Every finding on record at Lakeside Center for Rehabilitation and Healing

Based on observations, interviews, record review, and a review of facility policies and procedures, the facility failed to ensure that the resident environment was as free of accident hazards as was possible for one (Resident #47) of 31 sampled residents. The findings include: On 09/29/2025 at 1:11 PM, an aerosol can of Lysol disinfectant spray was observed located on Resident #47's bedside table. (Photographic evidence obtained) On 09/30/2025 at 11:23 AM, the resident was observed sitting up in a chair in his room with his spouse and daughter visiting. The resident's daughter was asked if she was aware of the can of Lysol that was now located on the resident's sink and where it came from. She stated, It belongs to him; we leave it here to spray his room at times. She was asked if the staff was aware of the Lysol, and whether or not any family teaching had been provided about environmental safety and storing aerosol sprays and other items that should not be left in a resident's room. She stated, No, they've never said anything about it. On 10/01/2025 at 10:35 AM, an aerosol can of Lysol disinfectant spray was observed located on the resident's sink. (Photographic evidence obtained) A review of Resident #47's record revealed an admission date of 12/12/2023 with diagnoses including hypertension, other specified disorders of the brain, occlusion and stenosis of the right carotid artery, dysphagia following cerebral infarction, Parkinson's disease, and a need for assistance with personal care. A review of the resident's Quarterly MDS (minimum data set) assessment, dated 9/19/2025, revealed a BIMS (brief interview for mental status) score of 02 out of 15 possible points, indicating severe cognitive impairment. The resident required set-up or clean-up assistance for eating, he was dependent on staff assistance for toileting, he was independent with bed mobility, and he required partial/moderate assistance with transfers. On 10/01/2025 at 12:54 PM, a review of the resident's active Care Plan revealed the following Focus Areas: The resident has an ADL (Activities of Daily Living) Self-Care Performance Deficit r/t (related to) a diagnosis of Parkinsonism. Date Initiated: 12/16/2023, Revision on: 12/16/2023. [Resident #47] has a Behavior Problem. He likes to put himself on the floor and crawl around. He resists care, refuses medication and has agitation. Date Initiated: 09/09/2024, Revision on: 06/30/2025. The resident has Impaired Cognitive Function/Dementia or Impaired Thought Processes r/t a diagnosis of dementia. Date Initiated: 12/16/2023, Revision on: 12/16/2023. A review of the resident's active physician's orders revealed: Ativan (anxiolytic) Injection Solution 2 milligrams/milliliter, Inject 0.5 milliliters intramuscularly every 12 hours as needed for severe anxiety for 14 Days (9/20/25-10/4/25) Sertraline (antidepressant) Oral Tablet 50 mg (milligrams), 1 tablet by mouth in the morning for depression 9/16/25 Clonazepam (long-acting tranquilizer) Oral Tablet Disintegrating 0.25 mg,1 tablet by mouth three times a day for anxiety 9/9/2025, and Buspirone (anxiolytic) Oral Tablet 30 mg, give 1 tablet by mouth two times a day for anxiety 5/28/25. On 10/02/2025 at 1:03 PM, an interview was conducted with Certified Nursing Assistant (CNA) B, who was asked how often she made resident rounds during her shift. She stated, every two hours. She was asked how she ensured the safety of the resident's environment. She replied, I make the bed, hang up clothes, and empty the trash. She was asked if the facility had a policy for the use of aerosol spray cans in resident care areas. She stated, They can't really have spray cans in their rooms. She was asked if she had received any training on restrictions of aerosol spray cans in the facility. She stated, yes. She was asked what she had been instructed to do if she observed aerosol spray cans in resident care areas. She replied, We take them out of their rooms and bring them to the nurses' station, and they discard them. On 10/02/2025 at 1:31 PM, an interview was conducted with Registered Nurse (RN) A, who was asked how often she conducted rounds on the residents. She replied, every two hours. She was asked how she maintained the residents' room environment. She stated, I clean up clutter, throw away things they don't need, or pick up paper off the floor. When she was asked if the facility had a policy for aerosol spray cans in resident care areas, she replied, yes. She was asked what she'd been instructed to do if she observed aerosol spray cans in resident care areas. She stated, We know to provide education to the resident and/or family that we can't allow those items because they are a hazard, and we remove them. On 10/02/2025 at 3:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) C, who confirmed that she was the nurse assigned to Resident #47 during the evening shift on 10/1/25 and 10/2/25. She was asked how often she made rounds on her residents. She replied, I try to do it every two hours, but sometimes it's according to what's going on with the patients. Sometimes a resident may need more care, and I may not be able to keep my rounds to every two hours. She was asked how she maintained the residents' room environment. She stated, I might clean the bedside table and get things prepared for the meal. I also make sure fall interventions and call lights are in place. She was asked if the facility had a policy for aerosol spray cans in resident care areas. She stated, Yes, we have a book that outlines what they should and should not have. She was asked what she had been instructed to do if she observed aerosol spray cans in resident care areas. She stated she would first provide education and the facility policy to show them that the item had to be checked out by maintenance to make sure it was safe and to determine whether they had an MSDS (material safety data sheet) allowing them to have it. On 10/02/2025 at 3:43 PM, LPN C was accompanied to room [ROOM NUMBER] (Resident #47's room). The nurse acknowledged the aerosol can of Lysol disinfectant that was still located on the resident's sink. She was asked if she identified the spray while she was working yesterday. She apologized for not observing the spray yesterday and stated, We try to catch things like this. She removed the can of Lysol from the room. On 10/02/2025 at 4:24 PM, an interview was conducted with the Director of Nursing (DON), who was asked if the staff received any training or education about resident safety as it pertained to aerosol spray cans in resident care areas. She stated, Yes they have, and the families have been told many times not to bring in cans of spray. She did not provide evidence of resident/family teaching about the prohibition of aerosol spray cans in resident care areas. She was asked what the staff had been trained to do if they observe aerosol spray cans in resident care areas. She replied, They know to remove it and educate the resident or family on why it's not safe to have it. A review of the facility's OSHA-Safety Data Sheet (SDS - 3 pages), revealed: A current SDS will be obtained and kept on file for each hazardous chemical stored or used on our premises. A review of the facility's policy on Environmental Services - Safe Environment (3 pages), revealed: In accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her own personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility that is frequented by residents and visitors, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.

Based on observations, interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure that residents who needed oxygen therapy received oxygen therapy as ordered for one (Resident #31) of 13 residents receiving oxygen therapy. The findings include: On 09/30/2025 at 11:19 AM, Resident #31 was observed lying in bed wearing a nasal cannula. She reported that she was doing well and had no concerns. She further stated she received 2 liters of oxygen, and the facility's food was great. The oxygen concentrator beside the resident's bed was out of her reach and was set with an oxygen flow rate of 2 liters per minute (2L/min). (Photographic evidence obtained) A review of Resident #31's active oxygen orders revealed: Oxygen: Nasal cannula ear cushions/padding every shift for pressure reduction (3/26/2025) Oxygen at 3 L/min continuous inhalation via nasal cannula every shift (3/26/2025) Oxygen saturation every shift (3/26/2025) Head of bed elevated per resident's request to prevent shortness of breath while lying flat every shift (3/26/2025) Oxygen tubing, cannula/mask change weekly and as needed one time a day every Saturday (8/2/2025). Other orders included: CPAP 8 cm H20 with 2L oxygen to be worn at bedtime for CPAP (3/27/2025) CPAP 12 cm H20 with sleep and as needed, may adjust settings as needed for compliance every shift for sleep apnea , apply CPAP every night with sleep and as needed naps (7/4/2025) Resident will have respiratory rate, lung sounds and oxygen saturation evaluation. Lung Sounds: C=Clear D=Diminished RA-Rales RH=Ronchi A=Absent Ask resident if experiencing nausea every shift notify DON (Director of Nursing) for temperature > 99.2 (3/25/2025). Further review of Resident #31's medical record revealed an admission date of 6/12/2024 with an initial admission date on 4/19/2018. The resident's primary diagnoses included acute and chronic respiratory failure with hypoxia. A review of the resident's End of PPS (Prospective Payment System) Part A Stay MDS (Minimum Data Set) assessment dated [DATE] revealed oxygen therapy, continuous, noninvasive mechanical ventilator, and CPAP. Resident #31 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. The resident required partial/moderate assistance for eating, and toilet transfers were not attempted due to medical condition or safety concerns. A review of the active Care Plan focus and goals revealed: The resident has a diagnosis of Asthma/ Chronic Obstructive Pulmonary Disease (Date Initiated: 06/19/2025) and oxygen therapy (Date Initiated: 07/10/2025 with Revision on: 07/10/2025). Interventions included providing oxygen per MD (physician) order. Monitor oxygen saturation as per MD order Date Initiated: 06/19/2025 with Revision on: 06/19/2025); and Oxygen Settings: Oxygen at 3 L/min continuous inhalation via nasal cannula per MD orders (Date Initiated: 07/10/2025 with Revision on: 07/10/2025). (Copy obtained) A review of the resident's September and October 2025 Medication Administration Record (MAR) revealed that nursing was signing off as having administered oxygen at 3 L/Min continuous inhalation via nasal cannula every shift. (Copy obtained) On 10/2/2025 at 10:28 AM, Resident #31 was observed lying in bed awake, wearing her nasal cannula when Licensed Practical Nurse (LPN) E verified that the oxygen flow rate on the resident's oxygen concentrator that was located next to the head of the resident's bed and out of her reach was set at 2 L/min. LPN E further verified the resident's oxygen order in the electronic medical record, stating the resident had two orders: continuous and at bedtime. The certified nursing assistants (CNAs), when completing vital signs, and the nurses provided ongoing monitoring of residents' oxygen therapy. Nurses ensured residents receiving oxygen therapy received oxygen at the correct flow rate as per the physicians' orders. Nurses on the night shift were responsible for changing residents' oxygen tubing. Correct oxygen settings were identified during follow ups and by reviewing the physicians' orders. Correct flow rate settings were communicated from one staff person to another during walking rounds at change of shift. When LPN E was asked if the resident changed her own oxygen flow rate, the nurse replied, no. When asked if the resident ever refused oxygen therapy, LPN E replied, no. On 10/2/2025 at 11:53 AM, the Director of Nursing confirmed that correct oxygen flow rate settings were identified by reviewing the physicians' orders. She stated nursing could adjust a resident's oxygen flow rate as necessary if the resident was in distress. Then the nurse would notify the physician of the concern and flow rate adjustment made and to request a new order. A review of the facility's policy and procedure titled Nursing - Oxygen Administration (undated), revealed: Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure . 11. Adjust the delivery device so that it is comfortable to the residents and the proper flow of oxygen is being administered. (Copy obtained)

Based on record review and interviews, the facility failed to ensure the Director of Nursing (DON) did not serve in the position of a charge nurse when the facility's census was greater than 60. Review of the facility staffing schedule dated 8/14/25 revealed that the DON was scheduled to work 7:00 pm - 7:00 am on the 500/600 hall cart. The census was noted as 116. During an interview on 8/14/25 at 11:55 am, the certified nursing assistant (CNA)/staffing coordinator, stated she used the facility census to plan for the staffing. She confirmed that the DON was scheduled to work tonight (8/14/25). She explained that the facility had a nurse shortage therefore the DON helped out on open slots. When asked how often the DON worked on the floor, she stated that she had to review the schedule.On 8/14/25 at 2:25 pm, the DON confirmed that she had been working on the floor when there is a need. She stated that the night shift had been the issue most of the time. She explained that she had worked at least 2-3 times a month. In an interview with the Administrator on 8/14/25 at 3:15 pm, he confirmed that the DON had worked the following dates: 6/9/25 (census 114), 6/10/25 (census 114), and 6/12/25 (census 112). (Copies obtained)

Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports, and interviews with staff, the facility failed to act in accordance with the resident's Advance Directives in accordance with his Full Code status (the desire to be resuscitated in the event his heart or breathing stopped) after finding him unresponsive with no respirations. This affected one (Resident #1) of four residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status deprived him of potentially lifesaving measures and likely contributed to his death. Immediate Jeopardy at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 5:20 a.m., the Immediate Jeopardy began. On [DATE] at 4:30 p.m., the Interim Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference F678 A closed electronic record review conducted for Resident #1 found he was admitted from the hospital on [DATE]. An AHCA form ,d+[DATE] (a Medicaid eligibility determination form completed by hospitals upon patient discharge to a nursing home), dated [DATE], revealed that Resident #1 had no Advanced Directives and no Do Not Resuscitate Order (DNRO) upon discharge. His diagnoses included fracture of the right shoulder and pelvis following a motor vehicle accident, hypertension (high blood pressure) and anxiety. Resident #1 had an Admission Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], revealing an admission from an acute-care hospital. He had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicating intact cognition. Active discharge planning was occurring for him to return to the community. A Death in Facility MDS assessment, dated [DATE], revealed that Resident #1 was discharged from the facility on [DATE]. His discharge status was deceased . The baseline care plan, dated [DATE], indicated Resident #1 had a physician's order for Cardio-Pulmonary Resuscitation (CPR). Further record review confirmed a physician's order for FULL CODE dated [DATE]. (Photographic evidence obtained) The Physician's Assistant - Certified (PA-C) saw Resident #1 for an initial visit on [DATE] and noted he was doing well. He was seen again on [DATE] and was last seen on [DATE] for follow-up for anxiety and discharge planning. The PA-C noted Resident #1 was feeling okay but reported anxiety. Resident #1 was noted as wanting to go home, and Social Services (SS) was working on his discharge. An electronic Progress Note authored by the Activities Aide on [DATE] noted Resident #1 was alert and oriented with the ability to make his needs known. Resident #1 is FULL CODE. (Photographic evidence obtained) A Social Services (SS) Progress Note, dated [DATE], indicated Resident #1 was consulted about his discharge plans and found he intended to return home. Resident #1 stated he could take care of himself at home. (Photographic evidence obtained) An electronic progress note authored by Licensed Practical Nurse (LPN) A on [DATE] at 6:28 AM, revealed that at approximately 5:20 AM, Certified Nursing Assistant (CNA) B came to another resident's room to report Resident #1 appeared to be having a seizure. CNA B said she had already reported this to Registered Nurse (RN) C. While LPN A was in the other resident's room, RN C went to that room to ask which resident was having the seizure. LPN A ran to Resident #1's room and observed the resident pale/yellow in color. When she called his name and touched his hand, he was unresponsive. LPN A did a sternal rub and Resident #1 began to gasp for air. She went to get oxygen while CNA B continued to keep the resident responding. A non-rebreather mask (a device that helps provide oxygen in an emergency) was used for oxygen delivery. RN C called 911 and LPN A and CNA B attempted to keep the resident responding. Resident #1 would only gasp one breath at a time periodically and was pursed-lip breathing. At approximately 5:30 AM, the resident no longer gasped for air and had no pulse. The ambulance arrived shortly thereafter and pronounced his death at 5:41 AM. There was no indication in the note that Resident #1's code status was checked or that chest compressions and/or other life-saving techniques were initiated when the resident stopped breathing. (Photographic evidence obtained) The Discharge Summary, dated [DATE], noted Resident #1's Advanced Directives were marked Other Directive, Full Code. (Photographic evidence obtained) A review of the facility's Emergency Care (CPR) Policy and Procedure (undated) revealed: Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop Advanced Directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics, decision-making policies and procedures, and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's Advanced Directives. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's Advance Directives or DNR order. In the absence of a DNR order or for those residents who do not have a valid DNR order, CPR must begin. Procedure: 1. At the time of admission, the facility will request copies of the resident's completed Advance Directives if any . 2. The resident/legal representative will be made aware that the resident has the right not to have CPR performed in the event of cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative . 3. A DNR or full code order should be entered and signed by the physician in [the electronic medical record system] and code status displayed on the resident's PCC header below their photo . 4. Code status will be noted on the monthly POS (physician's order sheet) and verified as accurate as part of the monthly POS review. 5. Should a resident experience cardiac emergency, staff will refer to the presence of a yellow form signed by the resident and physician to determine if CPR should be performed. 6. Advance Directives will be reviewed at least quarterly with the resident or legal representative by Social Services staff . 7. Any changes in DNR status will be communicated to care-giving staff and noted in the medical record immediately upon MD approval. 8. Staff will be educated regarding the Emergency Care (CPR) policy during orientation and at least annually thereafter. (Photographic evidence obtained) Further review of the facility records revealed that LPN A's written statement (undated), revealed that on [DATE] at 5:20 AM, the CNA informed her that Resident #1 may be having a seizure. The CNA stated she had informed the other nurse who was not far from Resident #1's room. When LPN A got to Resident #1's room, he was unresponsive to touch and his name. He gasped upon application of a sternal rub and oxygen was applied on high with a non-rebreather mask. The other nurse stayed at the nursing station and called 911 until EMS (Emergency Medical Services) arrived. Per EMS, 0541 (5:41 AM) was the time of death. (Photographic evidence obtained) An undated, written statement made by RN C, revealed that after being notified by the CNA and entering Resident #1's room, he was breathing irregularly. RN C tried to vigorously arouse him and ran to call 911. She returned to the resident's room where his nurse and CNA (LPN A and CNA B) were, and was notified that Resident #1 had expired. (Photographic evidence obtained) An interview was conducted with the Regional Director of Clinical Services (RDCS) on [DATE] at 3:11 PM. She explained that Resident #1 had been admitted on [DATE] for rehabilitation following a motor vehicle crash. He had multiple fractures. On [DATE] at around 5:20 AM, CNA B reported that Resident #1 began shaking during routine personal care. LPN A and RN C responded and found Resident #1 breathing, but otherwise unresponsive to a sternal rub. When Resident #1 ceased to breathe, no CPR was initiated, and he was pronounced deceased by paramedics at 5:41 AM. Resident #1's code status was Full Code. When LPN A was interviewed, she did not know why she did not start CPR. In a statement provided by RN C, she reported that Resident #1 presented with irregular breathing. She called 911 and LPN A was sent to the resident's room. 911 stated EMS was dispatched immediately. When RN C returned to the room, LPN A notified her that Resident #1 was no longer breathing and had expired. The RDCS confirmed that Resident #1's code status was not checked at any time during the event. In response to the event, all employed nurses' CPR certifications were checked and verified. Anyone who did not have a current, valid certificatin was not permitted to work until they did. A required training notification was sent to all staff on [DATE] and training began at 8:30 AM that same morning. Both LPN A and RN C were trained, but then suspended pending the outcome of the investigation, which started immediately. Code Blue drills were initiated daily on each shift. Training in CPR, Abuse and Neglect, and Code Blue drills was completed by [DATE] for all nurses but one, who would receive the training prior to returning to work. Agency nurses had to complete the education, and new staff would be provided this education during orientation. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted [DATE] to review the facility's response and plan of correction and a Performance Improvement Plan (PIP) was developed. The committee reviewed the Emergency Procedures policy and procedure, as well as new hire orientation and annual training. Residents who expired in the facility in the last 30 days were reviewed for code status and Advance Directives with no concerns identified. CNA B was interviewed via telephone on [DATE] at 10:30 AM. She explained that when she went to provide care to Resident #1 the morning of the event, he had a seizure. She ran, reported this to RN C, then went to get LPN A. When she and RN C went to Resident #1's room, he was mouth breathing. RN C asked, Where is LPN A? This is her patient! LPN A arrived and did sternal rubs as Resident #1 began mouth breathing less frequently. LPN A ran to get oxygen, instructed RN C to call 911, and told CNA B to keep doing sternal rubs and shaking/tapping Resident #1's shoulder. After initially gasping for air rapidly, Resident #1's breaths slowed to about one gasp every 10 seconds. LPN A asked, Where is RN A, she should be doing CPR. LPN A continued to shake the resident but then said, I can't get any readings on him. He is gone. She took the oxygen off and left the room. Maybe a minute later, the paramedics arrived and said he was dead. She did not know why LPN A did not do CPR since the process is that the nurse will call the code and start CPR. The code status is supposed to be checked immediately when finding a resident unresponsive. CNA B was trained in CPR at that time and the code status was in the resident's chart. She thought LPN A knew Resident #1's code status because she had him all night. She has since received all the training in abuse and neglect, Emergency Procedures and CPR and has participated in two Code Blue drills, which were being conducted often. On [DATE] at 11:35 AM, RN C was interviewed and explained that she was not assigned to Resident #1 the morning of the event. Toward the end of the shift, as she was finishing up morning medications (she did not recall the time), the assigned CNA (CNA B) approached her and said Resident #1 was not doing well. She went to Resident #1's room while CNA B went to get Resident #1's assigned nurse, LPN A. Resident #1 had a pulse but his breathing was labored. She walked out of the room to call rescue and as she was going out, LPN A and CNA B walked in. After calling 911, she was headed back to the resident's room but was called by a staff member in the other unit, and was told rescue was at the door and did not know where to go. RN C walked to the entrance to direct the rescue team then walked with rescue to the resident room. LPN A reported at that time that Resident #1 had stopped breathing. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the survey team as follows: A Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attaining/maintaining regulatory compliance. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director on [DATE]. Action steps taken included 1) Unit Managers verified the code status for each resident to ensure the paper and electronic medical record (EMRs) matched. A new binder was created to include residents who had elected a Do Not Resuscitate (DNR) order for easy access. The DNR form would be filed under the Documents tab in the EMR and in the hard (paper) chart, 2) Mock code blue drills were initiated on [DATE] at approximately 8:15 AM and will continue daily for one week, then move to weekly for 30 days, then monthly to ensure staff are trained to perform in the event of an actual emergency, 3) RN C and LPN A were suspended pending an investigation, 4) Staff in-service trainings were initiated on [DATE] related to emergency procedures and the facility policy. The in-services will be mandatory for all clinical staff and will be ongoing until all staff have been trained, 5) Employee files were checked for CPR Certifications on [DATE] and a documentation roster will be maintained. All facility nurses files were audited, 6) The Staff Development Coordinator and Human Resources Director reviewed new employee Orientation Checklist/Annual Checklists for clinical staff were reviewed, 7) All residents who expired in the facility the last three months were evaluated to ascertain and identify the cause of death and opportunities for improvement. A Root Cause Analysis was conducted and found the facility failed to call CODE BLUE or start CPR resulting in death. The Nurse did not initiate CPR per the resident's wishes and per the facility policy and procedure. The code status was present in the medical record. In-Service training on Advanced Directives, Emergency Procedures, Abuse/Neglect and Code Blue Drills commenced [DATE] at 8:30 AM and as of [DATE], twenty-four (24) out of twenty-five (25) facility nurses had been trained. The remaining nurse would not be permitted to return to work until she received the training. Mock Code Blue drills commenced [DATE] and were conducted daily on each shift through [DATE] and were now being conducted daily. Nurses' personnel files were audited on [DATE] with 100% of employed nurses CPR certification verified. LPN A and RN C were terminated on [DATE] as a result of the investigation. The Board of Nursing and law enforcement were notified. .

Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports and staff interviews, the facility failed to provide CPR prior to the arrival of Emergency Medical Services (EMS) personnel and in accordance with the resident's physician's order and Advance Directives when an unresponsive resident stopped breathing. This affected one (Resident #1) of four residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status (the desire to be resuscitated in the event that his heart or breathing stopped), deprived him of potentially lifesaving measures and likely contributed to his death. Immediate Jeopardy at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 5:20 a.m., the Immediate Jeopardy began. On [DATE] at 4:30 p.m., the Interim Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference F578 A closed electronic record review conducted for Resident #1, found he was admitted to the facility from the hospital on [DATE] with diagnoses including fracture of the right shoulder and pelvis following a motor vehicle accident. An AHCA form ,d+[DATE] (a Medicaid eligibility determination form completed by hospitals upon patient discharge to a nursing home), dated [DATE], revealed that Resident #1 had no Advanced Directives and no Do Not Resuscitate Order (DNRO) upon his discharge. Resident #1 had a physician's order dated [DATE] for FULL CODE. (Photographic evidence obtained) The Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed that Resident #1 was admitted from the hospital and had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicating intact cognition. Active discharge planning was occurring for Resident #1 to return to the community. The Death in Facility MDS assessment, dated [DATE], revealed Resident #1 was discharged from the facility on [DATE]. His discharge status was deceased . The baseline care plan, dated [DATE], noted Resident #1 had a physician's order for Cardio-Pulmonary Resuscitation (CPR). (Photographic evidence obtained) The Physician's Assistant - Certified (PA-C) saw Resident #1 for an initial visit on [DATE] and noted he was doing well. He was seen again on [DATE] and was last seen on [DATE] for follow-up for anxiety and discharge planning. The PA-C noted Resident #1 was feeling okay but reported anxiety. Resident #1 was noted as wanting to go home, and Social Services (SS) was working on his discharge. The Activities Aide authored an electronic progress note on [DATE] and reported that Resident #1 was alert, oriented, and able to make his needs known. His code status was FULL CODE. A Social Services (SS) Progress Note, dated [DATE], indicated Resident #1 was consulted about his discharge plans and found he intended to return home. Resident #1 stated he could take care of himself at home. (Photographic evidence obtained) On [DATE] at 6:28 AM, Licensed Practical Nurse (LPN) A authored an electronic progress note reporting that at approximately 5:20 AM, Certified Nursing Assistant (CNA) B came to report that Resident #1 appeared to be having a seizure. CNA B had already reported this to the Registered Nurse (RN). When LPN A went to Resident #1's room, she observed that he was pale/yellow in color. When she called his name and touched his hand, he was unresponsive. LPN A did a sternal rub, and Resident #1 began to gasp for air. She went to get oxygen while CNA B continued to keep the resident responding. A non-rebreather mask (a device that helps provide oxygen in an emergency) was used for oxygen delivery. RN C called 911 and LPN A and CNA B attempted to keep the resident responding. Resident #1 was gasping periodically and was pursed-lip breathing. At approximately 5:30 AM, the resident no longer gasped for air and had no pulse. The ambulance arrived shortly thereafter and pronounced his death at 5:41 AM. (Photographic evidence obtained) There was no indication in the progress note that the nurses checked Resident #1's code status or that chest compressions and/or other life-saving techniques were initiated when the resident stopped breathing. The Discharge Summary, dated [DATE], noted that Resident #1's Advanced Directives were marked Other Directive, Full Code. (Photographic evidence obtained) A review of the facility's Emergency Care (CPR) Policy and Procedure (undated) revealed: Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop Advanced Directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics, decision-making policies and procedures, and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's Advanced Directives. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's Advance Directives or DNR order. In the absence of a DNR order or for those residents who do not have a valid DNR order, CPR must begin. Procedure: 1. At the time of admission, the facility will request copies of the resident's completed Advance Directives if any . 2. The resident/legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative . 3. A DNR or full code order should be entered and signed by the physician in [the electronic medical record system] and code status displayed on the resident's PCC header below their photo . 4. Code status will be noted on the monthly POS (physician's order sheet) and verified as accurate as part of the monthly POS review. 5. Should a resident experience a cardiac emergency, staff will refer to the presence of a yellow form signed by the resident and physician to determine if CPR should be performed. 6. Advance Directives will be reviewed at least quarterly with the resident or legal representative by Social Services staff . 7. Any changes in DNR status will be communicated to care-giving staff and noted in the medical record immediately upon MD approval. 8. Staff will be educated regarding the Emergency Care (CPR) policy during orientation and at least annually thereafter. (Photographic evidence obtained) A written statement given by LPN A (undated), noted that on [DATE] at 5:20 AM, the CNA informed her that Resident #1 may be having a seizure. The CNA stated she had informed the other nurse, who was not far from Resident #1's room. When LPN A got to Resident #1's room, he was unresponsive to touch and his name. He gasped for air upon application of a sternal rub, and oxygen was applied on high with a non-rebreather mask. The other nurse stayed at the station and called 911 until EMS (Emergency Medical Services) arrived. Per EMS, 0541 (5:41 AM) was the time of death. (Photographic evidence obtained) A written statement made by RN C (undated), revealed that after being notified by the CNA and entering Resident #1's room, he was breathing irregularly. RN C tried to vigorously arouse him and ran to call 911. She returned to the resident's room where his nurse and CNA (LPN A and CNA B) were, and was notified that Resident #1 had expired. (Photographic evidence obtained) An interview was conducted with the Regional Director of Clinical Services (RDCS) on [DATE] at 3:11 PM. She explained that Resident #1 had been admitted on [DATE] for rehabilitation following a motor vehicle crash. He had multiple fractures. On [DATE] at around 5:20 AM, CNA B reported that Resident #1 began shaking during routine personal care. LPN A and RN C responded and found Resident #1 breathing, but otherwise unresponsive to a sternal rub. When Resident #1 ceased to breathe, no CPR was initiated, and he was pronounced deceased by paramedics at 5:41 AM. Resident #1's code status was Full Code. When LPN A was interviewed, she did not know why she did not start CPR. In a statement provided by RN C, she reported that Resident #1 presented with irregular breathing. She called 911 and LPN A was sent to the resident's room. 911 stated EMS were dispatched immediately. When RN C returned to the room, LPN A notified her that Resident #1 was no longer breathing and had expired. The RDCS confirmed that Resident #1's code status was not checked at any time during the event. In response to the event, all employed nurses CPR certification was checked and verified. Any who did not have it were not allowed to work until they did. A required training notification was sent to all staff on [DATE], and training began at 8:30 AM that same morning. Both LPN A and RN C were trained, but then suspended pending the outcome of the investigation, which started immediately. Code Blue drills were initiated daily on each shift. Training in CPR, Abuse and Neglect and Code Blue drills was completed by [DATE] for all nurses but one, who would receive the training prior to returning to work. Agency nurses had to complete the education and new staff were provided this education during orientation. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to review the facility's response and plan of correction, and a Performance Improvement Plan (PIP) was developed. The committee reviewed the Emergency Procedures policy and procedure, as well as new hire orientation and annual training. Residents who expired in the facility in last 30 days were reviewed for code status and Advance Directives, with no concerns identified. CNA B was interviewed via telephone on [DATE] at 10:30 AM. She explained that when she went to provide care to Resident #1 the morning of the event, he had a seizure. She ran, reported this to RN C, then went to get LPN A. When she and RN C went to Resident #1's room, he was mouth breathing. RN C asked, Where is LPN A? This is her patient! LPN A arrived and did sternal rubs as Resident #1 began mouth breathing less frequently. LPN A ran to get oxygen, instructed RN C to call 911, and told CNA B to keep doing sternal rubs and shaking/tapping Resident #1's shoulder. After initially gasping for air rapidly, Resident #1's breaths slowed to about one gasp every 10 seconds. LPN A asked, Where is RN A, she should be doing CPR. LPN A continued to shake the resident but then said, I can't get any readings on him. He is gone. She took the oxygen off and left the room. Maybe a minute later the paramedics arrived and said he was dead. She did not know why LPN A did not do CPR since the process was that the nurse would call the code and start CPR. The code status was supposed to be checked immediately when finding a resident unresponsive. CNA B said she was trained in CPR at that time and the code status was in the resident's chart. She thought LPN A knew Resident #1's code status because she had him all night. On [DATE] at 11:35 AM, RN C was interviewed and explained that she was not assigned to Resident #1 the morning of the event. Toward the end of the shift, as she was finishing up morning medications (she did not recall the time), the assigned CNA (CNA B) approached her and said Resident #1 was not doing well. She went to Resident #1's room while CNA B went to get Resident #1's assigned nurse, LPN A. Resident #1 had a pulse but his breathing was labored. She walked out of the room to call rescue and as she was going out, LPN A and CNA B walked in. After calling 911, she was headed back to the resident's room, but was called by a staff member in the other unit and was told rescue was at the door; they did not know where to go. RN C walked to the entrance to direct the rescue team, then walked with rescue to the resident's room. LPN A reported at that time that Resident #1 had stopped breathing. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the survey team as follows: A Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attaining/maintaining regulatory compliance. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director on [DATE]. Action steps taken included 1) Unit Managers verified the code status for each resident to ensure the paper and electronic medical record (EMRs) matched. A new binder was created to include residents who had elected a Do Not Resuscitate (DNR) order for easy access. The DNR form would be filed under the Documents tab in the EMR and in the hard (paper) chart, 2) Mock code blue drills were initiated on [DATE] at approximately 8:15 AM and will continue daily for one week, then move to weekly for 30 days, then monthly to ensure staff are trained to perform in the event of an actual emergency, 3) RN C and LPN A were suspended pending an investigation, 4) Staff in-service trainings were initiated on [DATE] related to emergency procedures and the facility policy. The in-services will be mandatory for all clinical staff and will be ongoing until all staff have been trained, 5) Employee files were checked for CPR Certifications on [DATE] and a documentation roster will be maintained. All facility nurses files were audited, 6) The Staff Development Coordinator and Human Resources Director reviewed new employee Orientation Checklist/Annual Checklists for clinical staff were reviewed, 7) All residents who expired in the facility the last three months were evaluated to ascertain and identify the cause of death and opportunities for improvement. A Root Cause Analysis was conducted and found the facility failed to call CODE BLUE or start CPR resulting in death. The Nurse did not initiate CPR per the resident's wishes and per the facility policy and procedure. The code status was present in the medical record. In-Service training on Advanced Directives, Emergency Procedures, Abuse/Neglect, and Code Blue Drills commenced [DATE] at 8:30 AM, and as of [DATE], twenty-four (24) out of twenty-five (25) facility nurses had been trained. The remaining nurse would not be permitted to return to work until she received the training. Mock Code Blue drills commenced [DATE] and were conducted daily on each shift through [DATE] and are now being conducted daily. Nurses' personnel files were audited on [DATE] with 100% of employed nurses' CPR certification verified. LPN A and RN C were terminated on [DATE] as a result of the investigation. The Board of Nursing and law enforcement were notified.

Based on observations, interviews, medical record review and facility policy review, the facility failed to ensure that it provided for an accurately documented medical record for two (Resident #7 and Resident #8) of two sampled residents whose medical records were reviewed for accuracy. The findings include: 1. On 07/01/2022 at 8:51 AM, Employee A, Licensed Practical Nurse (LPN) was observed giving Resident #7 his medication. Following the medication observation, Employee A, LPN demonstrated on the computer that the medications given to the resident were colored in green. The six medications confirmed by the LPN as being documented and administered to Resident #7 were as follows: 1 Tab (Mucinex) 600 milligrams (mg), expires 9/23 1 Tab [MEDICATION(S)] 500 micrograms (mcg), expires 1/23 1 Tab ([MEDICATION(S)]) Requip 0.25 mg expires 3/23 1 Tab [MEDICATION(S)] 5 mg, expires 6/23 1 Tab [MEDICATION(S)] 100 mg, expires 6/23 1 Capsule Tamsulosin 0.4 mg, expires 6/23 A review of the medication administration record (MAR) for Resident #7 conducted on 07/01/2022 at 10:00 AM revealed Employee A, LPN had documented the resident received [MEDICATION(S)] 25 milligrams, 1 Tablet by mouth one time a day related to hypertension. (Photographic evidence obtained) During an interview with Employee A, LPN on 07/01/2022 at 10:05 AM, she confirmed the medication [MEDICATION(S)] was not administered to Resident #7. The LPN stated she recalled there were only six tablets/medications in the medication cup, and she would have to address the missed medication. An interview was conducted with the Director of Nursing (DON) on 07/01/2022 at 11:37 AM. The DON provided a copy of a new note Employee A, LPN made in reference to Resident #7 not being given his [MEDICATION(S)] medication. (Copy obtained) 2. During a medication observation on 07/01/2022 at 10:17 AM, Employee B, LPN was observed giving Resident #8 two Cranberry 450 mg tablets. Employee B, LPN confirmed, she transcribed the medication from the bottle as Cranberry 450 mg. An interview was conducted with Employee B, LPN on 07/01/2022 at 11:45 AM. The LPN reviewed the MAR and the medication bottle and confirmed the documented dose was 50 milligrams dose less than the medication that was administered and pointed out that it was not accurately reflected in the medical record. A review of the medication administration record (MAR) for Resident #8 conducted on 07/01/2022 at 11:52 AM revealed the resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Initiated on 04/13/2022 at 17:00. (Photographic evidence obtained) An interview was conducted with the DON at Employee B, LPN nurse medication cart on 07/01/2022 at 11:55 AM. The DON stated, I want to know if there was a medication error. He was informed of the medication dose on the cart did not match the medication order documented in the computer. The DON agreed that Resident #8 received a dose that was different then the ordered dose for the Cranberry tablets. (Photographic evidence obtained) A telephone interview was conducted with Physician A, MD on 07/01/2022 at 2:11 PM. Physician A, MD indicated that treatment decisions are made based in part by what was documented in the resident medical record. He stated, I would assume that if a medication was documented administered in a MAR, then the medication was given. A review of the facility's policy on Administering Medications indicated, Medications shall be administered in a safe and timely manner, and as prescribed; Line #7: The individual administering the medication must check the label three times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication and at Line #16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate on the MAR.

Based on facility observations and staff interviews, the facility failed to ensure that a safe, clean, comfortable and homelike environment was maintained in 17 (Rooms 301, 302, 303, 304, 305, 306, 309, 310, 312, 313, 101, 102, 106, 107, 202, 205, 206) of 65 resident rooms as well as the hallways in Units 1, 2 and 3, during four of four survey days. Specifically, the facility failed to ensure resident rooms, bathrooms, and common use areas were maintained to ensure a sanitary, orderly, and comfortable interior. The findings include: Room 301: On 1/10/22 at 12:02 PM, room 301 was observed with air conditioner (AC) filters that appeared blackened with debris. The AC vents and casing were also soiled with dry surface staining and with debris coming out of the front vents. Plumbing pipe covers for the sink in the residents' room were broken and on the floor. The bathroom had sticky floors, the paper towel dispenser was broken, and the raised toilet seat was soiled. Additional observations on 1/11/22 at 9:00 AM and on 1/12/22 at 9:30 AM, found that AC filters were changed, but the vents and casing of the AC unit remained soiled with debris, and the plumbing pipe covering remained on the floor under the sink. The paper towel dispenser remained broken and the toilet remained visibly soiled. Observations on 1/13/22 at 10:30 AM, revealed the trash can in the shared bathroom did not have a liner. Room 302: On 1/10/22 at 12:07 PM, room 302 was observed. The AC was soiled with debris on the casing and in the vents. The bathroom floor was sticky, the raised portable toilet seat and frame were soiled, and the toilet seat below was also soiled. The chalking around the toilet base was discolored and blackened, and the soap dispenser at the sink was empty. Additional observations on 1/11/22 at 10:55 AM, revealed the bathroom remained soiled, there was a ripped liner in the bathroom trash can, and there was no soap at the residents' sink. An additional observation on 1/13/22 at 9:18 AM, revealed the debris on the AC vents and casing were still present. Room 303: On 1/10/22 at 12:15 PM, room 303 was observed. The AC filters were covered in debris, the vents had debris in them, and the casing was soiled. The paper towel dispenser was broken and hanging open. The toilet was running without stopping. The trash can was unlined and a soiled towel was observed hanging over the side of it. Observations on 1/11/22 at 9:00 AM and on 1/13/22 at 10:30 AM, revealed that the AC air filter had been changed, but the vent was still heavily soiled with debris. The toilet was still continuously running. The trash can was unlined and remained soiled. The paper towel dispenser cover was in place but was broken. Rooms 304/305/306/309: On 1/10/22 at 1:00 PM, it was observed in rooms 304, 305, 306 and 309, that the AC unit filters were blackened with debris. Additional observations on 1/11/22 at 10:55 AM, found that each of the AC filters had been changed, but a large amount of debris remained on the vents. Room 305: On 1/10/22 at 1:11 PM in room 305, the resident's privacy curtain was observed to be stained and soiled. Room 312: On 1/10/22 at 1:15 PM, room 312 was observed with an enteral feeding pump and IV (intravenous) pole that were soiled with dried liquid debris. The AC vents were soiled with dried liquid debris. The sink in the residents' room did not have soap or hand sanitizer available. Numerous observations throughout the day on 1/11/22 found no changes in the findings. Numerous observations throughout the day on 1/13/22, revealed that the enteral feeding pump had been cleaned but the IV pump remained soiled with dried liquid. The soap dispenser remained empty. Room 310/313: On 1/10/22 at 1:45 PM, rooms 310 and 313 were observed with dried liquid on the residents' floors, dried debris was observed on the residents' room walls, the AC filters and vents were darkened with debris, and the toilets were soiled. Room 101/102/106: On 1/13/22 at 12:00 PM, resident room AC vents were observed stained with debris hanging from the vents. Room 107: On 1/11/22 at 10:40 AM, the resident's closet door appeared to be broken. An additional observation on 1/13/22 at 3:33 PM, revealed no change to the broken door. Room 206: On 1/13/22 at 11:35 AM, the bathroom toilet seat was soiled with darkened material and the ceiling vent in the bathroom was covered in debris. Room 205: On 1/13/22 at 11:40 AM, the IV pole in the resident's room was visibly soiled with dried liquid. A heavily soiled air filter was also noted. Room 202: On 1/13/22 at 11:50 AM, room 202's AC casing was soiled, and six pills were found in the vents (5 white tablets, 1 pink tablet). Common Areas: Observations on 1/10/22 at 10:00 AM, on 1/11/22 at 2:00 PM, and on 1/13/22 at 3:45 PM, revealed that hallway handrails on Units 1,2, and 3 had large amounts of darkened dirt and debris between the handrails and the wall. A housekeeping observation was made on 1/11/22, which revealed only superficial exterior cleaning of the handrails on the 300 hallway. An interview was conducted on 1/13/2022 at 11:15 AM with Housekeeper L. He stated there were three housekeepers on the day shift, and they cleaned the resident rooms daily and as needed. He further stated they made sure to clean the bathrooms, toilets, dressers, and bedside tables. They filled the soap dispensers and paper towels, emptied the trash, replaced the can liners, and mopped the floors. An interview was conducted on 1/13/22 at 2:45 PM with Activities Staff H regarding the policy/procedure for alerting the housekeeping/maintenance department when repairs were needed in a resident's room. She stated she completed a form and placed it in the slot or under the door for Maintenance. An interview was conducted on 1/13/22 at 3:15 PM with Care Aide I regarding the policy/procedure for reporting a need for repairs in a resident's room. She stated she would tell the charge nurse or a housekeeper, and they would complete a form to request housekeeping or maintenance services. An interview was conducted Housekeeping/Maintenance Director M and the Nursing Home Administrator (NHA) on 1/13/22 at 4:00 PM, while conducting a facility tour. The Housekeeping/Maintenance Director stated he recently began his employement with the facility and the facility had a system installed in the building so he could improve the tracking and responses for repair requests. The NHA confirmed this. The identified resident rooms and common areas were visited and the areas of concern were identified. The NHA and Housekeeping/Maintenance Director M stated they would speak with the employees in his department to reeducate them on proper housekeeping and maintenance processes.

Based on record review and staff interview, the facility failed to maintain complete records of Notices of Medicare Non-coverage (NOMNC) and Advance Beneficiary Notices of Non-coverage (ABN) for two (Residents #16 and #415) of three sampled residents who were discharged from a Medicare A-covered stay with benefit days remaining in the last six months. Specifically, the records provided by the facility were without resident signatures to verify that the residents were made aware of the changes in coverage for services provided by the facility. The findings include: A record review for three residents with remaining Medicare Part A days, revealed that two (Residents #16 and #415) of the three residents who resided in the facility had missing signatures on both their NOMNC and ABN forms. (Copies obtained) The signature areas were blank and there was no date on either form. There was no documented evidence to verify that Residents #16 and #415 were notified of coverage changes related to services provided by the facility. The two residents' ABN forms did not have an Options box selected, a signature or a date of contact on them. On the two NOMNC forms, the signature and date areas were blank. These forms did not indicate by what method the participants were contacted, if they had declined, planned to appeal or were not available to sign the forms. The Regional Business Office Manager (RBOM) was interviewed on 1/13/22 at 11:03 a.m. She was asked why the signatures were missing on the forms and she stated she was told they could fill out information in the Additional Information area and that was enough. She was asked to explain the information in the Additional Information area on the NOMNC form, because it did not indicate how the resident was contacted, whether they declined, etc. She stated, Yes, I understand. She was asked to provide additional information to confirm these forms were given to the residents, however, no additional information was provided prior to the survey exit on 1/13/22 at approximately 7:45 p.m. .

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to follow orders for one (Resident #100) of two residents triggered for weight loss from a total sample of 46 residents. The findings include: A record review for Resident #100 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment, dated 12/23/21, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident's mobility needs were documented is extensive assistance of one person. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's orders for nutritional supplements included Magic Cup two times a day (started on 12/13/21), Mighty Shakes three times a day (started 10/18/21), and Resource 2.0 (nutritional supplement) three times a day (started 10/18/21). The resident's weight was recorded monthly. Her weight on 08/01/2021 was recorded at 101 pounds. On 01/01/2022, her weight was recorded at 88 pounds, which was a 12.87 % weight loss in five months. The resident's Care Plan, initiated on 1/6/2022, revealed a potential nutritional problem due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required a modified consistency of mechanical soft diet and left 25% or more food uneaten at most meals. She had a weight below Body Mass Index range with interventions that included administration of medications, monitor/record/report to doctor as needed signs symptoms of malnutrition and serve diet as ordered. A review of the Registered Dietitian's (RD) Nutrition Note, dated 12/13/2021, reported a 4.6% weight loss x 1 week, and her intake of the mechanical soft diet was 0-25% of most meals. The RD note dated 1/11/2022, reported a weight loss of 8.49% x 3 months, and that was below ideal body weight. The note indicated the resident's intake of her mechanical soft, thin liquids diet was 0-50% and she received Resource 2.0, 120 ml 3 times a day. A review of the Nursing Notes indicated the resident consumed 82% of her Resource 2.0, 120 ml (milliliters) three times a day. The RD recommended Magic Cup two times a day, which provided 580 kcal/18 g (grams) protein. An interview was conducted with Licensed Practical Nurse (LPN) B on 1/13/2022 at 11:40 AM. She stated she handled the tube feedings and the nutrition supplements like Resource. She stated the kitchen put the shakes and frozen Magic Cup on the meal trays. Yes, we have protocols for weight loss. We would notify the family, the doctor, and the Registered Dietitian. We give supplements to prevent weight loss like Resource, Magic Cup and shakes. LPN Q was interviewed on 01/13/2022 at 11:49 AM. She reported that she would defer to the RD and the resident's doctor if the resident was losing weight. I think the resident gets Resource three times a day. She does need to be encouraged to eat. An interview was conducted with the Certified Dietary Manger (CDM) on 01/13/2022 at 3:29 PM. She stated she entered the weekly weight loss list in the computer for the RD, so she would be prompted to see residents with weight loss, and then the RD would reassess those residents. The CDM was asked if all residents' diet sheets were current. She stated, I won't say that. A review of the Tray Slip form was done for the date of 1/13/22. The Tray Slip revealed that Resident #100 had a Mighty Shake on her Tray Slip only two times, but her orders were to have a Mighty Shake three times. She also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) During an interview with the CDM on 01/13/2022 at 5:23 PM, she stated, If a resident is supposed to get Mighty Shake on her tray three times a day, it should be on her Tray Slip. An interview was conducted with the RD at 5:40 PM on 1/13/2022. She reported that if a resident had a weight loss, she would reevaluate the resident and would put new supplement orders, etc., in the computer, then give them to the CDM. The CDM would put them in the kitchen computer system. The orders would then print on the Tray Slip for meal service staff to place the item(s) on the meal tray. The CDM was responsible for putting any new orders in the kitchen computer system. The RD reported she did not have access to this system and was unable to add the orders herself. Certified Nursing Assistant (CNA) S was interviewed on 01/13/2022 at 6:00 PM. She reported that dietary staff put nutritional supplements on meal trays before leaving the kitchen. CNA S stated she could not remember whether Resident #100 received any nutritional supplements. An interview was conducted with LPN T on 01/13/2022 at 6:05 PM. She reported that she had been working in the facility for three years and dietary staff put Magic Cup and Mighty Shake supplements on meal trays at each meal service. She stated the nurses were responsible for administering the medical nutritional supplements (i.e Resource 2.0). An interview was conducted with CNA U on 01/13/2022 at 6:10 PM. She reported that Resident #100 received Mighty Shake on her tray, but I have not seen any Magic Cup. The facility's policy addressing resident weight loss was requested but was not received over the course of the survey.

Based on record reviews, observations, and staff interviews, the facility failed to ensure residents who required respiratory services, received such services, consistent with professional standards of practice, for two (Residents #46 and #25) of two residents reviewed for oxygen administration, from a total of 46 residents in the sample. Specifically, the facility failed to ensure both residents were receiving oxygen as ordered by their physicians. The findings include: 1. A review of Resident #46's medical record revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment, dated 11/10/21, revealed the resident was documented as having shortness of breath or trouble breathing when sitting, at rest, or when lying flat. He was also documented as receiving oxygen. A physician's order, dated 3/9/21, instructed staff to provide the resident oxygen at a flow rate of 2 liters per minute via nasal cannula, continuously, every shift, for [CONDITION(S)]. A physician's order, dated 12/9/21, instructed staff to change the oxygen tubing every night shift, every Sunday. An observation of Resident #46 on 1/10/22 at 11:18 AM, revealed the resident resting in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. (Photographic evidence obtained) An observation of Resident #46 on 1/11/22 at 9:24 AM, revealed the resident resting in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was dated 1/1/22, and based on the physician's order, it should have been changed by 1/9/22. An observation of Resident #46 on 1/12/22 at 10:29 AM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was still dated 1/1/22, but the humidification receptacle was dated 1/10/22 at 6:00 AM. (Photographic evidence obtained) An observation of Resident #46 on 1/12/22 at 3:15 PM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was still dated 1/1/22. (Photographic evidence obtained) An observation of Resident #46 on 1/13/22 at 9:45 AM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The resident's oxygen tubing was undated. (Photographic evidence obtained) A review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a 1/12/22 interview with Certified Nursing Assistant (CNA) D at 2:58 PM, she stated oxygen management was solely the responsibility of the nurses. Her tasks were to report low levels of oxygen saturation, below 90%, and to report to the nurse when that occurred. She was also to report difficulty breathing and make sure the cannula is on their face. Communication of vital signs was made through a paper log which was handed to the nurse once it was completed. During a 1/13/22 interview with CNA C at 9:49 AM, she stated her responsibility was to obtain oxygen saturation levels during vital signs rounding, and to report back to the nurse if difficulty breathing was noted. The nurse would then reassess the resident's breathing effort and obtain further oxygen levels. CNA C further stated, Oxygen is a medication, so it's the nurse's responsibility to monitor that. She stated she would ask the nurse to review and verify the resident's oxygen administration order. During a 1/13/22 interview with Licensed Practical Nurse (LPN) B at 9:58 AM, she stated an overview of oxygen levels and orders was the nurses' responsibility, and the oxygen flow rate to be administered was indicated in the MAR. The CNA was responsible for checking oxygen levels during vital signs rounding and reporting back to the nurse if the resident was short of breath or having breathing difficulty. LPN B opened Resident #46's January 2022 MAR, and confirmed that her oxygen order was for 2 liters per minute via nasal cannula. During a 1/13/22 interview with the Director of Nursing (DON) at 2:33 PM, she stated oxygen administration, implemented by nursing, must be performed correctly, per the physician's order. She further stated oxygen tubing was replaced every seven days, usually on the 11-7 shift, and should be dated. 2. A review of Resident #25's medical record revealed and admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS, dated [DATE], revealed the resident was receiving oxygen. A review of the Physician's Order Sheets for January 2022, revealed a current order for oxygen, 2 liters per minute continuously, checked every shift, and oxygen tubing to be changed every Sunday. A review of Resident #25's Care Plan for Oxygen, initiated on 10/29/21, revealed she was receiving oxygen therapy due to ineffective gas exchange and [CONDITION(S)]. The interventions included: Change delivery method if resident eats, monitor for signs and symptoms of respiratory distress and report them to the doctor as needed. Oxygen settings via nasal cannula per physician's orders. An observation of Resident #25 in her room on 1/11/22 at 2:09 PM, revealed that her oxygen flow rate was set at 4 liters per minute, and the oxygen tubing was dated 1/3/2022. Based on the facility's protocol, the oxygen tubing should have been changed by 1/9/22. An observation of Resident #25 in her room on 1/12/22 at 3:00 PM, revealed that her oxygen flow rate was still set at 4 liters per minute. (Photographic evidence obtained) An observatin of Resident #25 in her room on 1/13/22 at 11:20 AM, revealed that her oxygen flow rate was now set at 2 liters per miute, however the oxygen tubing was still dated 1/3/2022. The facility policy on Oxygen Administration, last revised 10/2020, revealed the following: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Documentation of oxygen administration per policy and procedure include the recording of the rate of oxygen flow, route and rationale, the frequency and duration of the treatment. According to the National Center for Biotechnology Information (NCBI) at https://www.ncbi.nlm.nih.gov/books/NBK 3/ (Accessed 2/4/22 at 1:56 p.m.): Oxygen is vital to sustain life. However, breathing oxygen at higher than normal partial pressure leads to hyperoxia and can cause oxygen toxicity or oxygen poisoning. The clinical settings in which oxygen toxicity occurs is predominantly divided into two groups; one in which the patient is exposed to very high concentrations of oxygen for a short duration, and the second where the patient is exposed to lower concentrations of oxygen but for a longer duration. These two cases can result in acute and chronic oxygen toxicity, respectively. The acute toxicity manifests generally with central nervous system (CNS) effects, while chronic toxicity has mainly pulmonary effects. Severe cases of oxygen toxicity can lead to cell damage and death. Those at particular risk for oxygen toxicity include patients exposed to prolonged high levels of oxygen. Extended exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes leading to the collapse of the alveoli in the lungs. Pulmonary effects can present as early as within 24 hours of breathing pure oxygen. Symptoms include pleuritic chest pain, substernal heaviness, coughing, and dyspnea secondary to tracheobronchitis and absorptive atelectasis which can lead to pulmonary [CONDITION(S)]. Pulmonary symptoms typically abate 4 hours after cessation of exposure in the majority of patients. CNS effects manifest with a multitude of potential symptoms. Early symptoms and signs are quite variable, but twitching of perioral and small muscles of the hand is a fairly consistent feature. If exposure to oxygen pressures is sustained tinnitus, dysphoria, nausea, and generalized convulsions can develop.

Based on record review and staff interviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #410) of six residents reviewed for medication administration, from a total of 46 residents in the sample. Specifically, the facility failed to ensure antibiotics were administered for a newly admitted resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A review of Resident #410's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Baseline Care Plan, initiated on 1/3/22, documented that the resident was receiving antibiotic treatment. Interventions included the administration of the antibiotic as ordered by the physician. The Nursing Admission Assessment, dated 1/1/22, documented that the resident was as alert and oriented to person, place, time, and situation. She was admitted with an active infection requiring antibiotic therapy. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A second physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also showed missed doses on 1/10/22 at 5:00 PM and on 1/11/22 at 9:00 AM, secondary to a clogged IV administration site, as per nursing documentation. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nursing Progress Notes, revealed that on 1/2/22 was documented, awaiting pharmacy delivery of [MEDICATION(S)] 2 grams. A progress note dated 1/3/22, documented that [MEDICATION(S)] 2 grams was on order. A 1/10/22 progress note written at 9:07 PM, documented that line was bad, and on 1/11/22 at 11:30 AM, a progress note documented the IV port possible compromise. IV access team notified, and MD notified. A review of the Physician's Progress Notes revealed an Admission Note dated 1/6/22. It documented that the resident was to continue IV antibiotics [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) until 1/23/22 for [CONDITION(S)] of the right lower limb. The progress note did not indicate that the physician was aware that the resident had missed five doses of [MEDICATION(S)] and two doses of [MEDICATION(S)] prior to this visit. An interview was conducted with Licensed Practical Nurse (LPN) L at 2:30 PM on 1/13/22. She stated when a resident was admitted , the nurses went through all of the resident's paperwork and information received upon admission. Upon admission, the nurse contacted the pharmacy and put the medical information in the admitting resident's medical record. Depending upon the time of admission, the facility usually received the resident's medications on the next run, and if they did not come in, the nurse called the pharmacy, or had the medication sent STAT (immediately). LPN L added that the facility had a back-up system and staff could access the medication in the system if necessary. An interview was conducted with LPN K at 3:00 PM on 1/13/22. She stated the medications usually arrived on time, but if they did not arrive, she would check the back-up box for the medication, then call the pharmacy and document that in the resident's medical record. If a medication was unavailable, she would contact the physician to see whether he/she wanted to give new orders or instructions. An interview was conducted with the Director of Nursing (DON) at 2:00 PM on 1/13/22. She stated the admitting nurse reviewed all of the admission paperwork, and sent the medication list to the pharmacy for delivery on the next scheduled run. If the medications were not received, it was her expectation that the nurse would call the pharmacy to follow up. She further stated the facility had a back-up automated medication dispensing system for medication and antibiotics, so if it was needed, the nurse could pull medication from that system or they could call to have medications sent STAT from the pharmacy. She said if medication was not received and the resident missed a dose, there should be documentation in the progress notes indicating why the medication was not given, and that the physician had been notified. Usually, the physician would extend the dosing to the quantity needed so the resident received the correct number of doses. She said she would review the resident's chart and the physician would be notified. She further stated there should be no holes in the documentation of Resident #410's MAR. The facility policy on Antibiotic Orders, implemented on 1/27/21 without revision, revealed the following: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements.

Based on interviews, record review and policy and procedure review, the facility failed to ensure [CONDITION(S)] care was provided to one (Resident #1) of two residents reviewed for respiratory care, by failing to obtain and carry out physician orders for [CONDITION(S)] care and tracheal suctioning. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: According to Mayo Clinic (accessed [DATE] https://www.mayoclinic.org/tests-procedures/[CONDITION(S)]/about/pac- 673), a [CONDITION(S)] provides an air passage to breath when the usual route for breathing is somehow blocked or reduced. Review of Resident #1's closed medical record revealed an admitted [DATE], with was most recent readmission to the facility on [DATE]. Resident #1 was discharged from the facility on [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission minimum data set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) assessment was not conducted as the resident was rarely or never understood. Resident #1 required total assistance with activities of daily living. The resident had recently undergone placement of a [CONDITION(S)] on [DATE]. Review of the nursing progress notes revealed an entry dated [DATE] at 9:05 p.m. which indicated a care plan meeting was held with the resident's daughter and that the daughter voiced concerns about Resident #1's [CONDITION(S)] care and mouth care. Continued review of the nursing progress notes revealed an entry by Employee C, Licensed Practical Nurse (LPN) dated [DATE] at 10:16 p.m. which revealed the nurse was notified by the Certified Nursing Assistant (CNA) that the resident was not breathing. The nurse checked the resident and determined the resident was not responsive. A code blue was started at 10:18 p.m. and 911 was notified. Emergency medical services (EMS) arrived at the facility at approximately 10:28 p.m. and transferred the resident to the hospital. Review of Resident #1's physician orders revealed no orders for [CONDITION(S)] care or suctioning. Review of Resident #1's medication and treatment administration records for July and [DATE] revealed no documentation of [CONDITION(S)] care or suctioning. Review of Resident #1's comprehensive care plans revealed no focus areas or interventions for the care of her [CONDITION(S)]. On [DATE] at 3:45 p.m., an interview was conducted with Employee C, Licensed Practical Nurse (LPN). She acknowledged that she was assigned to Resident #1 at the time the resident was found unresponsive in her room. The nurse was asked to review the progress note she had written on [DATE]. She explained that she was notified by the Certified Nursing Assistant (CNA) that the resident was not breathing. She stated, I went over to her and tried to arouse her. She wouldn't even open her eyes I don't think. She didn't have a pulse. I had someone else check to see if she was a full code and I got ready for CPR. The nurse added that she was in the room when CPR was initiated but then left the room. She was unable to recall why she left the room and was unable to recall who was providing CPR. The nurse stated she was not able to recall what condition the resident's [CONDITION(S)] was in when she was found unresponsive and wasn't able to recall whether she had provided suctioning to the resident at any point during the assigned shift. When asked how she would have known to provide airway suctioning for the resident, Employee C stated, they have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:31 p.m., an interview was conducted with the Director of Staff Development (DSD). She was asked to explain the facility's process for ensuring staff competency when caring for residents with tracheostomies. She explained that she conducts a competency validation for each nurse during orientation and documents the competency on the facility's checklist. When asked whether the facility's policies required nurses to have a physician's order to suction the lower airway, the DSD stated, No, it doesn't need an order. It's a nursing independent judgement. When asked whether respiratory assessments and documentation of [CONDITION(S)] care were expected, the DSD stated, Yes. The nurse should document when they provide that care. The facility's policy for [CONDITION(S)] care was reviewed. The policy was titled [CONDITION(S)] care and was revised in [DATE]. Step 1 of the procedure guideline read, 1. Check physician order. (Photographic Evidence Obtained) The facility's protocol for suctioning the lower airway was reviewed. The policy was revised in [DATE]. Step 1 of the preparation guideline read, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning. (Photographic Evidence Obtained) On [DATE] at 10:15 a.m., an interview was conducted with Employee A, LPN Unit Manager. She stated she was not the admitting nurse for Resident #1. The nurse was asked to review the resident's admission assessment which was signed by her. She then stated, Oh, ok. I guess I was. The nurse continued to review the record and explained that she did not see any orders for [CONDITION(S)] care. When asked about the facility's admission process for residents with tracheostomies, the nurse explained that there were standing orders that would be entered for suctioning and [CONDITION(S)] care. When asked about the admissions review process, the nurse stated there was a team that reviewed admissions to ensure appropriate orders had been entered but stated, it doesn't look like that's what happened in this case. To answer your question, I don't see any suction or [CONDITION(S)] orders. When asked whether suctioning the airway required a physician's order, the nurse stated, Yes. When asked how often the facility was providing airway suctioning and [CONDITION(S)] care for Resident #1, the nurse stated, I can't say for sure. The facility's protocol for admission assessments was reviewed. The protocol was titled Admission Assessment and Follow Up: Role of the Nurse. The protocol directed nurses to conduct a physical assessment of the resident and notify the supervisor and attending physician of any needs that the resident may have. (Photographic Evidence Obtained) On [DATE] at 12:15 p.m., an interview was conducted with the Director of Nursing (DON). During the interview, the DON was asked about the facility's process for ensuring appropriate care is delivered for residents with tracheostomies. She explained that nurses are validated for competency using a competency checklist. The DON then acknowledged that suctioning of the lower airway did require a physician's order. She stated, The nurse should've entered the orders when the resident was admitted and the MDS nurse should've developed the care plan. The DON explained that the facility was revising the competency checklist for [CONDITION(S)] care to include a step to verify the physician's order. Post-transfer hospital records were reviewed. An examination dated [DATE] from the emergency room indicated the resident's [CONDITION(S)] appeared clogged and was difficult to attach the ambu bag. The [CONDITION(S)] was exchanged for a new one and ventilation was then easily commenced. Continued Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A second physician consultation report dated [DATE] identified the [MEDICATION(S)] plugging as the suspected cause of the resident's cardiac and respiratory arrest. (Photographic Evidence Obtained)

Based on observation, record review and staff interview, the facility failed to ensure intravenous fluids were administered as ordered and assessments were performed to monitor potential complications for one (Resident #2) of one sampled resident. The findings include: A record review for Resident #2 revealed an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She tested positive for COVID-19 on 12/27/20 and was moved to the COVID unit. She was alert with confusion, required extensive assist for activities of daily living and used wheelchair for mobility. During her stay on the COVID unit, she had a poor appetite and was taking fluids poorly. Lab results revealed she was dehydrated and on 1/3/21 and the physician's assistant (PA) ordered 5% [MEDICATION NAME] and 0.45 % normal saline intravenous (IV) solution at 75 ml/hour (milliliters per hour) continuously until 2 liters infused. An order was also given to insert a midline catheter. During a tour of the facility on 1/7/21 at 10:30 am, Resident #2 was observed sitting in her room in a wheelchair at the sink. There was an IV bag hanging on an IV pole with tubing connected to the resident. An observation of the IV bag found the solution was 5% [MEDICATION NAME] and 0.45 % normal saline (D5 1/2 NS). The bag did not have a label indicating a name, date, time the solution was hung or a flow rate. The tubing was not dated. Observation of the resident's left arm above the antecubital space revealed an IV insertion site covered with a dressing. There was no IV pump. The flow was regulated by a flow dial attached to the tubing; the dial was set to a marking between 60-80. An interview was conducted with the Licensed Practical Nurse (LPN) (Employee A) on 1/7/21 at 1:55 pm. She was asked why Resident #2 was receiving IV fluids and replied that it was for hydration. When asked how long Resident #2 was to receive the IV fluids, she said this order was for one liter then discontinue. She had been receiving IV fluids since 1/3/21 when she was on the COVID unit. When asked when this bag of fluid was hung, she said during the 11-7 shift. She was asked what what the IV flow rate was set at, and she said she would need to check the orders. When asked if the resident had a midline catheter, the nurse replied, No it was a peripheral line. She was asked who inserted the catheter and she verified that it was an outside company. She was asked if the IV nurse left documentation as to what type of catheter was inserted. She looked in the record but could not locate the information. She was asked why the IV bag did not have a label indicating the resident's name, date and time the bag was hung and the initials of the nurse who hung the bag. She said it was taken out of the emergency IV kit. When asked what the protocol was for labeling the bag when removed from the kit. She said there should be date, time and who hung the bag. She was asked if the IV solution for Resident #2 had a label or indicated when it was hung. She said, No. During the interview she was asked how often the IV site was assessed and where the information was documented. She said it should be checked every shift and documented in the medication administration record (MAR). She was asked where on the MAR could that be found. After she reviewed the MAR, she stated it was not there. She was asked if she documented in the progress notes regarding what solution was infusing, the rate of flow, the amount infused on her shift or the observation of the IV site, and she replied, No. An interview was conducted with LPN B on 1/7/21 at 2:10 pm. She was asked where Resident #2's IV order could be found. She stated she would check the orders and after having done that, stated none was found. When asked when the IV was started and who inserted it, she said she could not find that information. She was asked how often the IV site should be assessed. She said at least once a shift. She was asked where the nurses documented the IV assessments, and she replied the documentation should be on the MAR and in the progress notes. When asked whether monitoring of the IV site was on the MAR, she reviewed the MAR and progress notes and stated none was found. Further review of the record revealed the initial IV order for D5 1/2 NS 75 ml continuously until 2 liters was infused, was dated 1/3/21. The first bag (1 liter) was hung on 1/3/21 at 8:10 pm. There was no documentation verifying that the second bag was hung and the order completed. On 1/5/21, a second order was given for D 5 1/2 NS at 75 ml and run continuously until 2 liters were infused. The first bag (1 liter) was hung at 5:00 pm per the MAR, but there were no nursing progress notes regarding the IV infusion. There was no documentation regarding when the second bag was hung or when it was completed. On 1/6/21, an order was given for D 5 1/2 NS 75 ml, infuse 1 liter until complete. A review of the MAR revealed the bag was hung at 3:00 pm and was to infuse until 1:00pm on 1/7/21. An interview was conducted with the Risk Manager (RM) on 1/7/21 at 5:15 pm. She was asked to review the intravenous (IV) orders for Resident #2. She was asked why the resident was ordered intravenous therapy. The RM said she had tested positive for COVID on 12/26/20 and was placed in the COVID unit. She was not taking enough fluids and became dehydrated. She was seen by the PA on 1/2/21 and was ordered IV fluids. The PA ordered a midline catheter to be inserted. The facility used an outside IV company to insert midlines. The IV nurse came to the facility on [DATE]. The PA ordered 5% [MEDICATION NAME] and 0.45 % normal saline (D5W ½ NS) at 75 ml an hour continuesly until two liters were infused. The RM was asked when the first bag was (one liter) was hung. After a review of the Medication Administration Record (MAR), she stated it was hung on 1/3/21 at 8:10 pm. She was asked when the second liter was hung. She said she could not determine from the MAR when the bag was hung. She further stated she reviewed the nursing progress notes and found no documentation regarding resident being administered IV therapy. The RM was asked if there were any further orders for IV hydration, and she replied that an order was given on 1/5/21 for an additional 2 liters of D5W 1/2 NS at 75 ml/hr. She was asked when the first bag was hung for the 1/5/21 order, and she replied it was hung at 3:00 pm on 1/5/21. When asked when the resident received the second liter of fluid, the RM said it was not clear on the MAR. A third order was given on 1/6/21 for one liter of fluid. The bag was hung at 3:00 pm and was to run until 1:00 pm on 1/7/21. The RM was asked where the nurses documented monitoring and assessment of the IV site for signs of infection or complications (redness, infiltration, dressing in place), and she replied, On the MAR. She was asked if the IV site assessment was on the MAR, and she said No, however she would update the MAR to include the assessments. She was asked how the facility obtained the IV fluid to initiate the treatment. She stated they had an emergency IV kit that contained IV solutions and tubing. She was asked if the bags had a label to which the nurse could write the resident's name, date, time hung and the nurse administering. She said there were no labels, however the nurse was to put the date, time and initials when hanging the IV Fluid. When asked who was responsible for dating the IV tubing, she said the nurse that hung the bag. When asked what the policy was for changing the tubing, she said, Every 24 hours. The RM was asked to review the nursing progress notes from 1/3-1/7/21. She was asked if the nurses documented that Resident #2 had a midline in place, was receiving IV fluids, whether they were monitoring the IV site and when a new bag was hung. She replied No. A review of the facility's Intravenous Therapy policy included the following: Administration set/Tubing changes, label new tubing with date, time and initials. The following information should be recorded in the resident's record: the date and time of the administration set change, type of flow device, type of solution or medication infusing, the amount of solution or medication to be infused, the rate of infusion, the condition of the IV site, notification to the physician of any complications, resident response to treatment and signature and title of person recording the data.

Based on observation, interview and record review, the facility staff failed to ensure the proper use of personal protective equipment (PPE - isolation gown) in the COVID-19 isolation unit, and failed to monitor for signs and symptoms of coronavirus illness (fever, cough, shortness of breath) every eight hours as ordered by the physician for three (Residents #1, #2 and #3) of five COVID-19-positive residents. The findings include: 1. An observation of the COVID-19 isolation unit on 10/22/20 at 4:10 PM revealed one entry, which was also the exit. There was one isolation sign at the point of entry. A staff member delivered meals on a metal cart covered in clear plastic by the doorway of the designated COVID-19 unit and yelled out Trays here! Licensed Practical Nurse (LPN) A was observed handling the trays. She did not don her PPE isolation gown correctly in the COVID-19 unit. She did not tie all of the ties on her isolation gown, and the top of her isolation gown was observed not fully covering her upper torso (neck and chest area was not covered). During an interview on 10/22/20 at 5:37 PM, LPN A, the designated COVID-19 unit nurse, she confirmed that she did not tie all of the ties on her PPE isolation gown. She stated she forgot to do it. She further stated she had received the Centers for Disease Control (CDC) training on donning and doffing of PPE (gown) and the expectation was that all of the ties should be tied properly. During an interview on 10/22/20 at 11:30 AM, the Infection Control Nurse stated, Residents are monitored for signs and symptoms of coronavirus illness every shift. We monitor three times a day. We follow the CDC guidelines. A review of Resident #1's medical record revealed she was admitted to the facility on [DATE] and was diagnosed as COVID-19 positive on 9/28/2020. A review of the 9/17/2020 physician's orders [REDACTED]. Ask resident if experiencing nausea. Every shift notify DON (Director of Nursing) for temperature greater than 99.2. A review of Resident #1's Medication Administration Record [REDACTED]. 2. A review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and was diagnosed as COVID-19 positive on 10/13/2020. Further review of Resident #2's medical record revealed an 8/20/20 physician's orders [REDACTED]. Ask resident if experiencing nausea. Every shift notify DON for temperature greater than 99.2. A review of Resident #2's MAR, dated October 2020, revealed that COVID-19 checks were not thoroughly documented three times a day or every shift on 10/1, 10/4, 10/5, 10/8, 10/9, 10/11 or 10/14/2020. 3. A review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] and was diagnosed as COVID-19 positive on 10/14/2020. Further review of the record revealed a 9/30/2020 physician's orders [REDACTED]. Ask resident if experiencing nausea. Every shift. Notify DON for temperature greater than 99.2. A review of the resident's MAR, dated October 2020, revealed that COVID-19 checks were not thoroughly documented three times a day or every shift on 10/1, 10/2, 10/5, 10/6, 10/8, 10/13, 10/14 or 10/15/2020. During an interview with the Infection Control Nurse on 10/22/20 at 4:35 PM, she confirmed that the facility failed to monitor for signs and symptoms of coronavirus illness (fever, cough, shortness of breath) every shift as ordered by the physician for Residents #1, #2 and #3. She stated she would notify the physician. According to the CDC.gov (Centers for Disease Control and Prevention) resource in Responding to Coronavirus (COVID-19) in Nursing Homes updated on April 30, 2020, CDC recommends: Resident with new-onset suspected or confirmed COVID-19 should have increased monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least three times daily to identify and quickly manage serious infections: Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms.

Based on observations and staff interviews, the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable environment in three (rooms [ROOM NUMBER]) of 41 sampled resident rooms. These concerns (unknown dried liquids, breakfast food on floor and soiled bathrooms) could impede residents' enjoyment of their environment, and present potentially unsanitary and uncomfortable conditions. The findings include: During observations of resident rooms on 1/21/20, 1/22/20 and 1/23/20, the following concerns were identified: 1. On 1/21/20 at 10:49 AM, room [ROOM NUMBER]-B was observed with an unknown dried liquid on the floor and stains on the bed sheet and pillowcase. Another observation on 1/21/20 at 12:00 PM, revealed the same dried liquid remained on the resident's floor. On 1/22/20 at 8:58 AM, the resident in room [ROOM NUMBER]-B was observed in bed resting on his left side. Hi was not interviewable. Breakfast food was observed on the floor and the unknown dried liquid remained on the floor from yesterday (1/21/20). Additional observations on 1/22/20 at 1:00 PM and 1/23/20 at 8:24 AM revealed the unknown dried liquid and dried food residual remained on the resident's floor. On 1/23/20 at 11:55 PM, room [ROOM NUMBER]-B was observed to still have the unknown dried liquid on the floor. 2. In rooms [ROOM NUMBERS] on 1/21/20 at 11:28 AM the bathroom sinks and the floors in each of the rooms were soiled. On 1/22/20, the wall adjacent to room [ROOM NUMBER]-A bed was observed with two round, yellow, stained patches. Employee C, Registered Nurse (RN), who was attending to the resident in the A-bed, identified the yellow patches on the was as tube feeding formula stains. However, on 1/23/20 at 9:00 AM, the assigned housekeeper revealed in an interview that the stains on the wall were from feces. She cleaned the areas on 1/23/20 at 8:00 AM. The dresser cabinet in room [ROOM NUMBER] was also water-damaged at its base and was unsightly. 3. On 01/21/20 at 2:35 PM, the resident in room [ROOM NUMBER]-B complained that her bathroom shower had not been cleaned for at least one month. She stated the housekeeper may sweep daily but the room was not mopped daily. An interview was conducted with the Environmental Services Director on 1/23/20 at 12:00 PM, who stated Environmental Services staff were to clean rooms daily and as needed. When he was made aware of the condition of the floor in room [ROOM NUMBER] (dried liquid since 1/21/19), he stated it should have been cleaned up according to the facility's process. He further stated he was going to speak with his staff and reeducate them. The plan was to also increase the amount of quality control checks performed each shift. .

Based on observations, interviews, and record review, the facility failed to ensure that it adequately equipped two residents (Resident #58 and Resident #109) to call for staff assistance through a communication system which relayed the call directly to a centralized staff work area. The findings include: During the initial Stage 1 survey activity on 07/31/2017 at 1:04 PM, Resident #58 was asked to activate the call light. The resident was able to easily manipulate the call light switch and activate it, but it did not work. Several observations were made of the light above the room door and the call light wall attachment in the room. There was no indication that the call light was working. Employee B (Registered Nurse (RN) was present and confirmed that the call light was not working in Resident #58's room on 07/31/2017 at 1:04 PM. Several attempts had been made to activate the system. Employee B's supervisor stated that she would notify maintenance of the problem. During the interview on 07/31/2017 at 1:07 PM, Resident #58 was asked if she used the call light, and she nodded her head up and down in the affirmative and stated, Yes. She was asked if it took a long time for the staff to come and help her, and she nodded in the affirmative up and down again stating, 'Yes'. Another observation was made during the Stage 1 process on 07/31/2017 at 1:25 PM. The call light switch was depressed for Resident #109, but it didn't activate the call system. The light over the resident's door did not illuminate. No signal sounded. There was no indication that the call light was working. Employee F, Maintenance, was notified and confirmed that the call light was not operational. On 07/31/2017 at 1:31 PM, Employee G (Maintenance) arrived and changed out the call light device for Resident #109, confirming that the call light was not working. Once the device was changed, the call light was operational. The Director of Maintenance arrived at Resident #58's room with a call light cord on 07/31/2017 at 1:11 PM. The employee brought a new switch for the resident and stated to this surveyor, The switch is broken; see, they broke it. They broke it by putting too much pressure on it. The Maintenance Director also stated, You would notice it. Someone should have noticed it. The nursing staff write us a ticket, and we also check the call lights ourselves every month. I'll bring it (the log) to you in the conference room. The call light was confirmed as working once the cord had been replaced. An interview was conducted with Resident #4 on 8/01/2017 at 10:23 AM, at which time Employee C responded to the call light. Resident #4 stated, Sometimes the call light does not light up; not all of the time. The resident was asked how they would know the light was not working, and the resident stated, I go out and look right above my door there, as I am blessed to get out in my wheelchair and go and do what I want to do, and I go look at it and it is not on. Employee C, CNA, confirmed during an interview on 8/01/2017 at 10:26 AM, that Maintenance had repaired Resident #4's call light last week. Based on a review of the facility's monthly log for call light monthly checks and inspections, the maintenance staff was inspecting the call lights. However, it was not clear that when individual resident room call lights went out, that it was reported to maintenance for repair.

Based on resident record reviews and interviews with staff, the facility failed to revise the plan of care when [MEDICAL CONDITION] medications were discontinued for 1 of 5 residents reviewed for unnecessary medication use (Resident #101), out of a total of 31 sampled residents. The findings included: Record review for Resident #101 revealed a quarterly Minimum Data Set assessment (MDS), with an assessment reference date of 4/7/16. Resident #101 was coded with an active [DIAGNOSES REDACTED]. The box indicating receipt of anti-anxiety medications during this timeframe was left blank, indicating she had not received any. Resident #101's care plan, dated 4/29/16, included the use of anti-anxiety medications for an anxiety disorder. The goal was to be free from discomfort or adverse reactions related to anti-anxiety therapy, and to show decreased episodes of anxiety through the next review date. Interventions included resident education about risks, benefits, and side effects of anti-anxiety medication, administer medication as ordered, and monitor for side effects. Review of Resident #101's physician's orders [REDACTED]. The electronic order history revealed Resident #101 had a discontinued order for the use of [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 07/14/2016 at 12:58 PM. She reviewed the record for Resident #101, and confirmed the anti-anxiety medication was discontinued in February 2016, yet the care plan had not been revised to reflect this change. She stated she should have notified the care plan office after the anti-anxiety medication was discontinued. In an interview with the Care Plan Coordinator on 07/14/2016 at 1:35 PM, she stated she would have revised the plan of care by discontinuing the plan for anti-anxiety medication had she known Resident #101's medication had been discontinued. She stated she would need to revise the care plan for this resident.

Based on observations and staff interview, the facility did not dispose of garbage and refuse properly as evidenced by three of three dumpsters with food and trash debris around the dumpsters; broken equipment and cardboard piled next to the recycling dumpster, and the recycling dumpster was overflowing with damp cardboard boxes. (Photographic evidence obtained) The findings include: During the facility tour, the following was observed: 1. On 7/13/16 at 9:30 a.m., the recycling dumpster was observed overflowing with cardboard boxes that appeared saturated and wet. In addition, three feet of broken down, cardboard boxes was stacked behind the recycling dumpster next to an overturned laundry bin. Behind the dumpsters there were visual amounts of refuse that included two white gloves, several white pieces of paper, empty soda cans, empty food containers, and bags observed on the ground. 2. On 7/14/16 at 1:50 p.m., the recycling dumpster remained in the same condition as observed on 7/13/16. Additional amounts of refuse were observed behind the dumpsters that included white gloves, paper products which were wet and stuck to the ground, empty soda cans, empty food containers and bags, and additional cardboard boxes stacked on top of the piled cardboard boxes observed on 7/13/16. An interview was conducted on 7/14/2016 at 1:52 p.m. with the Nutritional Service Director. She confirmed the condition of the dumpsters and stated she was unsure of the pickup days for the recycling dumpster.

Based on observation, record review, and interview the facility failed to provide care according to professional standards of quality regarding administration of medication that lowered blood pressure for 1 resident (Resident #102), out of 5 residents reviewed for unnecessary medications, out of 40 sampled residents. The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences" which shall include, but not limited to the promotion of wellness, maintenance of health and prevention of illness of others, and the administration of medications and treatments as prescribed by a duly licensed practitioner. The findings include: During observation of medication administration for Resident #102 on 5/28/15 at 8:15AM, Employee A (LPN) was unable to obtain a blood pressure reading from the resident after 2 attempts. Employee A administered the resident's prescribed [MEDICATION NAME] Tablet (a medicine to lower blood pressure) 10 milligrams (mg). Employee A told the resident that she was going ahead and giving him his blood pressure medicine, because she knew his blood pressure always ran high. Employee A said she would try and take the resident's blood pressure again later. Review of the medical record for Resident #102 revealed a physician order [REDACTED]. The order also contained parameters to hold the medication for a systolic blood pressure (top number) below 110, or a diastolic blood pressure (bottom number) below 50. Review of the care plan for Resident #102 revealed an intervention to obtain blood pressure readings per physician orders. Resident #102's May, 2015 Medication Administration Record [REDACTED]. The prescribed blood pressure parameters were also on the MAR indicated [REDACTED]. The boxes designated on the MAR for the blood pressure values were marked with "X". On 5/28/15 at 9:50 AM the Director of Nursing (DON) confirmed that there was no blood pressure documentation on the MAR for Resident #102 for 5/23/15 - 5/28/15. She stated the electronic MAR indicated [REDACTED]. She further stated that the nurses could document the resident's blood pressure in other areas of the medical record. The DON was not able to locate any documentation of blood pressure monitoring prior to the administration of Resident #102's [MEDICATION NAME] from 5/23/15 - 5/28/15. Review of the package insert for [MEDICATION NAME] revealed under the heading Warnings and Precautions that the patient should be assessed for [MEDICAL CONDITION] when administering the medication. .

Based on medical record review, facility staff interview, and hospital staff interview, the facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) prior to admission for 1 resident (#222) out of 40 sampled residents reviewed for preadmission screening. Failure to perform this assessment prior to admission may lead to the facility admitting residents with mental illness or mental [MEDICAL CONDITION] who are not receiving the care and services they need in the most appropriate setting. The findings include: Review of the medical record for Resident #222 was conducted on 5/27/15 and no evidence was found of a Level 1 PASRR being completed prior to the resident being admitted to the facility on [DATE]. The Social Services Director provided a copy of a Level 1 PASRR for Resident #222 that was dated 5/27/15 and signed by the hospital RN Case Manager. Interview with the Administrator on 5/28/15 at 1:20PM revealed that the facility did not have a written policy or procedure for conducting the PASRR, or ensuring that it is completed prior to residents' admissions. She stated the admitting clerk goes to the hospital to look at the new admission and get the paperwork. If the PASRR is not completed the facility's Director of Nursing (DON) or Assistant Director of Nursing (ADON) can review the resident's medical record and complete the paperwork before the resident comes to the facility. The Administrator arrived at 1:40PM and reviewed the PASRR 1 for Resident #222 who was admitted to the facility on [DATE] and the PASRR was dated 5/27/15. The Administrator stated she didn't know why it wasn't done prior to the residents admission. Interview on 5/28/15 at 1:25PM with Employee F (Social Worker) revealed it was her job to review the admission and make sure the PASRR was done. She confirmed that the PASRR was supposed to be done prior to residents coming to the facility. On 5/28/15 at 2:30PM the Administrator produced an additional copy of a PASRR on Resident #222 that was dated 5/24/15 and signed by the same hospital case manager. The Administrator stated she talked to the admission clerk and she had the original PASRR form that was dated 5/24/15. On 5/28/15 at 4:30 PM an interview was conducted with the hospital case manager. The case manager stated that she completed the PASRR on Resident #222 on 5/27/15. She said that she did not work on 5/24/15, the day of the resident's discharge from the hospital. She was not aware of any PASRR completed for Resident #222 until 5/27/15, when she completed a Level 1 for the resident. .