Every finding on record at Life Care Center of Sarasota

Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of correction to correct deficient practice identified during the recertification survey originally conducted 9/11/2025 to 9/18/2025 as evidenced by: 1) to ensure two of six sampled residents (#2 and #10) had updated care plan interventions in place related to falls and 2) failed to: 1) prevent a fall with major injury for two Residents (#1 and #2) and, 2) prevent multiple falls for one Resident (#10) out of four residents sampled for injuries and accidents. Cross reference F656 and F689 Findings included:1)Review of the facility's plan of correction for the survey ending on 9/18/2025 with a completion date of 10/18/2025 revealed the following measure would be taken to correct the deficient practice which was identified at F656:(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place;The Director of Nursing / designee will complete 5 random weekly observations of residents with orthotics to ensure they are being applied and implemented according to the residents' plan of care. Results of the observations will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting for a period of 3 months or until sustained compliance is achieved.On 12/15/2025 and 12/16/2025 a revisit survey, in conjunction with new complaint surveys, was conducted to ensure compliance with F656. During these surveys, it was discovered that F656 remained out of compliance due to Resident #2 and Resident #10's care plans not being updated/revised with appropriate interventions. An interview was conducted with the facility's Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 12/16/2025 at 3:41 p.m. to discuss the corrective action taken by the facility to achieve compliance with F656 following the survey ending 9/18/2025. The DON stated education was provided to staff focusing on ensuring orthotics are being applied and implemented according to plan of care. The facility did not look at the various aspects of updating/revising residents' plan of care related to other care areas, when the plan of correction was formulated. 2)Review of the facility's plan of correction for the survey ending on 9/18/2025 with a completion date of 10/18/2025 revealed the following measure would be taken to correct the deficient practice which was identified at F689:(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place.The Director of Nursing / designee will complete a monthly audit (if this situation has occurred) of 1 resident who has relocated from the memory care unit to other units in the facility to ensure residents supervision needs are being provided according to the plan of care. Results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting for a period of 3 months or until sustained compliance is achieved.On 12/15/2025 and 12/16/2025 a revisit survey, in conjunction with new complaint surveys, was conducted to ensure compliance with F689. During these surveys, it was discovered that F689 remained out of compliance due to prevent a fall with major injury for two (Resident #1 and #2) and, 2) prevent multiple falls for one Resident (#10).An interview was conducted with the facility's Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 12/16/2025 at 3:41 p.m. to discuss the corrective action taken by the facility to achieve compliance with F689 following the survey ending 9/18/2025. The DON stated the plan of correction was focused on residents who were taken off the memory care unit. One of the things that were looked at were supervision needs for every resident that fell. She does not believe they educated everybody on the entirety of F689 and fall prevention. The check list was used to make sure staff were assessing.Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 11/4/2025, showed: Policy: The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. At a minimum, the QAPI program will: 1. Address all systems of care and management practices; 2. Include clinical care, quality of life and resident choice; 3. Utilize the best available evidences to define measure indicators of quality and facility goals that reflect process of care and facility operations that have been shown to be predictive of desired outcomes for residents; and 4. Reflect the complexities, unique care and services that the facility provides. Procedure: 1. The facility will ensure QAPI programs address systems of care and management practices. a. Systems of care (or care delivery systems) are the processes in place to achieve an expected clinical outcome. For example, the system for prevention of pressure ulcers also involves the system for ensuring adequate nutrition, as well as the systems for identification of changes in condition and infection prevention. 4. The authority for the planning and implementation of the Quality Assurance Performance Improvement (QAPI) program is delegated by the Board of Directors to the Divisional/Regional teams and the Executive Director at the facility. 5. The Executive Director assumes responsibility for the implementation and coordination of the Quality Assessment and Assurance (QAA) activities as defined in the facility's QAPI plan. The QAPI program is designed to sustain during times of transitions in leadership or staffing. 6. The Executive Director will assure the QAPI plan is reviewed annually by the Quality Assessment and Assurance (QAA) Committee. The QAA committee will make any necessary revision to the plan on an ongoing basis as indicated. Any changes to the plan will be communicated to the residents/patients, families, and associates through meetings and other means that are agreed upon by the QAA committee as they occur.

Based on observations, interviews and record review, the facility failed to to ensure care was provided in accordance with professional standards related to the use of orthotics for one resident (#100) of two residents reviewed during three days (9/8/2025, 9/9/2025, and 9/10/2025) of four days observed.Findings included: During multiple tours conducted on 9/8/2025 between 10:45 a.m. and 2:45 p.m., and on 9/10/2025 at 7:30 a.m. and at 9:50 a.m., Resident #100 was observed in his room lying in bed with no Right-hand splint/brace/hand carrot on and no heel protector boots on either of his feet. On 9/9/2025 at 9:40 a.m. an interview with Resident #100's family member who revealed they visited the resident daily. The family member Resident #100 was six feet four inches and that he lies in bed all day, by choice and his feet are always scrunched up against or positioned on top of the foot board. The family member revealed the resident had wounds on his heels and are being treated but did not think having his feet pressed up against or placed on top of the hard wooden foot board helped with healing and comfort. The family member stated having notified facility staff and assumed there was nothing that could be done. Resident #100 who had cognitive deficiencies with dementia was not interviewable and could not express if the bed was too short and if he had any discomfort or pain related to his feet placed on the foot board. The family member revealed not being aware of Resident #100's heel protector boots or a Right-hand splint/hand carrot device and having not seen them applied to the resident. An interview was conducted on 9/10/2025 at 10:00 a.m. with Staff T, Registered Nurse (RN)/Unit Manager in100 hall. Staff T revealed she was aware and knowledgeable of Resident #100's care and services. Staff T revealed she would follow up with the missing heel protector boots and Right-hand splint/brace. Staff T searched in the resident's room and confirmed both of his feet were without heel protector boots on and were positioned up against the footboard and he was not wearing a Right-hand splint/hand carrot. Staff T. confirmed Resident #100's feet should not have been pressed up against the foot board. Staff T left the room and was observed walking down the hallway with a clear plastic bag with contents to include heel protector boots. Staff T and another staff member entered the room with the bag of heel protector boots and donned them on the resident. A follow -up interview with Staff T confirmed she had to get boots from the therapy department. Staff T revealed the resident showed no behaviors or discomfort when placing the boots on. She confirmed the resident had not been assisted with the heel protector boots. Staff T confirmed not having observed the resident with the orthotics prior to this day. Review of Resident #100's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to: Alzheimer's, dementia, depression, restlessness and agitation, seizures, and need for personal assistance.Review of the current physician orders for the month of 9/2025 revealed the following orders:a . Monitor Splint/Brace/Medical device to R (right) hand. Check skin integrity around or under device, pain and circulation x shift and document any changes in progress notes (order date 8/27/2025).b . Splint/Brace/Medical device: Allmed therapy Carrot Hand Contracture Orthotics. Apply to R hand for at least 1 hour. On during the day and off at night. Assess pain level, circulation and skin integrity, every shift document in progress note any changes (order date 8/27/2025).c . Wound treatment for R heel: clean with n/s, apply silver alginate to wound bed, cover with gauze Island w/bdr, every night shift (order date 8/11/2025).d . Elevate heels when in bed to alleviate pressure as tolerated every shift (order date 9/16/2022). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview Mental Status (BIMS) score of 3 of 15 indicating the resident was severely impaired. Section GG revealed the resident had impairment on both sides with upper extremities, impairment on one side with lower extremity and was dependent on staff for ADLs (activities of daily living).Review of the nurse's progress notes dated 6/1/2025 through 9/10/2025 revealed there was no documentation related to the use of orthotics or refusals. Review of a physician's progress note dated 8/25/2025 revealed Resident #100 was seen today for monthly follow up. Resident with Pressure ulcer right heel stage 4, Pressure ulcer left heel stage 3, Wound care onboard managing treatments to include Encourage off-loading of pressure from the affected areas using specialized footwear or heel protectors. Review of Resident #100's Medication Administration Record (MAR)dated 9/2025 revealed:- Monitor splint/brace/medical device to Right hand. Check skin integrity around or under device, pain and circulation every shift document any changes in progress notes and notify MD (medical doctor) if appropriate (order date 8/27/2025).- Splint/Brace/Medical device: Allmed therapy carrot hand contracture orthosis. Apply to R hand for at least one hour. On during the day, and off at night. Assess pain level, circulation, and skin integrity. Every shift document in progress notes of changes and notify MD if appropriate (order dated 8/27/2025)Review of the MAR for all days in 9/2025 indicated documented as completed for both day and night. However, observations revealed no splints were donned or offered on days 9/8/2025, 9/9/2025, and 9/10/2025.Review of the current care plans with a next review date 10/19/2025 revealed:A . Dependent on staff and wife for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits, physical limitations, Alzheimer's. He chooses to stay in bed, with interventions in place. B . Has ADL self-care performance deficit r/t activity tolerance, progressive dementia with impaired cognition, psychosis with delusions, restless agitation, with interventions in place to include: Apply (R) hand carrot for at least one hour a day as tolerated and to be off at night. Assess pain level, circulation and skin integrity during use; Bed Mobility, the resident requires assist of (1) staff for repositioning and turning in bed.C . Impaired skin integrity Arterial ulcers R heel, with interventions in place to include: Enhanced barrier precautions,D . Risk for break in skin integrity r/t impaired mobility, incontinence, dx. of anemia, PVD, history of pressure ulcers and arterial ulcers, with interventions in place to include: Air mattress with bilateral bolsters, check placement and function, heel elevating boots per Current MD Order, Pressure reducing mattressOn 9/10/25 at 1:50 p.m. an interview was conducted with Staff W, Registered Occupational Therapist. Staff W revealed he was responsible to don and doff the Right-hand splint/brace/carrot hand roll daily for Resident #100. He further revealed that if he does not get to it, nursing will. Staff W stated not being sure what nursing staff member would be responsible each day. Staff W confirmed on the days he does not work, nursing should be donning and doffing the hand device. He revealed this device is to be used for contracture management and to lower the risk for further breakdown. Staff W did not have any documentation to support when he dons and doffs the device. He confirmed he does not document in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and that is the responsibility of the nurse.Various interviews were conducted on 9/10/2025 during the 7 a.m. -3 p.m. shift with assigned Certified Nursing Assistants and nurses on the 100 unit. These nursing staff did not know if Resident #100 utilizes heel protector boots or a Right-hand splint/hand carrot. The nursing staff stated not having seen Resident #100 with the devices. On 9/11/2025 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) They provided the facility's policy and procedure titled, splints and braces - upper extremity, review date of 9/20/2024 for review. The policy revealed: The facility will provide splints and braces to upper extremities in accordance with professional standards of practice, as outlined by [name of a digital reference tool and training platform] through the procedure link. The policy showed federal regulation stating - The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality. The procedure section revealed; The facility will utilize the Lippincott procedures: Splints and braces, upper extremity.The NHA and DON stated the facility did not have a specific policy and procedure related to contracture management program nor had a policy related to splints and braces for lower extremities.

Based on observations, record review, and interviews, the facility failed to provide adequate supervision to prevent a fall resulting in major injury and hospitalization for one resident (#11) of two residents reviewed.Findings Included:Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a primary diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. Other diagnoses included encounter for other orthopedic aftercare, muscle weakness, need for assistance with personal care, end stage renal disease, history of falling, and repeated falls.Review of a hospital history and physical for Resident #11 dated 09/09/2025 showed .the patient presented from nursing facility after having an outpatient X-ray that showed a femoral neck fracture. It was reported the patient had a fall on Saturday and had evaluation outpatient. Patient was complaining of hip pain while at dialysis. The X-ray showed a fracture. Patient does not appear in any discomfort or pain at this time. On arrival patient had a CT (Computed Tomography) of pelvis that showed a comminuted intertrochanteric fracture of the right femur with impaction; healed sacral and left pubic rami fractures. Compression screw noted within the left femoral neck per urology read.Review of a quarterly Minimum data Set (MDS) for Resident #11 dated 06/30/2025 revealed in section B the resident had impaired vision and sometimes understands verbal content. section C revealed the resident had a Brief Interview Mental Status score of 04, which meant severe cognitive impairment. Section GG revealed the resident used a wheelchair and walker for mobility and was dependent on staff for activities of daily living (ADLs) to include toileting hygiene, personal hygiene, and lower body dressing. Resident #11 required partial to moderate assistance for toilet transfers.Review of progress notes for Resident #11 dated 09/04/2025 revealed Resident #11 who resided in the memory care (Serenity) unit was readmitted to the facility following Covid diagnosis and was moved from the unit for isolation. The progress note dated 09/04/2025 at 4:56 p.m. showed, family member aware [Resident #11] will return to Serenity unit once she is finished with isolation.Review of a physician note dated 09/04/2025 at 4 p.m. revealed under assessment plan, family member stated demented [Resident #11] is confused and demands a UA (urinalysis) . Continue above medications and fall precautions.Review of a progress note dated 09/06/2025 at 4:21 p.m. revealed, nurse alerted to the room. Pt (patient) was found on the floor on her right side, on the right side of the bed. Bed was in the lowest position. Neuros initiated . Nurse helped the CNA (Certified Nursing Assistant) put the patient back in her bed. Nurse cleansed the skin tear RUE (right upper extremity) with normal saline, Zeroform and clean, dry dressing. Physician made aware. POA (power of Attorney) made aware.Review of a progress note dated 09/06/2025 at 9:21 p.m. revealed the resident was given Acetaminophen 325 MG (milligram), Give 2 tablets by mouth as needed for mild pain (1-3).Review of a skilled note dated 09/09/2025 revealed .Resident is a fall risk and assisted with all ADLs by CNA. Resident pain and medications are managed by nursing staff.Review of a physician progress note dated 09/09/2025 at 12:51 p.m. showed, Fall out of bed on 9/6, found on right side, minimum pain-now with increased pain. X-ray ordered, found to have acute left femoral neck fracture.Review of a progress note dated 09/09/2025 at 1:52 p.m. revealed, doctor called from hospital and resident will be admitted to the hospital at this time.On 09/10/2025 at 04:39 p.m. an interview was conducted with Staff S, Licensed Practical Nurse (LPN). Staff S stated Resident #11 experienced a fall on 09/06/2025 and reported being alerted by the CNA of Resident #11's fall. Staff S stated Resident #11 was observed on the floor, after which the resident was assisted to bed, then evaluations were completed for the resident.During an interview on 09/11/2025 at 10:40 a.m. with Staff I, CNA and Staff P, Registered Nurse (RN), Staff I, CNA explained assisting Staff R, CNA and Staff S, LPN in response to Resident #11's fall. Staff I, CNA stated Staff S, LPN looked at the resident and stated the resident was fine and instructed the CNAs to pick the resident up. Staff I, CNA stated the resident expressed pain in the right hip and grabbed the right hip.On 09/09/2025 at 3:05 p.m. an interview was conducted with Staff M, LPN/Unit Manager (UM) who explained Resident #11 went to a local hospital due to a fall on 09/06/2025. The Unit Manager stated Resident #11 was a long-term care resident residing in the Serenity wing. The resident had a respiratory infection, went to a hospital, was diagnosed with Covid and returned to the facility on [DATE]. Staff M stated the resident went to the Manatee/Cardiac wing, away from the Walkie Talkie residents in the Serenity wing. Staff M stated the resident was placed in the Manatee Wing for isolation and was planning to return to the Serenity wing on 09/09/2025. Staff M stated the resident was found on the floor and skin and pain assessments were performed. The staff member stated the resident had a skin tear to the right upper extremity. Staff M stated neuro checks were initiated but the X-ray was not ordered at the time. Staff M stated on 09/08/2025 the resident started complaining of pain and the X-ray was ordered on 09/09/2025 which showed a dislocation to right hip. Staff M stated the resident was referred to the emergency room for further scans.On 09/10/2025 at 9:34 a.m. an interview was conducted with Staff Y, CNA. Staff Y stated Resident #11 would propel self-down the hall. She stated someone was always watching the resident and the resident had not fallen for at least 6 to 7 months. The staff member stated the resident's bed was usually in a low position, unless care was being performed. Staff Y stated the resident would never use a call light at the time. She stated seldom, the resident would sit up but never tried to get out if bed. Staff Y stated someone was always watching the resident during their shift. The staff member stated resident #11 was familiar to the environment.An interview was conducted with Staff Z, CNA on 09/10/2025 at 9:46 a.m. Staff Z stated Resident #11 was typically in the dayroom, being monitored by staff and even when the resident was not participating in the activities, the resident would be placed in the living room for monitoring. Staff Z stated the resident was not left in the room by themselves. Staff Z stated they never saw the resident using a call light.During an interview with Staff V, LPN on 09/10/2025 at 10:01 a.m., this staff member stated Resident #11 was typically confused and staff tried to keep the resident involved in activities. Staff V stated the resident would not be in the room and would be involved in activities and self-propelling around the unit. Staff V stated the resident could not use the call light and confirmed the resident had not had a fall in the memory care unit. Staff V stated they believed the resident fell out of bed, due to not being able to self-propel around, and after not being able to get out of bed and that was why they attempted to do so by themselves. Staff V stated the staff in the Serenity wing would help transfer the resident.An interview was conducted with Staff AA, CNA/Activities Aide on 09/18/2025 at 09:15 a.m. Staff AA stated Resident #11 was typically involved in the group setting activities and the resident is typically supervised by all staff in the Serenity unit. Staff AA said, in this unit, no resident is left by themselves. Staff AA stated the resident had not fallen in the memory care unit and they spent most of the time rolling self around in the wheelchair.An interview was conducted with Staff U, CNA on 09/10/2025 at 9:30 a.m. Staff U stated the residents in the Serenity unit are watched all day and the every two hours schedule does not apply. Staff U stated the residents, and staff were always in the activities room. Staff U stated the staff makes sure the residents are monitored.An interview conducted on 09/18/2025 at 10:15 a.m. with Staff CC and BB, CNAs revealed the residents in the Serenity unit cannot go anywhere unsupervised, however the resident in the cardiac unit can go anywhere by themselves and do things by themselves. The staff members stated the residents in the serenity unit require more supervision than the residents in the cardiac unit. The staff members said, For cardiac unit residents, one can take their eyes off of the resident, but for the Serenity unit, one must keep eyes on the residents. They stated residents who require more attention are placed near the nursing station to receive constant checks. The staff members stated Resident #11 was placed in a different room for Covid isolation. Staff BB confirmed working with the resident when the resident was in the Serenity unit and two other times in the cardiac unit. Staff BB stated if they knew a resident came from the Serenity unit to the cardiac unit, they would pay more attention to the resident because the residents from there required more attention.An interview was conducted with Staff I, CNA on 09/18/2025 at 10:45 a.m. Staff I who typically worked the cardiac unit (Manatee) stated they check on their residents every hour or one and half hours. Staff I stated working with Resident #11 who was confused all the time. Staff I stated not knowing why the resident was in the cardiac unit, but that the resident did require more attention and supervision. Staff I stated Resident #11 tried to get up without assistance and tried to walk without assistance. Staff I stated they were to follow-up every hour or one and a half hour. Staff I confirmed having assisted another CNA in getting the resident back to bed after the fall. Staff I stated the resident mentioned pain on their hip. Staff I stated the nurse checked the resident and took vitals. On 09/18/2025 at 10:35 a.m. an interview was conducted with Staff P, RN who works the cardiac/Manatee unit. Staff P stated residents that come from the Serenity unit required more supervision due to the mental state of the resident. Staff P stated the residents are unable to use call lights. Staff P stated checking on residents during rounds when shift starts. This staff member stated the expectation was to check on a resident every two to three hours. Staff P stated on 09/08/2025 Resident #11 mentioned pain when they were seen by therapy. Staff P stated they notified the provider and an X-ray was requested.On 09/18/2025 a 12:46 p.m. an interview was conducted with the Physical therapy Assistant (PTA) the PTA stated they went to assess the resident because the family member mentioned the resident was in a lot of pain from a fall over the weekend. The PTA stated when they tried to move the resident, the resident would say ouch and so forth. The PTA stated moving the resident's leg slightly and the resident was grimacing. The PTA stated they notified the nurse.A telephone interview was conducted with Resident #11's physician on 09/18/2025 at 12:17 p.m. The physician stated being familiar with the resident. The physician said if a resident has a fall, it is possible not to have pain until a couple days later, though it is seldom. The physician stated even though the X-ray for Resident #11 was delayed by three more days, the result would be no different.An interview was conducted with the Risk Manager (RM) and The Director of Nursing (DON) on 09/18/2025 at 01:23 p.m. The DON and RM stated residents in the secure/memory care unit require more supervision than the residents who are not in the unit. The RM stated Resident#11 was placed in the cardiac unit for isolation because the residents in the secure unit wander into others rooms. the RM stated the resident did not require further supervision because they were not an elopement risk. The DON stated she thought the resident fell because she was trying to take herself to the bathroom. The DON stated the resident was used to being very social and attended activities.Review of a care plan for Resident #11 last revised on 07/07/2025 showed:Focus 1. Resident #11 has an ADL self-care performance deficit related to impaired cognition and need for staff assistance with ADLs and transfers. Resident returned from the hospital and had a fall at the hospital with the left hip fracture and surgical repair. Interventions included resident required assistance of one staff for bed mobility personal hygiene toilet juice and transfers.Focus 2. Resident #11 has a diagnosis of anxiety and is at risk for increased restlessness related to anxiety. Interventions included to observe the resident for behavior episodes and attempts to determine underlying cause. Consider location time of day persons involved and situations.Focus 3. Resident #11 has impaired cognitive ability/ impaired thought process related to dementia. Interventions included To cue, reorient and supervised as needed and to Keep the residence routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.Focus 4. Resident #11 is at risk for falls related to decreased mobility and cognition, initiated and history of recent fall. Interventions included Anti tippers to wheelchair, anticipate and meet the residents needs, assist with ADls as needed, call light within reach, provide appropriate footwear such as non skid socks or rubber soled shoes when ambulating or mobilizing in wheelchair, raised edge mattress, redirect from dining room after dinner and toileting programReview of a facility policy titled, Fall management, Revised 03/11/2025, revealed a Policy - The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Definitions: 3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Supervision/Adequate Supervision - Refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.

Based on observations, interviews and record review, the facility failed to implement care plan interventions related to the use of orthotics for one resident (#100) of two residents reviewed during three days (9/8/2025, 9/9/2025, and 9/10/2025) of four days observed. Findings included: During multiple tours conducted on 9/8/2025 between 10:45 a.m. and 2:45 p.m., and on 9/10/2025 at 7:30 a.m. and at 9:50 a.m., Resident #100 was observed in his room lying in bed with no Right-hand splint/brace/hand carrot on and no heel protector boots on either of his feet. On 9/9/2025 at 9:40 a.m. an interview with Resident #100's family member who revealed they visited the resident daily. The family member Resident #100 was six feet four inches and that he lies in bed all day, by choice and his feet are always scrunched up against or positioned on top of the foot board. The family member revealed the resident had wounds on his heels and are being treated but did not think having his feet pressed up against or placed on top of the hard wooden foot board helped with healing and comfort. The family member stated having notified facility staff and assumed there was nothing that could be done. Resident #100 who had cognitive deficiencies with dementia was not interviewable and could not express if the bed was too short and if he had any discomfort or pain related to his feet placed on the foot board. The family member revealed not being aware of Resident #100's heel protector boots or a Right-hand splint/hand carrot device and having not seen them applied to the resident. An interview was conducted on 9/10/2025 at 10:00 a.m. with Staff T, Registered Nurse (RN)/Unit Manager in100 hall. Staff T revealed she was aware and knowledgeable of Resident #100's care and services. Staff T stated not being aware Resident #100 had orders to utilize heel protector boots and stated they would look at the orders to get clarification. She reviewed the record and confirmed he was care planned and ordered for use of heel protector boots while in bed, and with feet to be elevated. Staff T went to Resident #100's room and confirmed Resident #100 was not wearing any type of Right-hand splint/brace or hand carrot device. Staff T revealed she believed it was the responsibility of Physical Therapy (PT) department to maintain the use and donning and doffing of the Heel protective boots and Right-hand splint/ hand carrot device on a daily basis. Staff T stated having reviewed Resident #100's medical record to include the Treatment Administration Record (TAR) for the month of 9/2025 and found there was no documentation of application of the orthotics. Staff T confirmed Resident #100 should be assisted with the heel protector boots and a Right-hand splint/hand carrot device. Review of Resident #100's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to: Alzheimer's, dementia, depression, restlessness and agitation, seizures, and need for personal assistance. Review of the current physician orders for the month of 9/2025 revealed the following orders:a . Monitor Splint/Brace/Medical device to R (right) hand. Check skin integrity around or under device, pain and circulation x shift and document any changes in progress notes (order date 8/27/2025).b . Splint/Brace/Medical device: Allmed therapy Carrot Hand Contracture Orthotics. Apply to R hand for at least 1 hour. On during the day and off at night. Assess pain level, circulation and skin integrity, every shift document in progress note any changes (order date 8/27/2025).c . Wound treatment for R heel: clean with n/s, apply silver alginate to wound bed, cover with gauze Island w/bdr, every night shift (order date 8/11/2025).d . Elevate heels when in bed to alleviate pressure as tolerated every shift (order date 9/16/2022). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview Mental Status (BIMS) score of 3 of 15 indicating the resident was severely impaired. Section GG revealed the resident had impairment on both sides with upper extremities, impairment on one side with lower extremity and was dependent on staff for ADLs (activities of daily living). Review of the nurse's progress notes dated 6/1/2025 through 9/10/2025 revealed there was no documentation related to the use of orthotics or refusals. Review of a physician's progress note dated 8/25/2025 revealed Resident #100 was seen today for monthly follow up. Resident with Pressure ulcer right heel stage 4, Pressure ulcer left heel stage 3, Wound care onboard managing treatments to include Encourage off-loading of pressure from the affected areas using specialized footwear or heel protectors. Review of Resident #100's Medication Administration Record (MAR)dated 9/2025 revealed:- Monitor splint/brace/medical device to Right hand. Check skin integrity around or under device, pain and circulation every shift document any changes in progress notes and notify MD (medical doctor) if appropriate (order date 8/27/2025). - Splint/Brace/Medical device: Allmed therapy carrot hand contracture orthosis. Apply to R hand for at least one hour. On during the day, and off at night. Assess pain level, circulation, and skin integrity. Every shift document in progress notes of changes and notify MD if appropriate (order dated 8/27/2025)Review of the MAR for all days in 9/2025 indicated documented as completed for both day and night. However, observations revealed no splints were donned or offered on days 9/8/2025, 9/9/2025, and 9/10/2025.Review of the current care plans with a next review date 10/19/2025 revealed:A . Dependent on staff and wife for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits, physical limitations, Alzheimer's. He chooses to stay in bed, with interventions in place. B . Has ADL self-care performance deficit r/t activity tolerance, progressive dementia with impaired cognition, psychosis with delusions, restless agitation, with interventions in place to include: Apply (R) hand carrot for at least one hour a day as tolerated and to be off at night. Assess pain level, circulation and skin integrity during use; Bed Mobility, the resident requires assist of (1) staff for repositioning and turning in bed.C . Impaired skin integrity Arterial ulcers R heel, with interventions in place to include: Enhanced barrier precautions, D . Risk for break in skin integrity r/t impaired mobility, incontinence, dx. of anemia, PVD, history of pressure ulcers and arterial ulcers, with interventions in place to include: Air mattress with bilateral bolsters, check placement and function, heel elevating boots per Current MD Order, Pressure reducing mattress On 9/10/25 at 1:50 p.m. an interview was conducted with Staff W, Registered Occupational Therapist. Staff W revealed he was responsible to don and doff the Right-hand splint/brace/carrot hand roll daily for Resident #100. He further revealed that if he does not get to it, nursing will. Staff W stated not being sure what nursing staff member would be responsible each day. Staff W confirmed on the days he does not work, nursing should be donning and doffing the hand device. He revealed this device is to be used for contracture management and to lower the risk for further breakdown. Staff W did not have any documentation to support when he dons and doffs the device. He also confirmed he does not document in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and that is the responsibility of the nurse. Various interviews were conducted on 9/10/2025 during the 7 a.m. -3 p.m. shift with assigned Certified Nursing Assistants and nurses on the 100 unit. These nursing staff did not know if Resident #100 utilizes heel protector boots or a Right-hand splint/hand carrot. The nursing staff stated not having seen Resident #100 with the devices. On 9/11/2025 at 2;00 p.m. the Director of Nursing (DON) provided the policy and procedure titled, Personal Centered Care Planning, with a last review date of 8/29/2025 for review. The Policy revealed; Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Definitions included: Interventions - are actions, treatments, procedures, or activities designed to meet an objective; Measurable - is the ability to be evaluated or quantified.The Procedure section revealed:1 The facility will develop a person-centered care plan that addresses the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline. 7. The care plan will be developed and implemented to ensure consistency with implementation across all shifts.

Based on observations, interviews and record review, the facility failed to provide one resident (#100) of thirty-nine sampled residents with a bed that met his height needs and comfort during three days (9/8/2025, 9/9/2025 and 9/10/2025) of four days observed. Findings included: On 9/8/2025 at 10:45 a.m. and 1:00 p.m. Resident #100 was visited while in his room. Both times observed, he was noted lying flat in bed with his head on a pillow. Further observations revealed Resident #100 was utilizing a mechanical air loss mattress system with bolsters on each side of the bed. The residents both feet were either pressed up against the end of the foot board or positioned on top of the foot board. Photographic evidence was taken with permission from Resident #100's wife, who was his decision maker.On 9/9/2025 at 8:30 a.m. and at 9:40 a.m., Resident #100's feet were observed propped up and pressed up against the end of the foot board. It appeared Resident #100 was tall in stature and not fitting comfortably in the bed. On 9/9/2025 at 9:40 a.m. an interview with Resident #100's family member who revealed they visited the resident daily. The family member Resident #100 was six feet four inches and that he lies in bed all day, by choice and his feet are always scrunched up against or positioned on top of the foot board. The family member revealed the resident had wounds on his heels and are being treated but did not think having his feet pressed up against or placed on top of the hard wooden foot board helped with healing and comfort. The family member stated having notified facility staff and assumed there was nothing that could be done. Resident #100 who had cognitive deficiencies with dementia was not interviewable and could not express if the bed was too short and if he had any discomfort or pain related to his feet placed on the foot board. During multiple tours on 9/9/2025 and on 9/10/2025 Resident #100 was observed in the same condition, his feet pressed against the foot of the bed.On 9/10/2025 at 10:00 a.m. an interview with Staff T, Registered Nurse (RN)/Unit Manager (UM) revealed she was knowledgeable of Resident #100 and his care and service needs. Staff T revealed the resident has dementia and does not get out of bed. Staff T revealed Resident #100 had wounds on his heels that is being treated for by the wound care team, and that he utilizes a mechanical air loss mattress with bolsters for comfort as well as decreasing risk for further pressure ulcers. Staff T confirmed Resident #100 was tall but could not say exactly how tall he was. Staff T went to Resident #100's room and confirmed his feet were pressed up against the foot board with a portion of one of his feet positioned on top of the wooden foot board. Staff revealed the foot board was bordering and placed against the end of the mattress. She revealed the foot board could be adjusted out but had not been done. Staff T confirmed Resident #100's feet were not placed properly and should not be positioned on the foot board due to him already having foot ulcers. Staff T stated Resident #100 should be wearing foot heel protector boots and was not aware why he was not wearing them. She confirmed he does not refuse the use of the protector boots, and stated staff should have been aware of the resident's feet pressing on the board.Review of Resident #100's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to: Alzheimer's, dementia, depression, restlessness and agitation, seizures, and need for personal assistance.Review of the current physician's orders for the month of 9/2025 revealed the following but not limited to orders:- Wound treatment for Right heel: clean with n/s, apply silver alginate to wound bed, cover with gauze island w/bdr (with a bordered dressing), every night shift (order date 8/11/2025).- Air mattress with bilateral bolsters check placement and function, every shift (order date 8/2/2024).- Skin prep to heels for skin protection every night shift (order date 6/6/2024).- Elevate heels when in bed to alleviate pressure as tolerated every shift (order date 9/16/2022).Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview Mental Status (BIMS) score of 3 of 15 indicating the resident was severely impaired. Section GG revealed the resident had impairment on both sides with upper extremities, impairment on one side with lower extremity and was dependent on staff for ADLs (activities of daily living).Review of the current care plans with a next review date 10/19/2025 revealed the resident was at risk for break in skin integrity r/t (related to) impaired mobility, incontinence, dx. (diagnosis) of anemia, PVD (Peripheral Vascular Disease), history of pressure ulcers and arterial ulcers, with interventions in place to include air mattress with bilateral bolsters, check placement and function, heel elevating boots per current MD (medical doctor) order, pressure reducing mattress. On 9/11/2025 at 1:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). They provided the Bed Inspection & Bed Maintenance and Bed Rail Installation policy and procedure with a last review date of 1/17/2025 for review. The policy revealed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When mattresses are used and purchases separately frame, the facility must ensure that the bed rails, mattress, and bed frames are compatible.Procedure:1. All new beds will be inspected by the maintenance department upon arrival to the facility. 5 . Routine inspections of the seven zones of entrapment are required for all bed and when there are any changes to the bed frame, mattress.a. Entrapment may occur in flat or raised bed positions:vii. Between head or footboard and mattress end.iv. Ensure that the mattress is appropriately sized for the bed frame.

Based on record review, interviews and policy review, the facility failed to report an injury of unknown origin for one resident (#11) of two residents sampled.Findings Included: On 09/09/2025 at 03:05 p.m. an interview was conducted with Staff M Licensed Practical Nurse (LPN) and Unit Manager (UM), of the Manatee unit. Staff M stated Resident #11 experienced a fall on 09/06/2025. Staff M stated the fall was not observed by staff. Staff M stated resident #11 went to the hospital on [DATE] after the resident complained of pain and an x-ray showed the resident had a hip fracture.On 09/10/2025 at 04:18 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). Staff R explained seeing Resident #11 on the floor on the right side of the resident's bed and laying on their right side. Staff R stated Resident #11 was not seen falling to the floor. Staff R stated Resident #11 complained of pain while receiving a bed bath.On 09/10/2025 at 04:39 p.m.an interview was conducted with Staff S, Licensed Practical Nurse (LPN). Staff S stated how or why the resident fell was unknown.On 09/11/2025 at 10:40 a.m. an interview was conducted with Staff P, Registered Nurse (RN), and Staff I, CNA. Staff I explained walking by Resident #11's room and observing Resident #11 on the floor and having notified the nurse. Staff I, stated Resident #11 expressed pain in the right hip, while being picked up off the floor.On 09/18/2025 at 12:46 p.m., an interview was conducted with Staff W Physical Therapy Assistant (PTA). Staff W stated Resident #11's family member/decision maker reported the resident was in pain due to a fall over the weekend. Staff W stated one of Resident #11's legs was moved slightly and the resident expressed pain. Staff W stated a nurse was notified. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a primary diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. Other diagnoses included encounter for other orthopedic aftercare, muscle weakness, need for assistance with personal care, end stage renal disease, history of falling, and repeated falls.Review of a hospital history and physical for Resident #11 dated 09/09/2025 showed .the patient presented from nursing facility after having an outpatient X-ray that showed a femoral neck fracture. It was reported the patient had a fall on Saturday and had evaluation outpatient. Patient was complaining of hip pain while at dialysis. The X-ray showed a fracture. Patient does not appear in any discomfort or pain at this time. On arrival patient had a CT (Computed Tomography) of pelvis that showed a comminuted intertrochanteric fracture of the right femur with impaction; healed sacral and left pubic rami fractures. Compression screw noted within the left femoral neck per urology read.Review of a quarterly Minimum data Set (MDS) for Resident #11 dated 06/30/2025 revealed in section B the resident had impaired vision and sometimes understands verbal content. section C revealed the resident had a Brief Interview Mental Status score of 04, which meant severe cognitive impairment. Section GG revealed the resident used a wheelchair and walker for mobility and was dependent on staff for activities of daily living (ADLs) to include toileting hygiene, personal hygiene, and lower body dressing. Resident #11 required partial to moderate assistance for toilet transfers.Review of a progress note dated 09/06/2025 at 4:21 p.m. revealed, nurse alerted to the room. Pt (patient) was found on the floor on her right side, on the right side of the bed. Bed was in the lowest position. Neuros initiated . Nurse helped the CNA (Certified Nursing Assistant) put the patient back in her bed. Nurse cleansed the skin tear RUE (right upper extremity) with normal saline, Zeroform and clean, dry dressing. Physician made aware. POA (power of Attorney) made aware.On 09/18/2025 at 01:23 p.m. an interview was conducted with the Director of Nursing (DON) and the Risk manager (RM)/Assistant Director of Nursing (ADON). The DON stated how the resident fell was unknown. The DON stated the resident experienced a fall and the injury sustained by Resident #11 was unwitnessed. The DON stated a five-day adverse should have been completed. The DON stated the incident should have been reported.Review of a facility policy titled Abuse- protection of Residents, reviewed 06/17/2024 revealed a policy - the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation.Procedure: The following methods to ensure the protection of residents during an investigation may include but are not limited to:5. Notification of the alleged violation to other agencies or law enforcement authorities.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty medication opportunities were observed, and four errors were identified for our residents (#39, #41, #71 and #88) out of eight residents resulting in an error rate of 13.33%. Findings included: On 9/9/25 at 8:32 a.m., Staff D, Registered Nurse (RN) was observed administering medication to Resident #39. Staff D, RN administered the following medications: Xanax 0.5mg (milligrams), Lexapro 20mg, losartan potassium 50mg, tamsulosin 0.4 mg and Lantus SoloStar pen injector. Staff D, RN dialed the dosage selector to 20 units on the Lantus SoloStar pen injector, cleaned the needle injector port with alcohol and inserted the needle into the injector port. Staff D, RN entered Resident #39's room prepared the injection site and administered the medication. When asked about priming the insulin injector pen Staff D, RN said, I don't do that.Review of Resident #39's admission record showed the resident was originally admitted on [DATE] and re-admitted on [DATE] with diagnoses not limited to Type 2 Diabetes Mellitus. On 9/9/25 at approximately 9:15 a.m., Staff V, Licensed Practical Nurse (LPN) was observed administering medication to Resident #71. Staff V, LPN crushed and administered the following medications: aspirin 81mg, cholecalciferol 1000 units, polysaccharide iron complex 150 mg, famotidine 20 mg, calcium citrate + vitamin D3 (calcium and vitamin D3 supplement).Review of Resident #71's admission record showed the resident was admitted on [DATE] with diagnoses to include fracture of the right femur, iron deficiency anemia and vitamin D deficiency.Review of Resident #71's orders showed orders including calcium citrate +oral tablet (multiple vitamins with minerals) Give 1 tablet two times daily for supplement, ordered date 2/25/25 and discontinued date 9/10/25. On 9/10/25 at 9:18 a.m. during an interview with the Director on Nursing (DON) and review of resident #71's Medication Administration Record (MAR), the DON said she recognized What's wrong and will contact Resident #71's Primary Care Physician (PCP) immediately.On 9/10/25 at 11:30 a.m., Staff A, LPN was observed administering medication to Resident #88. Staff A, LPN obtained fingerstick blood glucose and Resident #88's result was 251. Staff A, LPN reviewed the insulin orders and dialed the dosage selector to 6 units on the insulin Aspart, human pen injector, cleaned the needle injector port with alcohol and inserted the needle into the injector port. Staff A, LPN entered Resident #88's room prepared the injection site and administered insulin Aspart 6 units.Review of Resident #88's admission record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record include diagnoses of Diabetes Mellitus. On 9/10/25 at 11:38 a.m., Staff A, LPN was observed administering medication to Resident #41. Staff A, RN obtained fingerstick blood glucose, Resident #41's result was 396. Staff A, LPN reviewed the insulin orders and dialed the dosage selector to 13 units on the insulin lispro pen Injector, cleaned the needle injector port with alcohol and inserted the needle into the injector port Staff A, LPN entered Resident #41's room prepared the injection site and administered 13 units of insulin lispro. During an interview after the medications were administered, Staff A, LPN said, I forgot when asked about priming the insulin pen injectors. Review of Resident #41's admission record showed the resident was originally admitted on [DATE] and re-admitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus.During an interview on 9/10/25 at 12:50 p.m. the DON said insulin training was recently provided for the staff, and they were told to prime the pen. She said she expects staff to follow the training that was provided. Review of the facility's policy titled, Insulin Pen Administration, revised date 5/27/25 showed the following: Policy- The facility will ensure residents with orders for Insulin administration through the use of a pen delivery device is performed in accordance with current standards or practice and manufacturer's guidance. Procedure .4 The insulin pen should be primed prior to each use (in accordance with manufacturer's guidelines) to prevent the collection of air in the insulin reservoir.a. General guidance on priming an insulin pen in the absence of manufacturer's guidance.i). Dial 2 units by turning the dose selector clockwise ii, With the needle pointing up, push on the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat this procedure until at least one drop of insulin appears.Review of the facility's policy titled, General dose preparation and medication administration, revised date 11/15/24, revealed the following: Applicability- the procedures relating to general dose preparation and medication administration. Procedure .3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision to prevent one resident (#1) from exposure to the sun/heat, resulting in an altered mental status and skin damage to the legs, arms, and head, out of three residents sampled for outdoor activities. On 5/2/2025 Resident #1 was seated in a wheelchair in the courtyard area of the facility for approximately one hour from 2:45 p.m. to 3:45 p.m., during the hottest part of the day. Resident #1 was discovered to be unresponsive and had to be transferred to a higher level of care for treatment from sun/heat exposure. Findings included: Resident #1 was admitted to the facility in November 2024 with diagnoses including; Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus with neuropathy and chronic kidney disease, heart failure, muscle weakness, difficulty walking, cognitive communication deficit, dementia, cardiac pacemaker, and need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of the Order Summary Report, dated 3/06/22025-5/12/2025, revealed the following: -Aloe Vera external gel apply to affected areas topically every shift for sunburn for 7 days, initiated 5/4/25. -Benadryl allergy oral capsule (Diphenhydramine Hydrochloride) give 25 mg (milligrams) by mouth every 8 hours as needed for possible allergic reaction to skin, initiated 5/4/25. -Consult wound care for blisters on top of head, bilateral thighs, and left forearm, initiated 5/5/25. -Transfer out to hospital for evaluation, initiated 5/5/25. -Prednisone oral tablet give 40 mg by mouth one time a day for empiric for 5 days, initiated 5/5/25. A review of the Care Plan Report, initiated on 11/18/2024, revealed the following: 1-Focus area: Resident #1 is dependent on staff and family for meeting emotional, physical, and social needs related to physical limitations. (initiated 12/16/24; revised 2/18/25) Goal: The resident will maintain involvement in cognitive stimulation, social activities as desire through review date. Interventions included: -The resident needs assistance/escort to activity functions. Can propel self in wheelchair. -The resident preferred activities are ice cream time, eating in the main dining room, the outdoors, and visiting with family. 2-Focus area: Diabetes Mellitus (initiated 11/15/2024; revised 1/03/25) Goal: The resident will have no complications related to diabetes through the review date. Interventions included: -Avoid exposure to extreme heat or cold. -Observe and report PRN (as needed) any signs and symptoms of hypoglycemia, sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. A review of the Progress notes for Resident #1 revealed the following: -5/2/2025 16:38 Health Status Note Note Text: Patient [family member] notified of transfer to hospital. A review of the hospital Emergency Department (ED) Physician record from admission date 5/2/2025 for Resident #1 revealed the following: History of Present Illness: The patient presented to this ED for evaluation via EMS from [Facility name]. Caregivers at [Facility name] found the patient to be somnolent and minimally responsive after he was out sitting in the sun for a bit. They could not arouse him, so EMS was called. No fall reported, no fever, no vomiting or diarrhea. On arrival here, the patient is awake and alert but poorly interactive, no facial droop, moving all 4 extremities. Medical Decision Making: The ER work up include EKG (electrocardiogram), chest x-ray, routine labs, urinalysis, viral swab, CT imaging of the brain. All are found to be unremarkable, no acute findings. Dehydration and Rhabdomyolysis have both been ruled out. Patient appears to be acting much better after receiving a liter of IV fluid. Impression and Plan: Altered mental state Heat exposure A review of the Progress notes for Resident #1 after the ED visit revealed the following -5/3/2025 06:47 Health Status Note Note Text: Resident brought back from [local hospital] around 2130. [Family member] was with him at bedside. [Family member] brought in a bottle of Aloe Vera and Aquaphor. Aloe Vera orders are in system. New skin care integrity assessment initiated. 2 blisters on top of head, and 2 blisters on each upper thighs noted upon return. Redness to face, neck, and thighs. -5/3/2025 18:30 Health Status Note Note Text: Pt (Patient) noted with a moderate amount of clear yellow drainage emitting from the top of the scalp area. Area cleansed and covered. Spoke with NP (Nurse Practitioner) who gave orders for wound care to evaluate on Monday -5/4/2025 11:06 Health Status Note Note Text: Per orders from NP, stat (emergent) CBC (complete blood count)/CMP (comprehensive metabolic profile) ,stat pharmacy delivery of Prednisone 40 mg, and a hold on PT's (patient's) cream that is applied have all been processed. Benadryl order placed as well. -5/4/2025 15:52 Health Status Note Note Text: Upon further inspection by this RN (Registered Nurse) and weekend supervisor, PTs facial swelling appears to be decreasing. Wife present and agrees. NP notified of current -5/5/2025 08:55 Skin/Wound Note Late Entry: Note Text: Pt seen by [Wound Care Consultant] ARNP [Advanced Registered Nurse Practitioner] today. Pt alert & oriented to self, able to follow directions. Pt noted with blisters in BUE (bilateral upper extremities), bilateral thighs and top of head. Other blister on top of head has popped and dry out. No wound or open skin area. Swelling in R (right) side of jaw line and neck. Pt able to talk clearly, swallow his medication with water without difficulty. Primary ARNP in room at the same time to evaluate pt. MD (Medical Doctor) contacted at that time by ARNP. Pt would not be followed by [Wound Care Consultant] group since pt does not have any skin open area. Will continue to monitor. -5/5/2025 10:50 Provider Note Chief Complaint/History of Present Illness: Re-admit Patient found unresponsive and sent to ER (Emergency Room). CT (Computed Tomography) imaging negative for acute findings .Sent back to facility. Patient then was reported to be outside and a couple days later reported that he had sporadic large fluid filled blisters on head, B/L (bilateral) arms, and B/L groin areas all where sun had been exposed. Head blister has opened, and wound care will follow for this. He is unsure how long he was outside for. Agree with wound care's diagnosis of sun exposure vs (versus) drug induced bullous pemphigoid (a chronic, autoimmune blistering skin disease primarily affecting older adults). He does have increased facial swelling on the right side that has worsened since starting Prednisone 40 mg po (by mouth) QD (daily). Concern for airway protection and recommend to send to ER for IV (intravenous) steroids and eval . -5/5/2025 16:53 Provider Note Chief Complaint/History of Present Illness: .MD evaluated the patient today with POA (Power of Attorney) present. Concern was held regarding the patient's breathing and swelling around his neck predominantly on the right side of his neck. Blisters were present on his arms and thighs. Per report and per MD revise of facility documentation, patient was outside the day before with normal daily activities for the patient. He was subsequentially reported altered outside and was subsequently brought inside for evaluation. Patient typically spends significant time with his spouse in and out of the facility. MD recommended EMS (Emergency Medical Services) to be called and patient was transported to the hospital in stable condition. Plan: MD reviewed imaging and facility records extensively and conferred with additional board-certified physicians internal medicine physicians including a board-certified dermatologist. Per exam patient has darkened pigment on his anterior forearms as well as thighs. Dermatologist advised after serial imaging review that patient likely has a history of long-term photosensitivity reactions indicative of someone with chronic sun exposure. Facility documentation was reviewed by MD the patient was outside for less than an hour and became symptomatic Patient was sent to the ED for a higher level of care for airway protection -5/5/2025 16:53 Event Note Late Entry Note text: At approximately 3:46 p.m. this nurse was notified by other staff members that patient needed assistance, this nurse quickly went with staff members to assess resident. This nurse assessed resident, resident was noted to be responsive, awake and slowly responding. Other nurse helped to assess resident. Resident noted not to appear at baseline medical provider notified gave order to send out via EMS. 911 called per order and resident sent out to hospital. Spouse notified of change in condition and hospital transfer . -5/5/2025 1802 Transfer to Hospital Note Text: Alert and oriented X2, resting in bed .MD was in to see pt. regarding fluid filled blisters, redness of skin and swelling in right neck. 2:30 p.m. orders to sent to ER for evaluation, 911 was called and patient was transferred to hospital via stretcher with paramedics A review of the hospital Emergency Department (ED) Physician record from admission date 5/5/2025 for Resident #1 revealed the following: History of Present Illness: Patient is an [AGE] year-old male who 2 days ago was left out in the sun accidentally by the staff at [Facility name] patient was evaluated at our facility at that time he had some sunburn on both upper thighs and his arms. The redness is turned to blisters on both upper thighs and on his arms. Patient also states he was sent here for evaluation of shortness of breath there was a lab order form from [Facility name]. Patient appears in no obvious distress at this time. Patient denies any chest pain. Impression and Plan: -Leukocytosis (condition in which the white cell count is above normal and is frequently a sign of an infection). -Sepsis (condition that arises when the body's response to infection causes injury to its own tissues and organs). An interview was conducted on 5/12/2025 at 11:21 a.m. with Staff A, Registered Nurse (RN). Staff A, RN stated she was the primary nurse for Resident #1 on 5/02/2025. She stated Resident #1's family member came to the facility around 9 to 10 a.m. and spent most of the day with the resident. She said the last time she had seen the resident was before lunch to record his blood sugar. She stated it was around 11:00 a.m. She said the nursing assistant (Staff B, Certified Nursing Assistant, CNA) toileted the resident in the morning and took the resident to activities with the family member. She stated she did not know when the resident went outside or how long he had been outside. She said the family member left the facility around 1:45 to 2:00 p.m. Staff A, RN stated she was walking in the hallway, and she heard staff saying they needed assistance in the patio area around three something in the afternoon. She said she ran to the outside patio and saw Resident #1 in the ice cream parlor, sitting in the wheelchair. She said the resident's eyes were open and she checked for a pulse. She said the resident had a pulse and she starting calling his name and doing a rub on his chest, but he was not able to state his name. She said he was just moaning. She stated Resident #1 appeared tired and lethargic. Staff A, RN stated one of the other nurses (Staff C, Licensed Practical Nurse, LPN) came to help and took over the care for Resident #1 while she went to go get the paperwork to send Resident #1 to the hospital. She could not recall exactly what the resident was wearing at the time. She stated she did not put a progress note into the record at the time of the incident because she thought the other nurse was going to do it. She stated she put a note in the record a few days later when she found out no note was written. She stated the activities staff are supposed to check on the residents and give them water if they are outside. She stated the CNA's are supposed to go and check on their resident's if the resident is outside. She stated is a resident is alert and oriented, they can go outside. An interview was conducted on 5/12/2025 at 11:56 a.m. with Staff C, LPN. Staff C, LPN stated Staff D, Physical Therapist (PT) was walking near the court yard and found Resident #1 unresponsive. She stated around 3:30-3:45 p.m. a staff member was screaming her name to come and help a resident. She said when she arrived she noticed it was Resident #1. She stated Staff D, PT was bringing the resident inside as she arrived in the ice cream parlor. Staff C, LPN stated they moved the resident to the private dining area, and he was very warm to the touch. She said they brought the resident to the ground and laid him on the floor. She stated they checked his blood sugar, and it was okay, so she started putting wet cool rags on his groin and head area. She said she instructed other staff members to call 911 and get paperwork ready for transfer. Staff C stated Resident #1 was responding by opening his eyes and opening his hands, but he was not able to speak. She stated it was warm outside that day, but it was not extremely hot. She stated the resident had on a pair of black basketball shorts, and a gray shirt with sneakers and no hat. She stated he had no obvious skin injuries or head injury at the time. An interview was conducted on 5/12/2025 at 12:07 p.m., with Staff D, PT. Staff D, PT stated she was finishing up her day and had clocked out around 3:40 p.m. She stated she went out to the courtyard to speak with another resident, and she saw Resident #1 sitting in the court yard. She stated she knew Resident #1 well and she went over to say hello. She said he appeared to be resting, and she tried to wake him up, but he was not responding. She said Resident #1 did not appear to be his usual self. She said she went inside the ice cream parlor and asked someone to call for help with a medical emergency. She said she went and brought Resident #1 inside in his wheelchair. She said the nursing staff took over providing care for the resident. She stated she had not seen him throughout the day on 5/02/2025. She stated she did not know how long Resident #1 had been outside and she did not see any other staff members outside in the courtyard at the time. An interview was conducted on 5/12/2025 at 12:15 p.m. with Staff E, Activities Assistant (AA). Staff E, AA stated he saw Resident #1 at 2:15 p.m. and instructed the resident that he could not go outside at the time because the landscapers were working in the courtyard. He stated he brought Resident #1 to activities in the dining room and gave him some ice cream at 2:30 p.m. He stated that was the last time he saw Resident #1. He stated he had seen Resident #1 earlier in the day with his family member in the hallway. He stated he offers water or juice and sunscreen to residents who are outside. He stated there was some areas of shade in the courtyard and Resident #1 can move around freely in his wheelchair. An interview was conducted on 5/12/2025 at 12:27 p.m. with the Director of Nursing (DON). The DON said there is a button for residents to use to go outside and enter the courtyard. She stated staff are responsible to do rounds and check on residents. She stated the CNA's check on residents, but they would not document in the record. She stated the CNA's are required to do two hour checks on the residents depending on their needs. She stated some residents may need more supervision. She stated Staff E, AA was the last one to see Resident #1 around 2:30-2:45 p.m. when the resident went outside to eat his ice cream. She said based on the investigation Resident #1 was outside from 2:45 p.m.-3:45 p.m. The DON stated at 3:45 p.m. Resident #1, appeared he was sleeping in the court yard and the physical therapist stated he was not responsive. She said on Monday she spoke with Resident #1, and he was slow to respond and that is his baseline. She said, He is low speaking. She said the resident told her he just fell asleep out there. She said when Resident #1 came back to the facility they found a blister on the top of his head, and his arm. She said the next day the resident had some swelling on the right side of his neck, and some weeping from his head. The DON said the resident was responding to the treatments ordered and all the lab results appeared in normal limits. She said the doctors were trying to rule out an autoimmune disorder or some type of reaction. She stated Resident #1 has always gone outside and has never had any type of problem related to heat or sun before. She stated Resident #1 is still hospitalized and doctors are still trying to figure out what is going on. She stated the activities staff were responsible for checking in on the residents outside and providing hydration and sunscreen. An interview was conducted on 5/12/2025 at 1:12 p.m. with the Activities Director (AD). The AD stated they are responsible for checking on residents who are outside and offering them water and sunscreen. She stated they are responsible to document resident participation in activities on a participation log. She stated Resident #1 was more independent and able to move around in his wheelchair. She stated he did not participate in all activities, and he would go outside a few times a day. She stated Resident #1 would come and get ice cream in the afternoon and take it outside in the courtyard to eat it. She said this was Resident #1's normal routine. An interview was conducted on 5/12/2025 at 2:23 p.m. with the Nursing Home Administrator (NHA) and the DON. The NHA stated the facility started an investigation into the incident with Resident #1 right away. The NHA stated based on their investigation they believe Resident #1 was outside for a little less than an hour when he was found. The NHA stated there had been no previous concerns with the resident related to being outside. He stated they are still working with the doctor to investigate this incident. He stated they started an Adhoc QAPI plan (Quality Assurance and Performance Improvement Plan). An interview was conducted on 5/12/2025 at 2:47 p.m. with the Primary Care Provider (PCP). The PCP stated he was very familiar with Resident #1. The PCP stated he came in to see the resident the day after the incident. He stated he consulted a Dermatologist to discuss the case. He stated Resident #1 has a history of chronic sun exposure and likes to be outside. He stated the Dermatologist believed this may be an autoimmune reaction to the sun exposure or a drug induced illness. He stated they are providing treatment at the hospital and Resident #1's body reacted to something but there is no absolute cause at this time. He stated he did not believe the reaction was related to a sunburn, but the sun might have been the catalyst for the reaction. He stated they are still working on a definite diagnosis. An interview was conducted on 5/12/2025 at 3:15 p.m. with Staff B, CNA. Staff B stated she did not work with Resident #1 very often. Staff B stated she came in at 7:00 a.m. and worked a double that day. She stated she saw Resident #1 at 7:30 a.m. after breakfast. She stated she assisted the resident to the bathroom and took him to activities. She stated a family member came to see Resident #1 and she saw them walking around and then they went to lunch. She said she checked on him around 2:30 p.m. and he was in the activity room eating ice cream. She said that was the last time she saw him before the incident. Staff B stated she was there when Resident #1 returned from the hospital. She said he came from hospital around 9:00 p.m. She said she helped get him to his room. She stated his skin had boils. A telephone interview was conducted on 5/12/2025 at 3:35 p.m. with Resident #1's POA. The POA stated Resident #1 was still in the hospital and was not doing well. The POA stated the hospital was going to transfer the resident to another facility where they had a burn unit. She stated the doctors still do not know what exactly happened, but it was started by the sun exposure for some reason. The POA stated the blisters have gone down some but now they think he may have a staph infection on his head. She stated she arrived at the facility on 5/02/2025 around 11:30 a.m. and stayed until around 1:30 p.m. She stated she did not take the resident outside during her visit and when she left Resident #1 was doing fine. The POA stated she received a call around 4:30 p.m. stating the resident was being sent to the hospital. She said Resident #1 was dressed in shorts and a tee shirt. She stated Resident #1 was being seen by several specialists and wound care. She stated the resident likes to be outside, but he does have some cognitive deficits, and he does not always know when to drink water or to get out of the sun. The POA stated she has never had the resident out in the sun for an hour, and she always gets him back inside after about 20 minutes. She said 20 minutes is as long as she can stand in the heat. The POA stated the resident, Can present better than he is, but he really does not have a concept of how long he was outside or if he needs to drink. A review of the facility's policy titled Inclement Weather Restrictions, Issued 4/12/2018; Revised 9/27/2024, revealed the following: Policy: Most facilities have courtyards, porches, or secured patios that are available for resident use and for outdoor facility activities and events. These are subject to inclement weather restrictions. Procedure: 1. Courtyards, secured patios, and porches are available for use for residents except during inclement weather conditions. Guidelines to consider: a. Temperature < 32 degrees or >90 degrees b. Heat index > 100 degrees c. Excessive wind chill d. Excessive humidity e. Precipitation f. Severe weather watches or warnings 2. Resident should be dressed appropriately for weather conditions if outside. 3. Each facility should provide for periodic monitoring of residents in courtyards, secured patios, or porches to provide hydration in warmer weather. 4. Resident with moderate to severe cognitive impairment should be attended by staff or visitor when outside.

Based on record review, interview, and review of the facility's policy, the facility failed to 1.) ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) Level I for three (Residents #97, #43 and #13) of five residents admitted with mental health diagnoses and sampled for PASARR; and 2.) complete a PASARR Level II within 30 days for one (Resident #20) admitted to the facility under a 'hospital discharge exemption' of five residents sampled for PASARR. Findings include: 1. Review of the clinical record revealed Resident #97 was admitted to the facility on [DATE], and a primary diagnosis of Unspecified Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE], for Resident #97 revealed under Section I, diagnoses that included Non-Alzheimer's Dementia, Anxiety and Psychotic Disorder; and under Section N, antipsychotic and antidepressant medications were received during seven of the past seven days. Review of a PASARR Level I dated 11/28/2022, revealed Section 1A with Depressive Disorder and Psychotic Disorder checked 'yes' and Section II Part 5, 'does the individual have a primary diagnosis of dementia' checked 'no.' The clinical record did not reveal any additional PASARR (Level I nor Level II) assessments. 2. Review of the clinical record revealed Resident #20 was admitted to the facility on [DATE], and a primary diagnosis of Unspecified Dementia. Additional diagnoses included Depression and Psychosis. Review of the annual MDS dated [DATE] for Resident #20 revealed under Section I, diagnoses that included Non-Alzheimer's Dementia, Anxiety Disorder, Depression and Psychotic Disorder (other than schizophrenia); and under Section N, antipsychotic and antidepressant medications were received during seven of the past seven days. Review of a PASARR Level I dated 09/19/2021, revealed Section 1A with Anxiety Disorder checked 'yes' and Section II, Part 3B 'Due to mental illness, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials' checked 'yes.' Section II Part 5 'does the individual have a primary diagnosis of dementia' was checked 'yes.' Further review of the PASARR revealed Section III 'hospital discharge exemption' checked 'yes' and 'the individual is being admitted under the 30-day hospital discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF [nursing facility] must notify the Level I screener on the 25th day of the stay and the Level II evaluation must be completed no later than the 40th day of admission, on or before (date) [blank]' was checked 'yes.' The clinical record did not reveal any additional PASARR (Level I nor Level II) assessments. In an interview with Staff C, Social Services Director (SSD) on 04/12/2023 at 12:30 p.m., she confirmed Resident #20 was admitted under a hospital discharge exemption and a PASARR Level I or Level II was not completed within the 30-day timeframe. Additionally, the SSD confirmed Resident #97 had a primary diagnosis of Dementia checked 'no,' but the resident had a primary diagnosis of Dementia as per the admission face sheet. Review of facility-provided policy titled 'Pre-Admission Screening and Resident Review,' dated 06/06/2019 and revised 10/06/2022 revealed: Policy: The facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities (ID) and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by a state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. 13. Any resident with a newly evident or possible mental disorder, ID or related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review. 14. Referral for Level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or related condition who experience a significant change. 43453 3. Review of an admission record dated 04/13/23, revealed Resident #43 was admitted to the facility on [DATE]. An admission MDS dated [DATE] showed under Section I active diagnoses, the resident had anxiety disorder, Non-Alzheimer's Dementia, seizure disorder/epilepsy, and depression. A review of a quarterly MDS for Resident #43 dated 03/10/23, showed under Section I active diagnoses, the resident had anxiety disorder, Non-Alzheimer's Dementia, seizure disorder/epilepsy, and depression. A review of Resident #43's level I PASARR dated 05/03/22, showed none of the qualifying diagnosis were checked. Review of a psychiatric progress note for Resident #43 dated 03/26/23, showed the resident was admitted with a psychiatric history of depression for [AGE] years, the resident attempted suicide in her 30's or 40's and had a documented history of trauma. The record review indicated Resident #43 was not screened for level II PASARR with known qualifying diagnoses, to include a primary diagnosis of dementia. 4. Review of an admission record dated 04/13/23, revealed Resident #13 was readmitted to the facility on [DATE]. An admission MDS dated [DATE] showed under Section I active diagnoses, the resident was admitted with Non-Alzheimer's Dementia and depression. A review of a quarterly MDS for Resident #13 dated 03/18/23, showed under Section I active diagnoses, the resident had Non-Alzheimer's Dementia and depression. A review of Resident #13's level I PASARR dated 05/01/19, showed an incomplete PASSAR and none of the qualifying diagnosis were checked. On 04/12/23 at 12:19 p.m., an interview was conducted with Staff C, Social Services Director (SSD). She stated she reviewed all PASARRs upon admission. She looked for errors and alerted the DON (Director of Nursing) if any errors were noted. She stated if a resident did not have a PASARR and they had qualifying diagnoses, she would create a new PASARR upon admission or prior. Staff C stated if a new MDS diagnosis identified the resident had a new diagnosis, she would review the PASARR. Staff C stated they did review PASARRs during care plan meetings for their long-term patients. She stated they were auditing charts to ensure accuracy. Staff C confirmed PASARRs should reflect the resident's current diagnosis and their care plan would be updated. Staff C stated they had started a PIP (Performance Improvement Plan) for PASARRs, and all new admissions had been revised. She stated their goal was to review all their long-term residents. On 04/12/23 at 11:24 a.m., an interview was conducted with the Regional Clinical Nurse (RNC) she confirmed the resident's PASARR should have been completed following a new mental health diagnosis. She stated if a resident was admitted with a qualifying diagnosis, they would automatically update the PASARR. She confirmed if a resident acquired new diagnoses during their stay, a level I PASARR should be submitted. She stated a Level II PASARR should be submitted accordingly if the resident had qualifying diagnosis. The RNC stated she would resubmit the resident's PASARRs.

Based on record review and interview, the facility failed to provide rationale for long term use or limit the use of as needed antianxiety medications to less than 14 days for two (Residents #29 and #91) of five residents surveyed for unnecessary medications. Findings include: 1. Resident #29 was originally admitted to the facility on [DATE]. While conducting a record review, an order was identified for Ativan 0.5 milligrams (mg) by mouth every 4 hours as needed for anxiety/agitation/shortness of breath. The order was written on 3/16/23 and did not have an expiration date or rationale for long term use. Further record review revealed on 3/22/23, a Medication Regimen Review was conducted by the Consultant Pharmacist with the following documentation: Recommendation: Please discontinue as needed Ativan, tapering as necessary. If the medication cannot be discontinued at this time, please document the indication for use, the extended duration of therapy, and the rationale for the extended time period. Rationale for Recommendation: Centers for Medicare & Medicaid Services (CMS) requires that as needed orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the as needed order. (photo evidence obtained). 2. Resident #91 was admitted to this facility on 8/31/22. While conducting a record review, two orders were identified for as needed anti-anxiety medication written on 12/1/22 with no expiration dates or rationale for long term use. The medications were as follows: Ativan Tablet 0.5 mg. Give 1 tablet by mouth every 6 hours as needed for moderate anxiety/agitation/shortness of breath. May dissolve in 2 drops of water. Ativan Tablet 0.5 mg. Give 2 tablets by mouth every 6 hours as needed for severe anxiety, restlessness, or insomnia. The Director of Nursing (DON) was interviewed on 04/13/23 at 12:20 p.m. During the interview, the DON said both residents were on hospice and the medication was required for end of life care. She said she had contacted the provider and asked them to enter rationale for extended as needed orders. Review of facility policy Psychotropic Medication Use revision date 10/24/22 revealed: Policy 8. As needed psychotropic medications should be ordered for no more than 14 days. Each Resident who is taking an as needed psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month. 9. For psychotropic medications, excluding antipsychotics, that the attending physician believes an as needed order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record.

Based on interviews and record review, the facility failed to ensure pre and post dialysis care was provided for one (Resident #68) of four dialysis residents. Findings included: Review of the admission record dated 04/13/23, showed Resident #68 was admitted to the facility on [DATE] with diagnoses to include acute kidney failure and severe chronic kidney disease, stage 4, and dependence on renal dialysis. Review of active physician orders for Resident #68 showed: Dialysis patient receives dialysis at [name of facility] on Tuesday, Thursday, and Saturday at 10:30 a.m., start date 01/19/23. Check right chest dialysis port for bleeding or signs and symptoms of infection, every shift, start date 12/27/22. Liberal renal diet, Regular texture, thin consistency, start date 12/24/22. Medication orders around dialysis, at least 2 hours prior to or after return, start date 12/24/22. Review of a care plan with a revision date of 12/27/22 showed a focus on Dialysis- hemodialysis related to end stage renal disease. The goal showed the resident will have no signs/symptoms of complications from dialysis. Interventions included to check vital signs daily, dialysis treatments as ordered, dry weights obtained from dialysis center, encourage resident to attend dialysis, labs, and report to doctor, observed for bleeding at dialysis access site, observe for dry skin. Observe /report signs/symptoms of bleeding, hemorrhage, and provide therapeutic diet as ordered. Review of Resident #58's dialysis book dates 01/19/23 to 04/11/23 showed missing documentation for pre and post care. The document titled pre/post dialysis communication showed the following expectation: Pre dialysis (to be completed by SNF- [skilled nursing facility]): obtain vital signs, obtain weight, check lung sounds, assess condition of access/site, document if the resident is on antibiotic and diagnosis of the antibiotic use, check for bruit and thrill, indicate if the resident is to be given medications at the center, and if meal is to be given at the center. Post dialysis (to be completed by SNF): obtain vital signs, obtain weight, assess condition of access/site, check for bruit and thrill, and to indicate if there was change of site. Review of documents titled, pre/post dialysis communication showed: On 4/11/23 pre and post dialysis care was not documented as completed. On 3/23/23 post dialysis care was not documented as completed. On 3/14/23 pre and post dialysis care was not documented as completed. On 3/9/23 post dialysis care was not documented as completed. On 3/7/23 post dialysis care was not documented as completed. On 2/28/23 pre and post dialysis care was not documented as completed. On 2/25/23 pre and post dialysis care was not documented as completed. On 2/16/23 post dialysis care was not documented as completed. On 2/2/23 and 2/4/23: dialysis center section noted blank. On 1/28/23 pre and post dialysis care was not documented as completed. On 1/26/23 pre and post dialysis care was not documented as completed. On 1/24/23 pre and post dialysis care was not documented as completed. On 1/17/23 post dialysis care was not documented as completed. On 1/12/23 post dialysis care was not documented as completed. Two undated pages were also noted with no pre/post care documented as completed. On 04/12/23 at 09:23 a.m., an interview was conducted with Staff D, LPN (Licensed Practical Nurse). She stated she was assigned to the resident today and that she worked with him quite often. Staff D stated she prepared the resident for dialysis. Staff D said, Yes, the expectation is to make sure we are checking the bruit and thrill prior to sending the resident out. Makes sure the port is in place, no bleeding and obtain vitals. She stated she made sure the resident had taken their medications and they had lunch to take with them. Staff D confirmed the nurses should complete the dialysis communication documentation. On 04/12/23 10:29 a.m., an interview was conducted with Staff E, LPN. She stated the nurse assigned to the resident was responsible for completing the care pre and post dialysis. She stated they were expected to obtain vitals, check the site for bleeding, and document findings. She stated they review what the dialysis facility sent back to see if there were any care concerns. Staff E stated the nurse on duty should be reviewing the dialysis book and the Unit Manager (UM) should monitor the accuracy of the dialysis communication books. On 04/13/23 11:31 a.m., an interview was conducted with the Regional Clinical Nurse (RCN). She confirmed the documentation was missing. She stated the nurses were expected to complete the pre and post dialysis communication log. The RCN stated they should be monitoring the resident's vitals and port site as expected. On 04/13/23 11:33 a.m., an interview was conducted with the DON (Director of Nursing). She stated she would be educating the UM about monitoring documentation and addressing missed records. She stated she had reviewed Resident #68's record and noted the missed documentation. She stated she was concerned they would not be able to verify if the resident received the care, or if it was a documentation problem. She stated they reviewed all the other dialysis residents without concerns. The DON said, It was that one unit. We will be in-servicing staff to ensure post and pre dialysis care is completed and accurately documented. We should ensure any concerns are documented with appropriate notifications. A review of a facility policy revised 08/18/22 showed the facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the; on-going assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility and on-going communication and collaboration with the dialysis facility regarding dialysis care and services. Under procedure: the resident receiving dialysis shall receive consistent care pre and post dialysis. The vascular access site shall be checked daily with physician notification for any known or suspected problem. Under general guidelines: Assess for any signs/symptoms of infection, such as redness or edema at the vascular access site. Observe fluid restriction as ordered by physician. Assess vascular access site for signs of clotting or bleeding every shift. Monitor for any complaints of pain or discomfort at vascular access site. Notify the physician of any change in mental status or physical status. Document in the clinical nursing record, dialysis treatment completed, order changes, condition of shunt site, complaints from resident (if applicable). Pre dialysis: initiate pre/post dialysis communication form to be sent to the dialysis clinic with the resident. Post dialysis: obtain vital signs of resident upon return from dialysis and complete the pre/post dialysis communication form.

Based on observation, interview, medical record review, and policy on Indwelling Urinary Catheter Management, the facility failed to ensure one (Resident #52) of three residents sampled for indwelling urinary catheters was provided timely treatment and care in accordance with professional standards of practice. Findings Included: On 04/11/2023 at 11:01 a.m., an interview was conducted with Resident #52. She said her catheter was for urinary retention. She said she was a nurse for many years and knew about retention. She said she was not able to void, and nothing was coming out. She said she could feel distention in her bladder so she went to the hospital. Resident #52 stated, they straight cathed me and removed 4000 cubic centimeter (cc) of urine. They had performed tests at the hospital and found I had a cord compression to my spine. The compression was causing retention to my bladder. I had the surgery performed and went home with the catheter. She said after being at home, she recalled being dizzy when standing and fell . She said, I broke my hip and here for rehabilitation. Resident #52 denied any attempted voiding trials performed at the facility. She stated, I cant wait unit they remove it. I do Kegel exercises all the time. A Trial Without Catheter (TWOC) is when the catheter (the tube inserted into your bladder to drain urine) is removed from your bladder for a trial period to determine whether you can pass urine without it. Mayo Clinic Kegel exercises can prevent or control urinary incontinence and other pelvic floor problems. https://www.mayoclinic.org > in-depth > art-20045283. Review of the Admission Record form revealed she had resided at the facility for close to a month. The form listed diagnoses of periprosthetic fracture around internal prosthetic right hip joint, urinary tract infection, and retention of urine. Review of Physician notes dated 04/10/2023 revealed Endnotes: unspecified cord compression, spondylosis. Review of the hospital admission orders revealed an order for Augmentin oral tablet 500-124 mg (Amoxicillin & pot Clavulante) Give one tablet by mouth three times a day for urinary tract infection (UTI) for 7 days dated, 03/14/2023. Review of the medication administration record (MAR) reflected on 03/14/2023, the scheduled 2:00 p.m. (1400) and 9:00 p.m. (2100) doses documented with a number 10. Review of the Chart Codes revealed number 10= Other /See Progress Note. Review of progress notes dated 03/14/2023 at 4:55 p.m. (16:55) revealed, Orders - Administration Note, Note Text: Augmentin Oral Tablet 500-125 MG Give 1 tablet by mouth three times a day for UTI for 7 Days dose not available. On 03/14/2023 at 9:05 p.m. (21:05) Orders - Administration Note, Note Text: Augmentin Oral Tablet 500-125 MG Give 1 tablet by mouth three times a day for UTI for 7 Days Awaiting from pharmacy. Review of the hospital Discharge Summary print date 03/14/2023, Pending Results Culture urine ordered on 03/11/2023 at 1:22 p.m. (13:22) Microbiology Identification and susceptibility to follow. The discharge paper work did not reflect the urine culture sensitivity results that would indicate which antibiotic would be appropriate to treat the urinary tract infection. Review of Physician orders Bactrim DS oral tablet 800-160 mg -SULFAMETHOZONE;-Trimethoprim give on tablet by mouth two times a day for UTI order dated, 04/08/2023 at 2:50 p.m. (1450). Review of the MAR reflected Bactrim DS was first administered on 04/10/2023 at 0900, which indicated a 43 hour delay in starting the antibiotic. Review of the treatment administration record revealed,change catheter bag as needed for infection, obstruction or when the closed system is compromised dated 03/14/2023. No documentation was located in the medical record that reflected the catheter bag was changed after an infection was identified on 04/08/2023. Review of physician orders dated, 04/04/2023 revealed, UA & C&S Point-of-care Test Device: none. No documentation was located in the medical record that indicated how the urine specimen was obtained. Further review of the medical record reflected Resident #52's indwelling urinary catheter was placed sometime prior to her admission. On 04/12/2023 at 3:30 p.m., an interview was conducted with the Director of Nursing (DON). She said, Typically the cath bag is changed on an as needed bases. And we don't change the catheter for new urinary specimen like we did before, that had changed. The DON indicated she was unaware Resident #52's catheter bag was not changed after an infection was identified. She stated, I'll have it changed out. The DON was unaware Resident #52 admission orders for Augmentin were not provided as ordered. She reviewed the medical record and stated typically they would call the MD and get an extension of the dose. When asked about Resident #52's second ordered antibiotic/Bactrim that was ordered on 04/08/2023 and not administered until 04/10/2023, she confirmed it was her expectation the medication was started in a timely manner. The DON went on to say she was aware the resident had a voiding trial while in the hospital but it had failed. She said I think she might have had one here, but am not sure I will have to check. The DON added, If the trial [removing the catheter] doesn't ' work we will set her up to be seen by a urologist. On 04/13/2023 at 9:24 a.m., the DON stated she had left a message for the physician related to the delay in starting the Bactrim, and they were okay with the delay. The DON confirmed it was the first time the physician had been notified of the delay. She added, [Resident #52] is set up to start a voiding trial today, 04/13/2023. On 04/13/2023 at 11:52 a.m., an interview was conducted with the Minimum Data Set Coordinator (MDSC) and the Infection Control Preventionist (ICP). The MDSC indicated he was the ICP just last month, and CP had worked the position for one month. The MDSC said part of the process for the Antibiotic Stewardship program was that he would follow an order for a urinary specimen. He spoke about ensuring the correct antibiotic was ordered by reviewing the laboratory results for the organism and its sensitivity. He would review the physician's antibiotic order for the correct duration and discontinue date. The MDSC confirmed he would check the MAR to ensure the antibiotic was given as ordered. The ICP confirmed she followed the same process that included reviewing the MAR. She reviewed the medical record for Resident #52 and confirmed the Augmentin received reflected two doses of omission. She then stated, I missed it. When asked about new admissions on antibiotics, the MDSC stated, I would reach out to Medical Records for the culture and sensitivity results. Typically the antibiotic the resident was on would have the culture and sensitivity results in the paper work. He said he had not encountered new admissions with pending culture and sensitivity. When asked about a new admission with an indwelling urinary catheter, the MDSC and ICF both stated it is removed as soon as possible. Review of Resident #52 Care Plan revealed, Focus: The resident has an indwelling urinary Catheter: Urinary Retention related to (r/t) Urinary Retention obstructive uropathy, Goal: Will have no complications r/t indwelling catheter use. Date Initiated: 03/15/2023. A second care plan was reviewed with the Focus: The resident has a Urinary Tract Infection r/t indwelling cath date initiated: 03/15/2023, Revision on: 04/10/2023, Goal: The resident urinary tract infection will resolve without complications by the review date Target Date 07/09/2023. Review of the policy titled Surveillance of Infections revised: 12/13/2021 Surveillance Definitions for Urinary Tract Infections (UTI) B. For residents with an indwelling catheter. 2. Comments: Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for greater than (>)14 d). Review of policy titled Indwelling Urinary Catheter (Foley) Management Revised : 08/22/2022 Policy: The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed; 1. Documentation for the involvement of the resident in the discussion of the risks and benefits of the use of a catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of the catheter; 3. Identification and documentation of the clinical indications for the use of a catheter; as well as criteria for the discontinuance of the catheter when the indication for use is no longer present; 4. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; 5. Response of the resident during the use of the catheter; and 6. On going monitoring for changes in condition related to potential CAUTI's, recognizing response and addressing such changes. General Urinary Catheter Maintenance Guidelines: 5. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags base on clinical indication such as infection. Centers for Disease Control and Prevention. Healthcare-Associated Infections (HAIs)Catheter-associated Urinary Tract Infections (CAUTI) A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. https://www.cdc.gov/hai/ca_uti/uti.html.

Based on record review, interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level I upon a new qualifying mental health diagnosis for one (Resident #3) of five residents sampled for PASARRs . Findings included: Review of the electronic medical record (EMR) revealed Resident #3 was initially admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] showed Resident #3 did not have psychiatric or mood disorder diagnosis indicated. Review of a quarterly MDS dated [DATE] Section I, showed the resident had current diagnosis of Depression. Review of an admission record for Resident #3 dated 04/13/23, showed a diagnosis of depression, unspecified with an onset date of 12/23/22. Review of a physician order summary report for Resident #3 dated 04/13/23, showed Resident #3 was receiving Fluoxetine HCI (hydrochloride), give one tablet by mouth one time a day for depression. Review of Resident #3's PASSAR Level I screen dated 07/05/22 revealed no qualifying mental health diagnosis were indicated. Review of Resident #3's record revealed a PASSAR Level I screen was not submitted following a new qualifying mental health diagnosis of Depressive disorder. On 04/12/23 at 12:19 p.m., an interview was conducted with Staff C, Social Services Director (SSD). She stated she reviewed all PASARRs upon admission. She looked for errors and alerted the DON (Director of Nursing) if any errors were noted. She stated if a resident did not have a PASSAR and they had qualifying diagnoses, she would create a new PASARR upon admission or prior. Staff C stated if a new MDS diagnosis identified the resident had a new diagnosis, she would review the PASSAR. Staff C stated they did review PASARRs during care plan meetings for their long-term patients. She stated they were auditing charts to ensure accuracy. Staff C confirmed PASARRs should reflect the resident's current diagnosis and their care plan would be updated. Staff C stated they had started a PIP (Plan in Place) for PASARRs, and all new admissions had been revised. She stated their goal was to review all their long-term residents. On 04/12/23 at 11:24 a.m., an interview was conducted with the Regional Clinical Nurse (RNC). She confirmed the resident's PASSAR should have been completed following a new mental health diagnosis. She stated if a resident was admitted with a qualifying diagnosis, they would automatically update the PASSAR. She confirmed if a resident acquired new diagnoses during their stay, a level I PASSAR should be submitted. She stated a Level II PASSAR should be submitted accordingly if the resident had qualifying diagnosis. The RNC stated she would resubmit the resident's PASSAR. Review of facility-provided policy titled 'Pre-Admission Screening and Resident Review,' dated 06/06/2019 and revised 10/06/2022 revealed: Policy: The facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities (ID) and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by a state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. 13. Any resident with a newly evident or possible mental disorder, ID or related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review.

Based on interview and record review the facility failed to ensure that orders and implementation for behavior monitoring were in place for [CONDITION(S)] medications for one (Resident #10) out of five sampled residents. Findings included: Multiple observations were made of Resident #10 between the hours of 8 a.m. and 5 p.m. from 06/14/21 to 06/17/21. The Resident was always observed in bed, was awake and alert, engaged freely, and was confused. During an observation on 06/16/21 at 9:45 a.m., there was a person seated at the bedside who identified herself as a sitter hired through an agency. She said she was hired to sit with him during the day from 9:00 a.m. to 2:00 p.m. Staff K, Registered Nurse (RN) confirmed that the sitter was hired by the resident's family. Staff K was interviewed again on 06/16/21 at 2:48 p.m. She was seated at her medication cart just outside of Resident #10's open doorway. During the interview, the resident kept his eyes on Staff K. She confirmed that the sitter had left for the day so that was why she was positioned there in his view. She said he's calm, not agitated and as long as he can see you're there he's fine but said if she walked away out of his view he would try and get up which would cause him to fall. Review of Resident #10's medical record revealed that he was admitted to the facility on [DATE]. The resident's diagnoses included dementia, anxiety, and depression. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Inventory of Mental Status (BIMS) score of 3 which meant the resident had severe cognitive impairment. The MDS revealed that the resident required extensive to total assist with all mobility and activities of daily living (ADL) and had mood disturbance that included little interest in doing things and lethargy or restlessness. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2021 revealed orders for [MEDICATION(S)] tablet 10mg two times a day for anxiety and [MEDICATION(S)] HCl capsule delayed release particles 40mg one time a day for depression. The medications were documented administered and there was no behavior monitoring. The MAR and TAR for May 2021 revealed orders for [MEDICATION(S)] tablet 10mg two times a day for anxiety and [MEDICATION(S)] HCl capsule delayed release particles 40mg one time a day for depression. The medications were documented administered and there was no behavior monitoring. The MAR and TAR for June 2021 revealed orders for revealed orders for [MEDICATION(S)] tablet 10mg two times a day for anxiety and [MEDICATION(S)] HCl capsule delayed release particles 40mg one time a day for depression. The medications were documented administered and there was no behavior monitoring. The most recent psychiatry note dated 06/04/21 revealed the following plan and recommendations: Continue monitoring for response/potential adverse reactions .monitor mood, behavior, and appetite. An interview was conducted with the facility Director of Nursing (DON) on 06/17/21 at 3:07 p.m. She consulted the Electronic Health Record (EHR) for Resident #10 and confirmed that there were no orders for behavior monitoring in place related to [CONDITION(S)] use and no behavior monitoring was documented. She confirmed it had never been ordered or monitored since the resident's admission in September 2020. Regarding how it got missed she said, we audit every morning in clinical .we go through the list of recent orders that come through and I either give to the unit manager to check or follow up myself .I think this one just got missed .I'm going to put it in right now. A telephone interview was conducted on 06/17/21 at 6:10 p.m. with the facility's consulting pharmacist. She said she was new to the facility and had been assigned there for about a month. She said the only review she had completed at the facility so far was for May 2021. She confirmed that her review process included reviewing behavior monitoring. She said that if she found it to be missing, she would make a recommendation to put in place. She confirmed that she reviewed Resident #10 in her May 2021 review and did not note that behavior monitoring was missing and did not make any recommendations. The facility policy titled [CONDITION(S)] Medication Use revised 11/28/16 was reviewed. The procedure section revealed, Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services . and Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving [CONDITION(S)] medication .Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions.

Based on observations, interviews, and record review, the facility failed to ensure that a mechanically altered therapeutic diet was provided according to orders for one (Resident #97) out of eight sampled residents. Findings included: An observation was made on 06/16/21 at 9:43 a.m. in Resident #97's room. There were signs printed with large print and taped on his closet door that read: Please wait after each bite for the patient to finish swallowing before you give him another bite. Feed the patient small bites and small sips. Staff J, Certified Nursing Assistant (CNA) was interviewed following this observation. She confirmed she was Resident #97's CNA and said he needed to be fed. Staff K, Registered Nurse (RN) was interviewed. She confirmed she was his RN and said the resident was very confused, was dependent for mobility and care, and had to be fed. She said that his wife usually visited and fed him lunch. Photographic evidence obtained. On 06/16/21 at 12:53 p.m. Resident #97 was observed in bed. His wife was present, standing at bedside, attempting to feed him lunch. She said that she thought that the food on his tray wasn't right and said, he can't eat that. The tray and meal ticket were observed. The meal ticket was printed with Mech-Soft. The plate had a whole breadstick, noodles, ground meat, and whole steamed vegetables that included whole green beans, large broccoli florets, and pieces of red pepper. There was an unopened dish of fruit chunks also on the tray. His wife said he had accepted a little of the meat and some of his nutritional shake. The resident was observed not accepting bites of food that were offered, keeping his mouth closed and shaking his head. Photographic evidence obtained. At 5:40 p.m. on 06/16/21 Resident #97 was observed in bed in his room. There was no dinner tray present. At 5:45 p.m. Staff K took his dinner tray into the room and set it on the tray table against the wall on his side of the room and left the room. At 5:59 p.m. Staff K was observed entering the room, setting up the dinner tray, and preparing to feed the resident. The meal ticket was printed with Mech-Soft and the plate contained a bowl of refried beans and a soft tortilla shell with coarsely chopped tomatoes, ground meat, and lettuce inside. There was also a covered plate with two whole cookies on the tray. Observation continued until the resident would not accept more food. He only accepted a few bites of the refried beans and then proceeded to accept some of his fortified shake, after which the tray was removed. Photographic evidence obtained. Review of Resident #97's medical record revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] revealed that he had severely impaired cognitive skills and required extensive assistance of one person providing physical assistance for eating. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Speech Language Pathology (SLP) evaluation completed 06/10/21 revealed that the resident was admitted to the facility on a mechanical soft diet and that recommendation for diet remained for mechanical soft textures for all solid foods. An observation of breakfast was made on 06/17/21 at 8:15 a.m. Resident #97 was being assisted by a nursing student who was seated at bedside. The meal ticket read Mech-Soft, and the plate had scrambled eggs and pancakes on it. On 06/17/21 at 8:51 a.m. Staff L, SLP was interviewed. She confirmed that she was providing therapy for Resident #97 related to eating. She said she was consulted because of his dysphagia and confirmed he was on a mechanical soft texture diet. Staff L defined a mechanical soft diet as, things that are easy to chew .ground meat, steamed vegetables, pasta, food you can put gravy on .things you can make softer and easier to swallow. She said if feeding foods such as full-size cooked green bean, the bean should be cut into four parts before feeding. She said she would not consider lettuce, tomatoes, or a flour tortilla to be mechanical soft items. Staff M, SLP was interviewed on 06/17/21 at 9:33 a.m. She said that in order to be considered mechanical soft, meat should be processed into tiny pieces hamburger consistency, potatoes should be mashed not baked, canned fruit was allowed but not fresh, salads must be chopped, but no tomatoes, no cucumbers. Observation was made of the lunch meal on 06/17/21 at 12:39 p.m. Resident #97 was observed in bed being fed lunch by Staff L who was seated at bedside. Staff L confirmed it was a therapy session to work on the goal of educating his wife on proper technique to safely feed the resident. The meal ticket read, Mech-Soft and the tray contained a whole dinner roll, steamed carrots that had been further chopped/mashed, ground meat with gravy, mashed potatoes with gravy, and a whole piece of cake. Photographic evidence obtained. An interview was conducted with Staff N, Registered Dietician (RD) on 06/17/21 at 01:17 p.m. Because the facility's Certified Dietary Manager (CDM) had quit prior to the survey, Staff N was assisting to supervise and manage kitchen operations during the survey period. Staff N said that morning before the breakfast tray line started she had re-educated the kitchen staff on textures. She said she had done that because yesterday a resident on mechanical soft in the dining room was served a regular tray .she started eating the vegetable and I walked over and I asked if I could exchange her plate. Staff N confirmed she had replaced the resident's food with mechanical soft textured foods. She said she had also counseled the dietary aide responsible for confirming tickets with trays on the line that day and he said he was in a hurry. Regarding that staff member, Staff N said, he's already put his notice in for July .he's just going through the motions. Staff N confirmed that it was expected that the kitchen check each tray before it was served to ensure it had items on it that matched any therapeutic diet texture that was listed on the meal ticket. She explained the process: before tray is made a person at start of line reads off the ticket, then the food gets put on the tray, and then the person at the end of the line is supposed to check and match the ticket with the tray. She said, it is important because that could be someone's life if they are having difficulty swallowing. Staff N revealed that she had conducted an in-service with the kitchen staff on 05/11/21 that included reading tray tickets to ensure correct food textures and said she had done that because I was coming across myself that diet textures were being missed. The photographic evidence of Resident #97's lunch and dinner trays from 06/16/21 were revealed to Staff N and she identified that the only items on his lunch and dinner plates that were considered mechanical soft were the ground meat and the refried beans. She said that compliant texture foods were defined by the facility's corporation and revealed a printed list. She said for example that certain kinds of soft breads were allowed, and vegetables must be cooked very well and soft enough to mash up. She said that nursing staff was also supposed to be educated on recognizing correct textures. A follow up interview was conducted on 06/17/21 at 2:11 with Staff L and Staff M. They viewed the photographic evidence from Resident #97's lunch and dinner from 06/16/21 and confirmed that neither tray should have been served as they both contained foods that were not considered mechanical soft: tortilla, green beans, tomato, lettuce and maybe the breadstick. On 06/17/21 at 3:51 p.m. the facility Director of Nursing (DON) was interviewed. She said that when serving meals to residents, nursing staff were expected to look at the meal ticket, check to make sure the tray had what was listed, and if it did not match they were expected to return the tray to the kitchen and get a correct tray before serving to the resident. Regarding training, the DON said that during orientation they go over diets. She said, as diets change there is communication that happens between speech [SLP] and nurses generally. In response to observations made regarding Resident #97 she said, there's probably more training opportunity .it's been a crazy six months for us. On 06/17/21 at 4:05 p.m. Staff N followed up and reported there was no corporate or facility policy on checking trays for therapeutic diets. She provided documentation of the in-service she gave on 05/11/21. Review revealed that kitchen staff had attended and received training on Importance of accurately reading tray tickets, this includes diet textures.

Based on observations, interviews and record review, the facility failed to ensure that nail care was provided for one (#41) of 28 residents sampled as evidenced by the observations of the long fingernails on Resident #41's left hand and documentation from the record and interviews related to the condition of Resident #41's fingernails and toenails. Findings included: Observations of Resident #41 fingernails were done during a facility tour conducted on the University hallway on 06/14/21 at 9:28 a.m. they revealed a right hand with nails trimmed and the left hand with long thin nails with rough edges. Subsequent observations of Resident #41 fingernails on 06/14/21 at 12:30 p.m., and on 06/15/21 at 09:06 a.m. and 1:15 p.m. revealed the same findings; the fingernails of the right hand were trimmed, and the fingernails of the left hand were long thin and with rough edges. Resident #41 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated , 04/08/21 Section C (cognitive pattern) revealed a Brief Interview for Mental Status (BIMS) of 99 indicating that Resident #41 was unable to complete the assessment. A review of the care plan for Resident #41 revealed foci that included: initiated on 01/10/2019, The resident is at risk for break in skin integrity related to incontinence, immobility, weakness, contracture and deformity. Left upper extremity pain, percutaneous endoscopic gastrostomy (PEG) tube site, condom catheter. Interventions for this focus directed the certified nurse aide (CNA) to cleanse the left upper extremity and left hand between the skin folds, dry thoroughly, apply moisturizer, and cut nails as needed. Another focus initiated on 07/25/19 indicated: The resident requires ADL (Activity of Daily Living) assistance and therapy services as needed to maintain or attain the highest level of function for this Resident with congenital [CONDITION(S)], aspiration pneumonia, PEG insertion, pulmonary embolism, long history of dysphagia, Barrett's esophagus, and left [CONDITION(S)]. Interventions for this focus directed the nurse and CNA to assist with mobility as needed initiated 01/10/19. Requires extensive assistance with hygiene, oral care every shift initiated 07/25/21. Requires extensive/total assist of one with toileting and hygiene initiated 01/22/19. Transfers with extensive assist 1-2 persons, has left [CONDITION(S)], stands on right lower extremity, left upper extremity contracture, attention to skin care initiated 10/27/19. Turn and reposition every 2 hours and as needed initiated 08/12/19. Uses gestures, interpreter (sister), uses I-pad to communicate needs initiated 01/10/19. During an interview with Resident #41's sister and health care surrogate (HCS) on 06/15/21 at 16:45, she expressed frustration related to the condition of Resident #41's fingernails and toenails, she stated that the nails grow quickly and are not maintained as needed for proper hygiene, she stated that she must remind the facility of this and did so during the most recent care plan meeting on 4/27/21. The HCS stated that when Resident #41 was transferred to the hospital on 3/28/21 she observed his nails, she stated that his fingernails on both hands were very long and jagged, and his toenails were long and thick, so long in fact that they were curling under. She stated that she was horrified at the state of his toenails. She stated that Resident #41, . has always been a very clean and neat person, and this upsets him very much. An interview with Staff H, RN was conducted on 06/15/21 at 5:30 p.m. at which time Staff H, RN confirmed that Resident #41's sister had asked her to cut the fingernails of his left hand earlier that day, she stated that she was happy to do it when asked. An interview was conducted on 06/16/21 at 9:30 a.m. with Staff G, CNA in which she confirmed that Resident #41's fingernails are trimmed on Sundays. Staff G, CNA stated that because of the contracture of his left arm she is not comfortable trimming his fingernails, she stated that she would tell the nurse if she observed that his fingernails needed to be trimmed. Staff G, CNA could not recall the most recent time she noticed that Resident 41's fingernails needed trimming. A follow-up interview was conducted with the director of nursing (DON) on 06/16/21 at 3:30 p.m. at which time the DON confirmed that Resident #41's sister had expressed concern that his toenails and fingernails were not being trimmed on a regular basis. She confirmed she was aware that CNAs were not comfortable performing nail care on Resident #41's left hand. The DON stated that the nurse could perform the task instead of the CNA. The DON could not confirm that this directive had been communicated to nursing, including in the form of a revised care plan. An interview was conducted on 06/17/21 at 03:29 p.m. with Staff I who confirmed that she was responsible for scheduling appointments with the podiatrist for Resident #41. Staff I stated that during the care plan meeting on 04/27/21, Resident #41's HCS brought concerns related to his fingernails and toenails that needed trimming, Staff I stated that the nurse present took care of the fingernails at that time. Staff I stated and then provided documentation that Resident #41 was an established patient of (Clinic Name) Podiatry and received services from them on 05/11/21. Staff I could not confirm the prior date that Resident #41 received services from (Clinic Name) Podiatry and did not provide any additional documentation for any additional services prior to our exit on 06/17/21 at 19:30 p.m. Review of the documentation for the services provided to Resident #41 from (Clinic Name) Podiatry Group of Florida on 05/11/21 revealed the following: Patient seen at the request of a representative from the facility . SEE AS EMERGENCY, the document reads under subjective: This [AGE] year old male returns and presents with toe nails that are difficult to cut. The patient is under the care of Dr. (Name). Mycotic Nail Pain: Painful when [MEDICATION(S)] and pain with palpitation. Objective: There are 10 mycotic nails located on L1, L2, L3, L4, L5, R1, R2, R3, R4, R5, long, thick, discolored, +odor, +subungual debries, painful and long toenails, incurvated, painful on palpation. Assessment: .Tinea unguium, .Pain in right toe(s), .Pain in left toe(s) Plan: .Sharply debrided 1-10 symptomatic dystrophic nails by manual debridement with the use of nail nippers to decrease pain, as required by medical necessity .Sharply debrided 6-10 symptomatic nails. Manual debridement by use of nail nippers to debride all fungal nails in order to decrease pain and risk as required by medical necessity. Review of the Facility's policy for Activities of Daily Living (ADLs) with a revised date of 5/5/2020 revealed the following: Purpose, to ensure facilities identify and provide needed care and services that are patient centered ., Policy, the resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be documented and reported to the licensed nurse .A resident who is unable to carry out activities of daily living receives the necessary services to maintain .grooming, and personal and oral hygiene .Procedure, for fingernail care, the following procedure will be followed: 1. Ensure fingernails are clean and trimmed to avoid injury and infection. 2. Explain the importance of fingernail care to the resident ., 5. Report any abnormalities to the nurse.

Based on record review, and staff interviews the facility failed to provide one (#41) of five residents sampled, or their representatives, with a bed hold notice when they were transferred to an acute care facility. Findings included: Resident # 41 was admitted to the facility on [DATE] with the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 41's comprehensive Minimum Data Set (MDS) dated [DATE] reflected that Resident #41's brief interview for mental status (BIMS) could not be completed, the document also reflected that he had a feeding tube, and was non-verbal. A review of the nurse progress notes revealed an event dated 03/28/21. Shortly before midnight on 03/27/21, it was discovered that Resident #41 had produced coffee grounds emesis. The record revealed an order from the Physician Assistant to transfer Resident # 41 to an acute care facility for evaluation. The nurse progress note documented that the health care surrogate (HCS) was notified. During an interview with Resident #41's HCS on 06/15/21 at 4:45 p.m. She confirmed that she received a call on 03/28/21 at one in the morning that the Resident had been transferred to the hospital, she stated that she never received a written notification of the transfer and was not given any information on the bed hold policy. An interview with the Director of Nursing (DON) conducted on 06/17/21 at 2:03 p.m. revealed that the nurse had documented a progress note for the transfer of Resident #41 on 03/28/21, she added that there was no other documentation in the record, she added, the transfer packet which is our usual procedure was not completed for this transfer. A review of the facility's transfer packet revealed that it consisted of 1. the facility Bed Hold Policy, 2. AHCA (Agency for Health Care Administration) Form 3120-0002 April 2014 Nursing Home Transfer and Discharge Notice, 3. A Capabilities List (listing of the contact information for staff at the facility who can take off-hours calls related to hospital admissions and the return to the facility) 4. An attachment listing additional services available at the facility 5. Florida Health Care Association's SNF (Skilled Nursing Facility) to Hospital and Hospital to SNF COVID 19 Transfer Communication Tool, 6. Acute Care Transfer Document Checklist. An interview was completed on 06/17/21 with the Director of social service Staff I, she confirmed that residents who are their own responsible parties are asked to sign the bed hold policy document when they are transferred to the hospital, Staff I stated that if their condition is such that they cannot sign it, then we obtain their consent over the phone, or the facility's liaison visits the hospital to obtain the signature when they are able to sign.

Based on record review, and staff interviews the facility failed to provide two (#41, #86) of five residents sampled, or their representatives, with a written copy of the notice of transfer when they were transferred to an acute care facility. Findings included: 1) Resident # 41 was admitted to the facility on [DATE] with the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 41's comprehensive Minimum Data Set (MDS) dated [DATE] reflected that Resident #41's brief interview for mental status (BIMS) could not be completed, the document also reflected that he had a feeding tube, and was non-verbal. A review of the nurse progress notes revealed an event dated 03/28/21. Shortly before midnight on 03/27/21, it was discovered that Resident # 41 had produced coffee grounds emesis. The record revealed an order from the Physician Assistant to transfer Resident # 41 to an acute care facility for evaluation. The nurse progress note documented that the health care surrogate (HCS) was notified. During an interview with Resident #41's HCS on 06/15/21 at 4:45 p.m., she confirmed that she received a call on 03/28/21 at one in the morning that the Resident had been transferred to the hospital, she stated that she never received a written notification of the transfer. An interview with the Director of Nursing (DON) conducted on 06/17/21 at 2:03 p.m. revealed that the nurse had documented a progress note for the transfer of Resident #41 on 03/28/21, she added that there was no other documentation in the record, and said the transfer packet which is our usual procedure was not completed for this transfer. A review of the facility's transfer packet revealed that it consisted of 1. the facility Bed Hold Policy, 2. AHCA (Agency for Health Care Administration) Form 3120-0002 April 2014 Nursing Home Transfer and Discharge Notice, 3. A Capabilities List (listing of the contact information for staff at the facility who can take off-hours calls related to hospital admissions and the return to the facility) 4. An attachment listing additional services available at the facility 5. Florida Health Care Association's SNF (Skilled Nursing Facility) to Hospital and Hospital to SNF COVID 19 Transfer Communication Tool, 6. Acute Care Transfer Document Checklist. 2) Resident # 86 was admitted to the facility on [DATE] with the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #86's most recent quarterly MDS (minimum data set) dated 05/13/21 reflected a BIMS score of 14, indicating the resident had minimal to no cognitive impairment, the MDS section Q (participation in assessment and goal setting) documented that Resident #86 participated in the assessment and had no other legally authorized representative. A review of the Nursing Home to Hospital Transfer Form dated 05/01/21 at 07:57 a.m. revealed she was transferred to the hospital for evaluation of red swollen and painful bilateral lower extremities. The record included a copy of the facility's bed hold policy effective 11/28/16 signed by Resident # 86 on 5/1/21. An interview was completed on 06/17/21 with the Director of social service Staff I, she confirmed that residents who are their own responsible parties are asked to sign the bed hold policy document when they are transferred to the hospital. Staff I stated that transfer notices are not provided in writing to residents or their representatives, she confirmed that transfer notices in written form are faxed to the office of the State Long-term Care Ombudsman via a batch transfer performed monthly by the medical records department.

Based on observations, interviews and records review, the facility did not ensure dignity was maintained related to catheter care for 1 out of 8 residents with an indwelling catheter, (Resident #32). Findings include: During multiple facility tours on 06/14/21, 06/15/21 and 06/16/21, Resident # 32 was observed in his room, lying in bed, the catheter was visible from the hallway. The resident's catheter did not have a cover and his output was visible to those walking in the hallway. Resident #32 was noted to keep his room door wide open throughout the survey. Resident #32 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 is his own responsible party. An admission Minimum Data Set (MDS) dated [DATE]; Section C (cognitive patterns) resident has a BIMS (brief interview for mental status) of 15, indicating intact cognition. Section H (Bladder and Bowel) Resident has an indwelling catheter and ostomy. A review of the CNA (certified nurse's aide) task log in Kardex under Bowel and Bladder elimination revealed under question 4: Urinary continence (continence not related due to indwelling catheter) with check marks documented 3 times daily. A review of Resident #32's Care plan with a start date of 4/21/21 revealed, Focus: The resident has an indwelling suprapubic catheter due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions noted in the Care plan indicated catheter care every shift, educate resident and family regarding indwelling catheter and care. Observe and report to medical doctor for signs and symptoms of UTI (urinary tract infection) On 06/16/21 at 08:35 a.m. An interview was conducted with Staff A, CNA. Staff A, CNA was notified of the observation of Resident # 32's catheter being visible from the hallway. Staff A, CNA walked towards the room and made the observation. Staff A, CNA stated that the catheter bag should be covered. Staff A, CNA stated that this was not one of their bags, indicating Resident #32 came to the facility with this bag. Staff A, CNA continued to say that the catheter bag should be hanging on the other side of the bed, where it would not be visible to anyone walking by. When asked what she has been trained to do, Staff A, CNA stated it should be inside a bag for privacy. An interview was conducted with Staff B, LPN unit nurse on 06/16/21 at 09:44 am. Staff B was asked what to expect related to catheter bag storage. Staff B, LPN stated that it should not be exposed, the catheter should be in a bag for dignity reasons. On 06/16/21 03:53 p.m. an interview was conducted with Staff C, CNA. When asked if she has taken care of resident #32's catheter, Staff C stated that she empties it all the time. When asked if she had noticed that it was not stored in a bag, Staff C, CNA said, Yes, and I replaced it this morning and I put it inside a privacy bag. When asked if it should have been in a bag all along, Staff C stated catheters should be covered for privacy. A follow up interview was conducted on 06/16/21 at 08:35 a.m. with the DON (Director of Nursing) who confirmed that she noticed the incident this morning and it was a dignity issue. The DON further stated that the catheter bag should be covered and she asked Staff C, CNA to change the resident's catheter and make sure it is inside a bag for privacy. The DON stated she would start an in-service to remind all staff of the expectation. A review of the facility's assessment tool originally issued October 2017 and recently updated on January 5, 2021, under resident support / care needs revealed that the facility provides Bowel / bladder care and training including bowel and bladder training programs, incontinence prevention and care in order to maintain continence and promote resident dignity. A review of the facility's policy titled, Dignity reviewed on 05/19/20, policy states that each resident has the right to be treated with dignity and respect. Page 2, number 7 of the policy gives examples of treating residents with dignity and respect including but not limited to: refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered.

Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services to promote the healing of pressure ulcers for 1 (Resident #4) of 3 residents sampled for pressure injuries. Findings included: A review of Resident #4's Medical Record revealed that Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] dressing cover with Allevyn to left hip injury every day shift. Clean with normal saline prior to dressing change, dated 03/31/2021. - [MEDICATION(S)] dressing then Calcium Alginate pack to sacrum injury. Cover with Allevyn border every day shift. Clean with normal saline prior to dressing change, dated 03/31/2021. - Skin prep to bilateral heels every shift, dated 03/17/2021. A review of Resident #4's Care Plan revealed a problem, dated 12/24/2019, that Resident #4 had a break in skin integrity with presence of a stage 4 pressure injury of the sacrum, deep tissue injuries to bilateral heels, and left hip wound. Interventions included to perform treatments as ordered. An observation of Resident #4's left hip wound care was conducted on 04/26/2021 at 11:09 AM with Staff F, Registered Nurse (RN). During the observation, Staff F, RN was observed removing the dressing to Resident #4's left hip. The dressing was observed to be dated 04/24/2021. Staff F, RN performed the wound care for Resident #4 and dated the dressing for 04/26/2021. An interview was conducted on 04/26/2021 at 11:20 AM with Staff F, RN. Staff F, RN addressed that Resident #4's dressing was dated for 04/24/2021 and stated I wasn't going to point it out. Staff F, RN stated that she performed wound care treatments for most wounds in the facility on Monday through Friday and the nurses working on the floor performed wound care on the weekends. Staff F, RN stated that she was not sure if the treatment was to be completed daily and stated that Resident #4 may have refused the treatment on 04/25/2021. A review of Resident #4's Treatment Administration Record (TAR) for April 2021 revealed the following documentation: - [MEDICATION(S)] dressing cover with Allevyn to left hip injury every day shift. Clean with normal saline prior to dressing change. Treatment was not documented as completed on 4/10/2021. Treatment was documented as completed on 04/25/2021 by the facility's Assistant Director of Nursing (ADON). - [MEDICATION(S)] dressing then Calcium Alginate pack to sacrum injury. Cover with Allevyn border every day shift. Clean with normal saline prior to dressing change. Treatment was not documented as completed on 4/10/2021. Treatment was documented as completed on 04/25/2021 by the facility's ADON. - Skin prep to bilateral heels every shift. The treatment was not documented as completed on 04/03/2021 and 04/23/2021 on Night shift. The treatment was not documented as completed on 04/05/2021 on Evening shift. An interview was conducted on 04/26/2021 at 03:36 PM with the facility's ADON. The ADON stated that Resident #4 was in her care assignment for 04/25/2021. Nurse's working the floor were responsible for completing and documenting wound care for residents in their assignment on the weekends. The ADON stated that she didn't see anything for Resident #4's treatments when she reviewed her TAR on 04/25/2021. The ADON addressed that she documented that Resident #4's wound treatments were completed on 04/25/2021 but stated that she did not complete them. The ADON also stated that the documentation was an oversight on her part and that she had no knowledge of seeing the wound care orders on 04/25/2021. The ADON addressed that Resident #4's wound care was ordered to be completed daily. An interview was conducted on 04/26/2021 at 03:46 PM with the facility's Director of Nursing (DON). The DON stated that the facility's wound care nurse (Staff F, RN) performed the majority of wound care for residents from Monday to Friday every week and that nurses that work the floor were responsible for wound care for their assigned residents on the weekends. Wound care should be performed and documented in the resident's TAR as ordered. The nurse performing the wound care for that shift would be expected to verify the wound care that needed to be completed for that shift. The DON stated that if a resident refused a treatment, the code in the electronic record should reflect the resident's refusal and there should be no absence of documentation in the resident's TAR.

Based on staff, administrative, and physician interviews, record review, policies review, and family interview, the facility failed to ensure that emergency basic life support was immediately provided, including cardiopulmonary resuscitation (CPR), in accordance with resident advance directives. Facility staff failed to follow timely and appropriate initiation of CPR according to facility policy, procedures, and professional standards of quality related to CPR in accordance with the documented wishes for CPR for two (Resident #1 and Resident #2) of 13 sampled residents. On [DATE], Resident #1, a [AGE] year-old female, was assessed to be unresponsive with a significant change in condition. The assigned licensed nurse (Staff B) failed to confirm Resident #1's accurate code status, resulting in delayed initiation of critical life-supporting CPR. Resident #1's care plan, and signed advanced directives, indicated a full-code status. Investigation of Resident #1's change in condition led to the discovery of Resident #2, who was a full code assigned to Staff B. On [DATE], Resident #2, a [AGE] year-old male, was assessed to be unresponsive with a significant change in condition. The facility staff failed to immediately initiate CPR after verification of Resident #2's code status in accordance with the facility's policy and procedures related to CPR. The facility's failure to provide immediate CPR for Resident #1 and Resident #2 revealed a system-wide failure. This failure resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of D. Findings included: A record review of Resident #1's Alert Note in progress notes, dated on [DATE] at 12:45 a.m. by Licensed Practical Nurse (LPN)/Staff B, revealed, CNA (Certified Nursing Assistant) came to nurse to report at 12 45am, that the resident may have passed. Pulled chart and resident was a full code. Called medical emergency to (Resident #1's room) over the intercom. Retrieved the crash cart. CPR was started by (Staff C, Registered Nurse (RN)/Staff B, Licensed Practical Nurse (LPN)) and ambu bag (Bag Valve Mask used for resuscitation) was performed by (Staff A, CNA) until EMT (Emergency Medical Team) arrived at 1:10am. (Staff D, LPN) called 911 and printed paperwork for EMTs. EMTs called resident as deceased at 1:30am. Contacted DON (Director of Nursing) to report and to get ok to call (funeral home). Called (funeral home) around 2am. Stated they would be here in an hour and a half. Tried to contact Daughter at 1:45 a.m., left message on voicemail to call facility, gave nurse's name and facility's phone number. An interview on [DATE] at 3:00 a.m. with Staff C/RN revealed she was aware of Resident #1, and the incident that occurred on [DATE]. Staff C said, I was on another unit (Manatee Unit) and I was called over by (Staff B) who was caring for the resident, who was on the isolation unit (Ringling Unit). (Staff B/LPN) wanted me to pronounce the patient as deceased because I'm an RN and she is an LPN. She called me on the phone and asked me to come over and pronounce the patient being that I was the RN in the building at the time. So, I said sure and I verified that (Resident #1) had expired. (Staff B) did not call me to verify a code. (Staff B) said something about how she hadn't checked (Resident #1)'s code status. She asked me if I would start the code while she got the other stuff rolling and made calls. I said sure. I made sure she overhead paged medical emergency. Someone went and got the AED (Automated External Defibrillator for resuscitation), someone else got the crash cart. I started compressions before they brought the backboard. (Resident #1) was not breathing and no heartbeat . she's (Resident #1) not the coldest person I've ever touched . was not in rigor. Staff C clarified who verified Resident #1's code status. Staff C said, Both of us went out to the desk and checked it and that's when she asked me to start the code. I have no idea how much time elapsed from when (Resident #1) was found to when CPR was started. (Staff B) gave me no indication of time. I did not tell administration about the incident because (Staff B) told me she called the DON; I don't know what she told them. (Staff B) and I switched off a few times in CPR before Emergency Medical Services (EMS) got there. We performed max ,[DATE] minutes, maybe 3 switches every 50 compressions. Once EMS arrived around 1:10 a.m. I backed off and EMS performed CPR for about 20 minutes. Staff C confirmed that in Long-Term Care, the procedure once a resident is found unresponsive was to ascertain the code status if it was not already known, and if the patient was a full code then immediately start CPR. Staff C said, I don't believe (Staff B) checked the code status before she called me .but again, I was called to pronounce death. On [DATE] at 3:24 a.m., the DON and the Administrator joined the interview with Staff C. Staff C repeated the incident to administration. Staff C/RN said, I was called over to pronounce the death of Resident #1 by (Staff B) and I came over and ascertained patient wasn ' t breathing, no heartbeat, and I said yep you're right she's passed. I became aware that (Staff B) wasn't sure of (Resident #1's) code status and we went to check. (Resident #1) was a full code. (Staff B) asked me if I could start CPR, and I told her she needed to call the DON. (Staff B) overhead paged medical emergency, others arrived, not sure all who, we started a code, I did compressions, the AED arrived. I can't tell you the exact number of compression rounds, but I'm thinking about 3 switches between (Staff B) and I before EMS arrived. The DON revealed that Resident #1's death was reported to her; however, no nursing staff reported a delay in checking the resident's code status or a delay in CPR initiation. The DON confirmed it was a requirement for an LPN and an RN to check a resident's code status. The DON continued saying, The expectation for incident documentation is document in the chart. I try and get a timeline of the day before (an incident) and how the resident was doing. The DON confirmed that documentation was required in a progress note which should include the last assessment, and resident status, but no other specific data points. There was a sheet on the crash cart for timeline documentation. A record review of Resident #1's Admission Record revealed an admission date of [DATE], and a discharge date of [DATE], [DIAGNOSES REDACTED]. Further record review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated [DATE], found the resident ambulated with an assistive device with assistance of one required for transfers. The form also noted that Resident #1 was transferred for rehabilitation and repair of sutures. Resident #1's Resident/Family Education Assessment & Interdisciplinary Flow Record, signed without a date of completion, revealed the anticipated length of stay was equal to or less than one month. The document revealed that Resident #1 had no limitations or barriers to learning, was able to understand basic information, was motivated to learn, and was able to verbalize understanding. A record review of Resident #1's Advanced Directives Discussion Document, dated [DATE], revealed a status of Provide CPR obtained by a facility nurse, signed by both Resident #1 and a Facility Representative. Resident #1's Care Plan, initiated [DATE], revealed a full code status with a goal of honoring the resident's advanced directives. Resident #1's Active physician's orders [REDACTED]. Resident #1's progress notes, dated [DATE], by the Social Services Assistant (SSA), revealed that a full code status has been elected during the admission on [DATE]. The social worker spoke with the resident's daughter per Resident #1's request and gathered personal information. Resident #1 was living at home alone prior to arriving to the facility and received help from a private duty and the neighbor. The progress note stated that Resident #1 used a walker to ambulate. A record review of Psychosocial Note in progress notes, dated [DATE] at 10:07 a.m. by SSA, revealed, Assessment note for unplanned discharge MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE]: Resident #1 was unable to participate in her assessment related to her passing away on [DATE] . She was alert with confusion. Short and long-term memory loss was anticipated. Resident #1 did not seem aware of the reason that she was in a nursing facility. Her decision making was severely impaired. An interview on [DATE] at 4:25 p.m. with the Physician Assistant (PA) assigned to Resident #1 revealed that the PA recalled Resident #1. The PA used Resident #1's medical chart to recall information. The PA confirmed the resident's age and medical diagnosis. The PA said, She was coming to the facility for rehab. She was not being admitted for long term care at the time. It seems that she was living at home with caregivers and neighbors helped as well. She was doing physical therapy. She was a poor historian. She did not have a [DIAGNOSES REDACTED]. She wanted to be a full code. She had chest pain and was sent to the emergency room (ER) for an evaluation. The ER physician did not find anything acutely wrong with her. She came back with no change of plan that same day. Over the next few days she did not have a change of condition. It would not be unusual for a resident at this age to have a sudden change of condition. I do not recall who I was called by the night of the incident, but I was called late at night. I was told patient was found non-responsive, EMS was called, she was pronounced deceased . I do not recall who called me. After the death, the MD signed a death certificate stating that it was likely acute [MEDICAL CONDITION] infraction. She did have a left leg laceration . When the nurse interviewed (Resident #1), the resident was able to express that she wanted to be a Full Code. She was what I would expect for someone of 100, declining. When they come here hopefully, we can rehab them. She had a history of [REDACTED]. In my experience less than 1% of people recover after being found without a pulse. In fact, I don't think I've seen anyone walk out of the hospital after being provided with CPR, especially at that age. In this case, I don ' t think the outcome would have changed at all. The PA reported that it was absolutely the expectation to perform the advanced directive order in place for a resident regardless of their age. An interview on [DATE] at 4:47 p.m. with the Director of Social Services (DSS), revealed that there was a process for advanced directives. The DSS said, So when a patient is admitted , the nurse goes over the advanced directives. It is part of the nursing assessment upon admission. The nurse will have the patient sign if they can. If not, they will have to get a verbal from the family with witnesses. The DSS verified that Resident #1 wanted to be a full code. The DSS continued, That is the procedure. When we look at the chart, we look at the paperwork and make sure it is in line. We have 72 hours to review the documents. We would then care plan what their wishes are, talk with the resident about their wishes. The SSA (Social Services Assistant) worked with (Resident #1). The resident was not very clear, that is what the SSA told me. We care plan it in (the electronic medical record system) what the advanced directives are. Whenever we have a care plan meeting, we then review the code status, or if the resident has a drastic decline we discuss. To my knowledge the resident had a full code in place. We also talk about discharge planning, issues with depression, anxiety, if they need emotional support, if the patient desires us to call the family, we would also do that. I really don't know much about this resident. An interview on [DATE] at 4:52 p.m. with the SSA revealed they recalled Resident #1. The SSA said, Prior to coming here she was living at home alone, independently. This information I got from the daughter. The resident wasn't able to provide too much, but she gave me permission to talk to her daughter. (Resident #1) signed that she wanted to be a full code upon admission. I did not verify information from chart that she wanted to be a full code, my interaction was very brief. This is not a usual situation but when I met with her, she looked like she didn't feel well, and the next time she wanted me to talk to the daughter. I did not verify with the daughter her advanced directives. I just got a social history and living prior to her hospitalization . She was living at home, she was independent, the daughter planned on coming down from New York in about a week or two to figure out a plan for the resident's discharge. First interaction with the resident was a day or two before the [DATE] progress note. That was the date I entered the note, but I met her prior. The SSA confirmed that Resident #1 was a full code. An interview on [DATE] at 5:50 p.m. with Staff B/LPN revealed that she had worked in the facility for 2 years and 3 months. At the time of interview, Staff B acknowledged that her Basic Life Support (BLS) CPR card expired in [DATE]. Staff B said, I didn't know when we would be renewing it because I didn't notice renewal was posted on the back board. Staff B indicated that she recalled Resident #1, and the night of Resident #1's expiration. Staff B said, My shift started at 11:00 p.m., and I had not worked on Ringling in quite a while. The night of [DATE] was the first night I cared for the resident. Staff B provided a timeline of the incident involving Resident #1. Staff B said, Well, I can give you approximate times. About 12:45 a.m., the CNA (Staff A) came out and said she thought Resident #1 passed. I went into the room, checked the pulse, breathing, and Resident #1 had neither. I called the RN on Manatee, (Staff C), and told her I had a patient that expired and asked her to come over and verify it, and she came right away. I had just pulled the chart out when (Staff C) came over. I did not go into the room with (Staff C) because I was pulling the chart to check if (Resident #1) was a full code or DNR. (Staff C) came over within a couple minutes and went into the room. I had just got the chart out. I realized she was a full code. I said Resident #1 was a full code and (Staff C and Staff A) went back into the resident's room to begin CPR. I got the crash cart. I put the board underneath Resident #1's back and set up the ambu bag for the CNA. Before I got the crash cart, I called medical emergency over the intercom twice. I went back out to call 911, but (Staff D/LPN) was already making the call for me. I asked her to print out papers because the EMTs always want the orders and face sheet. I went back in. (Staff C) and I switched off about 3 times in CPR. One of the other CNAs had to go over to Manatee to get the AED and brought it back over. (Staff C) set it up and we probably switched off 5 or 6 times. The EMTs showed up about 1:10 a.m. Referring to what time the facility began CPR, Staff B said, (Staff C) walked in right after I started calling medical emergency, so we probably started it about 12:50 a.m. and went until 1:10 a.m. when they (EMTs) arrived. We switched off about 2 or 3 times, so we did it for about 20 minutes. The EMTs worked on (Resident #1) for about 20 minutes and then pronounced her deceased at 1:30 a.m. I can only estimate when CPR was started after the resident was found. I called medical emergency about 5 minutes after the aide reported it to me. (Staff A/CNA) went in with me to check on the resident. (Staff C) came over and went into the room as I was pulling the chart. (Staff C) came out of the room because I told her I was checking the chart. I called medical emergency about 5 minutes after (Staff A) reported it to me, so CPR was started about 5 to 6 minutes after (Resident #1) was discovered unresponsive. I called the DON and told her about the death. I tried to call (Resident #1's) daughter but she didn't answer, and I left a message. She never did call back. The funeral home picked up (Resident #1) about 3:30 a.m. The DON told me to leave a note about everything under the door for her to review. A note about what happened, but she was already there so I just gave it to her. Most of the other codes I was involved in were DNR. There was a gentleman (Resident #2) who was a full code that passed about ,[DATE] months ago. (Staff C) performed most of the CPR that time because I was making phone calls. I thought that everything had gone smoothly, like riding a bike. We got education on the code sheet today, but I had not known about the code sheet prior to today so no form was filled out for (Resident #1). An interview on [DATE] at 5:05 p.m. with Staff A revealed that she was involved with Resident #1's care and notified Staff B of the change in condition on [DATE]. Staff A said, When I come in on my shift, we get a report from the previous shift. I go check the residents at the beginning of the shift. I provided no care to (Resident #1) prior to the night of expiration. No problems were reported to me about (Resident #1) from the other aide, but I still go in and check on the resident. (Resident #1) was lying in bed by the window, I saw her feet. Then I start getting resident vitals, check on call lights. That night one of the other residents was very confused, so most of the beginning of the shift was spent with them. I got to (Resident #1's) room, which would be my last room in my order of getting vitals, she didn't look okay. I went straight to the nurse. The nursing station is right outside the door .The nurse (Staff B) evaluated Resident #1, called the other nurses, got the crash cart, and CPR was started. I was not in the room when the EMS arrived but prior to that I was. The nurse (Staff B) immediately came into the resident room, then left the room, and then made the announcement over the intercom code blue, which means a medical emergency. I can't say how long we were doing CPR for. An interview on [DATE] at 6:32 p.m. with Staff D, LPN revealed she was on duty the night of [DATE] and recalled Resident #1. Staff D provided a timeline of the event, I was on the University Unit and I heard the overhead page for a code on Ringling. I went and got the AED and brought it to (Resident #1's) room. (Staff B) asked me to call 911 and start the paperwork. (Staff B) made the call overhead. I saw (Staff B and Staff C) in (Resident #1's) room, they were performing CPR. (Staff A) was also in the room, from what I heard (Staff A) was the one who found the resident unresponsive. I was just in the doorway since I wasn't gowned up. I told 911 that the patient was unresponsive, they asked if the patient was breathing, I said yes since they were performing CPR. I told the other aide to wait outside to guide EMS in. I don't really remember times. Staff D indicated that her process when finding an unresponsive resident and determining that they were a full code was to, .Call the code, delegate to my aides about calling 911, get the crash cart. I'm fast, so it would probably take about a minute or two before I started CPR. I just start, I don't call another nurse, I tell the aides to overhead page and get everyone together. I'm an LPN and responsible for initiating CPR. Before starting CPR, I check if they are CPR or DNR in the chart or on the computer. That process should be immediately. Process doesn't take more than a minute or two to check the chart and begin CPR. There should be a staff member documenting time, procedure, and steps before the paramedics come in the nursing notes, like progress notes, time and notifications. Documentation should be a step by step outline. I'm not aware of any other documents that we are supposed to use. I'm not aware of any other documents on the crash cart. An interview on [DATE] at 12:47 p.m. with the DON and the Staff Development Coordinator (SDC)/RN revealed that education and training was provided to staff about what to do during a code situation. The SDC said, I've been in this position since [DATE]. Education and training about code is part of the general orientation that I provide to the nurses, One of the first things I do is to go through the chart in the admissions process, and obtain the resident's wishes about advanced directives (referring to the documentation provided to the resident about code status during the admission process). This is then followed up with a physician order [REDACTED]. These forms to become a full code or DNR are present in the facility for the residents and the nurses. If they find someone unresponsive, no pulse, I go through the process of paging medical emergency overhead. If you are at the nurses' station, grab the chart and go into the room. Instruct the aide to get the chart while the assessment of the resident occurs as soon as possible. Check the code status of the resident under the advanced directives tab of the chart. The SDC confirmed after a resident is assessed, their advanced directive must be verified. If a resident is a DNR, one RN or two LPNS have the capacity to pronounce death. If a resident is full code, CPR must be initiated as fast as possible. The SDC said, An LPN does not need someone to come verify if the resident is a full code or to begin CPR. The SDC revealed that facility procedure is for all nurses to respond to an overhead page for medical emergency. The responding nurses can delegate responsibilities such as retrieving the crash cart, making phone calls, and guiding EMS into the building upon arrival. Additionally, educational mock codes should be performed quarterly. The SDC said, .but it (mock code) has not been provided since [DATE] since we have been focusing on other things like infection control . in [DATE], a code was performed. There were no issues, but we did provide education then. It was just an opportunity to provide education. This was not extended to everyone, not to my knowledge. The SDC revealed that sign-in sheets are kept in her records regarding CPR training. Referring to the employee line list and how an employee ' s education is monitored, SDC said, It is a computer-based learning system. It is a printout of everything that staff member has done. I have two different certification programs. It populates on their work hire date anniversary. The computer program allows you to see what staff training history is. They have a 30-day period from date of anniversary to complete the training. Abuse and neglect training are done at least once a year. During this interview, the DON said, I started in [DATE]; we have not done a mock code since I started I ' m not sure if we have it written anywhere (referring to a step-by-step education plan for CPR), but I can look. I have not trained them on the code sheet. It was not a practice for me, it is now. I don't have evidence personally that staff was trained on it (referring to the code sheet), but it is part of the plan now to clearly document going forward. A follow-up interview with the SDC on [DATE] at 3:00 p.m. revealed that the code incident previously referred to in [DATE] was not an education but rather a post-incident meeting. An interview on [DATE] at 2:12 p.m. with the Medical Director (MD) revealed he met with Resident #1 when the resident was first admitted . The MD said, From what I recall, (Resident #1) was very elderly and complaining of chest pain which I sent her out to the hospital for. The MD confirmed there were no other changes of condition and that the PA notified him when Resident #1 was pronounced deceased . The MD reported that it was absolutely the expectation for facility staff to perform CPR on a resident identified as a full code. The MD confirmed that as a result of the incident involving Resident #1 the facility presented a draft intervention plan to prevent another occurrence. He confirmed he attended the monthly Quality Assurance meetings. The MD said, I will make sure to go over the plan with everyone and make sure they are better educated about everything. A telephone interview on [DATE] at 3:14 p.m. with Resident #1's daughter revealed that the reason Resident #1 originally went to the facility was because her toes were turning black. The daughter said, She was very good. The foot doctor recommended we take her to the cardiologist. He performed surgery on her leg to get circulation down to her toes again, and he told me the surgery went well. The big toe was totally black, and eventually they were thinking of amputating. Before she went to rehab (at the facility), she fell at the hospital. She got stitches in her leg again, and from there they sent her to rehab. They told me she was walking with her walker. I got very little information from that place (referring to the facility) and I spoke to a nurse, and she told me my mom seems to be okay, but I was not able to speak to her because she was very hard of hearing and so there was no sense of me talking to her on the phone. I was told not to hurry coming down because I could not visit her at the hospital or facility and that was it. The daughter provided a timeline of the events as told to her by the facility. The daughter said, I got a call about 1:45 a.m. but my phone was off. The next morning when I got the message and called back, I was told they tried to do CPR and revive her, but she passed and that is all I know. The last time I spoke to her was at the hospital. The hospital was able to arrange for me to speak with her. She wasn't quite coherent anymore, she kept saying come and visit me, and I tried to explain I couldn't because of [MEDICAL CONDITION]. The daughter revealed she had not been notified that Resident #1 went to the hospital while at the facility. The daughter said, No. I wasn't notified. I didn't know they sent her back to the hospital. No one told me that. I had trouble getting through to the facility. I was told the nurse was busy now, the nurse was handing out medication, and the nurse would call me back. Then I got a text message saying, oh, we had a wonderful day today, all the seniors were playing bingo, and I thought that's not right. There is no way my mom is playing bingo. She's lucky she knows how to open the TV. I had pretty much everything taken care of when she lived at home. We talked every day. She was okay until all this stuff started with her foot. I thought she was doing good. Resident #1's daughter revealed she wasn't aware of her mom wanting to be a full code. She stated, I wonder if she even knew what she was signing. The daughter reported that nobody from the facility ever reached out to discuss Resident #1's wishes regarding admissions and care. The daughter stated the facility only reached out one time. They told me that she was all right, she was taking her medication. But that ' s it, very little information. They left a message on my phone that she passed, and when I called back, they answered. I said I'm calling about my mother. And they told me that they tried to do CPR and that they had 911 coming in At least we got to celebrate her [AGE] year-old birthday before all this started. Everyone was there. It is a really great memory to have. It's just so sad how after all this COVID-19, all these people are dying without anyone with them. On [DATE] at 4:48 p.m., the Administrator provided documentation related to the EMS run report. The run report is a record used by the ambulance to record pre-hospital patient care and patient transfer care information when applicable. The Administrator confirmed that the Assistant Director of Nursing (ADON) contacted the County Emergency Services to retrieve Resident #1's information and was the person that documented the information provided. An interview on [DATE] at 4:30 p.m. with the ADON revealed that they contacted EMS on [DATE] at 10:30 a.m. The ADON stated they spoke with an operator who retrieved the run report information from the EMS internal system. The ADON revealed she read the facility documented progress notes recorded by Staff B regarding the timeline of when 911 was called, and EMS arrival time. The ADON verified that the information provided from the EMS system did not match the time of events as reported in the progress notes. Resident #1's Manatee County EMS Patient Care Record (run report) provided directly from the County Emergency Services, dated [DATE], revealed that the Est (estimated) Time Collapse to CPR was 15 minutes. The report documented that the first time CPR was administered by the facility was at 1:08 a.m. EMS received the call from the facility pertaining to a medical emergency at 1:09 a.m. EMS was dispatched at 1:10 a.m. and arrived on scene at 1:20 a.m. EMS was at the patient at 1:21 a.m. and resuscitation was discontinued at 1:35 a.m. due to obvious signs of death. A review of Resident #1's clinical record revealed a progress note indicating that the nurse was notified at 12:45 a.m. by the CNA that the resident may have passed. This 12:45 a.m. notification time of change in condition for Resident #1 was also stated by Staff B during her interview on [DATE] at 5:50 p.m. If the resident was initially found at 12:45 a.m., as indicated in the clinical record and staff interview, and CPR was first delivered by the facility staff at 1:08 a.m., as indicated on the EMS run report, an elapsed timeframe of 23 minutes occurred from the time Resident #1 was found unresponsive and the initiation of CPR occurred. Throughout the course of investigation related to delayed initiation of critical life-supporting CPR for Resident #1 on [DATE], additional information was received on [DATE] indicating that another resident also experienced a delay in CPR a few months prior. A review of facility records and information from the interview with Staff B, which occurred on [DATE] at 5:50 p.m., led to the identification of Resident #2. A record review of Resident #2's Progress Notes, dated [DATE], revealed a Health Status Note by Staff B, LPN. The note stated, Resident was deceased at 5:30 a.m. CNA called nurse to room to let her know that resident was non-responsive at 4:40 a.m. Checked chart and resident was Full Code. Nurse called Medical emergency over intercom. Nurse associates started CPR on resident. Called 911, called DON and called wife. EMT arrived and continued to perform CPR until 5:30 a.m. Wife came in just as EMT finished. CNA's cleaned resident up. Wife called (funeral home). They arrived at 7:55 a.m. A telephone interview on [DATE] at 9:34 a.m. with Staff C/RN regarding Resident #2 revealed she recalled working the night of [DATE] into the morning of [DATE] with some recollection of the night. Staff C confirmed a medical emergency occurred in Resident #2's room. Staff C confirmed involvement in Resident #2's code. Staff C provided a timeline of the incident events. I was in the cardiac unit. (Resident #2) belonged to another unit. Another nurse (Staff B) came to get me and I started CPR as she made the calls. I had the long hall and (Staff B) had the short hall, which included (Resident #2's) room. (Resident #2) was (Staff B's) resident for the night. (Staff B) wanted me to start the code, and she was going to make calls and get things going. I went into (Resident #2's) room to start the code and she made the overhead page for medical emergency. I cannot tell you who else was in the room, any names, or level of licensure they had, or whatever. Staff C did not know why Staff B did not immediately start CPR. Staff C stated, .I believe (Staff B) checked the code status. To my recollection she had already checked the code status prior to me arriving on the scene. I would imagine she coordinated calls to EMS, the doctors, the family, (TRUNCATED)

Based on staff interviews, record review, policies review, and review of Emergency Medical Services (EMS) run reports, the facility neglected two residents by failing to provide the required structures and processes to honor their advance directives for cardiopulmonary resuscitation (CPR). Resident #1 and Resident #2 experienced critical changes of condition on [DATE] and [DATE] respectively, each requiring immediate CPR in accordance with their advance directives and facility policy and procedure. The nursing staff assigned to the residents' care failed to ensure timely confirmation of code status and immediate initiation of CPR. Due to improper sequencing and delegation in accordance with facility policy and procedure and American Heart Association (AHA) standards for emergent CPR performance, there was a 12-minute delay in initiation of CPR for Resident #2 and a 23-minute delay in initiation of CPR for Resident #1. The facility failed to ensure that residents received the services necessary to avoid physical harm and failed to ensure that structures to include an effective training and evaluation program and oversight and monitoring of staff performance and credentials were in place. The facility failed to ensure that processes to include ongoing monitoring and supervision of staff's delivery and implementation of care, correct response to a medical emergency, and integration of facility-created tools to ensure accurate documentation of critical events were in place. As a result of the neglect, Resident #1 and Resident #2 did not receive immediate CPR in accordance with their wishes when they were discovered by staff without pulse or respiration. This failure resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of D. Findings included: A review of the facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised [DATE], reviewed [DATE] revealed the following: Position Statement & Guidelines .Each resident has the right to be free from abuse, neglect .of any type by anyone .It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect . Definitions .Neglect - means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The AHA defines CPR as an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after [MEDICAL CONDITION]. (https://cpr.heart.org/en/resources/what-is-cpr). The Association highlights the following as critical to life-sustaining outcome: Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION] .Trained rescuers are encouraged to perform some steps simultaneously (e.g. checking for breathing and pulse at the same time) in an effort to reduce the time to first compressions. Integrated teams of highly trained rescuers may use a choreographed approach that accomplishes multiple steps and assessments simultaneously rather than in the sequential manner used by individual rescuers. (https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/) The basic life support sequence outlined by the AHA for healthcare providers comprises the following order of actions: 1. Ensure scene safety. 2. Check for response 3. Shout for nearby help/activate the resuscitation team; can activate the resuscitation team at this time or after checking breathing and pulse. 4. Check for no breathing or only gasping and check pulse (ideally simultaneously). If no breathing (or only gasping) and no pulse immediately begin CPR. 5. Answer dispatcher's (EMS dispatcher) questions. 6. When the second rescuer arrives, provide 2-person CPR and use AED (automated external defibrillator)/defibrillator. (https://eccguidelines.heart.org/tables/2015-basic-life-support-sequence/) According to their published consensus statement endorsed by the American College of Emergency Physicians and the Society of Critical Care Medicine, the AHA states that Poor-quality CPR should be considered a preventable harm. (https://www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e d8654) The facility policy titled, Cardiopulmonary Resuscitation (CPR) Guidelines, revised [DATE] revealed the following: Purpose .To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians orders, such as DNRs (do not resuscitate orders), and the resident ' s advance directives. Federal Regulations .F678 .Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident ' s advance directives .The AHA urges all potential rescuers to initiate CPR unless: A valid Do Not Resuscitate (DNR) order is in place; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; Initiating CPR could cause injury or peril to the rescuer .If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident ' s advance directives and any related physician order, such as code status . Definitions . 'Cardiopulmonary resuscitation (CPR)' refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased . 'Code Status' refers to the level of medical interventions a person wishes to have started if their heart or breathing stops. Policy .CPR Certification .Staff must maintain current CPR certification for Healthcare Providers .Facility must address the provision of basic life support and CPR, including: .Directing staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and: .Who have requested CPR in their advanced directives .Facilities must have systems in place to ensure there is the number of staff present at all times per state guidelines who are properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency medical services arrives. Within the procedures section of the facility policy titled, Cardiopulmonary Resuscitation (CPR) Guidelines, reference is made to procedure resources by a clinical education resource vendor for CPR one-person rescue and CPR two-person rescue. It is documented that, This facility will utilize the following (clinical education resource vendor) Procedures. A review of the procedures revealed that both included the following: Introduction .Studies show that early CPR can improve a patient ' s likelihood of survival .To prevent a delay in chest compressions, the AHA changed the sequence of CPR .to C-A-B (compressions, airway, and breathing), which gives the highest priority to chest compressions when resuscitating a patient in [MEDICAL CONDITION]. Implementation .The AHA created .a step-by-step guide for CPR .Put on gloves and other personal protective equipment, as needed and available .Verify the safety of the environment .Assess whether the patient is unresponsive by tapping the patient on the shoulder and shouting, 'Are you all right?' .If the patient is unresponsive, shout for help and activate the emergency response system via mobile device (if appropriate) .Check to see whether the patient is apneic or only gasping .and, if you're able, simultaneously check for a pulse to minimize delay in detecting [MEDICAL CONDITION] and initiating CPR . Documentation .Document all of the events of resuscitation and the names of the individuals present. Record the reason CPR was initiated, whether the patient suffered from cardiac or respiratory arrest, the location where the arrest occurred, whether any witnesses were present, the time CPR began, and the duration of CPR. Note the patient's response, any complications, and any interventions you took to correct complications. If the patient also received ACLS (advanced cardiac life support) measures, document the interventions performed, the person who performed them and when, the equipment used, and the results. A review of the facility document titled, LPN Unit Licensed Practical Nurse (LPN) Job Description Primary, revision date [DATE] revealed the following: The LPN Unit Licensed Practical Nurse delivers quality nursing care to patients through interpersonal contact and provides care and services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and Life Care standards .Reports to Director of Nursing (DON) or other nursing supervisor .Must have CPR certification upon hire or obtain during orientation. CPR certification must remain current during employment .Must possess the ability to make independent decisions when circumstances warrant such action .Must be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing nursing functions in the post-acute care facility .Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing department .Must understand and follow company policies .Must be able to assign duties, instruct, and provide clinical supervision to CNAs .Must be able to chart appropriately and timely . 1. A review of the documentation in the medical record for Resident #1 revealed an Event Note dated [DATE] 12:45 a.m. entered and e-signed by Staff B, Licensed Practical Nurse (LPN). The note read: CNA (Certified Nursing Assistant) came to nurse at 12:45 a.m. to report that resident have passed. Pulled chart, she was a Full Code. Called medical emergency over intercom. Retrieved crash cart. CPR was started by (Staff C, RN/Staff A, CNA). CNA (Staff A) managed ambu bag (manual resuscitator). Nurse (Staff D, LPN) called 911 and printed paperwork for EMTs (Emergency Medical Technicians). They arrived and worked on resident until 1:30 a.m. and pronounced her deceased . Called DON (Director of Nursing) to give report and to check to see if we can call (funeral home). She said yes, contacted them at 2 a.m. and they arrived at 3:30 a.m. Tried to contact daughter at 1:45 a.m., left message to call facility, and gave our number. No return call as of 7:15 a.m. An Alert Note dated [DATE] 12:45 a.m. was entered following the event note, also authored and e-signed by Staff B. The note read: CNA came to nurse to report at 12:45 a.m., that the resident may have passed. Pulled chart and resident was a full code. Called medical emergency to room . over the intercom. Retrieved the crash cart. CPR was started by Nurse (Staff C)/Nurse (Staff B) and ambu bag was performed by CNA (Staff A) until EMT arrived at 1:10 a.m. Nurse (Staff D) called 911 and printed paperwork for EMTs. EMTs called resident as deceased at 1:30 a.m. Contacted DON (name) to report and to get the OK (okay) to call (funeral home). Called (funeral home) around 2 a.m. Stated they would be here in an hour and a half. Tried to contact daughter (name) at 1:45 a.m, left message on voicemail to call ., gave nurse's name and facility's phone #. An Event Note dated [DATE] 1:30 a.m. authored and e-signed by Staff B revealed, Resident was pronounced decease at 1:30am by paramedics. The document titled Weights and Vitals Summary revealed last entry of vitals prior to event was entered on [DATE] at 10:12 a.m.: blood pressure ,[DATE]; temperature 97.7 degrees Fahrenheit; pulse 78 beats per minute; respiration rate 20 breaths per minutes; Oxygen saturation 95% with oxygen via nasal cannula (liters not documented). An interview conducted on [DATE] at 3:00 a.m. with Staff C revealed she was aware of Resident #1 and the incident that occurred on [DATE]. When asked to provide a timeline of the incident, Staff C said, I was on another unit (Manatee Unit) and I was called over by (Staff B) who was caring for the resident, who was on the isolation unit (Ringling Unit). (Staff B) wanted me to pronounce the patient as deceased because I'm an RN and she is an LPN. She called me on the phone and asked me to come over and pronounce the patient being that I was the RN in the building at the time. So, I said sure and I verified that (Resident #1) had expired. (Staff B) did not call me to verify a code. (Staff B) said something about how she hadn ' t checked (Resident #1's) code status. She asked me if I would start the code while she got the other stuff rolling and made calls. I said sure. I made sure she overhead paged medical emergency. Someone went and got the AED (Automated External Defibrillator), (and) someone else got the crash cart. I started compressions before they brought the backboard. (Resident #1) was not breathing and no heartbeat. When asked how Resident #1 felt when verifying vitals, Staff C said, She's not the coldest person I've ever touched, (Resident #1) was not in rigor. When asked who verified Resident #1's code status. Staff C said, Both of us went out to the desk and checked it and that ' s when she asked me to start the code. I have no idea how much time elapsed from when (Resident #1) was found to when CPR was started, (Staff B) gave me no indication of time. I did not tell administration about the incident because (Staff B) told me she called the DON; I don't know what she told them. (Staff B) and I switched off a few times in CPR before Emergency Medical Services (EMS) got there. We performed max ,[DATE] minutes, maybe 3 switches every 50 compressions. Once EMS arrived around 1:10 a.m. I backed off and EMS performed CPR for about 20 minutes. Staff C confirmed that in Long-Term Care, the procedure when a resident was found unresponsive was to ascertain the code status if it was not already known, and if the patient was a full code then immediately start CPR. Staff C said, I don't believe (Staff B) checked the code status before she called me .but again, I was called to pronounce death. On [DATE] at 3:24 a.m., the DON and the Administrator were asked to join the interview with Staff C. Staff C was asked to repeat the incident to administration. Staff C said, I was called over to pronounce the death of (Resident #1) by (Staff B) and I came over and ascertained patient wasn't breathing, no heartbeat, and I said yep you're right she's passed. I became aware that (Staff B) wasn't sure of (Resident #1's) code status and we went to check. (Resident #1) was a full code. (Staff B) asked me if I could start CPR and I told her she needed to call the DON. (Staff B) overhead paged medical emergency, others arrived, not sure all who, we started a code, I did compressions, the AED arrived. I can't tell you the exact number of compression rounds, but I'm thinking in the neighborhood of 3 switches between (Staff B) and I before EMS arrived. The Administrator and DON were asked if any of this information regarding the possible delay in critical CPR had been shared with them. The DON said, Nothing was shared with me about the checking of the code status. The death itself was reported to me but nothing other than that. The DON confirmed it was a facility requirement for an LPN and an RN to check a resident's code status. The DON continued saying, The expectation for incident documentation is document in the chart. I try and get a timeline of the day before (an incident) and how the resident was doing. The DON confirmed that documentation was required in a progress note which should include the last assessment and resident status, but no other specific data points. She stated that there was a sheet on the crash cart for timeline documentation. An interview conducted on [DATE] at 4:25 p.m. with the Physician Assistant (PA) to Resident #1's assigned Medical Doctor (MD) revealed that the PA recalled Resident #1. The PA was provided a copy of Resident #1's medical chart to assist with recall of information. The PA confirmed the resident ' s age and medical diagnosis. The PA said, She was coming to the facility for rehab. She was not being admitted for long term care at the time. It seems that she was living at home with caregivers and neighbors helped as well. She was doing physical therapy. She was a poor historian. She did not have a [DIAGNOSES REDACTED]. She wanted to be a full code. She had chest pain and was sent to the emergency room (ER) for an evaluation. The ER physician did not find anything acutely wrong with her. She came back with no change of plan that same day. Over the next few days she did not have a change of condition. It would not be unusual for a resident at this age to have a sudden change of condition. I do not recall who I was called by the night of the incident, but I was called late at night. I was told patient was found non-responsive, EMS (Emergency Medical Services) was called, she was pronounced deceased . I do not recall who called me. After the death, the MD signed a death certificate stating that it was likely acute [MEDICAL CONDITION] infraction. She did have a left leg laceration . I wasn't surprised she had an acute event; my impression was that this was an acute event. Apparently, they called the daughter and the daughter was working on deeming (Resident #1) incapacitated and considering a DNR. And when the nurse interviewed (Resident #1), the resident was able to express that she wanted to be a Full Code. She was what I would expect for someone of 100, declining. When they come here, hopefully we can rehab them. She had a history of [REDACTED]. In my experience less than 1% of people recover after being found without a pulse. In fact, I don ' t think I've seen anyone walk out of the hospital after being provided with CPR, especially at that age. In this case I don't think the outcome would have changed at all. The PA reported that it was absolutely the expectation to perform the advanced directive order in place for a resident regardless of age. Further review of the medical record for Resident #1 revealed that she was admitted to the facility on [DATE] for rehabilitation. [DIAGNOSES REDACTED].#1 revealed that Provide CPR was selected in response to the line item, Please indicate your wishes regarding .Cardiopulmonary Resuscitation (CPR). A review of the active physician orders revealed an order for [REDACTED].Resident's Advance Directives will be honored. A progress note titled, Admission/Readmission Note dated [DATE] at 10:50 a.m. authored and e-signed by the Social Services Assistant revealed the following: Resident #1 was admitted to (facility) on [DATE] from (acute care hospital) with a dx (diagnosis) of arterial insufficiency and R (right) foot gangrene. Full code status has been elected. SW (Social Worker) spoke with (Resident #1's) daughter, (name), as per (Resident #1). (Daughter) states prior to hospitalization , (Resident #1) was living at home alone and used a walker to ambulate. (Resident #1) did have some assistance from her neighbor and a private duty who would help (Resident #1) with shopping and cleaning. A telephone interview conducted on [DATE] at 3:14 p.m. with Resident #1's daughter revealed that the reason Resident #1 originally went to the facility was because her toes were turning black. The daughter said, She was very good. The foot doctor recommended we take her to the cardiologist. He performed surgery on her leg to get circulation down to her toes again. And he told me the surgery went well . I got very little information from that place (referring to the facility) and I spoke to a nurse, and she told me my mom seems to be okay but I was not able to speak to her because she was very hard of hearing and so there was no sense of me talking to her on the phone. I was told not to hurry coming down because I could not visit her at the hospital or facility. And that was it. When asked to provide a timeline of events on [DATE] as provided to her by the facility, Resident #1 ' s daughter said, I got a call about 1:45 a.m. but my phone was off. The next morning when I got the message and called back, I was told they tried to do CPR and revive her, but she passed and that is all I know. The last time I spoke to her was at the hospital. The hospital was able to arrange for me to speak with her. She wasn't quite coherent anymore, she kept saying come and visit me and I tried to explain I couldn't because of [MEDICAL CONDITION]. When asked if the facility notified her regarding her mother going to the hospital with chest pain on [DATE], the daughter said, No. I wasn't notified. I didn't know they sent her back to the hospital. No one told me that. I had trouble getting through to the facility. I was told the nurse was busy now, the nurse was handing out medication, and the nurse would call me back. Then I got a text message saying, 'Oh, we had a wonderful day today, all the seniors were playing bingo' and I thought that's not right. There is no way my mom is playing bingo. She's lucky she knows how to open the TV. I had pretty much everything taken care of when she lived at home. We talked every day. She was okay until all this stuff started with her foot. I thought she was doing good. When asked if someone from the facility ever reached out to discuss Resident #1's wishes regarding admissions and care, her daughter said, No nothing pertaining to my mom except for the one time. It was someone from the facility. They told me that she was all right, she was taking her medication. But that's it, very little information. They left a message on my phone that she passed. And when I called back, they answered. I said I'm calling about my mother. And they told me that they tried to do CPR and that they had 911 coming in. They released the body to a funeral home, and I explained to the funeral director that her body must be picked up by cremation. The funeral home told me I owed them money. When asked if the facility waited for directions regarding releasing Resident #1's body, the daughter said, No, they really couldn't since it was in the middle of the night and my phone was off. At least we got to celebrate her [AGE] year-old birthday before all this started. Everyone was there. It is a really great memory to have. It's just so sad how after all this COVID-19, all these people are dying without anyone with them. An interview on [DATE] at 5:50 p.m. with Staff B revealed that she had worked in the facility for 2 years and 3 months. At the time of interview, Staff B acknowledged that her Basic Life Support (BLS) CPR card expired in [DATE]. Staff B said, I didn't know when we would be renewing it because I didn't notice renewal was posted on the back board. Staff B indicated that she recalled Resident #1, and the night of Resident #1's expiration. Staff B said, My shift started at 11:00 p.m., and I had not worked on Ringling in quite a while. The night of [DATE] was the first night I cared for the resident. Staff B provided a timeline of the incident involving Resident #1. Staff B said, Well, I can give you approximate times. About 12:45 a.m., the CNA (Staff A) came out and said she thought Resident #1 passed. I went into the room, checked the pulse, breathing, and Resident #1 had neither. I called the RN on Manatee, (Staff C), and told her I had a patient that expired and asked her to come over and verify it, and she came right away. I had just pulled the chart out when (Staff C) came over. I did not go into the room with (Staff C) because I was pulling the chart to check if (Resident #1) was a full code or DNR. (Staff C) came over within a couple minutes and went into the room. I had just got the chart out. I realized she was a full code. I said Resident #1 was a full code and (Staff C and Staff A) went back into the resident's room to begin CPR. I got the crash cart. I put the board underneath Resident #1's back and set up the ambu bag for the CNA. Before I got the crash cart, I called medical emergency over the intercom twice. I went back out to call 911, but (Staff D) was already making the call for me. I asked her to print out papers because the EMTs always want the orders and face sheet. I went back in. (Staff C) and I switched off about 3 times in CPR. One of the other CNAs had to go over to Manatee to get the AED and brought it back over. (Staff C) set it up and we probably switched off 5 or 6 times. The EMTs showed up about 1:10 a.m. Referring to what time the facility began CPR, Staff B said, (Staff C) walked in right after I started calling medical emergency, so we probably started it about 12:50 a.m. and went until 1:10 a.m. when they (EMTs) arrived. We switched off about 2 or 3 times, so we did it for about 20 minutes. The EMTs worked on (Resident #1) for about 20 minutes and then pronounced her deceased at 1:30 a.m. I can only estimate when CPR was started after the resident was found. I called medical emergency about 5 minutes after the aide reported it to me. (Staff A) went in with me to check on the resident. (Staff C) came over and went into the room as I was pulling the chart. (Staff C) came out of the room because I told her I was checking the chart. I called medical emergency about 5 minutes after (Staff A) reported it to me, so CPR was started about 5 to 6 minutes after (Resident #1) was discovered unresponsive. I called the DON and told her about the death. I tried to call (Resident #1's) daughter but she didn't answer, and I left a message. She never did call back. The funeral home picked up (Resident #1) about 3:30 a.m. The DON told me to leave a note about everything under the door for her to review. A note about what happened, but she was already there so I just gave it to her. Most of the other codes I was involved in were DNR. There was a gentleman (Resident #2) who was a full code that passed about ,[DATE] months ago. (Staff C) performed most of the CPR that time because I was making phone calls. I thought that everything had gone smoothly, like riding a bike. We got education on the code sheet today, but I had not known about the code sheet prior to today so no form was filled out for (Resident #1). The EMS run report (documentation of response to a medical emergency from time the call was received through completion) was reviewed for Resident #1 dated [DATE] and revealed the following: call received 01:09:46; on scene 01:20:18; unwitnessed cardiac (presumed) arrest prior to EMS arrival; CPR initiated by Healthcare professional (Non-EMS); time 1st CPR 01:08; estimated time from collapse to CPR 15 minutes; 100 yo (year old) female was found laying supine in bed at this location (nursing home) .CPR is in progress by FD (Fire Department) prior to EMS arrival on Scene. FD states staff called 911 after they found patient unresponsive and then started CPR on scene (unknown downtime; arrest not witnessed by staff and have no last time seen). FD states patient's core felt warm so they initiated efforts. Staff states patient is full code. A review of Resident #1's clinical record revealed a progress note indicating that the nurse was notified at 12:45 a.m. by the CNA that the resident may have passed. This 12:45 a.m. notification time of change in condition for Resident #1 was also stated by Staff B during her interview on [DATE] at 5:50 p.m. If the resident was initially found at 12:45 a.m., as indicated in the clinical record and staff interview, and CPR was first delivered by the facility staff at 1:08 a.m., as indicated on the EMS run report, an elapsed timeframe of 23 minutes occurred from the time Resident #1 was found unresponsive and the initiation of CPR occurred for Resident #1. During the course of this investigation, additional information was received on [DATE] indicating that another resident also experienced a delay in CPR a few months ago also involving Staff B. A review of facility records and an interview with Staff B on [DATE] at 5:50 p.m. led to the identification of Resident #2. 2. A review of the documentation in the medical record for Resident #2 revealed a Health Status Note within the nursing progress notes with an effective date of [DATE] 7:00 a.m. The author was recorded as Staff B. The note read: Resident was deceased at 5:30 a.m. CNA called nurse to room to let her know that resident was non-responsive at 4:40 a.m. Checked chart and resident was Full Code. Nurse called Medical emergency over intercom. Nurse associates started CPR on resident. Called 911, called DON and called wife. EMT (Emergency Medical Technician) arrived and continued to perform CPR until 5:30am. Wife came in just as EMT finished. CNA's cleaned resident up. Wife called (funeral home). They arrived at 7:55 a.m. The last nursing progress note entered prior to the resident's change in condition containing any resident status data was authored by an RN, effective date [DATE] 10:34 p.m. and revealed the following: VS (vital signs) ,[DATE] HR (heart rate) 122 RR (respiration rate) 20 O2 sat (oxygen saturation) 95% at 4L (liters). Hgb (hemoglobin) 6.8. (name), PA (Physician Assistant) notified. Pt. (patient) states he is comfortable. Will continue to monitor. A review of the document titled, eINTERACT Change in Condition Evaluation, effective date [DATE] 5:11 a.m., electronically signed by Staff C, RN revealed the following: The change in condition, symptoms or signs I am calling about is/are: .[MEDICAL CONDITION] .Respiratory arrest .This started on: [DATE] .Morning .Code Status FULL CODE .Most Recent Blood Pressure XXX,[DATE] .Date: [DATE] 22:40 .Most Recent Pulse .150 .Date: [DATE] 22:40 .Most Recent Respiration .18.0 .Date: [DATE] 22:40 .Most Recent O2 (oxygen) sats (saturation) .97.0% Date: [DATE] 00:46 .Oxygen via Nasal .Date and time of clinician notification: [DATE] 05:00 .Message left with PA (Physician Assistant), EMS (Emergency Medical Services) doing CPR. An interview was conducted on [DATE] at 4:01 p.m. with Staff E, CNA, who remembered Resident #2 and had been the aide that found Resident #2 unresponsive. Staff E said, I go in Resident #2's room and I found him, so I called the nurse. I was doing regular rounds. I knew he was dead because the heart was not beating, and he didn't respond so I called the nurse. I checked (Resident #2) for a pulse and breathing. Staff E confirmed reporting Resident #2 unresponsive to Staff B. Staff E said, (Staff B) called 911, started doing CPR, and called another nurse for help. Staff E confirmed the other nurse was Staff C. Staff E confirmed the following sequence of events after finding Resident #2 unresponsive: first telling the nurse, Staff B; next Staff B going into Resident #2's room and assessing the Resident, then Staff B going back to the nursing desk and calling so (TRUNCATED)

Based on staff interviews, record review, and policies review, the facility administration failed to ensure clinical staff appropriately adhered to facility established policies, procedures, and resident advanced directives related to preforming critical cardiopulmonary resuscitation (CPR) for two (Resident #1 and Resident #2) out of 13 sampled residents. On [DATE] Resident #2, a [AGE] year-old male, was assessed to be unresponsive with a significant change in condition. The assigned licensed nurse (Staff B) failed to immediately initiate CPR after verification of Resident #2's full-code status in accordance with facility's policy and procedures related to CPR. Facility administration failed to monitor, track documentation, provide education, and develop an action plan following the [DATE] event involving Resident #2, which led to a similar sequence of events involving the same assigned staff (Staff B) and a second vulnerable full-code resident, Resident #1. On [DATE], Resident #1, a [AGE] year-old female, was assessed to be unresponsive with a significant change in condition. This change in condition required timely and immediate initiation of critical life-supporting CPR in accordance with Resident #1's care plan and signed advanced directives. The assigned licensed nurse (Staff B) failed to confirm and immediately act upon Resident #1's full-code status, resulting in delayed initiation of critical life-supporting CPR. Resident #1 and Resident #2 were both pronounced deceased by Emergency Medical Services (EMS) following their change in condition. The facility's failure to follow their policies and procedures represented a system wide failure. Failure of the facility staff to ensure that residents expressed wishes related to advanced directives and the right to receive end of life treatment, were honored and protected, resulted in findings of Immediate Jeopardy, which was removed on [DATE] and reduced to a scope and severity of D. Findings Included: 1. A review of the facility document titled, Executive Director (ED) Job Description Primary: Department: Administration, revised date [DATE], revealed, The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations, and . standards. Provides oversight of key areas including . human resources . and clinical operations. Implements policies pertaining to patient care, care giving, and support staff . Reports to Regional Vice President. Working Conditions · Involved with patients, associates . personnel, etc. under all conditions and circumstances. · Attends and participates in continuing education programs. Specific Requirements · Must possess the ability to make independent decisions when circumstances warrant such action. · Must be knowledgeable of administration practices and procedures as well as the laws, regulations, and guidelines governing administrative functions in the post-acute facility. · Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the administration department. · Must perform proficiently in all competency areas including but not limited to: daily leadership, responsibilities, supervisory responsibilities . regulatory compliance, patient rights, and safety, and sanitation. · Must understand and follow company policies including . compliance procedures. · Must ensure patients receive high quality care. · Must ensure facility is compliant with all Federal, State, local, and JCAHO (The Joint Commission) requirements as well as serve as the facility's Compliance and Ethics Liaison. · Must ensure facility is . safe for the comfort, convenience and safety of patients . · Must effectively supervise team. A review of the facility document titled, Director of Nursing (DON) Job Description Primary: Department: Nursing Administration, revised date [DATE], revealed: The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and . standards. Reports to Executive Director (ED). Working Conditions · Works in department as well as throughout facility. · Involved with patients, associates . personnel, etc. under all conditions and circumstances. Specific Requirements: · Must be able to communicate effectively with physicians, nursing staff, and all other staff. · Liaisons with patients, families, support departments, etc. to adequately plan for patient needs. · Must be ale to collect, analyze, and manage data. · Must have expert knowledge in field of practice. · Must possess the ability to make independent decisions when circumstances warrant such action. · Must be knowledgeable of nursing administration practices and procedures as well as the laws, regulations, and guidelines governing nursing administration functions in the post-acute care facility. · Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing administration department. · Must perform proficiently in all applicable competency areas. · Must understand and follow company policies including . compliance procedures. · Promotes a culture of integrity and professionalism by adhering to . Code of conduct and completes mandatory Code of Conduct and other appropriate compliance training. · Actively implements the compliance program. · Must be able to plan, develop, organize, implement, evaluate, establish benchmarks, and direct staff. · Must be able to recruit, select, train, evaluate, counsel, and supervise nursing staff. · Must be able to assign appropriate level of CNAs and LPNs per shift. · Must be able to direct care provided by nursing staff. · Must be able to provide direct nursing care as necessary. · Must be able to perform functions of a staff nurse as required. · Must be able to concentrate and use reasoning skills and good judgement. A review of the facility document titled, RN Staff Development Coordinator (SDC) Job Description Primary, revision date [DATE] revealed the following: The RN Staff Development Coordinator plans, organizes, develops, and directs all in-service education to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and Life Care standards .Reports to Director of Nursing (DON) .Plans and participates in continuing education programs .Must have the desire and ability to effectively train and educate all nursing associates and other associates as applicable .Must have expert knowledge in field of practice .Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures related to facility education and training .Must understand and follow company policies .Must be able to plan, develop, conduct, evaluate, and coordinate staff training, education, in-service, and orientation .Must maintain associate training and in-service records . A review of the facility document titled RN Unit Registered Nurse (RN) Job Description Primary, revision date [DATE] revealed the following: The RN Unit Registered Nurse delivers quality nursing care to patients through interpersonal contact and provides care and services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being .Reports to Director of Nursing (DON) .Must have CPR certification upon hire or obtain during orientation. CPR certification must remain current during employment .Must be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing nursing functions in the post-acute care facility .Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing department .Must understand and follow company policies .Must be able to provide clinical supervision to CNAs (Certified Nursing Assistants) and LPNs (Licensed Practical Nurses) .Must be able to chart appropriately and timely. 2. A review of Resident #2's Admission Record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #2's Admission/Readmission Collection Tool- V2, dated [DATE], stated, Patient arrived via stretcher. Patient is alert, oriented, and able to verbalize understanding of care. After careful review, patient signed all of the admission paperwork. Patient vital signs are within acceptable limits . Patient's goal is to gain strength to return home. A record review of Resident #2's Minimum Data Set (MDS) 5-day scheduled assessment, dated [DATE], revealed short term and long-term memory were intact. Resident #2 was normally able to recall the current season, location of their room in the facility, orientation to living in a nursing home, and had cognitive skills for daily decision making at an independent level. Active [DIAGNOSES REDACTED]. A record review of Resident #2's Occupational Therapy: OT Evaluation & Plan of Treatment, signed and dated on [DATE] and revised on [DATE], revealed, Patient Goals: To feel better and return home. Potential for Achieving Rehab Goals: Patient demonstrates excellent rehab potential as evidenced by ability to follow multi-step directions, high prior level of function, high-cognitive functioning, motivated to participate and motivated to return to prior level of living. Focus of Plan of Treatment = Restoration. A record review of Resident #2's Advanced Directives Discussion Document, dated [DATE], revealed a status of Provide CPR obtained by a facility nurse, signed by both Resident #2 and a Facility Representative. A review of Resident #2's Care Plan, initiated [DATE], revealed a full code status with a goal of honoring the resident's advanced directives. Resident #2's Physician's Active Orders, dated [DATE], revealed an order for [REDACTED]. Resident #2's Social Service Assessment revealed code status was full code, that he had been independent at home using no DME (durable medical equipment), and that he was alert and oriented x 4 (person/place/time/situation). The assessment revealed that the resident had a longtime spouse, and in his retirement had enjoyed reading and volunteering. The assessment reflected that his discharge plan was to return home with his spouse. A record review of Resident #2's vital signs, dated [DATE] at 10:34 p.m., by a Registered Nurse (RN) showed, VS (vital signs) ,[DATE] HR (heart rate) 122 RR (respiration rate) 20 O2 sat (oxygen saturation) 95% at 4L (liters). Hgb (hemoglobin) 6.8. (name), PA (Physician Assistant) notified. Pt. (patient) states he is comfortable. Will continue to monitor. Resident #1's eINTERACT Change in Condition Evaluation, dated [DATE] and electronically signed by Staff C/RN, stated, The change in condition, symptoms or signs I am calling about is/are: .[MEDICAL CONDITION] .Respiratory arrest .This started on: [DATE] .Morning .Code Status FULL CODE .Most Recent Blood Pressure XXX,[DATE] .Date: [DATE] 22:40 .Most Recent Pulse .150 .Date: [DATE] 22:40 .Most Recent Respiration .18.0 .Date: [DATE] 22:40 .Most Recent O2 (oxygen) sats (saturation) .97.0% Date: [DATE] 00:46 .Oxygen via Nasal .Date and time of clinician notification: [DATE] 05:00 .Message left with PA, EMS (Emergency Medical Services) doing CPR. A record review of Resident #2's Progress Notes, dated [DATE], revealed a Health Status Note by Staff B, Licensed Practical Nurse (LPN). The note stated, Resident was deceased at 5:30 am. CNA (Certified Nursing Assistant) called nurse to room to let her know that resident was non-responsive at 4:40am. Checked chart and resident was Full Code. Nurse called Medical emergency over intercom. Nurse associates started CPR on resident. Called 911, called DON and called wife. EMT (Emergency Medical Team) arrived and continued to perform CPR until 5:30 am. Wife came in just as EMT finished. CNA's cleaned resident up. Wife called (funeral home). They arrived at 7:55 am. An interview on [DATE] at 4:01 p.m. with Staff E/CNA revealed she remembered Resident #2. Staff E stated, I go in (Resident #2's) room and I found him, so I called the nurse. I was doing regular rounds. I knew he was dead because the heart was not beating, and he didn't respond so I called the nurse. I checked (Resident #2) for a pulse and breathing. Staff E confirmed reporting Resident #2 unresponsive to Staff B. Staff E said, (Staff B) called 911, started doing CPR, and called another nurse for help. Staff E confirmed the other nurse was Staff C. Staff E confirmed the sequence of events after finding Resident #2 unresponsive was telling the nurse (Staff B), Staff B going into Resident #2's room, assessing the resident, going back to the nursing desk, calling someone, and then beginning CPR. A telephone interview on [DATE] at 9:34 a.m. with Staff C/RN regarding Resident #2 revealed she recalled working the night of [DATE] into the morning of [DATE] with some recollection of the night. Staff C confirmed a medical emergency occurred in Resident #2's room. Staff C confirmed involvement in Resident #2's code. Staff C provided a timeline of the incident events. I was in the cardiac unit. (Resident #2) belonged to another unit. Another nurse (Staff B) came to get me and I started CPR as she made the calls. I had the long hall and (Staff B) had the short hall, which included (Resident #2's) room. (Resident #2) was (Staff B's) resident for the night. (Staff B) wanted me to start the code, and she was going to make calls and get things going. I went into (Resident #2's) room to start the code and she made the overhead page for medical emergency. I cannot tell you who else was in the room, any names, or level of licensure they had, or whatever. Staff C did not know why Staff B did not immediately start CPR. She stated, .I believe (Staff B) checked the code status. To my recollection she had already checked the code status prior to me arriving on the scene. I would imagine she coordinated calls to EMS, the doctors, the family, and overhead page medical emergency. I honestly don't have a recollection who was with me performing CPR. I don't recall what time this happened. I think there was someone else who switched off with me during CPR, but I don't quite recall how many times we switched off or who it was. EMS showed up, but I have no idea what time. They hooked up the patient to their equipment and took over CPR. I have no idea about other interventions they had. When they came, I don't remember if I stayed on the scene. There is usually two or three of them and so it gets crowded but usually I stay in the periphery and so I'll run the paperwork, but I really don't remember. I usually get out of the way. I recall a wife being there, but I did not have any contact with her. The resident was deceased and did not get transferred to the hospital. Staff C continued, My role as a supervisor nurse over an LPN is to be a backup, to answer any questions, to make sure things are being done correctly. But it really is more of a resource position because I still have my own assignment. An LPN can initiate CPR. Nothing prior showed that (Staff B) was uncomfortable performing CPR. Referring to if there was an expectation for the residents' assigned nurse to perform CPR when the code status is determined, Staff C said, I mean, she could have. Most of the time I believe, it would probably be started before I came in. My first indication of a code is it is an overhead page. Sometimes someone will come running to me to tell me and then run back. Most of the time that is how it goes, normally, I would start the CPR. I don ' t know any reasons that I would not, or another nurse, would not start CPR right away. An interview on [DATE] at 10:03 a.m. with Staff B revealed she recalled Resident #2 as her usual patient on the night shift beginning at 11:00 p.m. Staff B confirmed working on Resident 2's unit and was the assigned nurse the night of the incident on [DATE]. Staff B provided a timeline of events once Resident #2 was found unresponsive on [DATE]. Staff B said, I can't totally remember the timeline, so I have to think about this. The CNA (Staff E) discovered (Resident #2), I can't remember the staff member's name. I happened to be at the nursing desk when she came and got me. I went to get my stethoscope to check the pulse, and then I went to get his chart. I saw that he was a full code. I thought I had waved at (Staff C), but I guess I went to the door and talked to her and asked her to start CPR while I started making calls to the wife, the DON, EMS. (Staff C) started CPR right away as I called 911. But I can't remember if she or I took the crash cart in there. I did not re-enter the room to assist, but I didn't do anything with the CPR. I called 911 right away. They ask questions like who is in there with the resident, their age, and that they are sending someone right away. I mean everything just flowed. I can't remember that far back. The thing was that the wife came when the EMTs were still here working on him. I was out in the hallway with her comforting her and stuff. And then EMS finished, and I said let them finish up because the resident had passed. It was a straight thing. I was not involved in performing the CPR. Referring to if CPR was immediately started for Resident #2 once the code status was determined, Staff B said, As far as I recall, the CNA (Staff E) found the resident, I notified (Staff C), and immediately started CPR. Um, I have performed CPR before. But some nurses would rather start the CPR, and some would rather initiate all the phone calling . I mean I could have (started CPR). I mean, I pulled the chart and checked that (Resident #2) was full code. I mean there's no reason I didn't start. There's no reason why. I do carry a CPR certification. On the one back in March it was valid (referring to holding a valid CPR certification during Resident #2's code), but not for (Resident #1). Not having a valid CPR card was not why I didn't start CPR on (Resident #1). I had to go back out to check (Resident #2's) chart to see if CPR was needed, and then I just went ahead and stepped inside the door to tell (Staff C) to start CPR. She could tell me no. She never said that she wanted to be the nurse starting CPR. EMS usually asks if CPR was started but I don't remember if they ask what time CPR is started. In this situation I felt that I should call 911 because I knew more about the resident, but I've started CPR before. I feel comfortable starting CPR. A telephone interview on [DATE] at 10:40 a.m. with Resident #2's wife revealed that she arrived at the facility during the incident. The wife said, I got there around the same time the medics did. They kind of shooed me out of the room. They did ask if he ever had gastro problems. I told them no, never. I know there was a lot of black that came out. I really didn't witness much. They told me that the facility had worked on him. The facility called me after he had passed. The facility let me know that my husband had passed away. I was shocked because he seemed to have been doing better. Two nurses had manually cleaned him out the night before but overall it seemed like he was improving. I had thought they had the wrong patient. He had been in the hospital because he had been sick, the hospital had released him. He was still having problems when he left the hospital. He had to be on oxygen and the facility did try and give him PT (physical therapy). When PT had come in the first time, he couldn't get up for a while. They didn't have any type of monitors on him, which I thought he needed. In my opinion, he should have never left the hospital. He did keep saying that he needs to get better and tried to push himself to do PT. His primary medical condition was that he had [MEDICAL CONDITIONS] and he had gotten one of his attacks, but he wasn't getting better. It was a combination of things. On the death record they listed that it was his heart. I took care of his advanced directive and did all that paperwork. I was involved, but the facility didn't have the staff to do what he needed. Prior to him being ill, he would walk around, do his things. He couldn't take long walks because of his breathing but that has been happening for the last [AGE] years. He was doing things around the house. At that time, he needed someone with him much more than the facility could provide. I think he left the hospital too soon. A telephone interview on [DATE] at 11:05 a.m. with the PA regarding Resident #2 revealed, We have a high turnover rate with highly skilled patients, but I do remember that it was a sudden death, unexpected. He wasn't that old either, he was pretty-young. I don't recall any details really. I can 100% tell you I wasn't in the building during the event. I really don't have anything else to offer about the incident, but if you have any additional questions feel free to call me. A review of Resident #2's County EMS Patient Care Record (run report) provided directly from the County Emergency Services, dated [DATE], revealed that the first time CPR was administered by facility was at 4:52 a.m. EMS received the call from the facility pertaining to medical emergency at 4:52 a.m. EMS was dispatched at 4:52 a.m. EMS arrived on scene at 4:57 a.m. and was at the patient at 5:00 a.m. Resuscitation was discontinued at 5:21 a.m. A review of Resident #2's clinical record revealed a progress note indicating the CNA called the nurse to the room because the resident was non-responsive at 4:40 a.m. If the resident was initially found at 4:40 a.m., as indicated in the clinical record, and CPR was first delivered by the facility staff at 4:52 a.m., as indicated on the EMS run report, an elapsed timeframe of 12 minutes occurred from the time Resident #2 was found unresponsive and the initiation of CPR occurred for Resident #2. A telephone interview on [DATE] at 1:39 p.m. with the Deputy Chief of Clinical Affairs for Manatee County EMS revealed that in situations where the [MEDICAL CONDITION] was not witnessed by EMS personnel, and when CPR had already been initiated prior to their arrival, the time entered as Time 1st CPR was an approximation based on information they are provided with (from facility personnel) when they arrive on the scene. 3. A record review of Resident #1's Admission Record revealed an admission date of [DATE], and a discharge date of [DATE], with [DIAGNOSES REDACTED]. Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated [DATE], revealed the resident ambulated with an assistive device with assistance of one required for transfers. The form also noted that Resident #1 was transferred for rehabilitation and repair of sutures. A record review of Resident #1's Resident/Family Education Assessment & Interdisciplinary Flow Record, signed without a date of completion, revealed the anticipated length of stay was equal to or less than one month. The document revealed that Resident #1 had no limitations or barriers to learning, was able to understand basic information, was motivated to learn, and was able to verbalize understanding. A record review of Resident #1's Advanced Directives Discussion Document, dated [DATE], revealed a status of Provide CPR obtained by a facility nurse, signed by both Resident #1 and a Facility Representative. A review of Resident #1's Care Plan, initiated [DATE], revealed a full code status with a goal of honoring the resident's advanced directives. A record review of Resident #1's Active physician's orders [REDACTED]. A record review of Resident #1's progress notes, dated [DATE], by the Social Services Assistant (SSA), revealed that a full code status has been elected during the admission on [DATE]. The social worker spoke with the resident's daughter, per Resident #1's request, and gathered personal information. Resident #1 was living at home alone prior to arriving to the facility and received help from a private duty and the neighbor. The progress note stated that Resident #1 used a walker to ambulate. A record review of Alert Note in progress notes, dated on [DATE] at 12:45 a.m. by Licensed Practical Nurse (LPN)/Staff B, revealed, CNA came to nurse to report at 12 45am, that the resident may have passed. Pulled chart and resident was a full code. Called medical emergency to (Resident #1's room) over the intercom. Retrieved the crash cart. CPR was started by (Staff C/Staff B) and ambu bag (Bag Valve Mask used for resuscitation) was performed by (Staff A/CNA) until EMTs arrived at 1:10am. (Staff D/LPN) called 911 and printed paperwork for EMTs. EMTs called resident as deceased at 1:30am. Contacted DON (Director of Nursing) to report and to get ok to call (funeral home). Called (funeral home) around 2am. Stated they would be here in an hour and a half. Tried to contact Daughter at 1:45am, left message on voicemail to call facility, gave nurse's name and facility's phone number. An interview on [DATE] at 3:00 a.m. with Staff C revealed she was aware of Resident #1, and the incident that occurred on [DATE]. Staff C said, I was on another unit (Manatee Unit) and I was called over by (Staff B) who was caring for the resident, who was on the isolation unit (Ringling Unit). (Staff B) wanted me to pronounce the patient as deceased because I'm an RN and she is an LPN. She called me on the phone and asked me to come over and pronounce the patient being that I was the RN in the building at the time. So, I said sure and I verified that Resident #1 had expired. (Staff B) did not call me to verify a code. (Staff B) said something about how she hadn't checked (Resident #1's) code status. She asked me if I would start the code while she got the other stuff rolling and made calls. I said sure. I made sure she overhead paged medical emergency. Someone went and got the AED (Automated External Defibrillator for resuscitation), someone else got the crash cart. I started compressions before they brought the backboard. (Resident #1) was not breathing and no heartbeat. (Resident #1) was not the coldest person I ' ve ever touched. (Resident #1) was not in rigor. Staff C clarified who verified Resident #1's code status. Staff C said, both of us went out to the desk and checked it and that's when she asked me to start the code. I have no idea how much time elapsed from when (Resident #1) was found to when CPR was started. (Staff B) gave me no indication of time. I did not tell administration about the incident because (Staff B) told me she called the DON; I don't know what she told them. (Staff B) and I switched off a few times in CPR before Emergency Medical Services (EMS) got there. We performed max ,[DATE] minutes, maybe 3 switches every 50 compressions. Once EMS arrived around 1:10 a.m. I backed off and EMS performed CPR for about 20 minutes. Staff C confirmed that in Long-Term Care, the procedure once a resident is found unresponsive was to ascertain the code status if it was not already known, and if the patient was a full code then immediately start CPR. Staff C said, I don't believe (Staff B) checked the code status before she called me .but again, I was called to pronounce death. On [DATE] at 3:24 a.m., the DON and the Administrator joined the interview with Staff C. Staff C repeated the incident to administration. Staff C said, I was called over to pronounce the death of Resident #1 by (Staff B) and I came over and ascertained patient wasn't breathing, no heartbeat, and I said yep you're right she's passed. I became aware that (Staff B) wasn't sure of (Resident #1's) code status and we went to check. (Resident #1) was a full code. (Staff B) asked me if I could start CPR, and I told her she needed to call the DON. (Staff B) overhead paged medical emergency, others arrived, not sure all who, we started a code, I did compressions, the AED arrived. I can't tell you the exact number of compression rounds, but I'm thinking about 3 switches between (Staff B) and I before EMS arrived. The DON revealed that Resident #1's death was reported to her; however, no nursing staff reported a delay in checking the resident's code status or a delay in CPR initiation. The DON confirmed it was a requirement for an LPN and an RN to check a resident's code status. The DON continued saying, The expectation for incident documentation is document in the chart. I try and get a timeline of the day before (an incident) and how the resident was doing. The DON confirmed that documentation was required in a progress note which should include the last assessment, and resident status, but no other specific data points. There was a sheet on the crash cart for timeline documentation. An interview on [DATE] at 4:25 p.m. with the Physician Assistant (PA) assigned to Resident #1 revealed that the PA recalled Resident #1. The PA used Resident #1's medical chart to recall information. The PA said, She was coming to the facility for rehab. She was not being admitted for long term care at the time. She was doing physical therapy. She was a poor historian. When she came in, as far as I recall, she was making her own decisions and she did not want to sign a DNR. She wanted to be a full code. She had chest pain and was sent to the emergency room (ER) for an evaluation. The ER physician did not find anything acutely wrong with her. She came back with no change of plan that same day. Over the next few days she did not have a change of condition. I do not recall who I was called by the night of the incident, but I was called late at night. I was told patient was found non-responsive, EMS was called, she was pronounced deceased . I do not recall who called me. After the death, the MD (Medical Director) signed a death certificate stating that it was likely acute [MEDICAL CONDITION] infraction. She did have a left leg laceration . When the nurse interviewed (Resident #1), the resident was able to express that she wanted to be a Full Code. The PA reported that it was absolutely the expectation to perform the advanced directive order in place for a resident regardless of their age. An interview on [DATE] at 5:50 p.m. with Staff B revealed that she has worked in the facility for 2 years and 3 months. At the time of interview, Staff B acknowledged that her Basic Life Support (BLS) CPR card expired in [DATE]. Staff B said, I didn't know when we would be renewing it because I didn't notice renewal was posted on the back board. Staff B indicated that she recalled Resident #1, and the night of Resident #1's expiration. Staff B said, My shift started at 11:00 p.m., and I had not worked on Ringling in quite a while. The night of [DATE] was the first night I cared for the resident. Staff B provided a timeline of the incident involving Resident #1. Staff B said, Well, I can give you approximate times. About 12:45 a.m., the CNA (Staff A) came out and said she thought Resident #1 passed. I went into the room, checked the pulse, breathing, and Resident #1 had neither. I called the RN on Manatee, (Staff C/RN), and told her I had a patient that expired and asked her to come over and verify it, and she came right away. I had just pulled the chart out when (Staff C) came over. I did not go into the room with (Staff C) because I was pulling the chart to check if (Resident #1) was a full code or DNR. (Staff C) came over within a couple minutes and went into the room. I had just got (TRUNCATED)