your question. I know I was in and out of his room several times when he was sick. It's hard for me to remember details without looking at the chart, but I believe he was on antibiotics for an upper respiratory infection. The day shift nurse and I assessed him at the end of day shift. His O2 sat (oxygen saturation) was above 90%. Anytime I have a resident who has something going on, I'm frequently in and out of the room. He was in a very upright position and I had them to reposition him on his side. At no point during the shift, with him being on his side, did I need to suction him because he was on his side and the sputum was coming out of his mouth. He could cough some, but couldn't cough hard enough to cough it out." LPN #1 was asked if the sputum had a color. She stated, "I believe it was yellow/green tinged." She was asked if she documented any of these assessments anywhere. She stated, "It's either in the Nurse's Notes or on the flow sheet." She was asked if she remembered staff reporting anything to her that night about Resident #2. She stated, "Anytime anything is told to me by staff or whoever, I may not be at a moment right then to go check on a resident. It depends on what the situation is. If I'm told that a person is blue, I'm going to stop what I'm doing right then." On [DATE] at 5:40 p.m., LPN #2, who was on duty the evening of [DATE], was asked during an interview if she remembered anything about the evening of [DATE] when Resident #2 was sent out of the facility. She stated, "He wasn't my resident." LPN #2 was asked if she remembered getting a phone call about the resident. She stated, "Oh yes! I do remember that now. I remember thinking how odd it was when I saw the number calling me was from another phone inside the facility. But yes, I do remember. It was (CNA #1) asking me to come over and look at (Resident #2) but... I've stepped on toes doing that and I really didn't want to do that again." LPN #2 was asked if she remembered why CNA #1 wanted her to come look at that resident. She stated, "She said he couldn't breathe." d. A Nurse's Note dated [DATE] (11:00 p.m. to 7:00 a.m.) and signed by LPN #5 documented, "Resp shallow, wet, rate 32. Congested with diminished bre

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility Administration failed to ensure the provision of necessary care and services to avoid physical harm for Resident #1 and Resident #2. The facility Administration failed to ensure staff responded to a call light and repeated verbal requests for help for 1 (Residents #1) of 3 (Residents #1, #2 and #5) case mix residents who were totally dependent on staff for care. The facility failed to ensure staff assessment and monitoring of a significant change in condition for 1 (Resident #2) of 4 (Residents #1, #2, #4 and #5) case mix residents who experienced a significant change in condition. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who after turning on her call light, repeating verbal requests for help, was not ensured immediate assistance and was later found to be without vital signs, and Resident #2, who after Certified Nursing Assistants repeatedly reported change of condition to LPN #1, was not assessed and was sent to the hospital on the next shift where he expired approximately eight hours and 40 minutes later. The failed practices were likely to cause more than minimal harm for 43 residents in the facility who required total assistance from staff and 35 residents in the facility who had a change in condition in the past 30 days, according to a list received from the Director of Nursing (DON) on [DATE] at 9:35 a.m. The facility was initially informed of the Immediate Jeopardy situations on [DATE] at 9:50 p.m., then again on [DATE] at 10:00 a.m. The findings are: 1. The Administrator's Job Description documented, "Job Summary: Responsible for the efficient operation of the Nursing Center. Ensures that high quality resident care services are provided to State standards at minimum costs... Main Duties: The Administrator has responsibility and authority for accomplishing the following duties within the limits of established policies, procedures, programs and budgets... 3. Insures that quality resident care services are provided in accordance with authorized policies and procedures. 4. Directs the recruitment, hiring and in-service training of qualified staff capable of accomplishing the Center's objectives... 11. Reviews the status of residents with professional staff and attending physicians in order to provide maximum patient care and optimum use of services." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 12 (,[DATE] indicates moderately impaired) on the brief interview for mental status (BIMS), was totally dependent on staff for all activities of daily living except eating and had no behaviors. a. A Nurse's Note dated [DATE] at 4:08 p.m. and signed by Registered Nurse (RN) #1 documented, "Called to resident's room by CNA (Certified Nursing Assistant). Found resident pale, dusky color, agonal resp (respirations), HR (Heart Rate) 60, SpO2 (oxygen saturation measured by pulse oximetry) 62%, nonresponsive, diaphoretic, flaccid. O2 (oxygen) via NC (nasal cannula) at 2 L (Liter), pupils equal, sluggish. Ambulance called, O2 increased to 6 L, SpO2 73%, BP (Blood Pressure) ,[DATE], resp 16, HR 103, responsive to voice, slurred speech, unable to follow commands, flaccid... 4:20 p.m. - Ambulance here to transport..." b. A Hospital History and Physical dated [DATE] documented, "Impression: Florid [MEDICAL CONDITIONS] - this is a clinical diagnosis... Known [MEDICAL CONDITIONS] with previous [MEDICAL CONDITION] infarctions... History of [DIAGNOSES REDACTED]." c. A Hospital Discharge Instruction sheet dated [DATE] documented, "Discharge Diagnosis: [REDACTED]. d. A Nurse's Note dated [DATE] at 2245 (10:45 p.m.) and signed by Licensed Practical Nurse (LPN) #6 documented, "CNA (,[DATE]) (3:00 p.m. to 11:00 p.m. shift) reported to LPNs ((LPN #1) and myself) (resident) was complaining of SOB (shortness of breath). LPNs entered (resident) room and found resident cyanotic and unresponsive (with) pupils fixed (and) dilated. V/S (vital signs) B/P (blood pressure) ,[DATE], R (respirations) 26, P (pulse) 48, O2 (oxygen) 48%. Administered O2 via NC (nasal canula) at 6 L/M (liters per minute) (and) notified (hospital) for an ambulance. (Resident) became more responsive as O2 sat (saturation) increased to 84% prior to arrival of ambulance... Transferred to (hospital)... 2:10 a.m. Returned to (nursing home) via ambulance (with) Dx (diagnoses) of [MEDICAL CONDITIONS] / [MEDICAL CONDITION]. Received N.O. (New order) to (increase) [MEDICATION NAME] to 20 mg (milligram) BID (twice daily)..." On [DATE] at 2:53 p.m., LPN #2 stated, "A couple of weeks before (Resident #1) passed away ([DATE]), she had a bad episode where she was unresponsive. The CNAs called me down there." She was asked if she was the resident's nurse. She stated, "No." She was asked why the CNAs called her instead of the resident's nurse. She stated, "I don't know." She was asked who the resident's nurse was that evening. She stated, "(LPN #1). The resident was unresponsive. I put the O2 cannula in her mouth and did a sternal rub and she started coming around. I asked (LPN #1) specifically if she had called 911 and she said no, she's a DNR (Do Not Resuscitate). I said I don't give a damn, she's sick. You've got to call 911. For some reason she thinks you don't call 911 if someone's a DNR." e. A Physician order [REDACTED]." f. A Nurse's Note dated [DATE] at 10:25 p.m. and signed by LPN #1 documented, "Resident found by staff, unresponsive to verbal or tactile stimulus. This LPN notified by staff. 10:30 p.(m.) Assessment by this LPN found resident unresponsive to verbal, tactile and sternum rub stimulus. Resident was noted to be (without) a pulse for 1 minute by palpation of carotid and auscultation was also found (without) respirations by auscultation for a period of 1 minute... (Doctor) notified... Family notified... Funeral home notified... (Doctor) here to pronounce..." 1) Interview with CNAs on duty at the time of the incident: On [DATE] at 8:15 p.m., CNA #4, who was on duty the evening of [DATE], was asked about the incident involving Resident #1. She stated, "We had just taken her off the bed pan and (Housekeeping Supervisor) started waxing. I don't remember if her call light was on, but she started saying help, help, somebody come here. She said that maybe 3 times. (Housekeeping Supervisor) blocked off the hall and said don't go down there." The CNA was asked if LPN #1 heard the resident calling for help. She stated, "Yes she heard her and said she just probably wanted on the bedpan and said not to go down there. I should have just went down there. I blame myself. I could have at least held her hand." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "Maybe 30 minutes. I know (CNA #2) called (Administrator) and (Administrator) told her the resident could have passed at any time." On [DATE] at 12:25 p.m., CNA #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "Me and (CNA #4) was working old north. (Housekeeping Supervisor) said he came in to wax the floors and that he was going to block off the hall. He put wet floor signs across the hall and some blue tape on the floor. He told us to tell certain residents that we would not be able to answer their call lights for a while. I could hear (Resident #1) yelling even on old north where I was doing bed checks. Her call light had been going off probably 20 minutes. We asked (Housekeeping supervisor and LPN #1) if we could go down the hall and they said no. (LPN #1) said she just needed the pee pan. I was so upset I called (Administrator) and she said 'well she could have died at any time. She had a bad heart.' She's done this before but we get her on her oxygen and she'll be okay." The CNA was asked what happened when the resident was found without vital signs. She stated, "(Housekeeping Supervisor) was pretty calm and he just went and sat down and started watching TV. (LPN #1) asked for a stethoscope. (LPN #2) came over and said we need to go ahead and call an ambulance and (LPN #1) said no you don't have to, she's a DNR. We thought we could feel a pulse occasionally, but it went away. She was blue." The CNA was asked if the resident had her oxygen on that evening. She stated, "When I went into the room her O2 tubing was on the floor and the concentrator was off." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "At least 20 minutes. I blame myself. I should've done something different. Even if we couldn't have saved her, at least she wouldn't have died alone." The CNA was asked if the resident had a habit of yelling for staff. She stated, "I've not ever heard her yell. I made the comment to (Housekeeping Supervisor) to just do half the hall because how would we know, with the entire hall blocked off, that if someone's alarm was going off they hadn't fallen. So what if she'd just been yelling for a pee pan - we had gotten that woman to where she was continent, so yeah, I think that needing a pee pan is significant." On [DATE] at 3:20 p.m., CNA #3, who was assigned to Resident #1 on the evening of [DATE], was asked during an interview about the incident that evening. She stated, "(Housekeeping Supervisor) said he was going to do the floors. We did an in-between bed check because our next bed check wasn't really due until 10:00 p.m. We went down the hall and told specific residents who normally get on their call light that the floor was being done and we couldn't come through here for a little while. (Resident #1) was one of them." The CNA was asked if Resident #1 was able to understand or comprehend what she was telling her. She stated, "Oh yes. She understood. When I went in to (Resident #1's) room, she actually asked me if (Housekeeping Supervisor) had already started. So (Housekeeping Supervisor) started and we were all up there at the desk, and no sooner had he finished and her call light comes on. We had asked (Housekeeping Supervisor) before he started how long it would be and he said probably 45 minutes. She started hollering help, help me girls. She did that sometimes. We asked him again how long it was going to be before we could go and he said probably 30 minutes." The CNA was asked approximately how much time passed between the resident's call light being activated and when she was found without vital signs. She stated, "Probably at least 30 minutes, maybe a little longer." The CNA was asked if LPN #1 told anyone not to go down the hall during the resident's call for help. She stated, "Not that I know of." The CNA was asked if (Housekeeping Supervisor) told staff not to go down the hall and check on the resident. She stated, "He told us not to walk across the wax until it was dry. I asked him a long time ago why he couldn't wax one half of the hall so we could go and check on residents. He said because it leaves a seam down the middle." CNA #3 was asked if she could do anything differently from that night, what would it be. She stated, "I would definitely walk down that hall." 2) Interview with LPNs on duty at the time of the incident: On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked how long she had worked for the facility. She stated, "I've been here three different times, but the most recent is from May to now." She was asked if she had been terminated from the facility before. She stated, "Yes." She was asked why she was terminated. She stated, "Documentation." LPN #1 was asked about the incident involving Resident #1. She stated, "We were up on North. Around the time I was finishing my med (medication) pass, the floor on new north was being waxed. We had made our rounds, then the wax was put on the floor. The resident put on her call light. I was at my med cart, (Housekeeping Supervisor) was there with his equipment. Some of the girls were by the break area and they looked to see who had their light on. (Housekeeping Supervisor) said 'give me 5 minutes'. As soon as he moved his equipment he went down there and found her. Then he informed me that I needed to come down the hall now. (Resident #1) was unresponsive, no vital signs. We paged the other LPN and she also determined the resident had no vital signs. (Resident #1) had a similar incident not long before this. That time she came around." The LPN was asked if the resident was verbally asking for assistance. She stated, "Yes. She hollered 'girls come help me.' She did that on a regular basis." LPN #1 was asked approximately how much time passed between the resident activating her call light and when (Housekeeping Supervisor) found her without vital signs. She stated, "Maybe 10 minutes. Even if I went long, I would say no more than 15 minutes." The LPN was asked why someone did not go down the hall when the resident requested help. She stated, "She would call out to me or the other girls if she saw us going down the hall. She usually just wanted the bedpan or to be moved in bed. That's what her tone of voice sounded like that night." The LPN was asked how she would be able to determine if a resident was in distress by the tone of their voice. She stated, "I don't know how to even answer that. There's a different tone, a different pitch. I didn't determine there wasn't a problem. That's why I asked (Housekeeping supervisor) how long it was going to be before we could go down the hall. You just learn residents by the tone of their voice. She was up for supper just before that and didn't appear in any distress." The surveyor stated, "I guess in this case she was apparently in distress or in need of immediate assistance." LPN #1 stated, "I don't think so. I don't know that because she sounded like she wasn't in any distress." LPN #1 was asked if she told anyone not to go down the hall and check on the resident when she was asking for assistance. She stated, "No." She then stated, "I followed policy that night by calling (Administrator) about what happened." The LPN was asked if anyone from administration came to the facility that night because of the incident. She stated, "No one came out that night." On [DATE] at 2:53 p.m., LPN #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "I knew that (Housekeeping supervisor) had been cleaning the floors. I'm sorry, but if one of my residents needs me, I'm gonna step on his newly waxed floor. They called me over there for that one too, but she was already gone." LPN #2 was asked if she was aware that the resident had activated her call light and had also been verbally calling for help before she was found without vital signs. She stated, "I became aware after the fact that her call light was on and she was calling for help. CNAs told me that." LPN #2 was asked if she was aware of any occasions when CNAs had reported serious information about residents to LPN #1 and the LPN not responding to it. She stated, "My CNAs are my eyes and ears. If they tell me something, I'm going... Yes, I've personally seen CNAs report things to her that she just brushes off, and doesn't respond to whatever it is they've told her." 3) Interview with the Housekeeping Supervisor: On [DATE] at 8:35 a.m., the Housekeeping Supervisor was asked about the incident that occurred involving Resident #1 on the evening of [DATE]. He stated, "I had just got done with putting down a coat of wax. About 5 minutes after I finished the wax, her call light came on. I don't like for the call lights to be on too long, but it takes 30 minutes for a coat of wax to dry. From the end of the hall to where I was sitting, it for some reason doesn't take the floor that long to dry. About 2, 3, maybe 4 minutes after her call light came on, she said help. About 3 or 4 minutes after that, she hollered help again in the same tone of voice. Then I started checking the floor to see how dry it was and it was dry enough to walk on, so I proceeded to go down the hall and I got to her room and checked on her, then I came out and hollered for the nurse." He was asked why no one responded to the resident the first time she called for help. He stated, "I don't know. The aides and the nurse was sitting right there. But she's done this before just to get her TV turned on or a drink of water. No one acted like it was a big deal that she was calling for help." The Housekeeping Supervisor was asked if he told staff not to go down the hall when the resident was calling for help. He stated, "No, and I didn't hear anyone ask if they could go down the hall." He was asked approximately how much time passed between the resident activating her call light and when he found her without vital signs. He stated, "Ten to 12 minutes." He was asked if the LPN on duty, LPN #1, told any of the CNAs to go down the hall and check on the resident. He stated, "No." He was asked if anyone suggested doing just half of the hall at a time so staff could respond to calls. He stated, "No." He was asked if it was okay to not respond to a call light or a resident yelling for help because there is wet wax on the floor. He stated, "No. I feel terrible." 4) On [DATE] at 9:00 a.m., the Housekeeping supervisor showed the surveyor where he and other staff members were sitting when Resident #1 called out for help. It was approximately 56 feet from the nurse's station where he and others were sitting to the door of Resident #1's room, then another 9 feet inside the room to the head of her bed. g. On [DATE] at 8:15 p.m., CNA #4 was asked if she had been involved in any in-services since the incident concerning answering call lights or resident's requests for help. She stated, "We had a meeting, ,[DATE] shift, a little while later about not blaming people for someone dying. But we all felt bad and were blaming ourselves, not (Housekeeping Supervisor) or (LPN #1)." The CNA was asked if she had ever had any problems with reporting serious concerns to LPN #1 and her not responding. She stated, "We tell (LPN #1) stuff all the time and she just blows it off." The CNA was asked if she had ever reported this to anyone. She stated, "We've reported this to (Administrator). (LPN #1) has been fired from here before and they brought her back." h. On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked if she was in-serviced or educated soon after the incident to ensure she understood that staff was to respond to a resident's call for help. She stated, "Yes, a day or so after the incident." LPN #1 was shown the in-service sheet dated [DATE] (19 days after the incident) and she was asked to identify her signature indicating that she had attended the in-service. She looked at it and said, "My signature is not on there." LPN #1 was asked if she could change anything about the events of that evening, what would she change. She stated. "I did my job that night. I don't think anything I could've done would have made a difference." i. On [DATE] at 7:40 p.m., CNA #6, who was on duty the evening of [DATE], was asked if she had ever passed along resident information to LPN #1 and then LPN #1 not respond to it. She stated, "(LPN #1) just kind of blows you off. Now (LPN #2), if I tell her something, she checks on it right then." CNA #6 was asked if she had been in-serviced since the incident on responding to residents who call for help. She stated, "I don't remember an in-service, but we had a ,[DATE] meeting about gossiping." j. The facility's Policy and Procedure for Answering the Call Light documented, "The purpose of this procedure is to respond to the resident's requests and needs... Answer the resident's call as soon as possible..." On [DATE] at 11:00 p.m., the following addendum was added to the policy and procedure: "Time frame for answering resident call lights. Regular call light - Located in the resident's room. Usually a white light that comes on outside the door. EVERY resident is to have a call light in place. NO EXCEPTIONS! These lights are to be answered within ,[DATE] minutes..." k. On [DATE] at 9:17 p.m., the Administrator was asked what she knew about the incident on [DATE] involving Resident #1. She stated, "I got a call from (LPN #1) around 10:00 p.m. or 10:30 p.m. saying they had just found the resident without vital signs and that she was a DNR. After that I got a call from (CNA #2) saying she wanted me to look at the way we were waxing the floors... We interviewed (Housekeeping Supervisor) and he said he had waxed the hall after bed check. He was at the cart and two aides were at the new north table doing books, two were down old north. He said her call light came on and he heard her say girls, come help me. Probably 5 minutes went by and she said that again. He told (LPN #1) to wait until he got his stuff picked up, then (Housekeeping Supervisor) went down and checked on her and she was without vital signs. I interviewed (LPN #1). She heard her 1 or 2 times. I asked her if she sounded like she was in distress and she said no... The resident's roommate said the next morning that she yelled for someone to put her on the bedpan." (According to the facility's assessment, Resident #1's roommate had a BIMS score of 6 indicating a severely impaired cognitive status). The Administrator was asked if this incident was reported to local law enforcement and the Office of Long Term Care. She stated, "No." The Administrator was asked if she had a documented in-service where the staff members involved in the [DATE] incident had signed indicating they had attended and understood the in-service. She stated, "We did all of them one on one, then we did the rest of the building on [DATE]." The Administrator provided no documentation of a one on one in-service where the involved staff members were educated on preventing reoccurrences. The Administrator was asked if the incident was discussed and an action plan initiated in their Quality Assurance committee. She stated yes, but provided no documentation to show this occurred. l. On [DATE] at 9:40 p.m., the Administrator provided three and a half pages of typed information that documented, "[DATE] - Concern from (CNA #2) - states the night (Resident #1) passed 'I think we should do something different with the waxing. I'm not saying anybody did anything wrong.' Admin (Administrator) - what makes you say that? (CNA #2) - well I heard (CNA #3) ask (Housekeeping Supervisor) if she could go answer (Resident #1's) light and he told her no, she couldn't walk on the floor. Admin - where were you working? (CNA #2) - I was on old north, but I had gone to the desk for something and overheard it and we couldn't get to her in time. Interview with (Housekeeping Supervisor) - States was waxing floors after last bed check; states he started after the aides went through and checked everyone; states he told the aides it would take him 45 to get all the way up the hall; states he did not tell anyone they could walk on the floor; states no one asked him if they could walk on the floor; states he was at north med cart when (Resident #1's) light came on; states he heard (Resident #1) say something like come here girls or come here help me girls; states he thought he heard her two or three times so he said let me get this stuff out of way and he got up to move the fans and went down the hall; states when he got to (Resident #1's) room she had passed away; states he immediately called for the nurse; states light was on maybe 15 mins (minutes) or less. Interview with (LPN #1) - states she was at med cart when (Resident #1's) light came on; states she heard (Resident #1) say come here or come help girls; states she heard (Resident #1) once and she looked up and (Housekeeping Supervisor) was picking up the fans saying let me get this stuff out of the way and he went down the hall; states she did not note any distress in (Resident #1's) voice, sounded like her normal call for the bed pan; states two aides were near the north station sitting area, two aides were down old north; states no aide ever approached (Housekeeping Supervisor) about going down the hall; states no other call lights were on down that hall... Interview with (CNA #3) - aide assigned to new north hall. States all 4 aides standing at north desk; denies asking (Housekeeping Supervisor) if they could go answer the light; states several lights were on but does not give clear answer as to whether these call lights were on the hall in question; states light was on 50 minutes; states (Housekeeping Supervisor) told them not to walk on floor but would not give a clear answer as to when he told her this; states we had just been in room [ROOM NUMBER] minutes before she passed (admin note here, then how was light on for 50 minutes); states she didn't attempt to go down the hall. Interview with (LPN #2) - LPN south hall - Since call light system sounds and lights up on both ends of the building, states there were no lights that were on for excessive lengths of time; states she would notice call lights longer than ,[DATE] minutes because they beep loudly for the north hall on the intercom for south hall; ...states she could not remember more than one light being lit up for call lights on north at that time. Interview with (CNA #4) - (blank). Re-interview with (LPN #1) - confirms the aides had been in the room ,[DATE] minutes before the call light came on and resident was not in any distress at that point. Findings: (Resident #1's) medical history - had 10% working capacity of heart, was admitted to nursing home because doctors told family she would probably pass away in middle of night when heart finally gave out, they didn't want her to be at home alone when that happened. Patient was a DNR (Do Not Resuscitate). The housekeeping supervisor that was waxing the floors seems to be very upset when answering his questions, he seems bullied into thinking he did something wrong. Aide (CNA #3's) story is not supported by either nurse nor the housekeeping supervisor, nor her own because of her admittance that she herself had been in the room [ROOM NUMBER] minutes before the call light was on but then tried to state it had been on for ,[DATE] minutes. Roommate of (Resident #1) stated that resident didn't seem like she was in trouble... LPN on south hall confirmed that no call lights were excessively long and states would have noticed one being on for more than 15 minutes... Admin has asked (Housekeeping Supervisor) to not wax any further til he can discuss with his floor consultant a different way possible to do the floors as a safety measure. All staff are inserviced that when the floors are being waxed, call lights must still be answered in a timely manner even if floors have to be re-done." m. On [DATE] at 11:15 a.m., the signature sheet for the in-service dated [DATE] was reviewed to ensure all staff had been in-serviced on responding to residents who call for help. According to the signature sheets provided and a list of current employees, at least 10 current employees had not been in-serviced on this. On [DATE] at 11:20 a.m., the DON was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She stated, "There's one or two on leave, but there's no reason why the rest shouldn't have been." On [DATE] at 11:40 a.m., LPN #3 was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She looked at the sign in sheet and stated, "It's not like they didn't have access to it. It's out there for 5 days." LPN #3 was asked if this was a formal in-service where everyone is gathered in a room, or was the in-service sheet placed at a location for staff to sign at their convenience. LPN #3 simply nodded her head. She was asked who was responsible for ensuring everyone signs and understands the content of the in-services. She stated, "I guess we're going to have to sit down and count signatures." n. The Immediate Jeopardy was removed on [DATE] at 10:03 p.m. and the scope and severity reduced to an "H", a pattern of actual harm, when the facility implemented the following plan of removal: 1) On [DATE] at 10:03 p.m., the LPN supervisor removed (LPN #1) from the floor and took charge of her hall. Her employment will be terminated by the Director of Nursing. 2) On [DATE], all nursing staff and maintenance/housekeeping on duty were in-serviced by the DON/LPN supervisor, and all on coming staff will be in-serviced regarding answering of call lights and/or calls for help within 5 minutes regardless of obstacles or floor situations, with all new hires being in-serviced immediately upon hire. 3) The DON/LPN supervisor will do daily audits every shift for four weeks, with all findings being corrected immediately and all information presented to the QA committee. 4) The facility is incorporating a new waxing system to allow waxing only to be done on one side of the hallway at a time completing 12 inch wide sections at a time to allow easy access over and into rooms if needed. 5) The QA committee meeting will be moved up to weekly for the duration of the audit. 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the BIMS, had a feeding tube for nutrition and was totally dependent on staff for all activities of daily living. a. A Nurse's Note dated [DATE] (no time) and signed by Registered Nurse (RN) #1 documented, "Resident congested, wet, gurgling vocalization noted. Suctioned airway with 125 ml (milliliters) yellowish frothy drainage collected. Resident tolerated well. Resp (respirations) unlabored." b. A Nurse's Note dated [DATE] (7:00 a.m. to 3:00 p.m. shift) and signed by LPN #4 documented, "Resident has wet 'gurgling' cough, lung sounds congested, has productive cough with yellow/green sputum. (Physician) notified of same. Order received for [MEDICATION NAME] 875 mg pgt (per g tube) BID (twice daily) x (times) 10 days; portable chest x ray." c. A Nurse's Note dated [DATE] (3:00 p.m. to 11:00 p.m. shift) and signed by LPN #1 documented, "V/S (vital signs) - B/P ,[DATE], P 69, R 20, T 97.5. Congestion with productive cough noted. No distress noted. Will cont (continue) to monitor. 8:00 p.m. - [MEDICATION NAME] 875 mg initial dose given per tube. No s/s (signs or symptoms) adverse reaction noted." There were no further assessments documented during the 3:00 p.m. to 11:00 p.m. shift. 1) Interviews with CNAs: On [DATE] at 12:59 p.m., CNA #1, who was on duty and assigned to Resident #2 the evening of [DATE], was asked during an interview what occurred that evening. She stated, "I remember that day just fine. Me and (CNA #3) were working. I've been taking care of (Resident #2) for about a year. I knew him, and yeah, he'd make weird noises and stuff would bubble up in the back of his throat, but it wasn't normal for him to make sounds like he was making that day. We had been told already that he had to be suctioned earlier that day." The CNA was asked if it was normal for him to require suctioning. She stated, "I don't think so. Early in the shift, he was okay, but not long into the shift he was totally different. At one point I went in there and he looked kind of blue and was gurgling. I called (LPN #1) and she came down there and said 'roll him over and let that[***]run out of his mouth.' The suction machine was by the nurse's station, but it never moved during my shift. He just got worse and worse as the shift went on. Around 10:15 p.m., he was like foaming at the mouth.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure all allegations involving neglect were immediately reported to the Administrator/designee, to ensure all allegations of neglect were thoroughly investigated, interventions were taken to ensure the safety of residents, and that the allegations were reported to the Office of Long Term Care, the local law enforcement, and to other officials in accordance with State law for multiple allegations of neglect involving 2 (Residents #1 and #2) of 6 (Residents #1 through #6) case mix residents. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who after turning on her call light, repeating verbal requests for help, was not ensured immediate assistance and was later found to be without vital signs, and Resident #2, who after Certified Nursing Assistants repeatedly reported change of condition to LPN #1, was not assessed and was sent to the hospital on the next shift where he expired approximately eight hours and 40 minutes later. The failed practices were likely to cause more than minimal harm for 43 residents in the facility who required total assistance from staff and 35 residents in the facility who had a change in condition in the past 30 days, according to a list received from the Director of Nursing (DON) on [DATE] at 9:35 a.m. The facility was initially informed of the Immediate Jeopardy situations on [DATE] at 9:50 p.m., then again on [DATE] at 10:00 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 12 (,[DATE] indicates moderately impaired) on the brief interview for mental status (BIMS), was totally dependent on staff for all activities of daily living except eating and had no behaviors. a. a. A Nurse's Note dated [DATE] at 4:08 p.m. and signed by Registered Nurse (RN) #1 documented, "Called to resident's room by CNA (Certified Nursing Assistant). Found resident pale, dusky color, agonal resp (respirations), HR (Heart Rate) 60, SpO2 (oxygen saturation measured by pulse oximetry) 62%, nonresponsive, diaphoretic, flaccid. O2 (oxygen) via NC (nasal cannula) at 2 L (Liter), pupils equal, sluggish. Ambulance called, O2 increased to 6 L, SpO2 73%, BP (Blood Pressure) ,[DATE], resp 16, HR 103, responsive to voice, slurred speech, unable to follow commands, flaccid... 4:20 p.m. - Ambulance here to transport..." b. A Hospital History and Physical dated [DATE] documented, "Impression: Florid [MEDICAL CONDITIONS] - this is a clinical diagnosis... Known [MEDICAL CONDITIONS] with previous [MEDICAL CONDITION] infarctions... History of [DIAGNOSES REDACTED]." c. A Hospital Discharge Instruction sheet dated [DATE] documented, "Discharge Diagnosis: [REDACTED]. d. A Nurse's Note dated [DATE] at 2245 (10:45 p.m.) and signed by Licensed Practical Nurse (LPN) #6 documented, "CNA (,[DATE]) (3:00 p.m. to 11:00 p.m. shift) reported to LPNs ((LPN #1) and myself) (resident) was complaining of SOB (shortness of breath). LPNs entered (resident) room and found resident cyanotic and unresponsive (with) pupils fixed (and) dilated. V/S (vital signs) B/P (blood pressure) ,[DATE], R (respirations) 26, P (pulse) 48, O2 (oxygen) 48%. Administered O2 via NC (nasal canula) at 6 L/M (liters per minute) (and) notified (hospital) for an ambulance. (Resident) became more responsive as O2 sat (saturation) increased to 84% prior to arrival of ambulance... Transferred to (hospital)... 2:10 a.m. Returned to (nursing home) via ambulance (with) Dx (diagnoses) of [MEDICAL CONDITIONS] / [MEDICAL CONDITION]. Received N.O. (New order) to (increase) [MEDICATION NAME] to 20 mg (milligram) BID (twice daily)..." On [DATE] at 2:53 p.m., LPN #2 stated, "A couple of weeks before (Resident #1) passed away ([DATE]), she had a bad episode where she was unresponsive. The CNAs called me down there." She was asked if she was the resident's nurse. She stated, "No." She was asked why the CNAs called her instead of the resident's nurse. She stated, "I don't know." She was asked who the resident's nurse was that evening. She stated, "(LPN #1). The resident was unresponsive. I put the O2 cannula in her mouth and did a sternal rub and she started coming around. I asked (LPN #1) specifically if she had called 911 and she said no, she's a DNR (Do Not Resuscitate). I said I don't give a damn, she's sick. You've got to call 911. For some reason she thinks you don't call 911 if someone's a DNR." e. A Physician order [REDACTED]." f. A Nurse's Note dated [DATE] at 10:25 p.m. and signed by LPN #1 documented, "Resident found by staff, unresponsive to verbal or tactile stimulus. This LPN notified by staff. 10:30 p.(m.) Assessment by this LPN found resident unresponsive to verbal, tactile and sternum rub stimulus. Resident was noted to be (without) a pulse for 1 minute by palpation of carotid and auscultation was also found (without) respirations by auscultation for a period of 1 minute... (Doctor) notified... Family notified... Funeral home notified... (Doctor) here to pronounce..." 1) Interview with CNAs on duty at the time of the incident: On [DATE] at 8:15 p.m., CNA #4, who was on duty the evening of [DATE], was asked about the incident involving Resident #1. She stated, "We had just taken her off the bed pan and (Housekeeping Supervisor) started waxing. I don't remember if her call light was on, but she started saying help, help, somebody come here. She said that maybe 3 times. (Housekeeping Supervisor) blocked off the hall and said don't go down there." The CNA was asked if LPN #1 heard the resident calling for help. She stated, "Yes she heard her and said she just probably wanted on the bedpan and said not to go down there. I should have just went down there. I blame myself. I could have at least held her hand." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "Maybe 30 minutes. I know (CNA #2) called (Administrator) and (Administrator) told her the resident could have passed at any time." On [DATE] at 12:25 p.m., CNA #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "Me and (CNA #4) was working old north. (Housekeeping Supervisor) said he came in to wax the floors and that he was going to block off the hall. He put wet floor signs across the hall and some blue tape on the floor. He told us to tell certain residents that we would not be able to answer their call lights for a while. I could hear (Resident #1) yelling even on old north where I was doing bed checks. Her call light had been going off probably 20 minutes. We asked (Housekeeping supervisor and LPN #1) if we could go down the hall and they said no. (LPN #1) said she just needed the pee pan. I was so upset I called (Administrator) and she said 'well she could have died at any time. She had a bad heart.' She's done this before but we get her on her oxygen and she'll be okay." The CNA was asked what happened when the resident was found without vital signs. She stated, "(Housekeeping Supervisor) was pretty calm and he just went and sat down and started watching TV. (LPN #1) asked for a stethoscope. (LPN #2) came over and said we need to go ahead and call an ambulance and (LPN #1) said no you don't have to, she's a DNR. We thought we could feel a pulse occasionally, but it went away. She was blue." The CNA was asked if the resident had her oxygen on that evening. She stated, "When I went into the room her O2 tubing was on the floor and the concentrator was off." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "At least 20 minutes. I blame myself. I should've done something different. Even if we couldn't have saved her, at least she wouldn't have died alone." The CNA was asked if the resident had a habit of yelling for staff. She stated, "I've not ever heard her yell. I made the comment to (Housekeeping Supervisor) to just do half the hall because how would we know, with the entire hall blocked off, that if someone's alarm was going off they hadn't fallen. So what if she'd just been yelling for a pee pan - we had gotten that woman to where she was continent, so yeah, I think that needing a pee pan is significant." On [DATE] at 3:20 p.m., CNA #3, who was assigned to Resident #1 on the evening of [DATE], was asked during an interview about the incident that evening. She stated, "(Housekeeping Supervisor) said he was going to do the floors. We did an in-between bed check because our next bed check wasn't really due until 10:00 p.m. We went down the hall and told specific residents who normally get on their call light that the floor was being done and we couldn't come through here for a little while. (Resident #1) was one of them." The CNA was asked if Resident #1 was able to understand or comprehend what she was telling her. She stated, "Oh yes. She understood. When I went in to (Resident #1's) room, she actually asked me if (Housekeeping Supervisor) had already started. So (Housekeeping Supervisor) started and we were all up there at the desk, and no sooner had he finished and her call light comes on. We had asked (Housekeeping Supervisor) before he started how long it would be and he said probably 45 minutes. She started hollering help, help me girls. She did that sometimes. We asked him again how long it was going to be before we could go and he said probably 30 minutes." The CNA was asked approximately how much time passed between the resident's call light being activated and when she was found without vital signs. She stated, "Probably at least 30 minutes, maybe a little longer." The CNA was asked if LPN #1 told anyone not to go down the hall during the resident's call for help. She stated, "Not that I know of." The CNA was asked if (Housekeeping Supervisor) told staff not to go down the hall and check on the resident. She stated, "He told us not to walk across the wax until it was dry. I asked him a long time ago why he couldn't wax one half of the hall so we could go and check on residents. He said because it leaves a seam down the middle." CNA #3 was asked if she could do anything differently from that night, what would it be. She stated, "I would definitely walk down that hall." 2) Interview with LPNs on duty at the time of the incident: On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked how long she had worked for the facility. She stated, "I've been here three different times, but the most recent is from May to now." She was asked if she had been terminated from the facility before. She stated, "Yes." She was asked why she was terminated. She stated, "Documentation." LPN #1 was asked about the incident involving Resident #1. She stated, "We were up on North. Around the time I was finishing my med (medication) pass, the floor on new north was being waxed. We had made our rounds, then the wax was put on the floor. The resident put on her call light. I was at my med cart, (Housekeeping Supervisor) was there with his equipment. Some of the girls were by the break area and they looked to see who had their light on. (Housekeeping Supervisor) said 'give me 5 minutes'. As soon as he moved his equipment he went down there and found her. Then he informed me that I needed to come down the hall now. (Resident #1) was unresponsive, no vital signs. We paged the other LPN and she also determined the resident had no vital signs. (Resident #1) had a similar incident not long before this. That time she came around." The LPN was asked if the resident was verbally asking for assistance. She stated, "Yes. She hollered 'girls come help me.' She did that on a regular basis." LPN #1 was asked approximately how much time passed between the resident activating her call light and when (Housekeeping Supervisor) found her without vital signs. She stated, "Maybe 10 minutes. Even if I went long, I would say no more than 15 minutes." The LPN was asked why someone did not go down the hall when the resident requested help. She stated, "She would call out to me or the other girls if she saw us going down the hall. She usually just wanted the bedpan or to be moved in bed. That's what her tone of voice sounded like that night." The LPN was asked how she would be able to determine if a resident was in distress by the tone of their voice. She stated, "I don't know how to even answer that. There's a different tone, a different pitch. I didn't determine there wasn't a problem. That's why I asked (Housekeeping supervisor) how long it was going to be before we could go down the hall. You just learn residents by the tone of their voice. She was up for supper just before that and didn't appear in any distress." The surveyor stated, "I guess in this case she was apparently in distress or in need of immediate assistance." LPN #1 stated, "I don't think so. I don't know that because she sounded like she wasn't in any distress." LPN #1 was asked if she told anyone not to go down the hall and check on the resident when she was asking for assistance. She stated, "No." She then stated, "I followed policy that night by calling (Administrator) about what happened." The LPN was asked if anyone from administration came to the facility that night because of the incident. She stated, "No one came out that night." On [DATE] at 2:53 p.m., LPN #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "I knew that (Housekeeping supervisor) had been cleaning the floors. I'm sorry, but if one of my residents needs me, I'm gonna step on his newly waxed floor. They called me over there for that one too, but she was already gone." LPN #2 was asked if she was aware that the resident had activated her call light and had also been verbally calling for help before she was found without vital signs. She stated, "I became aware after the fact that her call light was on and she was calling for help. CNAs told me that." LPN #2 was asked if she was aware of any occasions when CNAs had reported serious information about residents to LPN #1 and the LPN not responding to it. She stated, "My CNAs are my eyes and ears. If they tell me something, I'm going... Yes, I've personally seen CNAs report things to her that she just brushes off, and doesn't respond to whatever it is they've told her." 3) Interview with the Housekeeping Supervisor: On [DATE] at 8:35 a.m., the Housekeeping Supervisor was asked about the incident that occurred involving Resident #1 on the evening of [DATE]. He stated, "I had just got done with putting down a coat of wax. About 5 minutes after I finished the wax, her call light came on. I don't like for the call lights to be on too long, but it takes 30 minutes for a coat of wax to dry. From the end of the hall to where I was sitting, it for some reason doesn't take the floor that long to dry. About 2, 3, maybe 4 minutes after her call light came on, she said help. About 3 or 4 minutes after that, she hollered help again in the same tone of voice. Then I started checking the floor to see how dry it was and it was dry enough to walk on, so I proceeded to go down the hall and I got to her room and checked on her, then I came out and hollered for the nurse." He was asked why no one responded to the resident the first time she called for help. He stated, "I don't know. The aides and the nurse was sitting right there. But she's done this before just to get her TV turned on or a drink of water. No one acted like it was a big deal that she was calling for help." The Housekeeping Supervisor was asked if he told staff not to go down the hall when the resident was calling for help. He stated, "No, and I didn't hear anyone ask if they could go down the hall." He was asked approximately how much time passed between the resident activating her call light and when he found her without vital signs. He stated, "Ten to 12 minutes." He was asked if the LPN on duty, LPN #1, told any of the CNAs to go down the hall and check on the resident. He stated, "No." He was asked if anyone suggested doing just half of the hall at a time so staff could respond to calls. He stated, "No." He was asked if it was okay to not respond to a call light or a resident yelling for help because there is wet wax on the floor. He stated, "No. I feel terrible." 4) On [DATE] at 9:00 a.m., the Housekeeping supervisor showed the surveyor where he and other staff members were sitting when Resident #1 called out for help. It was approximately 56 feet from the nurse's station where he and others were sitting to the door of Resident #1's room, then another 9 feet inside the room to the head of her bed. g. On [DATE] at 8:15 p.m., CNA #4 was asked if she had been involved in any in-services since the incident concerning answering call lights or resident's requests for help. She stated, "We had a meeting, ,[DATE] shift, a little while later about not blaming people for someone dying. But we all felt bad and were blaming ourselves, not (Housekeeping Supervisor) or (LPN #1)." The CNA was asked if she had ever had any problems with reporting serious concerns to LPN #1 and her not responding. She stated, "We tell (LPN #1) stuff all the time and she just blows it off." The CNA was asked if she had ever reported this to anyone. She stated, "We've reported this to (Administrator). (LPN #1) has been fired from here before and they brought her back." h. On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked if she was in-serviced or educated soon after the incident to ensure she understood that staff was to respond to a resident's call for help. She stated, "Yes, a day or so after the incident." LPN #1 was shown the in-service sheet dated [DATE] (19 days after the incident) and she was asked to identify her signature indicating that she had attended the in-service. She looked at it and said, "My signature is not on there." LPN #1 was asked if she could change anything about the events of that evening, what would she change. She stated. "I did my job that night. I don't think anything I could've done would have made a difference." i. On [DATE] at 7:40 p.m., CNA #6, who was on duty the evening of [DATE], was asked if she had ever passed along resident information to LPN #1 and then LPN #1 not respond to it. She stated, "(LPN #1) just kind of blows you off. Now (LPN #2), if I tell her something, she checks on it right then." CNA #6 was asked if she had been in-serviced since the incident on responding to residents who call for help. She stated, "I don't remember an in-service, but we had a ,[DATE] meeting about gossiping." j. The facility's Policy and Procedure for Answering the Call Light documented, "The purpose of this procedure is to respond to the resident's requests and needs... Answer the resident's call as soon as possible..." On [DATE] at 11:00 p.m., the following addendum was added to the policy and procedure: "Time frame for answering resident call lights. Regular call light - Located in the resident's room. Usually a white light that comes on outside the door. EVERY resident is to have a call light in place. NO EXCEPTIONS! These lights are to be answered within ,[DATE] minutes..." k. On [DATE] at 9:17 p.m., the Administrator was asked what she knew about the incident on [DATE] involving Resident #1. She stated, "I got a call from (LPN #1) around 10:00 p.m. or 10:30 p.m. saying they had just found the resident without vital signs and that she was a DNR. After that I got a call from (CNA #2) saying she wanted me to look at the way we were waxing the floors... We interviewed (Housekeeping Supervisor) and he said he had waxed the hall after bed check. He was at the cart and two aides were at the new north table doing books, two were down old north. He said her call light came on and he heard her say girls, come help me. Probably 5 minutes went by and she said that again. He told (LPN #1) to wait until he got his stuff picked up, then (Housekeeping Supervisor) went down and checked on her and she was without vital signs. I interviewed (LPN #1). She heard her 1 or 2 times. I asked her if she sounded like she was in distress and she said no... The resident's roommate said the next morning that she yelled for someone to put her on the bedpan." (According to the facility's assessment, Resident #1's roommate had a BIMS score of 6 indicating a severely impaired cognitive status). The Administrator was asked if this incident was reported to local law enforcement and the Office of Long Term Care. She stated, "No." The Administrator was asked if she had a documented inservice where the staff members involved in the [DATE] incident had signed indicating they had attended and understood the inservice. She stated, "We did all of them one on one, then we did the rest of the building on [DATE]." The Administrator provided no documentation of a one on one in-service where the involved staff members were educated on preventing reoccurrences. The Administrator was asked if the incident was discussed and an action plan initiated in their Quality Assurance committee. She stated yes, but provided no documentation to show this occurred. l. On [DATE] at 9:40 p.m., the Administrator provided three and a half pages of typed information that documented, "[DATE] - Concern from (CNA #2) - states the night (Resident #1) passed 'I think we should do something different with the waxing. I'm not saying anybody did anything wrong.' Admin (Administrator) - what makes you say that? (CNA #2) - well I heard (CNA #3) ask (Housekeeping Supervisor) if she could go answer (Resident #1's) light and he told her no, she couldn't walk on the floor. Admin - where were you working? (CNA #2) - I was on old north, but I had gone to the desk for something and overheard it and we couldn't get to her in time. Interview with (Housekeeping Supervisor) - States was waxing floors after last bed check; states he started after the aides went through and checked everyone; states he told the aides it would take him 45 to get all the way up the hall; states he did not tell anyone they could walk on the floor; states no one asked him if they could walk on the floor; states he was at north med cart when (Resident #1's) light came on; states he heard (Resident #1) say something like come here girls or come here help me girls; states he thought he heard her two or three times so he said let me get this stuff out of way and he got up to move the fans and went down the hall; states when he got to (Resident #1's) room she had passed away; states he immediately called for the nurse; states light was on maybe 15 mins (minutes) or less. Interview with (LPN #1) - states she was at med cart when (Resident #1's) light came on; states she heard (Resident #1) say come here or come help girls; states she heard (Resident #1) once and she looked up and (Housekeeping Supervisor) was picking up the fans saying let me get this stuff out of the way and he went down the hall; states she did not note any distress in (Resident #1's) voice, sounded like her normal call for the bed pan; states two aides were near the north station sitting area, two aides were down old north; states no aide ever approached (Housekeeping Supervisor) about going down the hall; states no other call lights were on down that hall... Interview with (CNA #3) - aide assigned to new north hall. States all 4 aides standing at north desk; denies asking (Housekeeping Supervisor) if they could go answer the light; states several lights were on but does not give clear answer as to whether these call lights were on the hall in question; states light was on 50 minutes; states (Housekeeping Supervisor) told them not to walk on floor but would not give a clear answer as to when he told her this; states we had just been in room [ROOM NUMBER] minutes before she passed (admin note here, then how was light on for 50 minutes); states she didn't attempt to go down the hall. Interview with (LPN #2) - LPN south hall - Since call light system sounds and lights up on both ends of the building, states there were no lights that were on for excessive lengths of time; states she would notice call lights longer than ,[DATE] minutes because they beep loudly for the north hall on the intercom for south hall; ...states she could not remember more than one light being lit up for call lights on north at that time. Interview with (CNA #4) - (blank). Re-interview with (LPN #1) - confirms the aides had been in the room ,[DATE] minutes before the call light came on and resident was not in any distress at that point. Findings: (Resident #1's) medical history - had 10% working capacity of heart, was admitted to nursing home because doctors told family she would probably pass away in middle of night when heart finally gave out, they didn't want her to be at home alone when that happened. Patient was a DNR (Do Not Resuscitate). The housekeeping supervisor that was waxing the floors seems to be very upset when answering his questions, he seems bullied into thinking he did something wrong. Aide (CNA #3's) story is not supported by either nurse nor the housekeeping supervisor, nor her own because of her admittance that she herself had been in the room [ROOM NUMBER] minutes before the call light was on but then tried to state it had been on for ,[DATE] minutes. Roommate of (Resident #1) stated that resident didn't seem like she was in trouble... LPN on south hall confirmed that no call lights were excessively long and states would have noticed one being on for more than 15 minutes... Admin has asked (Housekeeping Supervisor) to not wax any further til he can discuss with his floor consultant a different way possible to do the floors as a safety measure. All staff are inserviced that when the floors are being waxed, call lights must still be answered in a timely manner even if floors have to be re-done." m. On [DATE] at 11:15 a.m., the signature sheet for the in-service dated [DATE] was reviewed to ensure all staff had been in-serviced on responding to residents who call for help. According to the signature sheets provided and a list of current employees, at least 10 current employees had not been in-serviced on this. On [DATE] at 11:20 a.m., the DON was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She stated, "There's one or two on leave, but there's no reason why the rest shouldn't have been." On [DATE] at 11:40 a.m., LPN #3 was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She looked at the sign in sheet and stated, "It's not like they didn't have access to it. It's out there for 5 days." LPN #3 was asked if this was a formal in-service where everyone is gathered in a room, or was the in-service sheet placed at a location for staff to sign at their convenience. LPN #3 simply nodded her head. She was asked who was responsible for ensuring everyone signs and understands the content of the in-services. She stated, "I guess we're going to have to sit down and count signatures." n. The Immediate Jeopardy was removed on [DATE] at 10:03 p.m. and the scope and severity reduced to an "H", a pattern of actual harm, when the facility implemented the following plan of removal: 1) On [DATE] at 10:03 p.m., the LPN supervisor removed (LPN #1) from the floor and took charge of her hall. Her employment will be terminated by the Director of Nursing. 2) On [DATE], all nursing staff and maintenance/housekeeping on duty were in-serviced by the DON/LPN supervisor, and all on coming staff will be in-serviced regarding answering of call lights and/or calls for help within 5 minutes regardless of obstacles or floor situations, with all new hires being in-serviced immediately upon hire. 3) The DON/LPN supervisor will do daily audits every shift for four weeks, with all findings being corrected immediately and all information presented to the QA committee. 4) The facility is incorporating a new waxing system to allow waxing only to be done on one side of the hallway at a time completing 12 inch wide sections at a time to allow easy access over and into rooms if needed. 5) The QA committee meeting will be moved up to weekly for the duration of the audit. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the BIMS, had a feeding tube for nutrition and was totally dependent on staff for all activities of daily living. a. A Nurse's Note dated [DATE] (no time) and signed by Registered Nurse (RN) #1 documented, "Resident congested, wet, gurgling vocalization noted. Suctioned airway with 125 ml (milliliters) yellowish frothy drainage collected. Resident tolerated well. Resp (respirations) unlabored." b. A Nurse's Note dated [DATE] (7:00 a.m. to 3:00 p.m. shift) and signed by LPN #4 documented, "Resident has wet 'gurgling' cough, lung sounds congested, has productive cough with yellow/green sputum. (Physician) notified of same. Order received for [MEDICATION NAME] 875 mg pgt (per g tube) BID (twice daily) x (times) 10 days; portable chest x ray." c. A Nurse's Note dated [DATE] (3:00 p.m. to 11:00 p.m. shift) and signed by LPN #1 documented, "V/S (vital signs) - B/P ,[DATE], P 69, R 20, T 97.5. Congestion with productive cough noted. No distress noted. Will cont (continue) to monitor. 8:00 p.m. - [MEDICATION NAME] 875 mg initial dose given per tube. No s/s (signs or symptoms) adverse reaction noted." There were no further assessments documented during the 3:00 p.m. to 11:00 p.m. shift. 1) Interviews with CNAs: On [DATE] at 12:59 p.m., CNA #1, who was on duty and assigned to Resident #2 the evening of [DATE], was asked during an interview what occurred that evening. She stated, "I remember that day just fine. Me and (CNA #3) were working. I've been taking care of (Resident #2) for about a year. I knew him, and yeah, he'd make weird noises and stuff would bubble up in the back of his throat, but it wasn't normal for him to make sounds like he was making that day. We had been told already that he had to be suctioned earlier that day." The CNA was asked if it was normal for him to require suctioning. She stated, "I don't think so. Early in the shift, he was okay, but not long into the shift he was totally different. At one point I went in there and he looked kind of blue and was gurgling. I called (LPN #1) and she came down there and said 'roll him over and let that[***]run out of his mouth.' The suction machine was by the nurse's station, but it never moved during my shift. He just got worse and worse as the shift went on. Around 10:15 p.m., he was like foaming at the mouth. I hollered at (LPN #1) again and she said 'I'm going out to smoke.' So, I wound up talking to the 11 to 7 shift nurse, (LPN #5), about him. She sent him out and the next morning he was dead." CNA #1 was asked if she took the resident's vital signs during her shift. She stated, "Yes, they were okay, but that was around 3:15 p.m. I asked (LPN #1) later in the shift if I could take them again and she said he was okay, that there was no need to. Some time during the shift, I can't remember exactly when, but we went to a facility phone and called (LPN #2) on the other side of the building and asked her if she would come look at him. She told us we needed to talk to (LPN #1) since she was his nurse. We, at one point, saw (LPN #3) in the hall and asked her if (Resident #2) was okay. She said he was fine, but we knew something was wrong with him." On [DATE] at 3:20 p.m., CNA #3, who was on d

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure Abuse/Neglect Prohibition written policies and procedures were implemented to ensure the provision of necessary care and services to avoid physical harm for Resident #1 and Resident #2. The facility failed to ensure staff responded to a call light and repeated verbal requests for help for 1 (Residents #1) of 3 (Residents #1, #2 and #5) case mix residents who were totally dependent on staff for care. The facility failed to ensure staff assessment and monitoring of a significant change in condition for 1 (Resident #2) of 4 (Residents #1, #2, #4 and #5) case mix residents who experienced a significant change in condition. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who after turning on her call light, repeating verbal requests for help, was not ensured immediate assistance and was later found to be without vital signs, and Resident #2, who after Certified Nursing Assistants repeatedly reported change of condition to LPN #1, was not assessed and was sent to the hospital on the next shift where he expired approximately eight hours and 40 minutes later. The failed practices were likely to cause more than minimal harm for 43 residents in the facility who required total assistance from staff and 35 residents in the facility who had a change in condition in the past 30 days, according to a list received from the Director of Nursing (DON) on [DATE] at 9:35 a.m. The facility was initially informed of the Immediate Jeopardy situations on [DATE] at 9:50 p.m., then again on [DATE] at 10:00 a.m. The findings are: 1. The facility's policy and procedure titled, "Abuse Prohibition Policy and Procedure", provided by the Director of Nursing (DON) on [DATE], documented, "...Identify: Employees are instructed annually and during orientation, then as needed, how to identify signs and symptoms of abuse/neglect... Investigation: Anytime there is suspected abuse/neglect or when any allegation is made, an internal investigation will be started... All parties involved will be interviewed... All residents will be protected from abuse utilizing this abuse prohibition policy every day... All employees suspected of or have allegations against them will be suspended pending outcome/findings of investigation... The administrator will notify OLTC (Office of Long Term Care) and prospective licensing boards if applicable... To protect the residents, it should always be your first thought to think abuse. When abuse is ruled out then you will know the residents are safe. Abuse should be considered in any unusual injuries/occurrences, and an investigation started to determine cause(s) of incidents..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 12 (,[DATE] indicates moderately impaired) on the brief interview for mental status (BIMS), was totally dependent on staff for all activities of daily living except eating and had no behaviors. a. A Nurse's Note dated [DATE] at 4:08 p.m. and signed by Registered Nurse (RN) #1 documented, "Called to resident's room by CNA (Certified Nursing Assistant). Found resident pale, dusky color, agonal resp (respirations), HR (Heart Rate) 60, SpO2 (oxygen saturation measured by pulse oximetry) 62%, nonresponsive, diaphoretic, flaccid. O2 (oxygen) via NC (nasal cannula) at 2 L (Liter), pupils equal, sluggish. Ambulance called, O2 increased to 6 L, SpO2 73%, BP (Blood Pressure) ,[DATE], resp 16, HR 103, responsive to voice, slurred speech, unable to follow commands, flaccid... 4:20 p.m. - Ambulance here to transport..." b. A Hospital History and Physical dated [DATE] documented, "Impression: Florid [MEDICAL CONDITIONS] - this is a clinical diagnosis... Known [MEDICAL CONDITIONS] with previous [MEDICAL CONDITION] infarctions... History of [DIAGNOSES REDACTED]." c. A Hospital Discharge Instruction sheet dated [DATE] documented, "Discharge Diagnosis: [REDACTED]. d. A Nurse's Note dated [DATE] at 2245 (10:45 p.m.) and signed by Licensed Practical Nurse (LPN) #6 documented, "CNA (,[DATE]) (3:00 p.m. to 11:00 p.m. shift) reported to LPNs ((LPN #1) and myself) (resident) was complaining of SOB (shortness of breath). LPNs entered (resident) room and found resident cyanotic and unresponsive (with) pupils fixed (and) dilated. V/S (vital signs) B/P (blood pressure) ,[DATE], R (respirations) 26, P (pulse) 48, O2 (oxygen) 48%. Administered O2 via NC (nasal canula) at 6 L/M (liters per minute) (and) notified (hospital) for an ambulance. (Resident) became more responsive as O2 sat (saturation) increased to 84% prior to arrival of ambulance... Transferred to (hospital)... 2:10 a.m. Returned to (nursing home) via ambulance (with) Dx (diagnoses) of [MEDICAL CONDITIONS] / [MEDICAL CONDITION]. Received N.O. (New order) to (increase) [MEDICATION NAME] to 20 mg (milligram) BID (twice daily)..." On [DATE] at 2:53 p.m., LPN #2 stated, "A couple of weeks before (Resident #1) passed away ([DATE]), she had a bad episode where she was unresponsive. The CNAs called me down there." She was asked if she was the resident's nurse. She stated, "No." She was asked why the CNAs called her instead of the resident's nurse. She stated, "I don't know." She was asked who the resident's nurse was that evening. She stated, "(LPN #1). The resident was unresponsive. I put the O2 cannula in her mouth and did a sternal rub and she started coming around. I asked (LPN #1) specifically if she had called 911 and she said no, she's a DNR (Do Not Resuscitate). I said I don't give a damn, she's sick. You've got to call 911. For some reason she thinks you don't call 911 if someone's a DNR." e. A Physician order [REDACTED]." f. A Nurse's Note dated [DATE] at 10:25 p.m. and signed by LPN #1 documented, "Resident found by staff, unresponsive to verbal or tactile stimulus. This LPN notified by staff. 10:30 p.(m.) Assessment by this LPN found resident unresponsive to verbal, tactile and sternum rub stimulus. Resident was noted to be (without) a pulse for 1 minute by palpation of carotid and auscultation was also found (without) respirations by auscultation for a period of 1 minute... (Doctor) notified... Family notified... Funeral home notified... (Doctor) here to pronounce..." 1) Interviews with CNAs on duty at the time of the incident: On [DATE] at 8:15 p.m., CNA #4, who was on duty the evening of [DATE], was asked about the incident involving Resident #1. She stated, "We had just taken her off the bed pan and (Housekeeping Supervisor) started waxing. I don't remember if her call light was on, but she started saying help, help, somebody come here. She said that maybe 3 times. (Housekeeping Supervisor) blocked off the hall and said don't go down there." The CNA was asked if LPN #1 heard the resident calling for help. She stated, "Yes she heard her and said she just probably wanted on the bedpan and said not to go down there. I should have just went down there. I blame myself. I could have at least held her hand." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "Maybe 30 minutes. I know (CNA #2) called (Administrator) and (Administrator) told her the resident could have passed at any time." On [DATE] at 12:25 p.m., CNA #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "Me and (CNA #4) was working old north. (Housekeeping Supervisor) said he came in to wax the floors and that he was going to block off the hall. He put wet floor signs across the hall and some blue tape on the floor. He told us to tell certain residents that we would not be able to answer their call lights for a while. I could hear (Resident #1) yelling even on old north where I was doing bed checks. Her call light had been going off probably 20 minutes. We asked (Housekeeping supervisor and LPN #1) if we could go down the hall and they said no. (LPN #1) said she just needed the pee pan. I was so upset I called (Administrator) and she said 'well she could have died at any time. She had a bad heart.' She's done this before but we get her on her oxygen and she'll be okay." The CNA was asked what happened when the resident was found without vital signs. She stated, "(Housekeeping Supervisor) was pretty calm and he just went and sat down and started watching TV. (LPN #1) asked for a stethoscope. (LPN #2) came over and said we need to go ahead and call an ambulance and (LPN #1) said no you don't have to, she's a DNR. We thought we could feel a pulse occasionally, but it went away. She was blue." The CNA was asked if the resident had her oxygen on that evening. She stated, "When I went into the room her O2 tubing was on the floor and the concentrator was off." The CNA was asked approximately how much time passed between the resident's call for help and when she was found without vital signs. She stated, "At least 20 minutes. I blame myself. I should've done something different. Even if we couldn't have saved her, at least she wouldn't have died alone." The CNA was asked if the resident had a habit of yelling for staff. She stated, "I've not ever heard her yell. I made the comment to (Housekeeping Supervisor) to just do half the hall because how would we know, with the entire hall blocked off, that if someone's alarm was going off they hadn't fallen. So what if she'd just been yelling for a pee pan - we had gotten that woman to where she was continent, so yeah, I think that needing a pee pan is significant." On [DATE] at 3:20 p.m., CNA #3, who was assigned to Resident #1 on the evening of [DATE], was asked during an interview about the incident that evening. She stated, "(Housekeeping Supervisor) said he was going to do the floors. We did an in-between bed check because our next bed check wasn't really due until 10:00 p.m. We went down the hall and told specific residents who normally get on their call light that the floor was being done and we couldn't come through here for a little while. (Resident #1) was one of them." The CNA was asked if Resident #1 was able to understand or comprehend what she was telling her. She stated, "Oh yes. She understood. When I went in to (Resident #1's) room, she actually asked me if (Housekeeping Supervisor) had already started. So (Housekeeping Supervisor) started and we were all up there at the desk, and no sooner had he finished and her call light comes on. We had asked (Housekeeping Supervisor) before he started how long it would be and he said probably 45 minutes. She started hollering help, help me girls. She did that sometimes. We asked him again how long it was going to be before we could go and he said probably 30 minutes." The CNA was asked approximately how much time passed between the resident's call light being activated and when she was found without vital signs. She stated, "Probably at least 30 minutes, maybe a little longer." The CNA was asked if LPN #1 told anyone not to go down the hall during the resident's call for help. She stated, "Not that I know of." The CNA was asked if (Housekeeping Supervisor) told staff not to go down the hall and check on the resident. She stated, "He told us not to walk across the wax until it was dry. I asked him a long time ago why he couldn't wax one half of the hall so we could go and check on residents. He said because it leaves a seam down the middle." CNA #3 was asked if she could do anything differently from that night, what would it be. She stated, "I would definitely walk down that hall." 2) Interview with LPNs on duty at the time of the incident: On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked how long she had worked for the facility. She stated, "I've been here three different times, but the most recent is from May to now." She was asked if she had been terminated from the facility before. She stated, "Yes." She was asked why she was terminated. She stated, "Documentation." LPN #1 was asked about the incident involving Resident #1. She stated, "We were up on North. Around the time I was finishing my med (medication) pass, the floor on new north was being waxed. We had made our rounds, then the wax was put on the floor. The resident put on her call light. I was at my med cart, (Housekeeping Supervisor) was there with his equipment. Some of the girls were by the break area and they looked to see who had their light on. (Housekeeping Supervisor) said 'give me 5 minutes'. As soon as he moved his equipment he went down there and found her. Then he informed me that I needed to come down the hall now. (Resident #1) was unresponsive, no vital signs. We paged the other LPN and she also determined the resident had no vital signs. (Resident #1) had a similar incident not long before this. That time she came around." The LPN was asked if the resident was verbally asking for assistance. She stated, "Yes. She hollered 'girls come help me.' She did that on a regular basis." LPN #1 was asked approximately how much time passed between the resident activating her call light and when (Housekeeping Supervisor) found her without vital signs. She stated, "Maybe 10 minutes. Even if I went long, I would say no more than 15 minutes." The LPN was asked why someone did not go down the hall when the resident requested help. She stated, "She would call out to me or the other girls if she saw us going down the hall. She usually just wanted the bedpan or to be moved in bed. That's what her tone of voice sounded like that night." The LPN was asked how she would be able to determine if a resident was in distress by the tone of their voice. She stated, "I don't know how to even answer that. There's a different tone, a different pitch. I didn't determine there wasn't a problem. That's why I asked (Housekeeping supervisor) how long it was going to be before we could go down the hall. You just learn residents by the tone of their voice. She was up for supper just before that and didn't appear in any distress." The surveyor stated, "I guess in this case she was apparently in distress or in need of immediate assistance." LPN #1 stated, "I don't think so. I don't know that because she sounded like she wasn't in any distress." LPN #1 was asked if she told anyone not to go down the hall and check on the resident when she was asking for assistance. She stated, "No." She then stated, "I followed policy that night by calling (Administrator) about what happened." The LPN was asked if anyone from administration came to the facility that night because of the incident. She stated, "No one came out that night." On [DATE] at 2:53 p.m., LPN #2, who was on duty the evening of [DATE], was asked about the incident that occurred involving Resident #1. She stated, "I knew that (Housekeeping supervisor) had been cleaning the floors. I'm sorry, but if one of my residents needs me, I'm gonna step on his newly waxed floor. They called me over there for that one too, but she was already gone." LPN #2 was asked if she was aware that the resident had activated her call light and had also been verbally calling for help before she was found without vital signs. She stated, "I became aware after the fact that her call light was on and she was calling for help. CNAs told me that." LPN #2 was asked if she was aware of any occasions when CNAs had reported serious information about residents to LPN #1 and the LPN not responding to it. She stated, "My CNAs are my eyes and ears. If they tell me something, I'm going... Yes, I've personally seen CNAs report things to her that she just brushes off, and doesn't respond to whatever it is they've told her." 3) Interview with the Housekeeping Supervisor: On [DATE] at 8:35 a.m., the Housekeeping Supervisor was asked about the incident that occurred involving Resident #1 on the evening of [DATE]. He stated, "I had just got done with putting down a coat of wax. About 5 minutes after I finished the wax, her call light came on. I don't like for the call lights to be on too long, but it takes 30 minutes for a coat of wax to dry. From the end of the hall to where I was sitting, it for some reason doesn't take the floor that long to dry. About 2, 3, maybe 4 minutes after her call light came on, she said help. About 3 or 4 minutes after that, she hollered help again in the same tone of voice. Then I started checking the floor to see how dry it was and it was dry enough to walk on, so I proceeded to go down the hall and I got to her room and checked on her, then I came out and hollered for the nurse." He was asked why no one responded to the resident the first time she called for help. He stated, "I don't know. The aides and the nurse was sitting right there. But she's done this before just to get her TV turned on or a drink of water. No one acted like it was a big deal that she was calling for help." The Housekeeping Supervisor was asked if he told staff not to go down the hall when the resident was calling for help. He stated, "No, and I didn't hear anyone ask if they could go down the hall." He was asked approximately how much time passed between the resident activating her call light and when he found her without vital signs. He stated, "Ten to 12 minutes." He was asked if the LPN on duty, LPN #1, told any of the CNAs to go down the hall and check on the resident. He stated, "No." He was asked if anyone suggested doing just half of the hall at a time so staff could respond to calls. He stated, "No." He was asked if it was okay to not respond to a call light or a resident yelling for help because there is wet wax on the floor. He stated, "No. I feel terrible." 4) On [DATE] at 9:00 a.m., the Housekeeping supervisor showed the surveyor where he and other staff members were sitting when Resident #1 called out for help. It was approximately 56 feet from the nurse's station where he and others were sitting to the door of Resident #1's room, then another 9 feet inside the room to the head of her bed. g. On [DATE] at 8:15 p.m., CNA #4 was asked if she had been involved in any in-services since the incident concerning answering call lights or resident's requests for help. She stated, "We had a meeting, ,[DATE] shift, a little while later about not blaming people for someone dying. But we all felt bad and were blaming ourselves, not (Housekeeping Supervisor) or (LPN #1)." The CNA was asked if she had ever had any problems with reporting serious concerns to LPN #1 and her not responding. She stated, "We tell (LPN #1) stuff all the time and she just blows it off." The CNA was asked if she had ever reported this to anyone. She stated, "We've reported this to (Administrator). (LPN #1) has been fired from here before and they brought her back." h. On [DATE] at 8:34 p.m., LPN #1, who was in charge of Resident #1's care on the evening of [DATE], was asked if she was in-serviced or educated soon after the incident to ensure she understood that staff was to respond to a resident's call for help. She stated, "Yes, a day or so after the incident." LPN #1 was shown the in-service sheet dated [DATE] (19 days after the incident) and she was asked to identify her signature indicating that she had attended the in-service. She looked at it and said, "My signature is not on there." LPN #1 was asked if she could change anything about the events of that evening, what would she change. She stated. "I did my job that night. I don't think anything I could've done would have made a difference." i. On [DATE] at 7:40 p.m., CNA #6, who was on duty the evening of [DATE], was asked if she had ever passed along resident information to LPN #1 and then LPN #1 not respond to it. She stated, "(LPN #1) just kind of blows you off. Now (LPN #2), if I tell her something, she checks on it right then." CNA #6 was asked if she had been in-serviced since the incident on responding to residents who call for help. She stated, "I don't remember an in-service, but we had a ,[DATE] meeting about gossiping." j. The facility's Policy and Procedure for Answering the Call Light documented, "The purpose of this procedure is to respond to the resident's requests and needs... Answer the resident's call as soon as possible..." On [DATE] at 11:00 p.m., the following addendum was added to the policy and procedure: "Time frame for answering resident call lights. Regular call light - Located in the resident's room. Usually a white light that comes on outside the door. EVERY resident is to have a call light in place. NO EXCEPTIONS! These lights are to be answered within ,[DATE] minutes..." k. On [DATE] at 9:17 p.m., the Administrator was asked what she knew about the incident on [DATE] involving Resident #1. She stated, "I got a call from (LPN #1) around 10:00 p.m. or 10:30 p.m. saying they had just found the resident without vital signs and that she was a DNR. After that I got a call from (CNA #2) saying she wanted me to look at the way we were waxing the floors... We interviewed (Housekeeping Supervisor) and he said he had waxed the hall after bed check. He was at the cart and two aides were at the new north table doing books, two were down old north. He said her call light came on and he heard her say girls, come help me. Probably 5 minutes went by and she said that again. He told (LPN #1) to wait until he got his stuff picked up, then (Housekeeping Supervisor) went down and checked on her and she was without vital signs. I interviewed (LPN #1). She heard her 1 or 2 times. I asked her if she sounded like she was in distress and she said no... The resident's roommate said the next morning that she yelled for someone to put her on the bedpan." (According to the facility's assessment, Resident #1's roommate had a BIMS score of 6 indicating a severely impaired cognitive status). The Administrator was asked if this incident was reported to local law enforcement and the Office of Long Term Care. She stated, "No." The Administrator was asked if she had a documented inservice where the staff members involved in the [DATE] incident had signed indicating they had attended and understood the inservice. She stated, "We did all of them one on one, then we did the rest of the building on [DATE]." The Administrator provided no documentation of a one on one in-service where the involved staff members were educated on preventing reoccurrences. The Administrator was asked if the incident was discussed and an action plan initiated in their Quality Assurance committee. She stated yes, but provided no documentation to show this occurred. l. On [DATE] at 9:40 p.m., the Administrator provided three and a half pages of typed information that documented, "[DATE] - Concern from (CNA #2) - states the night (Resident #1) passed 'I think we should do something different with the waxing. I'm not saying anybody did anything wrong.' Admin (Administrator) - what makes you say that? (CNA #2) - well I heard (CNA #3) ask (Housekeeping Supervisor) if she could go answer (Resident #1's) light and he told her no, she couldn't walk on the floor. Admin - where were you working? (CNA #2) - I was on old north, but I had gone to the desk for something and overheard it and we couldn't get to her in time. Interview with (Housekeeping Supervisor) - States was waxing floors after last bed check; states he started after the aides went through and checked everyone; states he told the aides it would take him 45 to get all the way up the hall; states he did not tell anyone they could walk on the floor; states no one asked him if they could walk on the floor; states he was at north med cart when (Resident #1's) light came on; states he heard (Resident #1) say something like come here girls or come here help me girls; states he thought he heard her two or three times so he said let me get this stuff out of way and he got up to move the fans and went down the hall; states when he got to (Resident #1's) room she had passed away; states he immediately called for the nurse; states light was on maybe 15 mins (minutes) or less. Interview with (LPN #1) - states she was at med cart when (Resident #1's) light came on; states she heard (Resident #1) say come here or come help girls; states she heard (Resident #1) once and she looked up and (Housekeeping Supervisor) was picking up the fans saying let me get this stuff out of the way and he went down the hall; states she did not note any distress in (Resident #1's) voice, sounded like her normal call for the bed pan; states two aides were near the north station sitting area, two aides were down old north; states no aide ever approached (Housekeeping Supervisor) about going down the hall; states no other call lights were on down that hall... Interview with (CNA #3) - aide assigned to new north hall. States all 4 aides standing at north desk; denies asking (Housekeeping Supervisor) if they could go answer the light; states several lights were on but does not give clear answer as to whether these call lights were on the hall in question; states light was on 50 minutes; states (Housekeeping Supervisor) told them not to walk on floor but would not give a clear answer as to when he told her this; states we had just been in room [ROOM NUMBER] minutes before she passed (admin note here, then how was light on for 50 minutes); states she didn't attempt to go down the hall. Interview with (LPN #2) - LPN south hall - Since call light system sounds and lights up on both ends of the building, states there were no lights that were on for excessive lengths of time; states she would notice call lights longer than ,[DATE] minutes because they beep loudly for the north hall on the intercom for south hall; ...states she could not remember more than one light being lit up for call lights on north at that time. Interview with (CNA #4) - (blank). Re-interview with (LPN #1) - confirms the aides had been in the room ,[DATE] minutes before the call light came on and resident was not in any distress at that point. Findings: (Resident #1's) medical history - had 10% working capacity of heart, was admitted to nursing home because doctors told family she would probably pass away in middle of night when heart finally gave out, they didn't want her to be at home alone when that happened. Patient was a DNR (Do Not Resuscitate). The housekeeping supervisor that was waxing the floors seems to be very upset when answering his questions, he seems bullied into thinking he did something wrong. Aide (CNA #3's) story is not supported by either nurse nor the housekeeping supervisor, nor her own because of her admittance that she herself had been in the room [ROOM NUMBER] minutes before the call light was on but then tried to state it had been on for ,[DATE] minutes. Roommate of (Resident #1) stated that resident didn't seem like she was in trouble... LPN on south hall confirmed that no call lights were excessively long and states would have noticed one being on for more than 15 minutes... Admin has asked (Housekeeping Supervisor) to not wax any further til he can discuss with his floor consultant a different way possible to do the floors as a safety measure. All staff are inserviced that when the floors are being waxed, call lights must still be answered in a timely manner even if floors have to be re-done." m. On [DATE] at 11:15 a.m., the signature sheet for the in-service dated [DATE] was reviewed to ensure all staff had been in-serviced on responding to residents who call for help. According to the signature sheets provided and a list of current employees, at least 10 current employees had not been in-serviced on this. On [DATE] at 11:20 a.m., the DON was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She stated, "There's one or two on leave, but there's no reason why the rest shouldn't have been." On [DATE] at 11:40 a.m., LPN #3 was asked if there was a reason why some current employees had not been in-serviced on responding to residents who call for help. She looked at the sign in sheet and stated, "It's not like they didn't have access to it. It's out there for 5 days." LPN #3 was asked if this was a formal in-service where everyone is gathered in a room, or was the in-service sheet placed at a location for staff to sign at their convenience. LPN #3 simply nodded her head. She was asked who was responsible for ensuring everyone signs and understands the content of the in-services. She stated, "I guess we're going to have to sit down and count signatures." n. The Immediate Jeopardy was removed on [DATE] at 10:03 p.m. and the scope and severity reduced to an "H", a pattern of actual harm, when the facility implemented the following plan of removal: 1) On [DATE] at 10:03 p.m., the LPN supervisor removed (LPN #1) from the floor and took charge of her hall. Her employment will be terminated by the Director of Nursing. 2) On [DATE], all nursing staff and maintenance/housekeeping on duty were in-serviced by the DON/LPN supervisor, and all on coming staff will be in-serviced regarding answering of call lights and/or calls for help within 5 minutes regardless of obstacles or floor situations, with all new hires being in-serviced immediately upon hire. 3) The DON/LPN supervisor will do daily audits every shift for four weeks, with all findings being corrected immediately and all information presented to the QA committee. 4) The facility is incorporating a new waxing system to allow waxing only to be done on one side of the hallway at a time completing 12 inch wide sections at a time to allow easy access over and into rooms if needed. 5) The QA committee meeting will be moved up to weekly for the duration of the audit. 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the BIMS, had a feeding tube for nutrition and was totally dependent on staff for all activities of daily living. a. A Nurse's Note dated [DATE] (no time) and signed by Registered Nurse (RN) #1 documented, "Resident congested, wet, gurgling vocalization noted. Suctioned airway with 125 ml (milliliters) yellowish frothy drainage collected. Resident tolerated well. Resp (respirations) unlabored." b. A Nurse's Note dated [DATE] (7:00 a.m. to 3:00 p.m. shift) and signed by LPN #4 documented, "Resident has wet 'gurgling' cough, lung sounds congested, has productive cough with yellow/green sputum. (Physician) notified of same. Order received for [MEDICATION NAME] 875 mg pgt (per g tube) BID (twice daily) x (times) 10 days; portable chest x ray." c. A Nurse's Note dated [DATE] (3:00 p.m. to 11:00 p.m. shift) and signed by LPN #1 documented, "V/S (vital signs) - B/P ,[DATE], P 69, R 20, T 97.5. Congestion with productive cough noted. No distress noted. Will cont (continue) to monitor. 8:00 p.m. - [MEDICATION NAME] 875 mg initial dose given per tube. No s/s (signs or symptoms) adverse reaction noted." There were no further assessments documented during the 3:00 p.m. to 11:00 p.m. shift. 1) Interviews with CNAs: On [DATE] at 12:59 p.m., CNA #1, who was on duty and assigned to Resident #2 the evening of [DATE], was asked during an interview what occurred that evening. She stated, "I remember that day just fine. Me and (CNA #3) were working. I've been taking care of (Resident #2) for about a year. I knew him, and yeah, he'd make weird noises and stuff would bubble up in the back of his throat, but it wasn't normal for him to make sounds like he was making that day. We had been told already that he had to be suctioned earlier that day." The CNA was asked if it was normal for him to require suctioning. She stated, "I don't think so. Early in the shift, he was okay, but not long into the shift he was totally different. At one point I went in the

Complaint # substantiated (all or in part) with these findings: Based on observations, record review and interview, Nursing Administration failed to ensure Resident #6 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Nursing staff failed to ensure that Cardiopulmonary Resuscitation (CPR) included respiratory support and that a back board was utilized to ensure effectiveness of chest compressions for 1 of 1 case-mix resident (Resident #6) who was found without vital signs. Nursing Administration failed to ensure CPR certified staff knew facility guidelines for determining code status of a resident for 1 of 1 (Resident #6) who had a physician ' s order for Do Not Resuscitate (DNR), was found unresponsive/ not breathing and CPR initiated. Nursing Administration failed to ensure the emergency crash cart was equipped with a back board, ambu bag and other essential equipment that would be needed to provide CPR on 2 of 2 emergency carts. Nursing Administration failed to ensure advance directive code status was available and accurate for 7 (Residents # 2, 3, 5, 6, 9, 10, and 11) and failed to ensure a physician ' s order was obtained in the presence of residents ' advanced directive for DNR for 2 (Resident #3 and 10) of 9 (Residents # 1 through 6 and 9 through 11) case mix residents with Advanced Directives. The failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death, for Resident #6 and was likely to affect 4 other case-mix residents (Residents #2, 4, 5 and 11) who had specific instructions for Code Status. The failed practices also had the likelihood to cause more than minimal harm for 14 residents who were DNRs according to the Administrator on [DATE] at 10:45 a.m. and 45 residents who were a Full Code Status according to a list provided by the Administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 2:08 p.m. The findings are: 1. The facility's "Director of Nursing Job Description" documented, "1. Updating, reviewing and/or setting policy and procedures to promote resident care and rights. 2. Ensure that residents are receiving adequate care ..." 2. Resident #6 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 6 (,[DATE] indicated severely impaired) on a Brief Interview for Mental Status. a. The Advance Directives (and) Medical Treatment Decisions form dated [DATE], signed by (Family Member # 1), documented, "... I have chosen to formulate and issue the following advance directives ... No Vent (Ventilator)/Respirator." b. The hospital Physician's Daily Progress Notes dated [DATE] documented, "... 4. Code Status - the staff has tried multiple times to reach the family listed as contact and has contacted the nursing home who apparently have trouble with family being out of contact. I have discussed a DNR status with the patient and he was able to tell me that he does not want to be put on machines or heroic measures if his heart stops. He does seem to understand his medical status and can answer questions appropriately, so per his request I will make him a DNR status ..." c. A physician order dated [DATE] documented, "DNR Do Not Resuscitate." d. The Care Plan reviewed on [DATE] documented, "Problem: DNR/Living Will; Comfort Care; No vent/resp (respirator)... Interventions: ... Keep resident comfortable." e. The [DATE] Physicians Orders sheet documented a physician order dated [DATE] for a DNR. The "Notes/Alerts" documented, "No Vent/No Respirator." f. The Nurse's Notes dated [DATE] at 5:15 a.m., written by Licensed Practical Nurse (LPN) # 1, documented, "Aide (Certified Nurses Assistant (CNA) # 2) called for nurse (LPN#1)to come to resident's room. Resident was unresponsive (with) (no) respirations noted. Checked (vital signs) and found (none) present. (CNA # 2) radioed for help from North Nurse (LPN # 2) and CPR Certified Aide (CNA # 1). (CNA # 1) began chest compression alternating with LPN (LPN # 2) while LPN (LPN 3) call for ambulance from (hospital). Informed (no) ambulance was available currently. Went to alternate compressions while LPN (LPN # 2) called for on call (Physician # 1). Continued to alternate compressions with (CNA # 1). (LPN # 2) returned to relieve LPN (LPN # 1) while she notified (Registered Nurse (RN) # 1), RN of events. (Physician # 1) arrived at 5:45 a.m. to examine resident. Pronounced death at 5:55 a.m..." The physician progress notes [REDACTED].# 1, documented, "... Called by (nursing home) at 5:34 a.m. to respond to a (patient) found in bed (without) pulse or (respiration). They reported (patient) to be a full code (and) started CPR. Ambulance was called however could not come due to being on another call. I obtained directions to this facility and arrived (at) (approximately) 5:50 a.m. Upon arrival to the (patient) room, chest compressions were being performed. ... (Nursing) reports there is a crash cart but they did compressions only (secondary) no one able to perform ACLS (Advanced Cardiac Life Support). (Patient was not bagged or assisted in his ventilation. ... Cause of death likely (respiratory) arrest (secondary) [MEDICAL CONDITION] ..." g. On [DATE] at 8:40 a.m., CNA # 2 was asked, "How do you know which resident's are DNRs?" CNA # 2 stated, "There used to be a dot on the door so we don't really know or a dot on the chart." CNA # 2 was asked, "What happened to (Resident # 6) on [DATE]?" CNA # 2 stated, "I went into get him up a little after 5 and he was not responsive. I called the nurse on the radio and I asked her to come to the room." CNA # 2 was asked, "When the nurse came to the room, what did she do?" CNA # 2 stated, "She checked the resident then went to check if (Resident # 6) was a code. We called the north nurse on the radio to come help. They ran down and they (CNA # 1 and LPN # 2) started CPR. (LPN # 1) said they needed to start CPR. (LPN # 1) was on the phone to get the ambulance." CNA # 2 was asked, "Who got the crash cart?" CNA # 2 stated, "I did." CNA # 2 was asked, "Was the back board on it?" CNA # 2 stated "No. " CNA # 2 was asked, "What were (LPN # 2 and CNA # 1) doing when you got to the room with the crash cart?" CNA # 2 stated, "Chest compressions." CNA # 2 was asked, "Did you see anyone doing breathing/ambu bag?" CNA # 2 stated, "No, I left and went on with my duties, there was nothing I could do after that." h. On [DATE] at 7:45 a.m. LPN # 1 was asked, "How do you know which residents are DNRs?" LPN # 1 stated, "Blue dots on resident name tags on doors, in chart." LPN # 1 was asked, "Where in the chart?" LPN # 1 stated, "In front on the face sheet under Advance Directives." LPN # 1 was asked, "Are you trained in CPR?" LPN # 1 stated, "Yes." LPN # 1 was asked, "How do you do CPR?" LPN # 1 stated, "That's a crazy question to answer. Make sure resident is not responsive, check for pulse and breathing, lift chin up, give 2 breaths, then start compressions - 30 compressions - check for pulse - 30 compressions - check for pulse again, then 2 more breaths." LPN # 1 was asked, "What was the code status for (Resident # 6)?" LPN # 1 stated, "He was not vent (ventilator) - code but no vent." LPN # 1 was asked, "What does that mean?" LPN # 1 stated, "We still do CPR but he was not to have a ventilator." LPN # 1 was asked to tell the surveyor about the code on [DATE]. LPN # 1 stated, "That was my first code ever ... At 5:15 a.m. (CNA # 2) radioed for me to come to room ... stat. I went to room, he was on his back, not breathing, no response. He had a blue dot on his door. I checked his chart. Chart said code but no vent. I sent (LPN # 2) and (CNA # 1) to start CPR while I called (hospital) ER room." LPN # 1 was asked, "Did you take the crash cart to the room?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Did you take the back/cardiac board?" LPN # 1 stated, "I don't remember." LPN # 1 was asked, "What happened next?" LPN # 1 stated, "ER said the ambulance was out and it would be awhile, so I called (RN # 1), RN Supervisor on call. She said she didn't know what to do, to call the physician. The hospital ER (emergency room ) called back saying it was going to be awhile on the ambulance. I went to the room and took (LPN # 2's) place and had her call the on call physician." LPN # 1 was asked, "When you took (LPN # 2's) place, what did you do?" LPN # 1 stated, "I started chest compressions." LPN # 1 was asked, "Who was providing breathing?" LPN # 1 stated, "I don't remember." LPN # 1 was asked, "Did you bag or ventilate (Resident # 6)?" LPN # 1 stated, "No." LPN # 1 was asked "Was there an ambu bag in the room?" LPN # 1 stated, "I don't remember one being there." LPN # 1 was asked, "The picture I have is 2 nurses and a CNA doing chest compressions and there is no ventilation/breathing support. Is that correct?" LPN # 1 stated, "That's the way it looks." LPN # 1 was asked, "Was there any reason you didn't do 30 compressions and 2 breaths as per the CPR procedure?" LPN # 1 stated, "Not that I know of." LPN # 1 was asked, "When doing chest compressions did (Resident # 6) have a back board/solid surface under him or was he going into the mattress?" LPN # 1 stated, "I believe it was into the mattress." LPN # 1 was asked, "Any in-services on CPR since (Resident # 6's) code?" LPN # 1 stated, "No." LPN # 1 had an American Heart Association Healthcare Provider card which documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED) Program. Issue Date: [DATE]. Recommended Renewal Date "[DATE]." i. On [DATE] at 8:20 a.m., LPN # 2 was asked, "How do you know which residents are DNRs?" LPN # 2 stated, "Blue dot on chart, look for DNR order in chart." LPN # 2 was asked, "Are you trained in CPR?" LPN # 2 stated, "Yes, certification is current." LPN # 2 was asked, "How do you do CPR?" LPN # 2 stated, "Check airway, listen, look for breathing, check for pulse, open airway, give 2 breaths. Start chest compressions, 15 compressions to 2 breaths after every round check to see if they are breathing." LPN # 2 was asked, "Were you the nurse on the north hall on [DATE]?" LPN # 2 stated, "Yes." LPN # 2 was asked, "How did you get involved in (Resident # 6's) code?" LPN # 2 stated, "I was called on walkie talkie and asked if I could come assist. I was passing meds, I put the med cart up and took off to south hall. The south nurse (LPN # 1) was checking to see if he was a code or not. (LPN # 1) told me as I was going past that he was a code, but no respirations." LPN # 2 was asked, "What does (Resident # 6's) physician order say?" LPN # 2 stated, "No vent/no respirator, I think she misunderstood that." LPN # 2 was asked, "You were told no respirations?" LPN # 2 stated, "Yes, at that point. She did come down a little while later and said she misread it and we started doing respirations." LPN # 2 was asked, "Who was doing respirations?" LPN # 2 stated, "I don't remember who all did them I did some of it." LPN # 2 was asked, "Did you use an ambu bag?" LPN # 2 stated, "Yes." LPN # 2 was asked, "Where did the ambu bag come from?" LPN # 2 stated, "Crash cart." LPN # 2 was asked to read the physician note of [DATE] regarding respirations. After review LPN # 2 stated, "I thought we'd done them (respirations)." LPN # 2 was asked, "Did you do respirations?" LPN # 2 stated, "Apparently not." LPN # 2 was asked, "Any reason why respirations were not done?" LPN # 2 stated, "No." LPN # 2 was asked, "Any back/cardiac board under (Resident # 6) during the code?" LPN # 2 stated, "No." LPN # 2 was asked, "Was there a back board on the crash cart?" LPN # 2 stated, "No." LPN # 2 was asked, "Any in-services on CPR since (Resident # 6) died ?" LPN # 2 stated, "No." LPN # 2 had an American Heart Association Healthcare Provider card whish documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED) Program. Issue Date: [DATE]. Recommended Renewal Date" ,[DATE]." j. On [DATE] at 7:02 a.m., CNA # 1 was asked, "How do you know which residents are DNRs?" CNA # 1 stated, "Our nurse tells us or look in care plan." CNA # 1 was asked, "What do you do if you find a resident without pulse/respirations/unresponsive?" CNA # 1 stated, "Go get a nurse - go fast, call on radio." CNA #1 was asked, "What does the nurse do?" CNA # 1 stated, "Go check chart for DNR and take whatever procedure needs to be taken after that." CNA # 1 was asked, "Are you trained in CPR?" CNA # 1 stated, "Yes, I'm CPR certified." CNA # 1 was asked, "How do you do CPR?" CNA # 1 stated, "Check if resident breathing, try to get resident to respond, tilt head to clear airway, 30 compressions to 2 breaths." CNA # 1 was asked, "Tell me about (Resident # 6's) CPR on [DATE], what happened?" CNA # 1 stated, "I was doing bed checks and (CNA # 2) asked me to come assist on the radio and so I went up there. The nurse (LPN# 2) was there and (CNA # 2) was in there. The nurse was doing chest compressions and (CNA # 2) was watching/standing by. When the nurses left the room or if they needed relief I would take over and did chest compressions." CNA #1 was asked, "Who did breathing/respirations?" CNA # 1 stated, "We only did chest compressions." CNA # 1 was asked, "Why no respirations?" CNA # 1 stated, "I don't know, they (LPN # 1 and 2) did everything." CNA # 1 was asked, "Were the nurses doing respirations/breathing?" CNA # 1 stated, " No." CNA # 1 was asked, "Was the crash cart brought to the room?" CNA # 1 stated, "I can't remember if it was there or not." CNA # 1 was asked, "Was there any back board under the resident?" CNA # 1 stated, "I can't remember, I don't think there was, seems like he was being pushed into the mattress with chest compressions." CNA # 1 was asked, "Any in-services/training on CPR since (Resident # 6's) code?" CNA # 1 stated, "No." CNA # 1 had an American Heart Association Healthcare Provider card which documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED (Automated External Defibrillator)) Program. Issue Date: [DATE]. Recommended Renewal Date" ,[DATE]." k. The facility's policy titled "Resident Code Status and Code Procedures" documented, "If a resident is found without vital signs: 1. Check resident's Code Status/DNR status. *Code status will be indicated by a blue dot by the name on the door to their room, and on the spine of the chart. If a resident does not have a blue dot, then that resident is considered to be a full code status. 2. If a resident is a DNR, notify family, doctor, coroner, and Director of Nursing (DON). 3. If a resident is not a DNR, initiate chest compressions and have another staff member call 911 or the EMS (Emergency Medical Service) ... 4. Continue basic first aide of compressions to 2 breaths, until EMS arrives, or until someone relieves you." The facility's policy titled "Cardiopulmonary Resuscitation" documented, "1. CALL. Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally. Call 911 and return to the victim. In most locations the emergency dispatcher can assist you with CPR instructions. 2. PUMP. If the victim is still not breathing normally, coughing or moving, begin chest compressions. Push down the center of the chest 2 inches 30 times. Pump hard and fast at the rate of at least 100/minute, faster than once per second. 3. BLOW. Tilt the head back and left the chin. Pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths. Each breath should take 1 second. Continue with 30 pumps and 2 breaths until help arrives. ..." An article titled "Cardiopulmonary Resuscitation (CPR): First Aid" by Mayo Clinic at http://www.mayoclinic.com/health/first-aid-cpr/FA documented, "... Here's advice from the American Heart Association: ...If you're well trained and confident in your ability, begin with chest compression ... Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. ... Put the person on his or her back on a firm surface. ... If you're trained in CPR and you've preformed 30 chest compressions, open the person's airway ... With the airway open ... prepare to give 2 rescue breaths. Give the first rescue breath - [MEDICATION NAME] one second - and watch to see if the chest rises. If it does rise, give the second breath. ... Thirty chest compressions followed by two rescue breaths is considered one cycle. ..." l. Additional staff interviews regarding correct procedures for CPR: 1) On [DATE] at 2:27 p.m. LPN # 5 was asked, "Are you trained in CPR?" LPN # 5 stated, "Yes." LPN # 5 was asked, "How do you do CPR?" LPN # 5 stated, "Flat surface, check pulse, make sure mouth is clean, start compressions 15 to 1." LPN # 5 was asked, "15 to 1?" LPN # 5 stated, "15 (chest compressions) to 1 breath if not breathing." 2) On [DATE] at 4:35 p.m., LPN # 6 was asked, "Are you trained in CPR?" LPN # 6 stated, "No current certification." LPN # 6 was asked, "How do you do CPR?" LPN #6 stated, "Resident flat on hard surface, tilt head, check pulse, chest compressions, if ambu bag, if not then breathe in mouth 5 to 2 - 5 chest compressions to 2 breaths." 3) On [DATE] at 9:50 a.m., LPN # 7 was asked, "Are you trained in CPR?" LPN # 7 stated, "Yes, trained, certification has expired." LPN # 7 was asked, "How do you do CPR?" LPN # 7 stated, "Check for respirations and pulse, make sure the resident is on a firm surface." LPN # 7 was asked, "Is the bed a firm surface?" LPN # 7 stated, "No, use a board under them or move the resident to the floor. Then begin compressions and breaths-5 compressions to 2 breaths." m. On [DATE] at 2:18 p.m., the emergency/crash cart at the exit door, approximately 15 feet from the north nurses station, had an Ambu bag, suction machine and tubing, and gowns. There was no cardiac/back board present on or next to the crash cart. 1) On [DATE] at 2:20 p.m., LPN # 3 was asked, "Does the north hall crash cart have a cardiac/back board?" LPN # 3 stated, "I've never seen one." 2) On [DATE] at 2:25 p.m., LPN # 4 was asked "Is there a cardiac/back board on the north hall crash cart?" LPN # 4 looked at the cart then stated, "No." 3) On [DATE] at 9:20 a.m., the Director of Nurses (DON) was asked to observe the north hall crash cart. The crash cart contained disposable gowns, a suction machine with canister and suction tubing, an ambu bag with mask, oxygen mask, and updraft machine. There was no back/cardiac board. The DON was asked, "Where is the back board?" The DON stated, "I'm not sure." The DON was asked, "Should one be on here?" The DON stated, "I'm not sure about that." The DON was asked, "If staff does CPR and there is no back board under the resident, is that going to be effective?" The DON stated, "No, they would have to move the resident to the floor." n. On [DATE] at 2:20 p.m., the south hall crash cart contained a CPR micro shield, a suction machine with canister, four suction catheter kits, one Yonkers, an ET (endotracheal) bulb, and a bagged ambu bag with mask. There was a back board on the floor next to the cart but was not connected/attached to the cart. An oxygen tank was in the closet with the crash cart but was not connected/attached to the cart. On [DATE] at 9:22 a.m., the DON was asked to observe the south hall crash cart. The crash cart contained a suction machine with canister, extension and suction tubing, gloves, an ambu bag with mask, suction supplies and oxygen regulator. There was no back board on the crash cart. The DON was asked, "Where is the back board?" The DON stated, "On the floor next to the crash cart" The DON was asked, "Do you monitor the crash cart's contents/ensure they are stocked?" There was no response from the DON. 1) On [DATE] at 2:40 p.m., LPN # 7 was asked, "Who is responsible for checking the crash cart?" LPN # 7 stated, "I'm not sure. I know as we use it, we are to restock it and make sure everything is there." LPN # 7 was asked, "Is there a list of what's supposed to be on the crash cart?" LPN # 7 stated, "No." 2) On [DATE] at 2:50 p.m., LPN # 5 was asked, "Who is responsible for checking the crash cart?" LPN # 5 stated, "Who ever used it last replaces what they used." LPN # 5 was asked, "Is there a list of what's supposed to be on the crash cart?" LPN # 5 stated, "No I've never seen one." o. On [DATE] at 9:30 a.m., the Director of Nursing (DON) was asked, "How does your staff know which residents are a DNR?" The DON stated, "We have blue dots on charts." The DON was asked, "Did you know your staff is not sure of how to identify if a resident is a DNR?" There was no response from the DON. This surveyor reviewed the notes/alert section of the Physician Orders for [DATE] for (Resident # 6) with the DON. Under notes/alerts "No vent/No respirator" was documented. This surveyor reviewed the events reported by the CNAs and LPNs for the code on Resident # 6 on [DATE]. The DON was asked, "Were you aware of the physician progress notes [REDACTED]. Our conclusion was a tube (endotracheal tube) was not dropped to start ventilations and with new CPR you only have to do chest compressions." The DON was asked, "Did you call the physician to clarify what she meant?" The DON stated, "No." The DON was asked, "Did you ask staff if they did respirations/ventilations?" The DON stated, "No." The DON was asked, "Did you know staff did not use a back board and no respirations were given?" The DON stated, "I didn't know they had not used a back board. I'm not clear if they did or didn't do respirations." The DON was asked, "Did you investigate what happened with (Resident # 6) and why CPR wasn't done properly?" The DON stated, "I didn't, (Administrator) was looking at this because of the abuse allegation made because of his bruises." The DON was asked, "Any in-services on identification of DNR status since (Resident # 6) died ?" The DON stated, "No, I'm not aware of any." The DON was asked, "Any in-services on CPR since (Resident # 6) died ?" The DON stated, "No." The DON was asked, "Did you know the north hall crash cart had no back board?" The DON stated, "Not until today." The DON was asked, "Did you know the back board was not on the south hall crash cart - that it's kept on the floor?" The DON stated, "No but who ever got the cart should have known to get the back board." The DON was asked, "Even a CNA who is not trained in CPR?" The DON stated, "Yes." p. On [DATE] at 10:30 a.m., the Administrator was asked, "How does you Advance Directive process work?" The Administrator stated, "When a resident is admitted they (nurse and resident/family) talk about advance directive - whether they want to choose one or not choose one. That goes to (Assistant Director of Nursing (ADON)) who puts it in the computer system. She puts it under alerts/notes. If it's an actual order it shows up under the physician orders. (ADON) gets a copy, the copy is supposed to go in their chart. If a DNR, she put a blue dot on the spine of the chart and by the resident's name outside of the door." The Administrator was asked, "If staff are looking under notes/alerts what should be there for (Resident # 6)?" The Administrator stated, "DNR." The Administrator was asked, "Were you aware that staff did a code on (Resident # 6) who had a physician order for [REDACTED]." The Administrator was asked, "With your system, can you understand your nurses, confusion over code status?" The Administrator stated, "Yes." The Administrator was asked, "Did you review the physician note dated [DATE]?" The Administrator stated, "Yes." The Administrator was asked, "When did you do that?" The Administrator stated, "Last week some time." The Administrator was asked, "Did you understand the staff did compressions only?" The Administrator stated, "Yes, I had a discussion with (DON). We discussed if they (staff) were trying to go by new guidelines or not. That's when we started interviewing everyone and got statements." The Administrator was asked, "Did you do any in-services or retraining of staff on Advance Directives or CPR?" The Administrator stated, "We haven't yet." 3. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on a Brief Interview for Mental Status. a. . A Living Will dated [DATE], received from the Administrator on [DATE] at 1:50 p.m. did not specify Advance Directive/Code Status. b. The [DATE] Physicians Orders sheet documented no orders for a DNR. , The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Living Will." c. On [DATE] at 1:55 p.m., the Assistant Director of Nursing (ADON) was asked, "What does 'Living Will' under notes/alerts mean to staff as far as CPR?" The ADON did not respond. On [DATE] at 2:25 p.m., LPN # 4, the evening shift (3:00 p.m. to 11:00 p.m.) LPN for the north hall, was asked, "What does 'Living Will' mean under notes/alerts on the MAR?" LPN # 4 stated, "DNR." 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status. . a. An Advance Directive dated [DATE] received from the ADON on [DATE] at 1:30 p.m. documented, "I DO NOT want any of the above, DO NOT RESUSCITATE." b. The Care Plan dated [DATE] did not address the resident's DNR status. c. The [DATE] Physicians Orders sheet documented no physician order for [REDACTED]. d. On [DATE] at 1:55 p.m., the ADON was asked, "Why wasn't (Resident # 3's) Advance Directive in the medical record?" The ADON stated, "It's my fault for not finding it and putting it there." The ADON was asked, "What is resident's code status per notes/alerts?" The ADON stated, "Full Code." 5. Resident # 2 was re-admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status. a. The Care Plan dated [DATE] did not address the resident's DNR status. On [DATE] at 1:55 p.m. the ADON was asked, "Where is (Resident # 2's) Advance Directive?" After looking through the residents' clinical record the ADON stated, "It's not here." 6. On [DATE] at 1:55 p.m. the Assistant Director of Nursing (ADON) was asked, "What is the process for Advance Directive/determining wishes for code status?" The ADON stated, "The resident/family goes over Advance Directive with whoever admits the resident and a copy is supposed to be put in the chart and a blue dot goes on the chart and name tag on door. It's supposed to be on the POS (Physician Order Sheet) and MAR (Medication Administration Record)." The ADON was asked, "Who is responsible for getting Advance Directives in the chart, blue dots on doors, charts, and on POS and MAR?" The ADON stated, "I am." The facility's policy titled "Do Not Resuscitate" documented, "Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions when there is a Do Not Resuscitate Order in effect. ... 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate Order (DNRO) Form must be completed and signed by the attending physician or resident (or resident's legal surrogate ...) and placed in the front of the resident's medical record. ... 3. Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT (Emergency Medical Technician) personnel transporting the resident to the hospital. ... 5. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. ... 7. Any resident with DNR status will have a blue dot on the door name plate and on their chart spine." 7. Additional staff interviews regarding identification of code status for residents: 1) On [DATE] at 2:20 p.m., LPN # 3 was asked, "How do you know if a resident is a full code?" LPN # 3 stated, "I look notes/alerts on the MAR." 2) On [DATE] at 2:25 p.m., LPN # 4, the evening shift LPN for the north hall, was asked, "How do you know if a resident is a DNR or full code?" LPN # 4 stated, "Look under notes/alerts on MAR." 3) On [DATE] at 6:48 a.m., CNA # 3 was asked, "How do you know which residents are DNRs?" CNA # 3 stated, "Blue dot on chart, in ADL (Activity of Daily Living) books under notes/alerts." 4) On [DATE] at 7:32 a.m., CNA # 4 was asked, "How do you know which residents are DNRs?" CNA # 4 stated, "We ask nurse - it's in the charts - nurse tells us when code status is changed." 5) On [DATE] at 3:40 p.m., CNA # 5 was asked, "How do you know which residents are DNRs?" CNA # 5 stated, "Chart - outside chart." 6) On [DATE] at 3:49 p.m., CNA # 6 was asked, "How do you know which residents are DNRs?" CNA # 6 stated, "On chart and bottom of ADL (Activity of Daily Living) sheet. Outside of chart, sticker says DNR." 7) On [DATE] at 4:04 p.m., CNA # 7 was asked, " How do you know which residents are DNRs?" CNA # 7 stated, "ADL book, I'm not sure." 8) On [DATE] at 4:21 p.m., CNA # 8 was asked, "How do you know which residents are DNRs?" CNA # 8 stated, "ADL books." 9) On [DATE] at 4:35 p.m., LPN # 6 was asked, "How do you know which residents are DNRs?" LPN # 6 stated, "On chart - look in chart should be on bottom of med orders." 10) On [DATE] at 9:12 a.m., CNA #9 was asked, "How do you know which residents are DNRs?" CNA # 9 stated, "Usually on chart - blue dots and right in front of chart." 11) On [DATE] at 9:22 a.m., CNA #10 was asked, "How do you know which residents are DNRs?" CNA # 10 stated, "Stickers - dots on chart, in ADL book." 12) On [DATE] at 9:40 a.m., CNA #11 was asked, "How do you know which residents are DNRs?" CNA # 11 stated, "In ADL book, inside chart but I can't look there." 8. On [DATE] at 10:45 a.m., the Administrator presented a list of 14 residents that were identified as having DNRs. An audit was done of the facility's identification system with the following findings: a. Resident # 9 was identified as a DNR on the listing provided by the Administrator and had no blue dot on the name tag on the resident's door. There was a blue dot on the spine of the chart. b. Resident #10 was not identified as a DNR on the listing provided by the Administrator. There was a blue dot on the name tag

Complaint # substantiated (all or in part) with these findings: Based on observation, interview, and record review, the facility failed to ensure Resident #6 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) included respiratory support and that a back board was utilized to ensure effectiveness of chest compressions for 1 of 1 case-mix resident (Resident #6) who was found without vital signs. The facility failed to ensure CPR certified staff knew facility guidelines for determining code status of a resident for 1 of 1 (Resident #6) who had a physician ' s order for Do Not Resuscitate (DNR), was found unresponsive/ not breathing and CPR initiated. The facility failed to ensure the emergency crash cart was equipped with a back board, ambu bag and other essential equipment that would be needed to provide CPR on 2 of 2 emergency carts. The facility failed to ensure advance directive code status was available and accurate for 7 (Residents # 2, 3, 5, 6, 9, 10, and 11) and failed to ensure a physician ' s order was obtained in the presence of residents ' advanced directive for DNR for 2 (Resident #3 and 10) of 9 (Residents # 1 through 6 and 9 through 11) case mix residents with Advanced Directives. The failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death, for Resident #6 and was likely to affect 4 other case-mix residents (Residents #2, 4, 5 and 11) who had specific instructions for code status. The failed practices also had the likelihood to cause more than minimal harm for 14 residents who were DNRs according to the Administrator on [DATE] at 10:45 a.m. and 45 residents who were a Full Code Status according to a list provided by the Administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 2:08 p.m. The findings are: 1. Resident #6 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 6 (,[DATE] indicated severely impaired) on a Brief Interview for Mental Status. a. The Advance Directives (and) Medical Treatment Decisions form dated [DATE], signed by (Family Member # 1), documented, "... I have chosen to formulate and issue the following advance directives ... No Vent (Ventilator)/Respirator." b. The hospital Physician's Daily Progress Notes dated [DATE] documented, "... 4. Code Status - the staff has tried multiple times to reach the family listed as contact and has contacted the nursing home who apparently have trouble with family being out of contact. I have discussed a DNR status with the patient and he was able to tell me that he does not want to be put on machines or heroic measures if his heart stops. He does seem to understand his medical status and can answer questions appropriately, so per his request I will make him a DNR status ..." c. A physician order dated [DATE] documented, "DNR Do Not Resuscitate." d. The Care Plan reviewed on [DATE] documented, "Problem: DNR/Living Will; Comfort Care; No vent/resp (respirator)... Interventions: ... Keep resident comfortable." e. The [DATE] Physicians Orders sheet documented a physician order dated [DATE] for a DNR. The "Notes/Alerts" documented, "No Vent/No Respirator." f. The Nurse's Notes dated [DATE] at 5:15 a.m., written by Licensed Practical Nurse (LPN) # 1, documented, "Aide (Certified Nurses Assistant (CNA) # 2) called for nurse (LPN#1)to come to resident's room. Resident was unresponsive (with) (no) respirations noted. Checked (vital signs) and found (none) present. (CNA # 2) radioed for help from North Nurse (LPN # 2) and CPR Certified Aide (CNA # 1). (CNA # 1) began chest compression alternating with LPN (LPN # 2) while LPN (LPN 3) call for ambulance from (hospital). Informed (no) ambulance was available currently. Went to alternate compressions while LPN (LPN # 2) called for on call (Physician # 1). Continued to alternate compressions with (CNA # 1). (LPN # 2) returned to relieve LPN (LPN # 1) while she notified (Registered Nurse (RN) # 1), RN of events. (Physician # 1) arrived at 5:45 a.m. to examine resident. Pronounced death at 5:55 a.m. ..." The physician progress notes [REDACTED].# 1, documented, "... Called by (nursing home) at 5:34 a.m. to respond to a (patient) found in bed (without) pulse or (respiration). They reported (patient) to be a full code (and) started CPR. Ambulance was called however could not come due to being on another call. I obtained directions to this facility and arrived (at) (approximately) 5:50 a.m. Upon arrival to the (patient) room, chest compressions were being performed. ... (Nursing) reports there is a crash cart but they did compressions only (secondary) no one able to perform ACLS (Advanced Cardiac Life Support). (Patient was not bagged or assisted in his ventilation. ... Cause of death likely (respiratory) arrest (secondary) [MEDICAL CONDITION] ..." g. On [DATE] at 8:40 a.m., CNA # 2 was asked, "How do you know which resident's are DNRs?" CNA # 2 stated, "There used to be a dot on the door so we don't really know or a dot on the chart." CNA # 2 was asked, "What happened to (Resident # 6) on [DATE]?" CNA # 2 stated, "I went into get him up a little after 5 and he was not responsive. I called the nurse on the radio and I asked her to come to the room." CNA # 2 was asked, "When the nurse came to the room, what did she do?" CNA # 2 stated, "She checked the resident then went to check if (Resident # 6) was a code. We called the north nurse on the radio to come help. They ran down and they (CNA # 1 and LPN # 2) started CPR. (LPN # 1) said they needed to start CPR. (LPN # 1) was on the phone to get the ambulance." CNA # 2 was asked, "Who got the crash cart?" CNA # 2 stated, "I did." CNA # 2 was asked, "Was the back board on it?" CNA # 2 stated "No. " CNA # 2 was asked, "What were (LPN # 2 and CNA # 1) doing when you got to the room with the crash cart?" CNA # 2 stated, "Chest compressions." CNA # 2 was asked, "Did you see anyone doing breathing/ambu bag?" CNA # 2 stated, "No, I left and went on with my duties, there was nothing I could do after that." h. On [DATE] at 7:45 a.m. LPN # 1 was asked, "How do you know which residents are DNRs?" LPN # 1 stated, "Blue dots on resident name tags on doors, in chart." LPN # 1 was asked, "Where in the chart?" LPN # 1 stated, "In front on the face sheet under Advance Directives." LPN # 1 was asked, "Are you trained in CPR?" LPN # 1 stated, "Yes." LPN # 1 was asked, "How do you do CPR?" LPN # 1 stated, "That's a crazy question to answer. Make sure resident is not responsive, check for pulse and breathing, lift chin up, give 2 breaths, then start compressions - 30 compressions - check for pulse - 30 compressions - check for pulse again, then 2 more breaths." LPN # 1 was asked, "What was the code status for (Resident # 6)?" LPN # 1 stated, "He was not vent (ventilator) - code but no vent." LPN # 1 was asked, "What does that mean?" LPN # 1 stated, "We still do CPR but he was not to have a ventilator." LPN # 1 was asked to tell the surveyor about the code on [DATE]. LPN # 1 stated, "That was my first code ever ... At 5:15 a.m. (CNA # 2) radioed for me to come to room ... stat. I went to room, he was on his back, not breathing, no response. He had a blue dot on his door. I checked his chart. Chart said code but no vent. I sent (LPN # 2) and (CNA # 1) to start CPR while I called (hospital) ER room." LPN # 1 was asked, "Did you take the crash cart to the room?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Did you take the back/cardiac board?" LPN # 1 stated, "I don't remember." LPN # 1 was asked, "What happened next?" LPN # 1 stated, "ER said the ambulance was out and it would be awhile, so I called (RN # 1), RN Supervisor on call. She said she didn't know what to do, to call the physician. The hospital ER (emergency room ) called back saying it was going to be awhile on the ambulance. I went to the room and took (LPN # 2's) place and had her call the on call physician." LPN # 1 was asked, "When you took (LPN # 2's) place, what did you do?" LPN # 1 stated, "I started chest compressions." LPN # 1 was asked, "Who was providing breathing?" LPN # 1 stated, "I don't remember." LPN # 1 was asked, "Did you bag or ventilate (Resident # 6)?" LPN # 1 stated, "No." LPN # 1 was asked "Was there an ambu bag in the room?" LPN # 1 stated, "I don't remember one being there." LPN # 1 was asked, "The picture I have is 2 nurses and a CNA doing chest compressions and there is no ventilation/breathing support. Is that correct?" LPN # 1 stated, "That's the way it looks." LPN # 1 was asked, "Was there any reason you didn't do 30 compressions and 2 breaths as per the CPR procedure?" LPN # 1 stated, "Not that I know of." LPN # 1 was asked, "When doing chest compressions did (Resident # 6) have a back board/solid surface under him or was he going into the mattress?" LPN # 1 stated, "I believe it was into the mattress." LPN # 1 was asked, "Any in-services on CPR since (Resident # 6's) code?" LPN # 1 stated, "No." LPN # 1 had an American Heart Association Healthcare Provider card which documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED) Program. Issue Date: [DATE]. Recommended Renewal Date "[DATE]." i. On [DATE] at 8:20 a.m., LPN # 2 was asked, "How do you know which residents are DNRs?" LPN # 2 stated, "Blue dot on chart, look for DNR order in chart." LPN # 2 was asked, "Are you trained in CPR?" LPN # 2 stated, "Yes, certification is current." LPN # 2 was asked, "How do you do CPR?" LPN # 2 stated, "Check airway, listen, look for breathing, check for pulse, open airway, give 2 breaths. Start chest compressions, 15 compressions to 2 breaths after every round check to see if they are breathing." LPN # 2 was asked, "Were you the nurse on the north hall on [DATE]?" LPN # 2 stated, "Yes." LPN # 2 was asked, "How did you get involved in (Resident # 6's) code?" LPN # 2 stated, "I was called on walkie talkie and asked if I could come assist. I was passing meds, I put the med cart up and took off to south hall. The south nurse (LPN # 1) was checking to see if he was a code or not. (LPN # 1) told me as I was going past that he was a code, but no respirations." LPN # 2 was asked, "What does (Resident # 6's) physician order say?" LPN # 2 stated, "No vent/no respirator, I think she misunderstood that." LPN # 2 was asked, "You were told no respirations?" LPN # 2 stated, "Yes, at that point. She did come down a little while later and said she misread it and we started doing respirations." LPN # 2 was asked, "Who was doing respirations?" LPN # 2 stated, "I don't remember who all did them I did some of it." LPN # 2 was asked, "Did you use an ambu bag?" LPN # 2 stated, "Yes." LPN # 2 was asked, "Where did the ambu bag come from?" LPN # 2 stated, "Crash cart." LPN # 2 was asked to read the physician note of [DATE] regarding respirations. After review LPN # 2 stated, "I thought we'd done them (respirations)." LPN # 2 was asked, "Did you do respirations?" LPN # 2 stated, "Apparently not." LPN # 2 was asked, "Any reason why respirations were not done?" LPN # 2 stated, "No." LPN # 2 was asked, "Any back/cardiac board under (Resident # 6) during the code?" LPN # 2 stated, "No." LPN # 2 was asked, "Was there a back board on the crash cart?" LPN # 2 stated, "No." LPN # 2 was asked, "Any in-services on CPR since (Resident # 6) died ?" LPN # 2 stated, "No." LPN # 2 had an American Heart Association Healthcare Provider card whish documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED) Program. Issue Date: [DATE]. Recommended Renewal Date" ,[DATE]." j. On [DATE] at 7:02 a.m., CNA # 1 was asked, "How do you know which residents are DNRs?" CNA # 1 stated, "Our nurse tells us or look in care plan." CNA # 1 was asked, "What do you do if you find a resident without pulse/respirations/unresponsive?" CNA # 1 stated, "Go get a nurse - go fast, call on radio." CNA #1 was asked, "What does the nurse do?" CNA # 1 stated, "Go check chart for DNR and take whatever procedure needs to be taken after that." CNA # 1 was asked, "Are you trained in CPR?" CNA # 1 stated, "Yes, I'm CPR certified." CNA # 1 was asked, "How do you do CPR?" CNA # 1 stated, "Check if resident breathing, try to get resident to respond, tilt head to clear airway, 30 compressions to 2 breaths." CNA # 1 was asked, "Tell me about (Resident # 6's) CPR on [DATE], what happened?" CNA # 1 stated, "I was doing bed checks and (CNA # 2) asked me to come assist on the radio and so I went up there. The nurse (LPN# 2) was there and (CNA # 2) was in there. The nurse was doing chest compressions and (CNA # 2) was watching/standing by. When the nurses left the room or if they needed relief I would take over and did chest compressions." CNA #1 was asked, "Who did breathing/respirations?" CNA # 1 stated, "We only did chest compressions." CNA # 1 was asked, "Why no respirations?" CNA # 1 stated, "I don't know, they (LPN # 1 and 2) did everything." CNA # 1 was asked, "Were the nurses doing respirations/breathing?" CNA # 1 stated, " No." CNA # 1 was asked, "Was the crash cart brought to the room?" CNA # 1 stated, "I can't remember if it was there or not." CNA # 1 was asked, "Was there any back board under the resident?" CNA # 1 stated, "I can't remember, I don't think there was, seems like he was being pushed into the mattress with chest compressions." CNA # 1 was asked, "Any in-services/training on CPR since (Resident # 6's) code?" CNA # 1 stated, "No." CNA # 1 had an American Heart Association Healthcare Provider card which documented, "This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the American Heart Association for the BLS (Basic Life Saver) for Healthcare Providers (CPR and AED(Automated External Defibrillator)) Program. Issue Date: [DATE]. Recommended Renewal Date" ,[DATE]." k. The facility's policy titled "Resident Code Status and Code Procedures" documented, "If a resident is found without vital signs: 1. Check resident's Code Status/DNR status. *Code status will be indicated by a blue dot by the name on the door to their room, and on the spine of the chart. If a resident does not have a blue dot, then that resident is considered to be a full code status. 2. If a resident is a DNR, notify family, doctor, coroner, and Director of Nursing (DON). 3. If a resident is not a DNR, initiate chest compressions and have another staff member call 911 or the EMS (Emergency Medical Service) ... 4. Continue basic first aide of compressions to 2 breaths, until EMS arrives, or until someone relieves you." The facility's policy titled "Cardiopulmonary Resuscitation" documented, "1. CALL. Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally. Call 911 and return to the victim. In most locations the emergency dispatcher can assist you with CPR instructions. 2. PUMP. If the victim is still not breathing normally, coughing or moving, begin chest compressions. Push down the center of the chest 2 inches 30 times. Pump hard and fast at the rate of at least 100/minute, faster than once per second. 3. BLOW. Tilt the head back and left the chin. Pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths. Each breath should take 1 second. Continue with 30 pumps and 2 breaths until help arrives. ..." An article titled "Cardiopulmonary Resuscitation (CPR): First Aid" by Mayo Clinic at http://www.mayoclinic.com/health/first-aid-cpr/FA documented, "... Here's advice from the American Heart Association: ...If you're well trained and confident in your ability, begin with chest compression ... Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. ... Put the person on his or her back on a firm surface. ... If you're trained in CPR and you've preformed 30 chest compressions, open the person's airway ... With the airway open ... prepare to give 2 rescue breaths. Give the first rescue breath - [MEDICATION NAME] one second - and watch to see if the chest rises. If it does rise, give the second breath. ... Thirty chest compressions followed by two rescue breaths is considered one cycle. ..." l. Additional staff interviews regarding correct procedures for CPR: 1) On [DATE] at 2:27 p.m. LPN # 5 was asked, "Are you trained in CPR?" LPN # 5 stated, "Yes." LPN # 5 was asked, "How do you do CPR?" LPN # 5 stated, "Flat surface, check pulse, make sure mouth is clean, start compressions 15 to 1." LPN # 5 was asked, "15 to 1?" LPN # 5 stated, "15 (chest compressions) to 1 breath if not breathing." 2) On [DATE] at 4:35 p.m., LPN # 6 was asked, "Are you trained in CPR?" LPN # 6 stated, "No current certification." LPN # 6 was asked, "How do you do CPR?" LPN #6 stated, "Resident flat on hard surface, tilt head, check pulse, chest compressions, if ambu bag, if not then breathe in mouth 5 to 2 - 5 chest compressions to 2 breaths." 3) On [DATE] at 9:50 a.m., LPN # 7 was asked, "Are you trained in CPR?" LPN # 7 stated, "Yes, trained, certification has expired." LPN # 7 was asked, "How do you do CPR?" LPN # 7 stated, "Check for respirations and pulse, make sure the resident is on a firm surface." LPN # 7 was asked, "Is the bed a firm surface?" LPN # 7 stated, "No, use a board under them or move the resident to the floor. Then begin compressions and breaths-5 compressions to 2 breaths." m. On [DATE] at 2:18 p.m., the emergency/crash cart at the exit door, approximately 15 feet from the north nurses station, had an ambu bag, suction machine and tubing, and gowns. There was no cardiac/back board present on or next to the crash cart. 1) On [DATE] at 2:20 p.m., LPN # 3 was asked, "Does the north hall crash cart have a cardiac/back board?" LPN # 3 stated, "I've never seen one." 2) On [DATE] at 2:25 p.m., LPN # 4 was asked "Is there a cardiac/back board on the north hall crash cart?" LPN # 4 looked at the cart then stated, "No." 3) On [DATE] at 9:20 a.m., the Director of Nurses (DON) was asked to observe the north hall crash cart. The crash cart contained disposable gowns, a suction machine with canister and suction tubing, an ambu bag with mask, oxygen mask, and updraft machine. There was no back/cardiac board. The DON was asked, "Where is the back board?" The DON stated, "I'm not sure." The DON was asked, "Should one be on here?" The DON stated, "I'm not sure about that." The DON was asked, "If staff does CPR and there is no back board under the resident, is that going to be effective?" The DON stated, "No, they would have to move the resident to the floor." n. On [DATE] at 2:20 p.m., the south hall crash cart contained a CPR micro shield, a suction machine with canister, four suction catheter kits, one Yonkers, an ET (endotracheal) bulb, and a bagged ambu bag with mask. There was a back board on the floor next to the cart but was not connected/attached to the cart. An oxygen tank was in the closet with the crash cart but was not connected/attached to the cart. On [DATE] at 9:22 a.m., the DON was asked to observe the south hall crash cart. The crash cart contained a suction machine with canister, extension and suction tubing, gloves, an ambu bag with mask, suction supplies and oxygen regulator. There was no back board on the crash cart. The DON was asked, "Where is the back board?" The DON stated, "On the floor next to the crash cart" The DON was asked, "Do you monitor the crash cart's contents/ensure they are stocked?" There was no response from the DON. 1) On [DATE] at 2:40 p.m., LPN # 7 was asked, "Who is responsible for checking the crash cart?" LPN # 7 stated, "I'm not sure. I know as we use it, we are to restock it and make sure everything is there." LPN # 7 was asked, "Is there a list of what's supposed to be on the crash cart?" LPN # 7 stated, "No." 2) On [DATE] at 2:50 p.m., LPN # 5 was asked, "Who is responsible for checking the crash cart?" LPN # 5 stated, "Who ever used it last replaces what they used." LPN # 5 was asked, "Is there a list of what's supposed to be on the crash cart?" LPN # 5 stated, "No I've never seen one." o. On [DATE] at 9:30 a.m., the Director of Nursing (DON) was asked, "How does your staff know which residents are a DNR?" The DON stated, "We have blue dots on charts." The DON was asked, "Did you know your staff is not sure of how to identify if a resident is a DNR?" There was no response from the DON. This surveyor reviewed the notes/alert section of the Physician Orders for [DATE] for (Resident # 6) with the DON. Under notes/alerts "No vent/No respirator" was documented. This surveyor reviewed the events reported by the CNAs and LPNs for the code on Resident # 6 on [DATE]. The DON was asked, "Were you aware of the physician progress notes [REDACTED]. Our conclusion was a tube (endotracheal tube) was not dropped to start ventilations and with new CPR you only have to do chest compressions." The DON was asked, "Did you call the physician to clarify what she meant?" The DON stated, "No." The DON was asked, "Did you ask staff if they did respirations/ventilations?" The DON stated, "No." The DON was asked, "Did you know staff did not use a back board and no respirations were given?" The DON stated, "I didn't know they had not used a back board. I'm not clear if they did or didn't do respirations." The DON was asked, "Did you investigate what happened with (Resident # 6) and why CPR wasn't done properly?" The DON stated, "I didn't, (Administrator) was looking at this because of the abuse allegation made because of his bruises." The DON was asked, "Any in-services on identification of DNR status since (Resident # 6) died ?" The DON stated, "No, I'm not aware of any." The DON was asked, "Any in-services on CPR since (Resident # 6) died ?" The DON stated, "No." The DON was asked, "Did you know the north hall crash cart had no back board?" The DON stated, "Not until today." The DON was asked, "Did you know the back board was not on the south hall crash cart - that it's kept on the floor?" The DON stated, "No but who ever got the cart should have known to get the back board." The DON was asked, "Even a CNA who is not trained in CPR?" The DON stated, "Yes." p. On [DATE] at 10:30 a.m., the Administrator was asked, "How does you Advance Directive process work?" The Administrator stated, "When a resident is admitted they (nurse and resident/family) talk about advance directive - whether they want to choose one or not choose one. That goes to (Assistant Director of Nursing (ADON)) who puts it in the computer system. She puts it under alerts/notes. If it's an actual order it shows up under the physician orders. (ADON) gets a copy, the copy is supposed to go in their chart. If a DNR, she put a blue dot on the spine of the chart and by the resident's name outside of the door." The Administrator was asked, "If staff are looking under notes/alerts what should be there for (Resident # 6)?" The Administrator stated, "DNR." The Administrator was asked, "Were you aware that staff did a code on (Resident # 6) who had a physician order for [REDACTED]." The Administrator was asked, "With your system, can you understand your nurses, confusion over code status?" The Administrator stated, "Yes." The Administrator was asked, "Did you review the physician note dated [DATE]?" The Administrator stated, "Yes." The Administrator was asked, "When did you do that?" The Administrator stated, "Last week some time." The Administrator was asked, "Did you understand the staff did compressions only?" The Administrator stated, "Yes, I had a discussion with (DON). We discussed if they (staff) were trying to go by new guidelines or not. That's when we started interviewing everyone and got statements." The Administrator was asked, "Did you do any in-services or retraining of staff on Advance Directives or CPR?" The Administrator stated, "We haven't yet." 2. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on a Brief Interview for Mental Status. a. A Living Will dated [DATE], received from the Administrator on [DATE] at 1:50 p.m. did not specify Advance Directive/Code Status. b. As of [DATE] at 1:50 p.m., the [DATE] Physicians Orders sheet documented no orders for a DNR. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Living Will." c. On [DATE] at 1:55 p.m., the Assistant Director of Nursing (ADON) was asked, "What does 'Living Will' under notes/alerts mean to staff as far as CPR?" The ADON did not respond. On [DATE] at 2:25 p.m., LPN # 4, the evening shift (3:00 p.m. to 11:00 p.m.) LPN for the north hall, was asked, "What does 'Living Will' mean under notes/alerts on the MAR?" LPN # 4 stated, "DNR." 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status. . a. An Advance Directive dated [DATE] received from the ADON on [DATE] at 1:30 p.m. documented, "I DO NOT want any of the above, DO NOT RESUSCITATE." b. The Care Plan dated [DATE] did not address the resident's DNR status. c. The [DATE] Physicians Orders sheet documented no physician order for [REDACTED]. d. On [DATE] at 1:55 p.m., the ADON was asked, "Why wasn't (Resident # 3's) Advance Directive in the medical record?" The ADON stated, "It's my fault for not finding it and putting it there." The ADON was asked, "What is resident's code status per notes/alerts?" The ADON stated, "Full Code." 4. Resident # 2 was re-admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status. a. The Care Plan dated [DATE] did not address the resident's DNR status. On [DATE] at 1:55 p.m. the ADON was asked, "Where is (Resident # 2's) Advance Directive?" After looking through the residents clinical record the ADON stated, "It's not here." 5. On [DATE] at 1:55 p.m. the Assistant Director of Nursing (ADON) was asked, "What is the process for Advance Directive/determining wishes for code status?" The ADON stated, "The resident/family goes over Advance Directive with whoever admits the resident and a copy is supposed to be put in the chart and a blue dot goes on the chart and name tag on door. It's supposed to be on the POS (Physician Order Sheet) and MAR (Medication Administration Record)." The ADON was asked, "Who is responsible for getting Advance Directives in the chart, blue dots on doors, charts, and on POS and MAR?" The ADON stated, "I am." The facility's policy titled "Do Not Resuscitate" documented, "Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions when there is a Do Not Resuscitate Order in effect. ... 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate Order (DNRO) Form must be completed and signed by the attending physician or resident (or resident's legal surrogate ...) and placed in the front of the resident's medical record. ... 3. Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT (Emergency Medical Technician) personnel transporting the resident to the hospital. ... 5. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. ... 7. Any resident with DNR status will have a blue dot on the door name plate and on their chart spine." 6. Additional staff interviews regarding identification of code status for residents: 1) On [DATE] at 2:20 p.m., LPN # 3 was asked, "How do you know if a resident is a full code?" LPN # 3 stated, "I look notes/alerts on the MAR." 2) On [DATE] at 2:25 p.m., LPN # 4, the evening shift LPN for the north hall, was asked, "How do you know if a resident is a DNR or full code?" LPN # 4 stated, "Look under notes/alerts on MAR." 3) On [DATE] at 6:48 a.m., CNA # 3 was asked, "How do you know which residents are DNRs?" CNA # 3 stated, "Blue dot on chart, in ADL (Activity of Daily Living) books under notes/alerts." 4) On [DATE] at 7:32 a.m., CNA # 4 was asked, "How do you know which residents are DNRs?" CNA # 4 stated, "We ask nurse - it's in the charts - nurse tells us when code status is changed." 5) On [DATE] at 3:40 p.m., CNA # 5 was asked, "How do you know which residents are DNRs?" CNA # 5 stated, "Chart - outside chart." 6) On [DATE] at 3:49 p.m., CNA # 6 was asked, "How do you know which residents are DNRs?" CNA # 6 stated, "On chart and bottom of ADL (Activity of Daily Living) sheet. Outside of chart, sticker says DNR." 7) On [DATE] at 4:04 p.m., CNA # 7 was asked, " How do you know which residents are DNRs?" CNA # 7 stated, "ADL book, I'm not sure." 8) On [DATE] at 4:21 p.m., CNA # 8 was asked, "How do you know which residents are DNRs?" CNA # 8 stated, "ADL books." 9) On [DATE] at 4:35 p.m., LPN # 6 was asked, "How do you know which residents are DNRs?" LPN # 6 stated, "On chart - look in chart should be on bottom of med orders." 10) On [DATE] at 9:12 a.m., CNA #9 was asked, "How do you know which residents are DNRs?" CNA # 9 stated, "Usually on chart - blue dots and right in front of chart." 11) On [DATE] at 9:22 a.m., CNA #10 was asked, "How do you know which residents are DNRs?" CNA # 10 stated, "Stickers - dots on chart, in ADL book." 12) On [DATE] at 9:40 a.m., CNA #11 was asked, "How do you know which residents are DNRs?" CNA # 11 stated, "In ADL book, inside chart but I can't look there." 7. On [DATE] at 10:45 a.m., the Administrator presented a list of 14 residents that were identified as having DNRs. An audit was done of the facility's identification system with the following findings: a. Resident # 9 was identified as a DNR on the listing provided by the Administrator and had no blue dot on the name tag on the resident's door. There was a blue dot on the spine of the chart. b. Resident #10 was not identified as a DNR on the listing provided by the Administrator. There was a blue dot on the name tag on the resident's door and a blue dot on the spine of the chart. The resident's chart contained a Living Will that did not specify code/DNR directives. There was no physician order for [REDACTED].