Every finding on record at Longwood Health and Rehabilitation Center

Based on interview, and record review, the facility failed to provide the resident representative with access to personal and medical records within 24 hours (excluding weekends and holidays) of a written request for 1 of 2 residents reviewed for resident rights, of a total sample of 4 residents, (#1).Findings:Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, major depressive disorder and dementia.A review of the Quarterly Minimum Data Set with Assessment Reference Date of 3/25/26, revealed the resident #1 was cognitively impaired with a Brief Interview for Mental Status score of 6 out of 15.Review of the medical record revealed resident #1 became a ward of the state and a plenary guardian was appointed by the county court on 2/04/26.On 4/23/26 at 11:46 AM, the Medical Records Director said the process of receiving medical records was not very long, typically two to three days. He explained the legal arm from corporate determined the release of medical records once a request was made. He recalled resident #1's guardian requested medical and financial records, and she was given all the information she needed at the time. He explained resident #1's guardian was not able to receive financial records because the Business Office Manager was not on the premises at the time, and she refused physical copies of the record at that time. A few minutes later, the Medical Records Director presented the facility's Authorization for Use and disclosure of Protected Health Information form completed by resident #1's guardian on 3/26/26. The form revealed the guardian requested the medical and billing records from 9/04/20 to the present date, in electronic format. The Medical Records Director explained their company had changed and may be delayed as some information might be in another system. He said he explained this to the guardian at that time.On 4/23/26 at 1:51 PM, in a joint interview with the Social Services Director and the Business Office Manager, they said they were unaware the resident's guardian requested medical records. They said they had never met resident #1's guardian nor received any emails or phone calls from her requesting medical or financial records. The Business Office Manager explained since the new company took over on 11/03/20 and the resident was admitted in September of that year, the records from the two months from September to November were probably with the previous company.On 4/23/26 at 3:15 PM, resident #1's court appointed guardian said she had requested medical and financial records for resident #1 but was told she had to make a written request. She explained they could not access the financial records because the Business Office Manager was not there at the time. The guardian said she came to the facility to make a formal request soon after that but still had not received anything from them. The guardian recalled after making multiple calls, she was recently told by the Medical Records Director the facility was still working on her request.On 4/23/26 at 5:54 PM, in a joint interview with the Nursing Home Administrator (NHA) and the Director of Nursing, they said residents had a right to access their medical records at any time or as soon as possible. The NHA said in this case, the request concerned records that went back to previous ownership. The NHA explained when records were requested, he felt perhaps 10 days was acceptable but said having to wait almost a month, was not.The facility's undated policy on the Right to Access/Purchase Copies of records stated, It is the policy of the facility to allow the resident access to personal and medical records pertaining to the resident in such a manner to acknowledge and respect resident rights.

Based on observation, interview, and record review, the facility failed to ensure that physician ordered medications were not left unattended at residents' bedside for 1 of 2 residents, reviewed for quality of care, of a total of 4 sampled residents, (#1).Findings:On 2/19/26 at 12:27 PM, a medication cup with four pills (one yellow tablet, one pink tablet, one white tablet, one pink and gray capsule), and one six-ounce clear plastic cup with clear liquid and a spoon inside of it was sitting on resident #1's bedside table with his lunch tray. Resident #1, alert to person, place and time, explained the medications in the cup were his 9:00 AM medications previously left by the nurse. He said the clear plastic cup with clear liquid was his MiraLAX that was also left at bedside by the nurse. On 2/19/26 at 12:51 PM, assigned Licensed Practical Nurse (LPN) A, stated she did not know where the medications left on the bedside came from. She mentioned the medications were not there when she administered the resident's 9:00 AM medications. The nurse stated she didn't usually leave medications at residents' bedsides but explained she left resident #1's 9:00 AM liquid stool softener (MiraLAX) on his bedside table in a clear six-ounce plastic cup. On 2/19/26 at 12:54 PM, the Director of Nursing (DON) acknowledged the cup with the medications on resident #1's bedside table, then took the cup from resident #1's bedside table and stated that he would investigate what the medications were. Review of resident #1's current physician orders revealed he had orders for Aspirin oral capsule 81 milligrams (mg) - give 1 tablet by mouth in the morning for PAD (peripheral artery disease) - start date 10/25/25 9:00 AM, Flomax capsule 0.4 mg - give 1 capsule by mouth in the morning for benign prostatic hyperplasia - start date 12/24/25 at 9:00 AM, Losartan potassium tablet 25 mg - give 1 tablet by mouth one time a day for hypertension (high blood pressure) - start date 10/25/25, 9:00 AM, MiraLAX oral packet 17 grams - give 17 grams by mouth one time a day for constipation - start date 10/25/25 at 9:00 AM, and Oxybutynin chloride extended release 24 hour, 10 milligram tablet - give 1 tablet by mouth one time a day for overactive bladder - start date 11/27/25 at 9:00 AM. Review of the facility's Medication Administration Record (MAR) revealed that resident #1's 9:00 AM, medications were documented as given by LPN A, on 02/19/26 at 9:00 AM, in conflict with the medications observed still in a cup on resident #1's bedside table. On 2/19/26 at 2:25 PM, the DON stated he spoke to the physician by phone to verify resident #1 medications. He stated the 4 medications in the medication cup were Aspirin 81 mg, Flomax 0.4 mg, Losartan 25 mg, Oxybutynin 10 mg, and the clear liquid in the cup was MiraLAX. The DON confirmed these medications were resident #1's medications scheduled for 9:00 AM, still sitting on the bedside table three and a half hours later at 12:27 PM. Review of the facility's policy revised October 2023, entitled Medication Administration, indicated that medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines #15, indicated for staff to observe resident consumption of medication, and #19 indicated, Report and document any adverse side effects or refusals.

Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to transmission-based precautions for 2 of 7 residents reviewed for infection control, out of a total sample of 48 residents, (#81, and #29) and maintain a complete antibiotic stewardship program. The facility also failed to adhere to proper infection control practices related to hand hygiene and personal protection equipment (PPE) use. Findings: 1. Review of resident #29's medical record revealed she was originally admitted to the facility on [DATE] with diagnoses including myasthenia gravis (an autoimmune condition that causes skeletal muscle weakness), sequalae of cerebral infarction, osteoarthritis, and fibromyalgia (chronic condition that causes pain in muscles and soft tissues all over the body). The Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 8/13/25 revealed resident #29 had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. On 9/29/25 at 11:24 AM, resident #29 stated she was diagnosed with flu and strep throat the previous Friday. She explained she first became ill around a week ago, and when she could not eat or swallow, she called her primary care physician (PCP) located outside the facility and scheduled an appointment. She stated she saw the PCP on the previous Friday and was prescribed Amoxicillin and another medication for the flu which she did not receive until Sunday. Resident #29's room was not identified for isolation, and no personal protection equipment was observed outside or inside her room. Review of an After Visit Summary form dated 9/26/25 revealed resident #29 was diagnosed with influenza type B and sore throat. The document showed medications Oseltamivir, Amoxicillin and Fluticasone were ordered. Review of resident #29's medical record revealed a Psychotherapy Progress Note dated 9/27/25 which read, in part, . Patient very sick with upper respiratory infection. She presents weak looking and weak appearing. She is planning on calling her son to drop off soup and tea. On 10/02/25 at 5:25 PM, the Director of Nursing (DON) stated resident #29 did not give a copy of the After Visit Summary to the nurse when she returned from the appointment on 9/26/25. The DON explained a nurse found the form the next day in resident #29's room during rounds. The DON indicated the medications were entered into the system on 9/27/25 with the first doses given at 8:00 AM on 9/28/25. The DON could not confirm if the assigned nurse on 9/26/25 contacted the PCP's office after resident #29 returned from the appointment for post-visit summary and instructions. The DON validated no documentation regarding the After Visit Summary was found in resident #29's medical record. Review of resident #29's physician's orders revealed no orders for Droplet Precautions until 10/02/25, six days after the diagnosis of influenza. 2. On 10/01/25 at approximately 9:05 AM, Sitter G was observed exiting room B-14 while wearing gloves and talking with another staff member in the hallway. On 10/01/25 at 9:10 AM, Sitter G was observed as she re-entered room B-14 wearing the same gloves. Sitter G stated she was going to transfer a meal tray to the bedside table but had to inform the Certified Nursing Assistant (CNA) about something that needed immediate attention. Sitter G acknowledged she was supposed to remove the gloves and sanitize her hands before exiting the room but did not do so. 3. On 10/01/25 at approximately 5:10 PM, CNA H was observed stepping out of room B-11 holding a soiled bag while still wearing gloves. CNA H entered the soiled utility room, discarded the soiled bag and exited a few minutes later still wearing gloves. CNA H then removed the gloves, discarded them in a trash can located by the nurse's station and washed her hands with soap and water in the bathroom near the nurse's station. On 10/01/25 at 5:20 PM, CNA H explained she had provided a shower for a resident in room B-11 and changed the bed sheets afterward. She shared she usually kept her gloves on until after she discarded the bag in the soiled utility room. She validated that a few moments earlier she had kept the gloves on until after she exited the soiled utility room. She said she had received infection control training and knew that removing gloves before exiting a resident's room was required but was confused about what to do when carrying soiled bags. She stated removing gloves before leaving the room would require her to use her bare hands to hold the bag, which she was uncomfortable doing. On 10/02/25 at 11:52 AM, the Assistant Director of Nursing (ADON) stated infection control education had been provided to all staff including reminders about glove removal before leaving a resident's room. He shared for staff who did not feel comfortable holding a soiled bag with bare hands, staff had the option to use paper to hold it or double bag it, especially if dripping could occur. He confirmed wearing gloves from a resident's room to the hallway was considered a break in infection control. He mentioned he was not informed about resident #29's flu diagnosis until recently, when she was started on isolation. Review of the Transmission-Based (Isolation) Precautions policy and procedure revised on 8/15/22 revealed the facility's intent to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's mode of transmission. The policy stated nursing staff would place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. The policy revealed signage including instructions of specific PPE to be placed conspicuously outside the resident's room. Review of the Infection Prevention and Control policy and procedure revised on 8/15/22 revealed the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections in accordance with accepted national standards and guidelines. Review of the Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities by the Centers for Disease Control included, Ill residents should be placed on droplet precautions with room restriction and be excluded from participating in group activities . (Retrieved from www.cdc.gov on 10/06/25.) 4. Resident #81 was admitted to the facility on [DATE] from the hospital. The Comprehensive Minimum Data Set assessment dated [DATE] indicated diagnoses including dementia, and end stage renal disease. Review of resident #81's physician orders revealed an order for Ertapenem sodium solution reconstituted 1 gram to be given intravenously (IV) every 24 hours for urinary tract infection for six days starting on 9/26/25. Review of laboratory results for resident #81 revealed on 9/19/25 a complete blood count (CBC) with differential was drawn and the resident's white blood cells (WBC) were 23.2 cells per microliter (K/uL). The normal range for WBC's is 3.8 to 10.8 K/uL and an elevated level could indicate an infection. The resident also had a urinalysis and culture with reflex drawn. A physician note dated 9/26/25 at 2:25 PM, revealed the resident's urine culture was positive for Klebsiella pneumonia. The physician documented the resident was started on an antibiotic 1 gram daily for five days which the physician indicated was discussed with the Assistant Director of Nursing (ADON) who was also the IP. Extended-spectrum beta-lactamase-producing (ESBL) Enterobacterales are resistant to common antibiotics and require complex treatment. One of the ESBL-producing Enterobacterales includes Klebsiella pneumoniae. These bacteria can cause infections in places such as the urinary tract and bloodstream, and can cause increased mortality and hospitalization, (retrieved from www.cdc.gov on 10/10/25). On 9/30/25 at 10:41 AM, the Infection Preventionist (IP) confirmed the was responsible for monitoring all residents who received antibiotics and any residents with devices such as IVs and foley catheters in the facility. He explained he monitored residents with devices because they increased the resident's risk for infection. The IP stated he was unsure if resident #81 had any devices such as an IV. He recalled there were two residents in the facility who had IV's, but he could not remember if resident #81 was one of them. Enhanced Barrier Precautions is an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve the use of a gown and gloves during high-contact resident care activities to prevent infections in vulnerable people, (retrieved from https://www.cdc.gov on 10/10/25). On 10/02/25 at 2:16 PM, the Infection Preventionist was observed in resident #81's room without gloves or a gown, preparing to administer intravenous (IV) medication. The resident was sitting on the right side of his bed with the room divider curtain on his right side. Above the resident's bed was a sign which indicated the resident was on Enhanced Barrier Precaution. The IP was seen to don gloves at that time and begin to prepare and administer the IV medication. The IP brushed himself against the resident, his wheelchair and the resident's curtain in order to hang the IV antibiotic medication on the IV pole behind the resident. The IP finished preparing and administering the medication, removed his gloves and performed hand hygiene with alcohol sanitizer before he exited the room. He did not wear a gown during the entire time he was in resident #81's room providing care. On 10/03/25 at 12:19 PM, the IP stated he had been in the position for three months and had never worked as an IP before. He explained his titles and responsibilities included the Assistant Director of Nursing, Staff Educator and occasionally worked on the floor when needed. He confirmed he had read the infection control policies when he started in the position and had a short training session with an IP from a sister facility. He explained the IP position was vacant when he started and the position had been vacant for a while. The IP confirmed that resident #81 was on enhanced barrier precautions and acknowledged he did not wear a gown when he administered the resident's IV medication but should have. Review of the facility's policy and procedure for Transmission-Based Precautions (TBP) revised 8/15/22 revealed that signage that included instructions for use of specific PPE would be placed in a conspicuous location outside the resident's room with either the CDC category of TBP or to see the nurse before entering the room. The document indicated the order for transmission-based precautions/isolation should specify the type of precaution and reason for the transmission-based precaution. Review of the facility's policy and procedure for Infection Prevention and Control Program (ICPC) revised 8/15/22 revealed a resident with an infection or communicable disease would be placed on transmission-based precaution as recommended by the current CDC guidelines. The facility did not have a policy dedicated to Enhanced Barrier Precautions. 5. On 9/30/25 at approximately 10:45 AM, the IP acknowledged part of his role as the IP was to track and monitor antibiotic use. He confirmed that part of the monitoring included verifying antibiotics were given for a full course and that residents did not miss any doses. He explained if a resident missed a dose, the physician should be notified to verify if the course of the antibiotics should be extended. The IP stated the expectation for an unavailable antibiotic was for staff to check the emergency supply kit to see if it was available there and notify the physician to obtain an order for an alternative medication if it was not available. Review of the resident #81's electronic medication administration record (EMAR) for September 2025 revealed the physician ordered antibiotic medication Ertapenem sodium solution was not administered on 9/26/25 with an administration note that read, Waiting on pharmacy delivery; on 9/28/25, the medication was not administered and an administration note indicated that a midline IV was ordered and the physician was aware; and on 9/29/25, the medication was not administered and an administration note read, Waiting on pharmacy. In a phone interview on 10/11/25 at 11:15 AM, the Pharmacy Manager clarified that Ertapenem could be administered through a peripheral line if the duration was for less than 10 days. He stated that from his records there was no issue with the medication being unavailable to the facility. He verified that four doses of the antibiotic medication were delivered to the facility on the 9/26/25 for resident #81. The Pharmacy Manager noted that Ertapenem Intramuscular (IM) 1 gram was available in the emergency supply kit as an alternative if there had been an issue with an available IV site for delivery of the medication. On 9/30/25 at 10:45 AM, the IP and Director of Nursing (DON) confirmed there was no documentation on 9/26/25 or 9/29/25 that the physician was notified that resident #81 missed doses of the medication. The IP stated he did not realize the resident did not receive multiple doses of his antibiotic as ordered. On 10/01/25 at 6:00 PM, the IP stated he had not participated in the medication regimen review since he started. He acknowledged he had not performed antibiotic audits during the last month and stated it fell through the cracks. On 10/03/25 at 1:09 PM, the DON stated that she believed the reason the nurses did not administer the antibiotic medication was because staff were unsure if the Ertapenem could be given through a peripheral line. She explained the staff were waiting until a midline was inserted to administer the medication. The DON clarified the staff must have thought pharmacy was responsible for inserting the midline which was why they documented they were waiting on pharmacy. She acknowledged that staff should have called the pharmacy to verify if the medication could be given through a peripheral line if they were unsure. The DON verified that part of her role was to oversee the IP and make sure aspects such as antibiotic stewardship were implemented. The DON explained that management was focused on other facility issues and had not realized aspects of the infection control program were not being performed. Review of the facility's policy and procedure for Antibiotic Stewardship Program revised 8/23/2022 revealed the antibiotic stewardship program included protocols and a system to monitor antibiotics. The document indicated that antibiotic use would be monitored during each monthly medication regimen review when the resident had been prescribed or was taking an antibiotic. Random audits of antibiotic prescriptions were to be performed to verify completeness and appropriateness.

Based on interview, and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.Findings:On a previous recertification survey dated 4/12/24, Centers for Medicare & Medicaid Services (CMS) Enforcements were issued that included F0584 (Safe/Clean/Comfortable/Homelike Environment), F0842 (Resident Records - Identifiable Information), and F0880 (Infection Prevention & Control). On 10/03/25 at 2:30 PM, the Nursing Home Administrator (NHA) explained that their QAPI program included non-compliance assessments/review, and identification of identified problems reported by each department during their monthly regular and Ad Hoc (when needed) meetings. She recalled the last monthly meeting was held on 9/25/25, and the last Ad Hoc meeting was held on 8/25/25 for a change in the facility's NHA. The NHA explained that a four-step process was used to identify what issues the committee decided to work on that included identification of the problem, investigation for the root cause, development of a correction plan, and tracking of progress and trends for one year which was the facility's practice.On 10/03/25 at approximately 2:45 PM, a joint review of the facility's QAPI binder and Performance Improvement Plans (PIPs) since the last recertification was conducted with the NHA and Director of Nursing (DON). Documentation of monitoring for previously identified deficiencies was incomplete or missing. For example, in February 2025, the facility identified Dietary Department concerns. The facility conducted an Ad Hoc QAPI meeting where the committee developed a PIP to correct the issue. When asked to review the monitoring documentation and audits, the NHA and DON were unable to locate the records. The NHA stated, the Certified Dietary Manager's last day was last Wednesday; she had a PIP for Dietary concerns, and she kept them separate. From 9/29/25 to 10/03/25, a recertification and complaint survey was conducted, and deficient practice was again identified for F0584 (Safe/Clean/Comfortable/Homelike Environment), F0842 (Resident Records - Identifiable Information), and F0880 (Infection Prevention & Control).The facility did not implement an ongoing, systematic QAPI program to ensure that identified problems were corrected and prevented from recurring. The failure of the facility to maintain complete monitoring documentation and address repeated deficiencies demonstrated that the QAPI program was not effective.Review of the facility's undated standards and guidelines titled, 2025 Quality Assurance & Performance Improvement (QAPI) noted the program's intentions included multiple resources and best available evidence to ensure their data collection tools and monitoring systems were in place and consistent for, proactive analysis. The program outlined identification and prioritization of problems and opportunities based on performance indicator data, resident and staff input, and other information. Projects were used to determine gaps or patterns in care systems that could result in quality problems and/or identification of opportunities to make improvements. The document indicated that all QAPI goals and action plans were to be stored in the QAPI binder.

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 48 residents, (#68).Findings: Resident #68 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and major depressive disorder. A review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 6/30/25 revealed resident # 68 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact. The assessment indicated he did not exhibit any behaviors and did not reject care. A review of resident #68' s electronic medical record revealed no physician's order for self-administration of medications and did not contain an assessment for self-administration of medications. A review of the Medication Administration Audit report showed Licensed Practical Nurse (LPN) B administered the scheduled 9:00 AM medications at 10:15 AM on 9/29/25. On 9/29/25 at 11:19 AM, resident #68 was observed sitting up in bed watching television. A medication cup which contained pills was noted on his bedside table. Resident #68 explained the nurse left the cup there because he usually takes a while to swallow the pills. On 9/29/25 at 11:21 AM, LPN B confirmed he was the assigned nurse for resident #68 and had administered his medications. He confirmed resident #68 was not allowed to self-administer his own medications. LPN B accompanied the surveyor to the resident's room and observed the medications on the bedside table. He explained that he saw resident #68 lift the medication cup to his mouth but got distracted by the roommate. LPN B acknowledged he should have stayed and watched the resident take all of his medications. On 9/29/25 at 11:29 AM both the A wing Unit Manager (UM) and the Director of Nursing (DON) were at the nurse's station and were made aware of the situation. The A wing UM stated that it was unacceptable for LPN B to leave the medications with resident # 68 and should have stayed with the resident. The A wing UM explained she was not aware that resident #68 wanted to self- administer his medications. The DON clarified that there were no residents in the facility who were assessed for self-administration of medications. She stated that her expectation was for LPN B to have stayed and watched resident #68 take his medications. Review of the facility's policy and procedure for Medication Administration revised in October 2023, revealed in section 15 of their policy explanation and compliance guidelines that staff were directed to Observe resident consumption of medication. The facility's policy and procedure for Resident Self-Administration of Medication, implemented in November of 2020, read, A resident may only self- administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview, and record review, the facility failed to provide the necessary maintenance services to ensure a homelike environment in 3 of 32 rooms in the B- wing, (rooms #13, #14, and #17). Findings: On 9/29/25 at 11:20 AM, broken window blinds were noted in room [ROOM NUMBER]. On 9/30/25 at 11:28 AM, resident #19, in room [ROOM NUMBER], stated the clock on the wall had been without a battery for five days. He mentioned he informed the staff, but they had not fixed it, so he could not tell how long he waited for his call light to be answered. Later, on 10/01/25 at 9:17 AM, resident #19 stated his clock was still not working. On 9/30/25 at 12:25 PM, broken window blinds were noted in room [ROOM NUMBER]. On 10/02/25 at 10:01 AM, the blinds in rooms #13 and #17 were still broken, and the wall clock in room [ROOM NUMBER] remained nonfunctional. On 10/02/25 at 1:38 PM, the Maintenance Director stated he was responsible for the maintenance of the building, including residents' rooms. He indicated he performed routine inspections of residents' rooms and repaired items as needed. He explained staff entered work orders in their electronic system (TELS), which he or his assistant checked multiple times daily. He stated they did not maintain records of their room inspections. The Maintenance Director emphasized the importance of keeping residents' rooms in good condition for their comfort and dignity. At approximately 1:44 PM, observations of the above-mentioned rooms were conducted with the Maintenance Director, who acknowledged the findings. Later, at 2:58 PM, the Maintenance Director reviewed the TELS report for the above-mentioned rooms and confirmed the issues had not been previously identified. On 10/02/25 at 1:47 PM, Housekeeper F was cleaning room [ROOM NUMBER] and stated she verbally reported her findings from cleaning residents' rooms to maintenance. She acknowledged the broken window blinds and stated she had not reported them to the Maintenance Director because she had not noticed them earlier. She mentioned it was important for residents to have their rooms clean and orderly so they could feel good and welcome. She added she would not like her own home to be dirty or have broken items. The facility's policy titled Safe and Homelike Environment revised on 4/11/23 read, . the facility will provide a safe, clean, comfortable, and homelike environment, . The form revealed general considerations of reporting any furniture in disrepair to Maintenance promptly and reporting unresolved environmental concerns to the Administrator.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services according to professional standards for monitoring and management of an intravenous (IV) therapy site for 1 of 2 residents reviewed for IV access, (#81), and failed to provide appropriate care and services according to professional standards for medication administration for 1 out of 2 residents, (#87), out of a total sample of 48 residents.Findings: 1. Resident #81 was admitted to the facility on [DATE] from an acute care hospital following a fall. He was admitted with diagnosis including fracture of sacrum, fracture left pubis, fracture right ilium, essential tremor, cognitive communication deficit, Parkinson's with dyskinesia, and dementia. On 9/30/2025 at 10:18 AM, resident #81 was observed in his wheelchair in the dining room. He was noted to have a short peripheral intravenous line (IV) to his left forearm which was undated and a single lumen midline to his left arm hanging down from his sleeve. Resident #81 lifted his sleeve to reveal a midline dressing dated 9/29/25. Resident #81 could not recall why he needed the IVs. A short peripheral intravenous line is a catheter, up to three inches long, inserted into one of the superficial veins of an extremity. A midline catheter is longer than 3 inches and is inserted into the upper arm through a larger vein of the upper extremity with the catheter tip located at or near the level of the axilla and distal to the shoulder. (retrieved from www.infusioninstitute.com on 10/06/25). Review of laboratory results for resident #81 revealed on 9/19/25 a complete blood count (CBC) with differential was drawn and the resident's white blood cells (WBC) were 23.2 thousand cells per microliter (K/uL). The normal range for WBC's were 3.8 to 10.8 K/uL and an elevated level could indicate an infection. The resident also had a urinalysis and culture with reflex drawn and the urinalysis per physician was unremarkable. A physician note dated 9/26/25 revealed the resident's urine culture was positive for Klebsiella pneumonia and he was started on an antibiotic 1 gram daily for five days which was discussed with the Assistant Director of Nursing (ADON). Resident #81's physician orders revealed an order for Ertapenem 1 gram intravenous every 24 hours for UTI for six Days with a start date of 9/26/25. Review of resident #81's progress notes revealed a note from 9/27/25 at 11:51 PM, stating a 22 gauge IV was inserted into the left forearm after one successful attempt which the resident tolerated well. The IV antibiotic was started. Review of the physician's orders for resident #81 revealed no order for insertion of a peripheral IV line and no orders to monitor the IV insertion site, flush the line with normal saline, or change the dressing. Review of resident #81's physician orders revealed an order to insert a midline for antibiotic therapy with a start date 9/29/25 which was administered at 12:49 PM. There were no orders to monitor the midline IV site, flush the line with normal saline, or change the dressing. On 9/30/25 at 10:31 AM, Licensed Practical Nurse (LPN) A confirmed that resident #81 had a peripheral IV to his left forearm which did not have a date and a midline to his left upper arm which was dated 9/29/25. She reviewed the physician orders and verified there were no orders for the midline nor the peripheral IV to be flushed, monitored, or have the dressings changed. On 9/30/25 at 10:45 AM, the Director of Nursing (DON) confirmed there were no physician orders to monitor, flush or change the dressing of the peripheral IV nor to monitor, flush or change the dressing to the midline IV. She explained the nurses were expected to add those orders whenever a resident had an IV site. She was unable to explain why those orders were not obtained. Review of the facility's policy for Intravenous Therapy revised 8/02/22 revealed the facility would adhere to accepted standards of practice regarding infusion practices. The document indicated that IV dressings would be changed every 72 hours unless otherwise ordered by the physician. Staff were directed to check IV sites every four hours or as per facility protocol and as needed for signs and symptoms of infection or inflammation. 2. Resident #87 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease, dysphagia, dry eye syndrome of unspecified lacrimal gland and chronic kidney disease. Review of the Minimum Data Set (MDS) annual assessment with an assessment reference date (ARD) of 7/23/25 revealed resident #87 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. The document indicated she had impaired vision. Review of resident #87's electronic medical record (EMR) revealed a physician's order for Lubricating Plus Eye Drops Ophthalmic Solution 0.5 % (carboxymethylcellulose sodium) and nurses were instructed to instill two drops in both eyes every 12 hours for dry eyes. On 9/29/25 at 11:04 AM, resident #87 was observed in bed. She reported that she had not received her eye drops as ordered. On 10/02/25 at 11:38 AM, Registered Nurse (RN) C verified she was the assigned nurse for resident #87 and had administered her eye drops. RN C presented a blue and white box from her cart which read generic eye lubricant without the resident's name or date on the box. RN C confirmed that she administered the eye drops to resident #87 that morning and knew the eye drops belonged to her even though the box did not have her name on it. RN C reviewed the physician's order and verified the order was for Lubricating Plus Eye Drops Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium). She acknowledged the generic lubricating eye drops which she administered earlier were not the eye drops that were prescribed. She explained she did not realize she had administered the wrong ones. RN C stated she should have verified the medication prior to administration and was sorry that she administered the wrong medication. On 10/02/25 at 11:45AM the Unit Manager (UM) for the A Wing acknowledged resident #88 received the wrong eye drops and stated that the facility had the correct medication in the stock room. The A Wing UM expressed she did not understand the reason generic eye drops were even in the medication cart because the resident did not receive the generic drops. The UM confirmed RN C and other nurses required education on medication administration. On 10/02/25 at 12:04 PM, the DON acknowledged resident #87 received the wrong eye drops. The DON shook her head and stated she could not understand why the nurse did not give the correct eyedrops. Review of the facility's policy and procedure on Medication Administration revised October 2023, revealed in section 10 of the policy's explanation and compliance guidelines, the nurses were instructed to Review MAR [medication administration record] to identify medication to be administered.

Based on interview, and record review, the facility failed to develop a trauma-informed care plan based on a resident's past experiences and preferences to mitigate triggers that could cause re-traumatization, for 1 of 1 resident reviewed for abuse, of a total sample of 48 residents, (#29).Findings: Review of resident #29's medical record revealed she was originally admitted to the facility on [DATE] with diagnoses including myasthenia gravis (an autoimmune condition that causes skeletal muscle weakness), sequalae of cerebral infarction, osteoarthritis, an fibromyalgia (chronic condition that causes pain in muscles and soft tissues all over the body). The Minimum Data Set admission assessment with Assessment Reference Date of 8/13/25 revealed resident #29 had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. On 9/29 at 11:24 AM, resident #29 reported she had a problem with a male resident on 9/06/25. She presented a partial copy of a grievance form filed on the day of the incident. She stated the staff were not watching the male resident, and he entered her room. She explained a Certified Nursing Assistant (CNA) had left the male resident sitting in a chair in her room and walked away. She stated the male resident then got up from the chair, moved toward her, pushed her bedside table aside, and sat at the edge of her bed. She stated she screamed and yelled while the male resident cursed. She described feeling terrified and uncertain about what he might do to her. Resident #29 shared she had previously survived an attempted murder, and the event triggered memories of that trauma. She stated she felt defenseless because she could not stand or use her hands. She reported no staff were in her room and when they arrived, they laughed and told her it was okay. She stated the entire unit must have heard her screams. She indicated the staff eventually removed the male resident. She shared a manager later visited her and explained what had occurred. She indicated she was informed the male resident was on a one-to-one supervision, but she said she still did not feel safe. She questioned, Was he trying to have sex? What would he do to me? and shared staff often did not respond quickly when she pressed her call light. Resident #29 also reported suffering from post-traumatic stress disorder. Review of resident #29's comprehensive care plan revealed it did not include a focus on trauma-informed care. Review of a Grievance/Complaint Report filed by resident #29 on 9/06/25 read, Resident stated male resident entered her room approximately 11:45 AM and sat in chair by her door shouting . The form showed resident #29 was informed about changes made to supervise the male resident, but she remained upset that he had entered her room. Review of resident #29's Social Services - Trauma-Informed Care Evaluation dated 8/10/25 revealed affirmative responses for the following questions, Has anyone ever made or pressured you into some type of unwanted sexual contact? If the event happened, did you think your life was in danger or you might be seriously injured? and . were you seriously injured. Her identified triggers for potential re-traumatization was self. Review of resident #29's medical record included a Psychotherapy Progress Note dated 9/13/25 which read, . She shared a recent experience when another resident entered her room and she was triggered. Her traumas of almost getting killed three times by her ex-partners. She said it took staff intervention to calm her down and Hydroxyzine . A Psychotherapy Progress Note dated 9/20/25 indicated, . She shared traumas she encountered while growing up and many traumas as an adult that have impacted her life experiences. All of those adverse experiences have been catalysts to her current response to the environment and hypervigilance. On 10/01/25 at 2:42 PM, during a telephone interview, CNA J recalled resident #29 was screaming and visibly upset when a male resident sat on her bed. She stated her and other staff removed the male resident from resident #29's room. On 10/01/25 at 4:37 PM, the Assistant Business Office Manager stated she was the Manager on Duty on 9/06/25. She recalled being informed resident #29 requested to speak with a manager. She indicated resident #29 told her a male resident had entered her room, which made her very upset. She mentioned resident #29 explained she was startled due to her history of sexual abuse. The Assistant Business Office Manager said resident #29 was extremely irate and may have received medication afterward to calm her down. On 10/02/25 at 2:24 PM, LPN I reported overhearing resident #29 screaming while passing medications on 9/06/25. She recalled entering resident #29's room where she observed three staff members struggling to remove the male resident who was sitting at the edge of resident #29's bed. LPN I indicated she assisted staff in removing him. She stated resident #29 shared she was fearful due to prior traumatic experiences with males. On 10/01/25 at 4:49 PM, the Social Services Director (SSD) stated she had completed a psychosocial evaluation on 8/10/25 in which resident #29 shared her history of sexual abuse and trauma. The SSD stated she referred the resident for psychological services and counseling. The SSD acknowledged she should have developed a trauma-informed care plan but became focused on providing immediate support instead. The SSD acknowledged the 9/06/25 incident was another opportunity the facility had to update the care plan to address trauma as a focus area. Review of the facility's policy Trauma Informed Care revised on 7/27/22 revealed the intent to provide care and services which met professional standards and used approaches that were culturally competent, accounted for experiences and preferences and addressed the needs of trauma survivors by minimizing triggers and/or re-traumatization. The guidelines included identifying a resident's history of trauma and triggers and developing and implementing individualized care plan interventions. The policy read, Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan.

Based on interview, and record review, the facility failed to ensure pharmacy recommendations were implemented in a timely manner for 1 of 5 residents reviewed for Unnecessary Medication Regimen Review, out of a total sample of 48 residents, (#19).Findings: Review of the medical record revealed resident #19 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/22/25. His diagnoses included type 2 diabetes mellitus (DM), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following a cerebral infarction, atrial fibrillation, and heart failure. A review of resident #19's Recommendation Outcomes form dated 8/25/25 showed the pharmacist identified several medications that could cause hypoglycemia: Glimepiride 2 milligrams (mg) orally (PO) every morning for DM, Metformin 1000 mg PO twice a day, Humulin 70/30 injection 20 units before meals (AC), Trulicity injection 2 mg subcutaneous once weekly, and Humalog sliding scale to be used AC and at bedtime. The pharmacist recommended adding a hold parameter for the Humulin 70/30 order, stating Resident has a high risk of hypoglycemia due to the additive effects of multiple Diabetes meds. A handwritten note by the Director of Nursing (DON) dated 8/29/25 read, T.O. (telephone order) Hold for parameter blood glucose below 150. The physician agreed and signed the order on 8/29/25. Review of resident #19's physician's orders revealed an order dated 2/19/25 for Humulin 70/30 to inject 20 units AC. The order was discontinued on 9/23/25 at 1:56 PM and a new order for Humulin 70/30 to inject 15 units AC was started on 9/23/25 at 4:30 PM. The physician's orders, however, did not include a parameter to hold the insulin if the resident's blood glucose (BG) was below 150. The active orders confirmed this parameter was not officially added until 10/01/25. Review of resident #19's care plan, revised on 2/05/25, with a focus on diabetes management, noted he was at risk for both hyperglycemia and hypoglycemia. The goal was to minimize complications related to hyper/hypoglycemia. Interventions instructed nurses to Administer medications as ordered. Review of resident #19's Medication Administration Record (MAR) for August and September 2025 showed Humulin 70/30 was scheduled three times daily at 6:30 AM, 11:30 AM, and 4:30 PM. Documentation revealed nurses administered 28 doses of Humulin 70/30 between 8/31/25 and 9/22/25 despite the physician's hold order for BG levels under 150. Resident #19's BG level ranged between 87 and 148 on days administered outside of parameters. A review of resident #19's Pharmacist's Recommendation to Prescriber form dated 6/27/25 revealed the resident had PRN (as needed) orders for non-acute pain management: Hydrocodone- APAP 5-325 milligrams (mg) every 4 hours (Q4H) PRN and Morphine solution 20 mg/milliliters (mL) Q4H PRN for pain, shortness of breath (SOB), or respiratory distress. The pharmacists recommended adding a pain scale to these PRN orders. Review of resident #19's physician's orders revealed an order dated 6/11/25 for Hydrocodone 5-325 mg Q4H PRN pain, which was discontinued on 10/01/25. A new order entered the same date read Hydrocodone-acetaminophen 5-325 mg Q4H PRN for non-acute pain. The Morphine 20 mg/mL 5 ml Q4H PRN Pain/SOB/Respiratory distress non-acute pain dated 4/23/25 was also discontinued and reentered on 10/01/25. Neither of these orders included the pain scale recommendation from the pharmacist. On 10/02/25 at 6:43 PM, the DON confirmed resident #19's pharmacy recommendations and physician order for Humulin 70/30 were not followed. She stated she updated the orders on 10/01/25 after reviewing them and realizing the recommended parameters had not been entered. The DON reported she believed nurses were following sliding scale parameters used for Humalog insulin and assumed the same applied to Humulin, even though the hold order was not added as recommended by pharmacy. A review of the facility's Medication Administration policy and procedure, revised on 10/2023, read, Medications are administered by licensed nurses, . as ordered by the physician and in accordance with professional standards of practice, .

Based on interview, and record review, the facility failed to ensure the medical record reflected documentation of an incident between residents and follow-up assessments for 1 of 1 residents reviewed for abuse, out of a total sample of 48 residents, (#29).Findings: Review of resident #29's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included myasthenia gravis (an autoimmune condition that causes skeletal muscle weakness), sequalae of cerebral infarction, osteoarthritis, an fibromyalgia (chronic condition that causes pain in muscles and soft tissues all over the body). The Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 8/13/25 revealed resident #29 had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. On 9/29/25 at 11:24 AM, resident #29 reported she had a problem with a male resident on 9/06/25. Resident #29 showed a partial copy of a grievance form filed on the day of the incident. She stated a Certified Nursing Assistant (CNA) left the male resident sitting in a chair in her room and walked away for a moment. She recalled the male resident got up, came near her, pushed her bedside table aside, and sat at the edge of her bed. She stated she was screaming while the male resident was cursing. She said she was terrified and did not know what he would do to her. Resident #29 shared a man had previously tried to kill her and this incident triggered those memories. She explained due to her medical conditions, she could not stand or use her hands and therefore felt defenseless. She stated staff entered her room a few minutes later and eventually removed the male resident from her room. She indicated she received a visit from a manager after the incident and she explained what happened, and the manager filed a grievance on her behalf. She said her nurse came after the incident and obtained her blood pressure (BP) which was 162/90 and that it had never been that high before. Review of resident #29's medical record did not reveal any documentation about the incident on 9/06/25 or the BP of 162/90. Review of resident #29's Progress Notes revealed a psychotherapy note dated 9/13/25 which read in part, Patient is being followed due to history of anxiety and depression with new onset of acute stress reaction . She shared a recent experience when another resident entered her room and she was triggered. Her traumas of almost getting killed three times by her ex-partners. She said it took staff intervention to calm her down and Hydroxyzine . On 10/01/25 at 4:37 PM, the Assistant Business Office Manager stated she was the Manager on Duty on 9/06/25 and met with resident #29 after the incident. She said resident #29 was visibly upset because a male resident had entered her room and sat on her bed. The Assistant Business Office Manager indicated resident #29 told her she had history of sexual abuse, and the incident caused her distress. The Assistant Business Office Manager stated she informed resident #29 the issue was being addressed and completed the grievance form. The Assistant Business Office Manager stated she believed resident #29 received a medication to calm her down after the incident. On 10/02/25 at 2:24 PM, Licensed Practical Nurse (LPN) I stated on 9/06/25, while passing medications, she heard resident #29 screaming and went to her room to check on her. She recalled seeing three staff members and a male resident sitting at the edge of resident #29's bed. She indicated the staff were having trouble removing the male resident from the room, so she assisted. LPN I stated she asked resident #29 if she was hurt and resident #29 told her the male resident did not touch her. LPN I said resident #29 refused a head-to-toe assessment. LPN I indicated resident #29 shared she was fearful because of prior experiences with males. When asked about documentation of the incident or assessment that day, LPN I said she did not recall entering any notes in the medical record. LPN I acknowledged the incident should have been documented but did not remember doing so. On 10/02/25 at 11:52 AM, the Assistant Director of Nursing (ADON) stated he was working on 9/06/25 and was informed by LPN I about the incident involving resident #29 and the male resident. The ADON shared he spoke with resident #29 and completed a grievance form because she was upset. He explained he reassigned the male resident to one-to-one supervision but did not enter any notes regarding the incident in resident #29's medical record. Later at 4:30 PM, the ADON stated the facility's expectation was for accurate documentation in the medical record, including resident's refusals. On 10/2/25 at 5:25 PM, the Director of Nursing (DON) validated resident #29's medical record did not include the incident on 9/06/25 and acknowledged it should have been documented. Review of the facility's Documentation in Medical Record policy and procedure revised on 8/25/22 read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The guidelines listed directed licensed staff and interdisciplinary team members to document all assessments, observations, and services in the medical record in accordance with state law and facility policy.

Based on interview, and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed and failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary resuscitation (CPR) for 1 of 8 residents reviewed for Advanced Directives of a total sample of 8 residents, (#1). These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. He was taken to his room where a licensed nurse initiated CPR without first verifying the resident's code status in the medical record. Emergency Medical Services (EMS) arrived at the facility at midnight and continued to provide CPR for another 20 minutes before resident #1 was transported to the hospital where he was intubated and stabilized until his wife requested life support be withdrawn. The facility failed to honor the resident's wishes not to be resuscitated and the physician order for Do Not Resuscitate. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a Do Not Resuscitate Order (DNRO) Advance Directive at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed [DATE] based on verification of the facility's corrective actions. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross reference F678. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including fracture of right femur, senile degeneration of brain, unspecified dementia, dysphagia (trouble swallowing), and chronic kidney disease stage III. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of ,d+[DATE] which indicated he had severe cognitive impairment. A care plan for Advance Directives was initiated [DATE] which indicated resident #1 had an established Full Code order in place and identified his wife as his proxy and emergency contact. Review of the electronic medical record (EMR) revealed a care plan minutes form from [DATE], scanned into the miscellaneous documents. The form indicated those in attendance included resident #1's wife, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Under resident/family concern was written, change code status to DNR. Review of resident #1's EMR revealed a State of Florida Do Not Resuscitate Order (DNRO) form signed by resident #1's wife on [DATE]. A Nurses Progress Note dated [DATE] at 1:07 AM revealed Certified Nursing Assistant (CNA) A observed resident #1 was unresponsive and notified nurse. Licensed Practical Nurse (LPN) B arrived on the scene, assessed the resident and confirmed he was unresponsive. The note indicated resident #1 was immediately transferred to his room where staff initiated CPR at 11:51 PM, and emergency services were called at 11:54 PM. EMS arrived on the scene at midnight and continued to provide resuscitation efforts. Resident #1 was transferred to a nearby hospital by EMS at 12:20 AM. A Social Services progress note dated [DATE] revealed resident #1's wife was contacted regarding his change in condition. The note indicated the caller was informed by his wife resident #1 had been intubated at the hospital and expired 30 minutes after the he was taken off the ventilator. On [DATE] at 9:55 AM, the DON reported she was in the care plan meeting with resident #1's wife on [DATE]. The DON recalled she had a conversation with resident #1's wife regarding his code status. She explained resident #1 received hospice services at home prior to entering the hospital but he came into the facility as Full Code. The DON stated she explained the difference between Full Code and DNR to the resident's wife who then decided she wanted resident #1 to be a DNR. She then called the Social Service Assistant (SSA) and informed her of the wife's wish to be a DNR. The DON recalled the wife then signed the DNRO form. She stated she told the ADON to contact the doctor and to update resident #1's code status in the EMR. The DON recalled Licensed Practical Nurse (LPN) B called her in the middle of the night to inform her of the code. She explained she questioned LPN B because the wife had signed the DNRO form earlier that day. LPN B informed the DON that resident #1 was listed as Full Code in the EMR. The DON explained she spoke to the ADON later that morning who stated she had forgotten to update the EMR with the change in resident #1's code status. She confirmed LPN B should have checked the EMR and the Code Status Binder to confirm the code status per facility policy. The DON acknowledged resident #1 was a DNR at the time CPR was performed. In a phone interview on [DATE] at 12:32 PM, the ADON confirmed she was in the care plan meeting on [DATE]. She recalled resident #1's wife wanted him to be a DNR and she went with the SSA to sign the DNRO form. She acknowledged the DON told her the wife signed the form and asked her to update the EMR with the new code status. The ADON recalled she was busy with another staff member and had asked the DON to remind her. She explained the DON did not remind her and she forgot to update the EMR. The ADON explained any nurse could have updated the EMR with the new code status. She said she did not know why someone else did not do it. In a phone interview on [DATE] at 10:14 AM, the SSA stated she was called into the care plan meeting and was told resident #1 had a DNRO form at home. The SSA informed resident #1's wife she had a DNRO form in her office that could be signed and would be activated that day. She explained resident #1's wife signed the form. The SSA reported she uploaded a scan of the form to the EMR and placed a copy in the Code Status Binder on the code cart on the unit on the afternoon of [DATE]. She stated the following morning she was told resident #1 was found unresponsive and the nurses provided CPR. Once she got to the facility, the SSA discovered resident #1's code status had not been updated in the EMR. On [DATE] at 8:54 AM, LPN B stated she was assigned to resident #1 on the night of [DATE]. She recalled seeing resident #1 in his wheelchair by the nurse's station. LPN B reported as she was rounding, she heard another staff member announce a Code Blue. She stated resident #1 had been found unresponsive and she assisted with getting him to his room and into the bed. LPN B stated she asked for someone to check his code status and heard someone reply he was a Full Code. She explained she asked again if he was a Full Code, and the person said it again. LPN B reported she then began chest compressions at 11:51 PM. She stated she alternated compressions with other nurses until EMS arrived. LPN B recalled she then went outside the room to verify the resident's code status for herself when she first switched off with another nurse. LPN B stated the code cart was in the resident's room. She acknowledged she did not check the Code Status Binder located on the cart to verify resident #1's code status. She reported EMS arrived at midnight and took over CPR. She stated EMS continued chest compressions through the time they transported resident #1 to the hospital at 12:20 AM. In a phone interview on [DATE] at 3:05 PM, LPN C confirmed she worked the night of [DATE]. She stated she heard another nurse call a Code Blue from the other wing and ran over to assist. LPN C recalled she assisted getting resident #1 into bed. She did not recall who started the chest compressions but stated she did participate in providing CPR to resident #1. She stated she thought LPN B checked resident #1's code status but was not aware of where she got the information. LPN C acknowledged she did not verify resident #1's code status as CPR was already in progress. In a phone interview on [DATE] at 2:32 PM, Registered Nurse (RN) D confirmed she was working the night of [DATE]. She recalled hearing a Code Blue called on the opposite unit and ran to that unit. RN D stated when she arrived at resident #1's room, LPN B and LPN C were already there. She explained she saw LPN B performing chest compressions. RN D reported that she alternated with LPN B and LPN C to perform CPR on resident #1. She stated she thought the code status had been confirmed since CPR was already in progress. RN D recalled she saw resident #1 was identified as Full Code in the EMR but acknowledged she did not check the Code Status Binder on the code cart to verify. In a phone interview on [DATE] at 12:02 PM, resident #1's wife confirmed she signed the DNRO on [DATE] during a care plan meeting at the facility. She explained her husband received hospice care previously at home and had been a DNR. She stated the facility called her sometime during the night after she had signed the new DNRO to inform her of the Code Blue and that her husband was being sent to the hospital. Resident #1's wife stated she did not know why they performed CPR since their wishes were for DNR. She reported the hospital called her on [DATE] at approximately 1:00 AM to update her on her husband's status. She told them she did not want her husband to be intubated. She explained the hospital staff informed her he had already been intubated. Resident #1's wife stated she went to the hospital that morning and talked with a doctor in order to get the tube removed. She recalled two doctors had to sign off and the tubes were removed around 10:00 AM. She explained she sat with her husband, holding his hand until he passed away a short time later at 10:30 AM. Resident #1's wife explained she had signed the DNRO because she did not want to prolong his life and did not want him to suffer. She stated her husband did not want to suffer either. On [DATE] at 11:13 AM, the Administrator stated the DON called her on [DATE] at approximately 12:,d+[DATE]:45 AM to inform her of CPR being provided to resident #1. She explained an investigation was initiated that morning. The Administrator reported the ADON failed to update the EMR with the correct code status. She acknowledged the nurses should have verified resident #1's code status in the EMR and Code Status Binder on the code cart before initiating CPR. The Administrator verified this resulted in resident #1 being provided life saving measures against his wishes. The Facility's policy and procedure for Advanced Directives and Code Status dated [DATE] read, It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with Stated and Federal Regulations. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] a medical record audit was completed for current residents to ensure DNR forms were present in the electronic medical record for residents with DNR orders. *On [DATE] through [DATE] current licensed nurses were educated on resident's rights regarding treatment and Advanced Directives by the Director of Nursing/delegate. * 40 out of 41 total licensed nurses received education; 98% of nurses: On [DATE] 10 out of 41 nurses completed the education, 24% of nurses, On [DATE] an additional 29 of 41 nurses completed their education, 71% of nurses. On [DATE] an additional 1 of 41 nurses completed the education, 2%. 1 remaining licensed nurse to receive education upon return from leave and prior to working next shift. *New hire nurses at the facility will receive the above education during orientation and prior to working an assignment. *On [DATE] through [DATE] current licensed nurses participated in mock code drills: *18 out of 41 total Licensed Nurses participated in mock code drills; 44% of nurses: On [DATE] 11 out of 41 nurses participated in mock code drills, 27% of nurses. On [DATE] 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift. *New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment. *On [DATE] through [DATE] residents and/or responsible parties for current residents residing in facility were interviewed by Social Services/Delegate to validate current physician orders for code status reflect resident and/or responsible party's current wishes for code status. Code status updated, if applicable based on interviews conducted. *Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] completed with Medical Director, Administrator, and additional Interdisciplinary team (IDT) members on the adherence to CPR policy and policy and procedure for Resident Rights Regarding Treatment and Advance Directives and a review of the root cause analysis was completed. *As part of the ongoing Quality Assurance Assessment (QAA) process, an ad hoc QAPI was conducted on [DATE] that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on the Advance Directives process, code process and results of audits. No discrepancies or concerns were noted related to Advanced Directive code status standards and guidelines. Interviews conducted on [DATE] with 10 licensed nurses across all shifts indicated they were knowledgeable of Advance Directives and where to verify the code status in the EMR and the code status binder prior to providing CPR. The surveyors validated the education with attendance sheets for Code Blue drills and in-services. Review of QAPI audits revealed daily Code Blue drills were conducted per performance improvement plan. The resident sample was expanded to include four additional residents, three who elected DNR status and one with Full Code status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to Advance Directives.

Based on record review, and interview, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of resuscitation or code status in an emergency for 1 of 8 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#1). On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. He was taken to his room where a licensed nurse initiated CPR without first verifying the resident's code status in the medical record. Emergency Medical Services (EMS) arrived at the facility at midnight and continued to provide CPR for another 20 minutes before resident #1 was transported to the hospital where he was intubated and stabilized. The facility failed to honor the resident's wishes not to be resuscitated and physician's order for Do Not Resuscitate. The facility's failure to ensure staff followed procedures related to honoring an Advanced Directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross reference F578. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including fracture of right femur, senile degeneration of brain, unspecified dementia, dysphagia (difficulty swallowing), and chronic kidney disease stage III. Review of the Minimum Data Set admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of ,d+[DATE] which indicated he had severe cognitive impairment. Review of the electronic medical record (EMR) revealed a care plan minutes form dated [DATE] scanned into the miscellaneous documents. The form indicated those in attendance at the meeting included resident #1's wife, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Under resident/family concern was written, change code status to DNR. Review of resident #1's EMR revealed a State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] that was signed by the resident's wife and his attending physician. The document showed the resident representative's signature under the statement, Being informed of my right to refuse cardiopulmonary resuscitation (CPR), including artificial ventilation, cardiac compression, endotracheal intubation and defibrillation, direct that CPR be withheld or withdrawn from me. The physician's statement read, I direct the withholding or withdrawal of CPR from the patient in the event of the patient's cardiac or respiratory arrest. Resident #1's EMR contained a physician order dated [DATE] which read, Full Code. The Facility's policy and procedure for Advanced Directives Code Status dated [DATE] read, It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations. The form indicated a resident's code status should be verified by the physician's order tab in the EMR and the corresponding form should be visualized in the code status binder. A Nurse's Progress Note dated [DATE] at 1:07 AM, revealed Certified Nursing Assistant (CNA) A observed resident #1 was unresponsive and notified the nurse. Licensed Practical Nurse (LPN) B arrived on the scene, assessed resident #1 and confirmed he was unresponsive. The note indicated resident #1 was immediately transferred to his room and staff initiated CPR at 11:51 PM and emergency services were called 11:54 PM. Emergency Medical Services (EMS) arrived on the scene at midnight and continued to provide resuscitation efforts. Resident #1 was transferred to the hospital by EMS at 12:20 AM. On [DATE] at 9:55 AM, the DON reported she was in the care plan meeting with resident #1's wife on [DATE]. The DON recalled she had a conversation with resident #1's wife regarding his code status. The DON stated she explained the difference between Full Code and DNR to the wife who then decided to sign a DNRO. The DON explained she asked the Social Services Assistant (SSA) to assist the wife with the DNRO and directed the Assistant Director of Nursing (ADON) to contact resident #1's physician and to update the EMR. She recalled Licensed Practical Nurse (LPN) B called her in the middle of the night to inform her of the code. The DON state she questioned LPN B because the wife had signed a DNRO form. LPN B informed her resident #1 was listed as Full Code in the EMR. The DON acknowledged the EMR had not been updated and resident #1 was a DNR at the time CPR was performed. In a phone interview on [DATE] at 12:32 PM, the ADON confirmed she attended the care plan meeting on [DATE]. She recalled resident #1's wife signed a DNRO. She acknowledged the DON told her to contact the doctor and update the EMR with the new code status. The ADON stated she was busy with another staff member and asked the DON to remind her. She explained she forgot to update the EMR. The ADON stated any nurse could have updated the EMR with the new code status. In a phone interview on [DATE] at 10:14 AM, the SSA confirmed she met with resident #1's wife who signed a DNRO form on [DATE]. The SSA reported she uploaded the form to the EMR and placed a copy in the Code Status Binder on the crash cart on the afternoon of [DATE]. She stated the following morning she was told resident #1 coded and the nurses provided CPR. Once she got to the facility, the SSA discovered the code status had not been updated in the EMR. On [DATE] at 4:09 PM, Certified Nursing Assistant (CNA A) confirmed she was the assigned CNA for resident #1 on [DATE]. She recalled resident #1 was in his wheelchair at the nurse station and he was not moving or breathing. She notified a nurse who called a code blue. CNA A reported staff responded to the call, and she assisted in getting resident to his room and into bed. She explained she stepped outside the room and the nurses took over. CNA A stated she did not know who verified resident #1's code status or who started resuscitation efforts. She did recall seeing the crash cart in the room but did not know who brought it. On [DATE] at 8:54 AM, LPN B stated she was assigned to resident #1 on the night of [DATE]. She described the sequence of events on [DATE], the day resident #1 received CPR. She recalled hearing another staff member announce a Code Blue. LPN B stated she observed resident #1 was unresponsive at nurse station and she assisted with getting him to his room and into the bed. LPN B explained she asked for someone to check code status and heard someone say he was a Full Code. She asked again if he was a Full Code, and the person said it again. LPN B reported she then began chest compressions at 11:51 PM. She stated she switched off with other nurses until EMS arrived at midnight. LPN B recalled she went outside the room to verify resident's code status for herself when she first switched off with another nurse. LPN B stated the crash cart was in the resident's room. She acknowledged she only checked the computer and did not check the Code Status Binder to verify resident #1's code status. She reported EMS took over CPR when they arrived. LPN B stated EMS continued chest compressions until 12:20 AM when they transported resident #1 to the hospital. In a phone interview on [DATE] at 3:05 PM, LPN C confirmed she was working the night of [DATE]. She stated she heard another nurse calling a Code Blue from the other wing and ran over to assist. LPN C recalled she assisted getting resident into bed. She did not recall who started chest compressions but stated she did participate in providing CPR to resident #1. She stated she was sure LPN B checked resident #1's code status. She reported LPN B came back to the room and stated he was a Full Code. She did know how LPN B verified the code status. LPN C acknowledged she did not verify resident #1's code status as CPR had already started. In a phone interview on [DATE] at 2:32 PM, Registered Nurse (RN) D confirmed she was working the night of [DATE]. She recalled hearing a code blue called on the opposite unit and ran to that unit. RN D stated when she arrived LPN B and LPN C were already in resident #1's room. She explained she saw LPN B performing chest compressions. RN D reported that she traded off with LPN B and LPN C to perform CPR. She stated she thought code status had been confirmed since CPR had been started. RN D recalled she later saw resident #1 was a full code in the EMR. She acknowledged she did not check before CPR began and did not check the Code Status Binder on the crash cart to verify. In a phone interview on [DATE] at 12:02 PM, resident #1's wife confirmed she signed a DNRO on [DATE] during a care plan meeting. She stated the facility called her sometime during the night and informed her of the code and her husband being transferred to the hospital. Resident #1's wife stated she did know why they did that since he was a DNR. She reported the hospital called her on [DATE] at approximately 1:00 AM to update her on resident #1's status. She told the caller she did not want her husband to be intubated. She explained the caller informed her he had already been intubated. Resident #1's wife stated she went to the hospital that morning and had to talk with a doctor to get the tube removed. She recalled two doctors had to sign off and the tubes were eventually removed around 10:00 AM. She stated she went into the room and sat with her husband holding his hand until he passed away at 10:30 AM. Resident #1's wife explained she had signed the DNRO because she did not want to prolong his life and did not want him to suffer. She stated her husband did not want to suffer either. On [DATE] at 11:13 AM, the Administrator stated the DON called her on [DATE] around 12:,d+[DATE]:45 AM and informed her of CPR being provided to resident #1. She explained an investigation was initiated that morning. The Administrator reported that resident #1's wife had signed a DNRO and the ADON failed to update the EMR with the correct code status. She acknowledged the nurses should have verified resident #1's code status in the EMR and Code Status Binder on the crash cart per policy. The Administrator verified this resulted in a resident with a DNR being provided CPR. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] through [DATE] current licensed nurses were educated on facility's CPR policy and on procedure for performing a code to include confirmation of resident code status prior to initiating CPR. Post test and code procedure competencies completed to validate comprehension. *39 of 41 total licensed nurses received education; 95% of nurses: On ,d+[DATE] ,d+[DATE] 10 out of 41 nurses completed the education, 24% of nurses, On [DATE] an additional 29 of 41 nurses completed their education, 71% of nurses. 2 remaining licensed nurse to receive education upon return from leave and prior to Working next shift. *New hire nurses at the facility will receive the above education during orientation and prior to working an assignment. *On [DATE] through [DATE] current licensed nurses participated in Mock Code Drills: *18 of 41 total licensed nurses participated in mock code drills; 44% of nurses On [DATE] 11 out of 41 nurses participated in mock code drills, 27% of nurses, On [DATE] 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift. *New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment. *Ad Hoc QAPI on [DATE] completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to CPR policy and checking the residents code status prior to initiating CPR. Interviews conducted on [DATE] with 10 licensed nurses across all shifts indicated they were knowledgeable of Advanced directives and where to verify the code status in the EMR and the code status binder prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include four additional residents, 3 who elected DNR status and 1 with Full Code status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to Advanced directives. Based on the facility's corrective actions, the survey team determined the immediate jeopardy was removed [DATE].

Based on observation, interview, and record review, the facility failed to ensure licensed nurses had the skills and competencies to provide care and services, according to plans of care, to meet the needs of all residents in the facility. Findings: Cross reference F676, F677, F694, F755, F759, F761, F806, F842, and F880. During the facility's Recertification survey from 4/08/24 to 4/12/24, the following concerns were identified and discussed with members of nursing management and nursing administration: On 4/08/24 at 1:48 PM, the Director of Nursing (DON) was informed of findings related to both residents in the facility who had intravenous (IV) access sites. He was made aware an admission nurse did not identify and document one resident's IV site and none of the assigned nurses assessed the site or questioned the lack of physician orders, therefore no care and services were ordered or provided until the facility was notified by State Survey Agency staff. The DON was informed the other resident's IV dressing was not changed according to physician orders. He validated the nurses did not follow the facility's protocols. On 4/08/24 at 2:20 PM, the Assistant Director of Nursing (ADON) was informed of concerns related to a nurse who left medication unattended on top of the medication cart, and the same nurse's infection control practices related to disposal of a used sharp, not performing hand hygiene after removal of gloves and prior to medication administration, and failure to disinfect a blood glucose meter after use. She was made aware the nurse recalled only a brief orientation which did not include competency checks, and expressed minimal knowledge of the policies and procedure reviewed with her. On 4/09/24 at 5:48 PM, the B Wing Unit Manager (UM) confirmed all nurses assigned to a resident failed to appropriately pursue acquisition of an ordered eye ointment. She verified 13 nurses completed daily documentation for over one month to indicate the medication was given, although it was never in the facility. The UM explained during her investigation, she interviewed two of the 13 nurses who inaccurately documented administration of the eye ointment, and they informed her they used an alternate medication without informing the physician. On 4/09/24 at 5:59 PM, the B Wing UM was informed another resident did not receive a prescribed skin ointment for several days as nurses did not contact the pharmacy to ensure timely delivery of the medication. On 4/09/24 at 6:10 PM, the ADON discussed a nurse's omission of medications during medication pass observation. She confirmed nurses were to administer all medications as ordered by the physician and document administration at the time it occurred. On 4/10/24 at 11:28 AM, the ADON was informed of infection control concerns identified during wound care observation related to a nurse who did not change her gloves or perform hand hygiene throughout the procedure. On 4/10/24 at 5:29 PM, the ADON confirmed during a 3-month period, several nurses administered multiple doses of a blood pressure medication outside of the physician-ordered parameter. She acknowledged the nurses' actions indicated they either did not carefully read or comprehend the order. On 4/12/24 at 10:43 AM, the DON acknowledged direct care nurses and nursing management failed to identify a resident's declining ability to feed himself and initiate a therapy referral in a timely manner. He was informed of concerns related to personal hygiene tasks including nail care and shaving that were not performed regularly as evidenced by the unkempt appearance of residents. The DON stated nurses were ultimately responsible for observing their assigned residents' personal hygiene during all interactions throughout the shift, supervising Certified Nursing Assistants to ensure care was given, and documenting all refusal of care. On 4/10/24 at 5:11 PM, the ADON explained she was the facility's Staff Development Coordinator. She stated after the all-staff general orientation, she met with every newly hired nurse to review her expectations. The ADON confirmed she used the facility's written policies and procedures to educate nurses before they were placed on resident care assignments. She stated she felt nurses were provided with adequate education during orientation and they performed some competencies. The ADON confirmed the facility did not conduct an annual skills fair or review competencies at regular intervals to ensure all nurses possessed or maintained the skills necessary to care for residents. The ADON validated the concerns identified during the Recertification survey related to the performance of some nurses. She acknowledged the nurses did not meet the facility's expectations, adhere to policies and procedures, and reflect basic standards of nursing practice. The ADON said, The nurses are not doing what they were trained to do. On 4/10/24 at approximately 5:30 PM, the ADON acknowledged on 4/08/24 at 2:20 PM, when she was informed of the concerns regarding the nurse who was not aware of the facility's policy and procedures for disinfecting the glucose meter, she stated the device could be cleaned and disinfected with a disinfectant wipe or alcohol. The ADON was informed the facility's policy and procedure for Glucometer Disinfection and the manufacturer's manual specified use of a registered healthcare disinfectant, not an alcohol wipe. She provided a document titled Glucometer Cleaning and Disinfection Competency (undated) which instructed nurses to clean and disinfect the meter with either a bleach wipe or an alcohol wipe, both of which were approved. The ADON acknowledged although nurses were provided with registered healthcare disinfectant wipes for the task, the competency document did not reflect the facility's policy. She was unable to provide any competencies for the nurse who did not disinfect the glucose meter. On 4/10/24 at 12:34 PM, the Corporate Director of Education acknowledged the nursing competency for glucose meter disinfection indicated use of alcohol was appropriate. She explained when she was made aware of the issue, the ADON was provided with a new competency document that did not include the use of alcohol. The Corporate Director of Education stated the company planned to move towards standardized competencies with a requirement for all nurses to perform return demonstrations. She acknowledged all nurses, even experienced ones, needed a thorough orientation to the facility's policies and procedures as protocols differed by setting. On 4/12/24 at 10:07 AM, the DON provided a Competency Based Orientation packet that included checklists with performance objectives related to topics including infection control practices and policies, universal precautions, provision of nursing care, nursing documentation, understanding equipment use and disinfection, resident advocacy, and safe medication administration. The DON confirmed there was no evidence the packet or preceptor checklists were being utilized to verify competencies of newly hired and current staff nurses. He explained the ADON was also the Staff Development Coordinator and the Restorative Nurse, and the combination of those roles in a single job description presented challenges for adequate monitoring of nursing education. Review of the Facility Assessment, approved on 2/29/24, revealed a purpose to determine the resources needed to competently care for the facility's residents. The document indicated the resources included, All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. The Facility Assessment revealed the facility's training program involved an orientation process and ongoing training, and staff would be trained on policies and procedures consistent with their roles. The document indicated nurses would be trained on topics to include compliance and ethics, effective communication, resident rights, and infection control.

Based on interview and record review, the facility failed to ensure care plan meetings were attended by residents and/or their representatives, and the required members of the interdisciplinary team (IDT) for 2 of 4 residents reviewed for care planning, of a total sample of 43 residents, (#8 and #24). Findings: 1. Review of the medical record revealed resident #8, a [AGE] year old male, was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, hypertension, depression, anxiety, generalized muscle weakness, and mild protein-calorie malnutrition. The resident's face sheet listed his mother as his emergency contact, and included her address, telephone number, and email contact information. The Minimum Data Set (MDS) Annual assessment with assessment reference date (ARD) of 12/22/23 revealed resident #8 was interviewed regarding his preferences. The document indicated the resident felt it was very important to have family involved in discussions about his care. Review of the MDS Quarterly assessment with ARD of 3/18/24 revealed resident #8 had adequate hearing and vision, clear speech, clear comprehension, and was able to express his ideas and wants. The resident had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. On 4/08/24 at 11:37 AM, resident #8 stated he had never been invited to a care plan meeting or participated in any IDT meetings in his room. Resident #8's mother was at his bedside and she explained since her son's admission to the facility in December 2022, she attended the first and only care plan meeting in January 2024. The resident's mother stated the facility did not send invitation letters ahead of time and staff were aware email was not her preferred method of communication. She confirmed it was very important to her and her son to be involved in discussions regarding all aspects of his care. Resident #8 validated attendance at care plan meetings would be beneficial as the care team could address his concerns. Review of Care Plan Meeting Minute forms revealed from December 2022 to April 2024, the facility scheduled five care plan meetings for resident #8. Attendance sheets showed four of the five meetings, the Admission meeting on 1/03/23 and Quarterly meetings on 4/20/23, 7/06/23, and 10/31/23, were not attended by the resident or his mother. The forms showed none of the five meetings were attended by a Certified Nursing Assistant (CNA), and there was no representative from the Dietary department at the meeting on 4/20/23. The attendance sheet for the meeting on 7/06/23 was signed by an MDS nurse only and indicated the meeting was rescheduled. However, there was no documentation in the medical record to show the meeting was ever held. On 4/10/24 at 4:40 PM, MDS Coordinator F explained it was essential for residents and/or their representatives to be invited to and participate in care plan meetings. He acknowledged the care plan meeting minutes indicated resident #8's mother only attended the recent annual care plan meeting on 1/11/24. He confirmed the facility should make efforts to accommodate preferences for location and time of care plan meetings to ensure all necessary participants were involved. MDS Coordinator F reviewed resident #8's medical record and confirmed there was no evidence the resident ever received an invitation or attended a care plan meeting. He verified there were no IDT progress notes regarding any care plan meeting discussions for this resident. 2. Review of the medical record revealed resident #24, an [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diffuse large cell lymphoma, generalized muscle weakness, stroke with left side weakness and paralysis, spondylosis (degenerative changes in the spine), arthropathy (joint disease), and right hip fracture. The resident's face sheet listed her son and granddaughter as emergency contacts and included their contact information. The MDS Admission assessment with ARD of 11/17/23 revealed resident #24 was interviewed regarding her preferences. The document indicated the resident felt it was very important to have family or a close friend involved in discussions about her care. The MDS Discharge-Return Anticipated assessment with ARD of 3/25/24 revealed the resident's short-term memory was intact and she had independent cognitive skills for daily decision making. On 4/08/24 at 11:16 AM, resident #24 stated she did not recall receiving either written or verbal invitations to care plan meetings. Review of the medical record revealed no documentation of an Admission care plan meeting in November 2023. A Care Plan Meeting Minutes form dated 2/22/24 indicated a quarterly meeting was attended by resident #24, and only two members of the IDT, MDS Coordinator E and the Social Services Assistant. On 4/10/24 at 4:30 PM, MDS Coordinator F confirmed care plan meetings should be held on admission and then quarterly. He validated resident #24's medical record did not include care plan meeting invitations for the resident and her representatives or documentation of a care plan meeting on admission. MDS Coordinator E explained the purpose of the care plan meeting was to identify and discuss the resident's needs to ensure the provision of appropriate care and services. She verified the meetings should be attended by MDS staff, Unit Managers, and representatives of the Therapy, Dietary, and Activities department. MDS Coordinator E explained the facility was running behind with care plan meetings, and some meetings either did not take place or were not attended by the required members of the IDT. On 4/12/24 at 10:43 AM, the Director of Nursing stated his expectation was residents and/or their representatives and all required members of the IDT would participate in care plan meetings. He verified MDS staff were to document a summary of the discussions in the medical record after the meeting to ensure all team members were aware of concerns, requests, and changes in the plan of care. Review of the facility's policy and procedure for Comprehensive Care Plans, revised on 7/27/22, revealed the care planning process would incorporate the resident's preferences in developing the goals of care. The document indicated the care plan would be prepared by an IDT that included at least a Registered Nurse and Certified Nursing Assistant who were familiar with the resident's needs, a member of Food and Nutrition Services, and the resident and/or the representative. The policy revealed additional staff would attend as determined by the resident's needs. The document indicated the care plan would be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to provide timely and appropriate treatment and services to maintain and/or improve the ability to perform activities of daily livings (ADLs) related to eating for 1 of 1 resident reviewed for decline in ADLs, of a total sample of 43 residents, (#8). Findings: Review of the medical record revealed resident #8, a [AGE] year old male, was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, generalized muscle weakness, lack of coordination, unspecified muscle contracture, and mild protein-calorie malnutrition. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 3/18/24 revealed resident #8 had adequate hearing and vision, clear speech, clear comprehension, and was able to express his ideas and wants. The resident had a Brief Interview for Mental Status score of 15, which indicated he was cognitively intact. The MDS assessment revealed resident #8 had functional limitation in range of motion with impairment of all extremities and he required partial to moderate assistance for eating. The document indicated resident #8 last received Occupational Therapy services from 1/02/23 to 2/22/23, and he did not receive Restorative Nursing Program Services during the 7-day look back period. Resident #8 had a care plan for decreased ability to perform ADLs including eating, initiated on 1/04/23. The goal was the resident would maintain the highest possible level of ADL ability as evidenced by his ability to perform ADLs. The interventions included, monitor the resident for decline in ADL function and refer to therapy if a decline in ADLs was noted, provide therapy services as ordered by the physician, and monitor for complications of immobility and contractures. A care plan for nutritional problems, initiated on 1/10/23, revealed resident #8 had inconsistent meal intake and required finger foods. The goal was resident #8 would maintain adequate nutritional status. The interventions included provide and serve diet as ordered, monitor and record meal intake, and the Registered Dietitian was to evaluate the resident and make recommendations as needed. On 4/08/24 at 11:37 AM, resident #8's mother stated she attended a care plan meeting approximately three months ago, during which she discussed concerns regarding her son's ability to feed himself. She explained he was supposed to receive finger foods due to limited mobility in his hands, but the kitchen often gave him oatmeal, rice or corn even though he could not use utensils. The resident's mother recalled, They said they would find a curved spoon for him so he could feed himself. We asked for therapy and they said he is on the list. She verified the facility had not yet started therapy to work on his eating skills and he had not been provided with a specialty utensil. Review of resident #8's Annual Care Plan Meeting Minutes form dated 1/11/24 revealed attendees included his mother and father, representatives from the Nursing and Social Services departments, Advanced Practice Registered Nurse (APRN) G, and the Certified Dietary Manager (CDM). The meeting was not attended by any staff from the therapy department and there was no documentation of discussions regarding therapy services or adaptive utensils. On 4/10/24 at 5:53 PM, the CDM recalled resident #8's last care plan meeting and discussions with the resident's parents. The CDM confirmed he suggested an adaptive spoon for resident #8 as a possible approach to improve his food options and intake. He stated to his knowledge, he could not make a therapy referral but he expected the Nursing department to follow up. The CDM said, I never heard anything about it after that. On 4/11/24 at 9:41 AM, Licensed Practical Nurse (LPN) C stated she was regularly assigned to care for resident #8. She confirmed the resident had limited mobility in his hands, but he could grasp and hold some items. LPN C said, It might be beneficial for him to have a device to feed himself. On 4/11/24 at 9:46 AM, resident #8 expressed interest in an adaptive spoon as he felt he would be able to eat a wider selection of foods if he were able to feed himself. On 4/11/24 at 10:02 AM, the Director of Rehabilitation explained all residents in the facility were screened by therapy staff at least quarterly, to identify if they would benefit from therapy services. She stated the quarterly screening was a brief, general screening, but staff could complete a screening request form if a specific area of concern was identified. The Director of Rehabilitation confirmed she did not receive a screening request form after resident #8's care plan meeting in January. She verified referrals were important as they provided the opportunity for therapy staff to evaluate, identify, and treat ADL concerns. The Director of Rehabilitation stated resident #8's quarterly screenings done on 6/24/23, 9/16/23, 12/22/23, and 3/19/24 did not result in recommendations for therapy services. She provided a Patient Observation(s) for Therapy Form dated 4/09/24, completed by the Director of Nursing (DON), that indicated resident #8, Needs help eating. On 4/11/24 at 1:01 PM, APRN G recalled the care plan meeting discussion regarding adaptive devices for self-feeding. She stated although resident #8 was expected to decline due to his disease process, he could maintain or possibly increase strength in his upper extremities and participate in his ADLs with therapy interventions. On 4/12/24 at 10:43 AM, the DON verified someone from the Nursing department should have referred resident #8 for therapy services after the care plan meeting in January 2024. He explained once he was made aware, he investigated, and completed the referral form himself. The DON said, I feel that the facility should have helped him to continue feeding himself. The facility's policy and procedure for Activities of Daily Living (ADLs), revised 11/29/22, revealed the facility would ensure a resident's abilities in ADLs did not deteriorate unless unavoidable. Review of the facility's policy and procedure for Adaptive Feeding Equipment, revised in January 2024, revealed residents who required assistance in feeding were potential candidates for adaptive utensil use, as determined by the Occupational Therapist. The document indicated residents who needed assistance should be referred to therapy services and if treatment was deemed necessary, a plan would be developed to include use of adaptive equipment. The policy revealed the Dietary department would be notified of the resident's need for adaptive equipment and the appropriate utensil would be placed on the resident's meal trays.

Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living care (ADLs) for dependent residents related to shaving and nail care for 3 of 5 residents reviewed for ADLs, of a total sample of 43 residents, (#73, #77, and #83). Findings: 1. Review of the medical record revealed resident #83, a [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke with left side weakness and paralysis, adult failure to thrive, and generalized muscle weakness. Review of the Minimum Data Set (MDS) Significant change in status assessment with assessment reference date (ARD) of 2/09/24 revealed resident #83 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. The MDS assessment showed resident #83 exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The resident had functional limitation in range of motion with impairment to his upper and lower extremities on one side. The document revealed resident #83 was dependent on staff for personal hygiene and bathing. Resident #83 had a care plan for risk for decreased ability to perform ADLs related to chronic disease process and recent illness, initiated on 3/29/23. The interventions instructed nursing staff to assist the resident with ADLs including bathing. On 4/08/24 at 4:43 PM, inspection of resident #83's hands revealed all fingernails were dirty, with a significant amount of dark brown to black substance underneath all nails. The right hand fingernails were approximately 1/3 inch long and the left hand fingernails were longer. When asked if he wanted staff to provide nail care, resident #83 said, Of course, I want my nails to be trimmed and clean. They haven't done my nails in a while. It's been maybe two or three months. On 4/08/24 at 4:44 PM, the Assistant Director of Nursing (ADON) confirmed resident #83's fingernails were dirty and too long. She validated the length of his fingernails as 1/3 inch and longer. The resident informed the ADON he wanted his fingernails cut, but he had not reminded the Certified Nursing Assistants (CNAs) for a while. The ADON explained it was unnecessary for residents to remind staff to perform ADL care. Review of resident #83's Weekly Skin Evaluation forms revealed nurses completed full-body evaluations on 3/18/24, 3/26/24, and 4/02/24. The forms showed the nurses did not note the condition of the resident's fingernails. Review of an ADL flow sheet dated 3/14/24 to 4/11/24 revealed CNA documentation of one refusal of a bath during the 30-day look back period. 2. Review of the medical record revealed resident #77, an [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia and the need for assistance with personal care. The MDS Quarterly assessment with ARD of 3/13/24 revealed resident #77 had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS assessment showed resident #77 exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The resident required substantial to maximal assistance for personal hygiene. Review of resident #77's medical record revealed he had a care plan for ADL self-care deficit initiated on 10/11/22. The interventions indicated the resident required assistance of one staff member for personal hygiene. A care plan for hospice services due to end-stage heart failure, initiated on 3/24/23, had a goal for the resident to be comfortable through his end of life journey. The interventions included provide ADL support. On 4/08/24 at 10:09 AM, resident #77 had long, bristly, unkempt facial hair on his cheeks, chin, and neck. The resident's hair was long and messy, and the fingernails on both hands were long, jagged, and sharp, with a dark brown substance wedged under all nails. Resident #77 rubbed his face and stated he would like to be shaved, but more than anything, he wanted a haircut. On 4/08/24 at 10:58 AM, resident #77's assigned nurse, Registered Nurse (RN) J, confirmed all residents had designated shower days. When asked if she monitored her assigned residents' personal hygiene and supervised CNAs to ensure ADL care was done, RN J stated she assumed CNAs knew what to do and when to do it. On 4/08/24 at 11:01 AM, RN J assessed resident #77's hands and described his fingernails as dirty and long. She acknowledged the resident needed to be shaved. RN J stated she did not notice the ADL concerns when she administered his medication earlier that shift. On 4/08/24 at 11:03 AM, CNA I confirmed she was assigned to care for resident #77 during the 7:00 AM to 3:00 PM shift. She was informed the resident had dirty fingernails, unshaved facial hair, and an overall unkempt appearance. She stated she attempted personal hygiene care within the last hour, but the resident refused. On 4/08/24 at 4:21 PM, resident #77 remained unshaved and his fingernails were still long, jagged, and dirty. On 4/08/24 at 4:59 PM, resident #77's ADL status was unchanged. The B Wing Unit Manager (UM) assessed the resident and validated the findings related to nail care and shaving. She stated he was scheduled to have a bath today on the day shift and the assigned CNA should have provided full personal hygiene care. Resident #77 confirmed he still wanted to be shaved, get a haircut, and have his fingernails cut. Review of resident #77's Weekly Skin Evaluation forms revealed nurses completed full-body evaluations on 3/18/24, 3/26/24, 3/29/24, and 4/05/24. The forms did not show documentation regarding the condition of the resident's fingernails. Review of an ADL flow sheet dated 3/16/24 to 4/09/24 revealed no CNA documentation of refusal of a bath during the 30-day look back period. 3. Review of the medical record revealed resident #73, a [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (brain bleed), seizures, and carpal tunnel syndrome. Review of the MDS Quarterly assessment with ARD of 12/26/23 revealed resident #73 had clear speech, clear comprehension, and was able to express his ideas and wants. The resident's BIMS score was 14, which indicated he was cognitively intact. He exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment showed resident #73 was dependent on staff for personal hygiene and bathing. Resident #73 had a care plan for ADL self-care performance deficit related to weakness and decreased mobility, initiated on 4/21/22. The interventions included total dependence on one staff member for bathing, extensive assistance of one staff member for personal hygiene, and perform skin inspection. On 4/08/24 at 10:37 AM, resident #73 had an excessive amount of facial hair. His long whiskers covered both cheeks, his chin and extended down his neck towards the collarbones. The resident stated he asked a few times, but had not been shaved since he transferred to the B Wing from the other unit approximately three months ago. He recalled a CNA on the other unit used to shave him regularly with an electric razor. Resident #73 confirmed he would prefer to get rid of the untidy hair on his cheeks and neck, and keep a moustache with a neatly trimmed goatee. On 4/08/24 at 4:55 PM, the B Wing UM discussed the concerns identified regarding inadequate personal hygiene care for residents #73, #77, and #83. The UM stated she monitored the ADL status of residents on the B Wing by randomly spot-checking to ensure CNAs performed ADL care as required. She explained simply documenting refusal of care was not enough, and she expected nurses and CNAs to offer encouragement and intervene to promote acceptance of necessary care. The UM verified baths and nail care were to be provided at a minimum of twice weekly. She stated nurses and CNAs on all shifts were responsible for inspecting residents' overall ADL and hygiene status and provide care as necessary. On 4/12/24 at 10:48 AM, the Director of Nursing (DON) stated nurses were ultimately responsible for observing their assigned residents' ADL status and ensuring appropriate personal hygiene care was provided. He explained opportunities to identify concerns related to nail care included when CNAs performed or assisted with hand hygiene before meals and when nurses conducted weekly skin evaluations. He verified assistance with bathing, nail care, and shaving should be provided on scheduled days and as needed. He explained all refusals of care should be reported to the nurse and recorded by the CNA as three or more instances would trigger an alert for the UM. Review of the job description for Certified Nursing Assistant, dated April 2020, revealed the CNA would perform direct care duties under the supervision of licensed nurses. Essential duties included the provision of personal care such as bathing and grooming, daily and as needed. The facility's policy and procedure for Activities of Daily Living, revised on 11/29/22, revealed staff would provide ADL care and services including bathing and grooming. The document read, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure care and services for intravenous (IV) catheters according to standards of practice for 2 of 2 residents reviewed for IV catheter care, of a total sample of 43 residents, (#90, & #108). Findings: 1. Resident #90 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes, diabetic neuropathy, chronic obstructive pulmonary disease, displaced left femur, Methicillin Resistant Staphylococcus Aureus (MRSA), chronic kidney disease, and hypertension. On 4/08/24 at 1:52 PM, resident #90 was in bed in his room. He had a peripherally inserted central line catheter (PICC) to his left upper arm with a semi-permeable dressing dated 3/31/24. He said he was getting intravenous medication for a, MRSA infection. A peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in your arm .(retrieved on 4/23/24 from www.mayoclinic.org). Review of resident #90's medical record revealed a Physician order dated 4/05/24 to observe catheter site every shift before and after medication administration and dressing changes for redness, swelling, warmth and or loosening or soiled dressing. There was another order dated 4/05/24 that incorrectly identified the type of IV resident #90 had as a Midline instead of a PICC. The order read for nurses to change the Midline dressing every week on Wednesday with transparent dressing. On 4/08/24 at 1:49 PM, when asked why resident #90's dressing had not been changed for 8 days, since 3/31/24, the Assistant Director of Nursing stated PICC dressings were changed on Wednesdays. She explained because the resident had been readmitted to the facility on a Friday, the PICC dressing was not due to be changed until the next Wednesday, 4/10/24 . The Infusion Nurses Society specified IV site care frequency was based on type of dressing: Transparent semipermeable dressings should be changed every 5-7 days and gauze dressings should be changed every 2 days, (retrieved on 4/23/24 from www.sciencedirect.com). 2. Resident #108, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included systemic Lupus (autoimmune disease), convulsion, disease of spinal cord and encounter for surgical aftercare following surgery on the nervous system. On 4/08/24 at 1:16 PM, resident #108 sat in a wheelchair in her room. She had a Midline IV catheter on her right upper arm. The dressing site had a semipermeable dressing dated 3/22/24. She stated nurses used the Midline for blood draws in the hospital, but the IV tubing was getting bothersome and she planned to ask the nurse to remove it. On 4/08/24 at 1:22 PM, assigned Licensed Practical Nurse (LPN) C observed resident #108's Midline dressing on her right upper arm dated 3/22/24. LPN C, confirmed resident #108's Midline dressing had not been changed in 17 days but should have been changed every 7 days, per nursing standards of practice. A few minutes later, LPN C stated there were no orders to perform flushes or dressing changes for resident #108's Midline. Review of resident #108's Physician orders revealed no orders for dressing changes or flushes for the resident's Midline IV since she was readmitted to the facility on [DATE] . A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm. The end of a midline, inside your body, does not go past the top of your armpit. The midline catheter can stay in place up to 30 days, (retrieved on 4/26/24 from www.drugs.com) On 4/08/24 at 1:27 PM, the B-wing Unit Manager (UM) confirmed the Midline dressing dated 3/22/24. The B-wing UM explained resident #108 was readmitted to the facility from an acute care hospital on 3/28/24 with a Midline IV dressing dated 3/22/24. She stated the protocol was for the nurse to review the admitting orders with the Physician, make the Physician aware of the IV, and obtain orders for the IV such as dressing changes, IV flushes, or discontinuance if not in use. On 4/09/24 at 1:48 PM, the Director of Nursing (DON) stated nurses should contact the physician for orders because the facility had no standing orders to address PICC'S or Midline IVs. The DON confirmed both resident #90's PICC dressing and resident #108's Midline dressing should have been changed at least every seven days per facility policy and nursing standards. Review of the undated, PICC/Midline/CVAD Dressing Change policy revealed PICC's, and Midline dressings should be changed weekly or more frequently if soiled to decrease the potential for infection as ordered by the Physician.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services related to timely acquisition and proper administration of physician-ordered medication to meet the needs of 3 of 6 residents reviewed for Medication Administration, of a total sample of 43 residents, (#73, #77, and #98). Findings: 1. Review of the medical record revealed resident #77, an [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypotension (low blood pressure), heart failure, atherosclerotic heart disease, and chest pain. Review of the Order Summary Report revealed resident #77 had a physician order dated 12/19/23 for Midodrine HCl 10 milligrams (mg), give one tablet by mouth every eight hours for hypotension. The order included a parameter to hold the medication for a systolic blood pressure (SBP) of greater than 120 millimeters of mercury (mm/Hg). Midodrine is a cardiovascular drug that works by constricting blood vessels and increasing blood pressure. It is prescribed to treat low blood pressure which causes severe dizziness or light-headedness that affects daily life (retrieved on 4/24/24 from www.drugs.com/mtm/midodrine.html). The American Heart Association indicates blood pressure is recorded as two numbers, and the first or upper number, the systolic blood pressure, measures how much pressure blood exerts against artery walls when the heart contracts (retrieved on 4/24/24 from www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings). Review of resident #77's Medication Administration Records (MARs) from January 2024 to April 2024 revealed Midodrine 10 mg was not held according to the physician's parameter for SBPs greater than 120 mm/Hg as follows: In January 2024, nurses administered 23 of 93 doses for SBPs from 121 to 133 mm/Hg. In February 2024, nurses administered 11 of 87 doses for SBPs from 122 to 148 mm/Hg. In March 2024, nurses administered 10 of 93 doses for SBPs from 121 to 129 mm/Hg. In April 2024, nurse administered 2 of 29 doses for SBPs from 122 to 126 mm/Hg. On 4/10/24 at 5:29 PM, the Assistant Director of Nursing (ADON) confirmed nursing documentation on resident #77's MARs indicated nurses administered his Midodrine 10 mg in error, on several occasions when it should have been held for blood pressure levels above the limit set by the physician. The ADON acknowledged it was a risk to administer this medication if the resident's SBP was above 120 mm/Hg as it might cause a significant, unintended increase in blood pressure. She stated her expectation was nurses would read physician orders thoroughly and administer medications as ordered. 2. Review of the medical record revealed resident #73, a [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (brain bleed), seizures, and carpal tunnel syndrome. Review of the Medication Review Report for the period January to April 2024 revealed resident #73 had a physician order dated 3/06/24 for Artificial Tears Ointment, instill 0.25 inch in both eyes at bedtime for irritation. On 4/08/24 at 10:31 AM, resident #73 stated he had a concern related to persistent, itchy and watery eyes. He recalled a provider visited him over a month ago and determined he needed eye medication. The resident said, I never heard from them about eye drops after that. I am still having the same problem. My eyes still water. On 4/09/24 01:40 PM, resident #73's assigned nurse, Registered Nurse (RN) H, checked the electronic medical record and verified he had a physician order for eye ointment. She checked all drawers of the medication and treatment carts but did not find any eye medication for the resident. The B Wing Unit Manager (UM) was informed of resident #73's concern. On 4/09/24 at 2:00 PM, the B Wing UM stated she contacted the pharmacy and discovered the order for resident #73's eye ointment was never filled by the pharmacy as it was a stock medication, not a prescription medication. On 4/09/24 at 5:48 PM, the B Wing UM stated the Central Supply Coordinator informed her the facility did not stock Artificial Tears Ointment. She explained she went through the central supply stock and logs and there was no evidence the eye ointment was ever acquired for resident #73. The UM stated any of the nurses scheduled to give the eye ointment should have called the pharmacy and notified the physician when they discovered the medication was not available. She stated she interviewed two of the nurses who documented administration of the eye ointment and they informed her they used facility stock lubricant eye drops since the prescribed ointment was not available. The UM validated it was not acceptable for nurses to administer a substitute medication without a physician order or borrow from another resident's supply. 3. Review of the medical record revealed resident #98, a [AGE] year old male, was admitted to the facility on [DATE] with diagnoses including stroke with right side paralysis, generalized muscle weakness, and contact dermatitis (skin inflammation and rash). Review of resident #98's Order Summary Report revealed physician orders dated 4/02/24 for a dermatology consult for a rash on his back, and Clindamycin Phosphate 1% gel, apply to affected areas on the trunk three times daily for 30 days for acne. On 4/09/24 at 8:56 AM, from the hallway outside resident #98's room, he was overheard as he loudly complained he had not received a necessary ointment for a skin condition. When the Activities Assistant exited the room, she confirmed resident #98 told her nurses had not administered his ointment for several days. On 4/09/24 at 9:04 AM, resident #98 stated he had an extensive rash on his back, shoulders, and chest. He lifted his shirt and showed numerous raised red areas and pustules scattered on his torso. The resident said, I am to be getting a cream three times daily. I last got it late Thursday. They said they would order it and then they said you can't get it on the weekend. Resident #98 expressed frustration regarding the missed doses as the rash bothered him and he wanted the treatment to be done as ordered by the physician On 4/09/24 at 9:25 AM, RN H checked all drawers of the medication and treatment carts and confirmed there was no container of Clindamycin Phosphate 1% gel for resident #98. Review of resident #98's MAR for April 2024 revealed he received three doses of Clindamycin Phosphate 1% gel daily as ordered from Wednesday 4/03/24 at 9:00 AM to Friday 4/05/24 at 5:00 PM. The document showed the medication was not available or not given from Saturday 4/06/24 at 9:00 AM to Wednesday 4/10/24 at 9:00 AM, except for Sunday 4/07/24 at 9:00 AM and 1:00 PM. Review of the pharmacy Delivery Tracking form revealed the initial tube of resident #98's Clindamycin Phosphate 1% gel was placed in tote for delivery to the facility on [DATE] at 1:40 AM. The document indicated a second tube was ordered on 4/09/24 at 9:59 AM and placed in the tote a few hours later at 1:47 PM. On 4/09/24 at 5:59 PM, the B Wing UM stated she applied resident #98's ointment on Thursday 4/04/24. She recalled the tube was very small and she could not verify whether or not he received the ointment as prescribed over the weekend. The UM stated she was not aware the medication was not available until RN H was informed of the resident's complaints this morning. The UM explained she called the pharmacy to request a larger size tube and the medication would be delivered later today. On 4/11/24 at 2:39 PM, the B Wing UM stated she could not explain how the nurse documented administration of the Clindamycin Phosphate 1% gel if it was not re-ordered and delivered on the weekend. She said, I am telling you what I was told. On 4/11/24 at 2:47 PM, RN K confirmed she did not apply the scheduled 9:00 AM dose of resident #98's Clindamycin Phosphate 1% gel yesterday morning as she could not locate the box. She verified the resident received his first dose from the new tube at 1:00 PM yesterday, 4/10/24. RN K explained the tube was very small and would last only two to three days. On 4/11/24 at 2:52 PM, the Evening Shift Nursing Supervisor stated on Saturday 4/06/24, he saw resident #98's tube of Clindamycin Phosphate 1% gel. He stated the small tube was almost empty and there was not enough medication to cover the resident's rash. He stated to his knowledge the medication was not available over the weekend. He stated he would not speculate as to why the day shift nurse on Sunday 4/07/24 documented administration of medication that was unavailable. The Evening Shift Nursing Supervisor stated nurses were expected to re-order medication before it was finished and call the pharmacy if clarification was necessary. The facility's policy and procedure for Pharmacy Services, revised 4/17/23, revealed the facility would provide pharmaceutical services that reflected current standards of practice and met the needs of each resident. The document indicated the facility would adhere to procedures that ensured accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs.

Based on interview and record review, the facility failed to ensure the medical record accurately reflected administration of a prescribed eye ointment over a 34-day period for 1 of 6 residents reviewed for medication administration, of a total sample of 43 residents, (#73). Findings: Review of the medical record revealed resident #73, a [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (brain bleed), seizures, and carpal tunnel syndrome. Review of the Medication Review Report for the period January to April 2024 revealed resident #73 had a physician order dated 3/06/24 for Artificial Tears Ointment, instill 0.25 inch in both eyes at bedtime for irritation. On 4/08/24 at 10:31 AM, resident #73 stated he had a concern related to persistent, itchy and watery eyes. He recalled a provider visited him over a month ago and determined he needed eye medication. The resident explained he had never received any medication for his eyes even though he mentioned it to a few nurses. Review of resident #73's Medication Administration Record (MAR) for March and April 2024 revealed the document was initialed by 13 nurses over 34 days to indicate they administered the Artificial Tears Ointment to both eyes at bedtime as ordered. On 4/09/24 at 2:00 PM and 5:48 PM, the B Wing UM stated after she was informed of the conflict between resident #73's statement and documentation in his medical record, she contacted the pharmacy. The UM explained she discovered the order for the resident's eye ointment was never filled by the pharmacy, and there was no evidence Central Supply ever ordered it. She validated resident #73 did not receive the eye ointment although multiple nurses documented it was given. The UM stated it was wrong for nurses to sign off on medication that was not administered. On 4/12/24 at 10:29 AM, the Director of Nursing (DON) acknowledged it was significant that all nurses assigned to resident #73 for over 30 days signed the MAR to verify a medication administration task that did not actually occur. He explained it was essential for the medical record to accurately show the care and services provided for residents. The DON added that physicians relied on the accuracy of the medical record to determine the effectiveness or outcome of prescribed medications and treatments. The facility's policy and procedure for Documentation in Medical Record, revised on 11/28/23, read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident. The document indicated false information should not be documented.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves during wound care to prevent cross-contamination for 1 of 1 resident reviewed for pressure ulcers, (#90), of a total sample of 43 residents; failed to disinfect a glucometer according to manufacturer's instructions and facility policy and procedures, failed to appropriately dispose of a used sharp, and failed to ensure appropriate infection control practices prior to medication administration. Findings: 1. Resident # 90 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes, diabetic neuropathy, chronic obstructive pulmonary disease, displaced left femur, Methicillin resistant Staphylococcus aureus, chronic kidney disease, and hypertension. On 4/08/24 at 1:34 PM, resident #90's left foot was observed with a gauze dressing. The resident stated he had an infected wound on the bottom of his foot. Review of the Treatment Administration Record revealed physician orders for wound care dated 4/05/24 included daily treatment of the resident's left foot. The order directed nurses to cleanse with saline solution, apply medical honey and gauze, and cover with kerlix(roll gauze). On 4/10/24 at 11:16 AM, the Wound nurse prepared to perform wound care for resident #90's left foot wound. She explained the resident had a wound infection and staff were required to wear personal protective equipment (PPE) when providing care. The wound nurse prepared a barrier sheet with square gauze, roll gauze, and a bottle of saline. The Wound nurse performed hand hygiene, removed a gown and gloves from the caddy on the door, and donned them. She placed the barrier with supplies on resident #90's overbed table. The Wound nurse repositioned resident #90's left leg on a pillow and removed the dressing which was saturated with moderate serosanguinous (blood and serous fluid) drainage from the left foot wound. Still wearing the same gloves, the Wound nurse picked up the bottle of saline, poured it onto a square gauze pad, and now cleaned the left foot wound. She opened another gauze square and patted dry the wound bed. Then she squeezed the medical honey onto a tongue depressor and smeared it onto the wound bed. The Wound nurse applied a dry 4-inch x 4-inch gauze over the medical grade honey, then wrapped the left foot wound with the roll gauze dressing and secured it with tape. After the dressing change was completed, the wound nurse doffed her PPE, performed hand hygiene, and exited resident #90's room. The wound nurse validated she did not perform hand hygiene or change gloves between dirty and clean tasks after she removed resident #90's dirty dressing and cleaned the infected wound. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following: Before moving from work on a soiled body site to a clean body site on the same patient, (retrieved on 04/23/24 from www.CDC.gov). On 4/10/24 at 11:28 AM, the Assistant Director of Nursing (ADON) expressed her concern when informed of the break in infection control during resident #90's left foot wound care when the Wound nurse did not change gloves or perform hand hygiene. A review of the facility's policy and procedure for Hand Hygiene, revised on 5/21/22, revealed hand hygiene was indicated and would be performed before and after handling clean or soiled dressings, using soap and water or alcohol-based hand rub. 36489 2. On 4/08/24 at 1:59 PM, Registered Nurse (RN) J retrieved a glucose meter or glucometer, a lancet or needle, an alcohol wipe package, and a testing strip from her medication cart. She explained she had to check a resident's blood glucose level. On 4/08/24 at 2:01 PM, RN J donned a pair of gloves, placed the testing strip in the glucometer, pricked the resident's finger with the lancet, and held the finger to guide blood drops onto the strip. Once she obtained the blood glucose reading, RN J held the lancet, strip, and alcohol pad in her palm and removed her glove by rolling it inside out to collect the items inside the glove. On 4/08/24 at 2:02 PM, RN J returned to her medication cart and dropped the rolled gloves into the open trash container on the right side of the cart and placed the glucometer on top of the cart. When asked if there was a designated container for sharps such as needles and lancets, RN J pointed to the hard plastic box located above the open trash container on the medication cart. She verified, I just rolled the needle up in my gloves and dropped it in the trash. RN J did not perform hand hygiene after removing her gloves. On 4/08/24 at 2:04 PM, RN J picked up the glucometer without gloves, unlocked the medication cart, and dropped the device into the top drawer without cleaning or disinfecting it. She confirmed the glucometer was the only one in the medication cart and she used it for all residents on her assignment who required blood glucose monitoring. When asked about the required frequency for cleaning and disinfecting the device, RN J said I cleaned the glucometer at the start of the shift. I will clean at the end of shift. She stated she already used the glucometer approximately four times during the shift. RN J did not perform hand hygiene after touching the glucometer. On 4/08/24 at 2:10 PM, RN J extracted a small medication cup from underneath a towel on the left side of the medication cart. Without performing hand hygiene, RN J unlocked the medication cart and retrieved two blister packs of pills from a drawer. She punched pills from the packs into the medication cup and took the cup to a resident's room. On 4/08/24 at 2:14 PM, RN J returned to the medication cart. She confirmed she did not perform hand hygiene after removing the gloves she used for the fingerstick procedure, after handling the glucometer, or prior to preparing pills for administration. RN J explained she did not have a container of hand sanitizer on or near the medication cart, but she acknowledged there was hand sanitizer available in wall dispensers nearby. On 4/08/24 at 2:20 PM, the ADON was informed of concerns related to RN J's infection control practices. She confirmed lancets should always be placed in designated sharps containers to prevent needlestick injuries to nursing and housekeeping staff. The ADON explained the facility's policy and manufacturer's instructions indicated nurses were to disinfect the glucometer after use on each resident. She stated her expectation was nurses would perform hand hygiene by using hand sanitizer or washing hands with soap and water after removing gloves and definitely before doing medication pass. Review of the facility's policy and procedure for Glucometer Disinfection (undated) revealed a purpose to provide guidelines for the disinfection of glucose monitoring devices to prevent transmission of blood borne diseases to residents and employees. The document indicated devices would be cleaned and disinfected after each use according to manufacturer's instructions for multi-resident use. The policy revealed glucometers were to be disinfected with a registered healthcare disinfectant that was effective against viruses including human immunodeficiency virus (HIV), Hepatitis C, and Hepatitis B. The procedure instructed nurses to don gloves, obtain the blood sample, remove and discard the gloves, and perform hand hygiene before exiting the room. Next, nurses would retrieve two disinfectant wipes, one to clean, and the second to disinfect the device. The nurse would then discard the disinfectant wipes in the trash and perform hand hygiene. The policy indicated the glucometer should be allowed to air dry. Review of the glucometer manufacturer's Instruction Manual revealed a recommendation to clean and disinfect the device with a disinfectant detergent or germicidal wipe between use on patients. The document read, Contact with blood presents a potential infection risk and instructed healthcare professionals to wash hands after removing gloves. The instructions on the container of Germicidal Disposable Wipes provided by the facility revealed the wet time to ensure proper disinfection of devices was two minutes. The facility's policy and procedure for Hand Hygiene, revised on 5/21/22, read, Staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The document indicated the use of gloves did not replace hand hygiene and staff should wash hands or use hand sanitizer before donning gloves, immediately after removing gloves, and after handling items potentially contaminated with blood. Review of the facility's policy and procedure for Medication Administration, revised in October 2023, revealed medication would be administered .in accordance with professional standards of practice, in a manner to prevent contamination or infection. The document included the instruction for nurses to wash hands prior to medication administration.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect by not assessing and providing immediate and necessary respiratory care and services for an oxygen dependent resident with a tracheostomy to prevent repeated dislodgement and subsequent death for 1 of 1 resident reviewed for tracheostomy status of a total sample of 7 residents, (#1). A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and at risk for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to assess and provide immediate care for an oxygen dependent resident with a tracheostomy after a fall contributed to resident #1's demise, and placed all residents dependent on oxygen or had tracheostomy at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F684, F695, F726. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and feeding tube. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert and disoriented but could follow simple instructions. The form noted the resident's trach tube size was 4 and that he received oxygen via a trach collar. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, tracheostomy care every day shift. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complication, and notify the physician of abnormal findings. The BIMS (Brief Interview For Mental Status) Evaluation with effective date of [DATE] at 1:10 PM, revealed a score of 5, that indicated the resident had severe cognitive impact. A progress note documented by RN A dated [DATE] at 11:59 PM, revealed the resident took off trach x 2 and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by Registered Nurse (RN) A on [DATE] at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM . Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM, revealed the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. Review of the resident's clinical record revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions including increased observations were implemented after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Review of the resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM and found resident #1's body still on the floor. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM, and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder and kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of Epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her statement to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the Director of Nursing (DON), and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and did not need a dose of the newly ordered Lorazepam. He validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received appropriate care after he fell from his bed; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. An essential duty and responsibility listed on the Job description for Registered Nurse with date of [DATE] read, Document in EHR (Electronic Health Record) in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. The policy Medical Emergency Response implemented on ,d+[DATE], and reviewed/revised on [DATE] read, the employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance . A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. The facility's policy Abuse, Neglect and Exploitation with implementation date of ,d+[DATE] and reviewed/revised date of [DATE] described neglect as a 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. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. *On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. *On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, 6 CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other tracheostomy dependent resident. The resident sample was expanded to include additional residents who were at risk for falls, and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition.

Based on interview, and record review, the facility failed to provide emergency care and services for an oxygen dependent resident with a tracheostomy to prevent the dislodgement of life saving device after a fall for 1 of 7 sampled residents, (#1). A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to properly assess and respond to a medical emergency for an oxygen-dependent resident with a tracheostomy contributed to resident #1's death, and placed all residents who had a tracheostomy or depended on continuous oxygen therapy at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600, F695, F726 Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. His diagnoses included, acute/chronic respiratory failure, non-traumatic ischemic infarction of muscle, tracheostomy dependent and feeding tube. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert, but disoriented, and could follow simple instructions. His Trach size was 4 and he received oxygen via a trach collar. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, and tracheostomy care every day shift. The BIMS (Brief Interview For Mental Status) Evaluation dated [DATE] at 1:10 PM revealed a score of 5 out of 15 that indicated the resident had severe cognitive impact. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. The Fall Risk Evaluation dated [DATE] revealed resident #1 was considered at risk for falls with a score of 13. A total score of 10 or greater would be considered High risk for potential falls. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complication, and notify the physician of abnormal findings. Nursing progress notes documented the resident's oxygen mask was on the floor and the resident's trach was out on [DATE] at 1:57 AM. The nurse, RN D attempted to reinsert the trach but was unable to and the resident was transferred to the hospital for trach replacement. The resident returned to the facility at 4:15 AM and at 7:00 AM, his trach was pulled out again. The resident was transferred to the hospital a second time for trach replacement and returned on [DATE] at 1:36 PM. The note read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. A progress note documented by RN A on ,d+[DATE]/ 23 at 7:35 PM read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PMand ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM revealed that the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. The resident's clincial record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM and found resident #1's body still on the floor, face up. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder. urine, and the kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her stated to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident was breathing, and his color was good. She explained she did not have time to check his blood pressure, and verbalized that all she checked was his pulse, and she left him lying on the floor face down. RN A stated she has worked with residents with a trach before, however she could not say if resident #1 was lying on his trach when he was found on the floor face down. RN A stated that when she called the resident's son to notify him of the resident's fall, and that she was going to send him to the hospital, the son asked why no one was watching him. She did not have an answer for him, telling him she had to prepare the documents for transfer. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the Director of Nursing (DON), and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and he validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received emergency care; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. The facility's policy Medical Emergency Response implemented on ,d+[DATE], and reviewed/revised on [DATE] read, the employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance . A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: * On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. * On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, six CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other oxygen-dependent residents with tracheostomies. The resident sample was expanded to include additional residents who were at risk for falls, utilized oxygen and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition.

Based on interview and record review, the facility failed to provide necessary respiratory care and services for an oxygen-dependent resident with a tracheostomy to prevent repeated dislodgements of the life-saving device for 1 of 1 resident reviewed for tracheostomy status, (#1), and failed to ensure oxygen therapy was administered as ordered by the physician for 1 of 2 residents reviewed for oxygen use, (#2), of a total sample of 7 residents. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM, and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to develop and implement appropriate approaches to maintain optimal respiratory status, and failure to properly assess and respond to a medical emergency for an oxygen-dependent resident with a tracheostomy contributed to resident #1's death, and placed all residents who had a tracheostomy or depended on continuous oxygen therapy at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600, F684, and F726. 1. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and gastrostomy tube or feeding tube. He was transferred back to the hospital soon after he arrived at the facility. A Hospital Internal Medicine History and Physical note dated [DATE] explained resident #1 was just discharged from [name of the hospital] last night to SNF (Skilled Nursing Facility). Upon arrival at the SNF, they rerouted him to [name of the hospital] stating that their facility did not have the capability of taking care of patients with trach. They said that they were unaware that he had a trach when they accepted him. A hospital Internal Medicine progress note with a date of service of [DATE] at 1:57 PM, revealed while in the hospital, resident #1 required wrist restraints. The note indicated the hospital was in process of weaning use of the restraints and the resident was down to mittens only. His principal problem was noted as chronic respiratory failure, and his active problem was listed as Tracheostomy dependent. Resident #1's medical record showed the facility readmitted him eight days later, on [DATE]. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert and disoriented but could follow simple instructions. The form noted the resident's trach tube size was 4 and that he received oxygen via a trach collar. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, tracheostomy care every day shift, and Eliquis 5 milligram (mg) daily for blood clot prevention. The BIMS (Brief Interview For Mental Status) Evaluation with effective date of [DATE] at 1:10 PM, revealed a score of 5, that indicated the resident had severe cognitive impairment. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. The Tracheostomy Flow Sheet revealed assessments conducted on [DATE] at 1:10 PM, and on [DATE] at 3:20 PM, noted the resident was on oxygen at 5 liters per minute, tracheostomy care was provided, and a spare trach and a handheld manual resuscitation bag valve mask were available. The Fall Risk Evaluation dated [DATE] revealed resident #1 was considered at risk for falls with a score of 13. A total score of 10 or greater was considered High risk for potential falls. The Skilled Evaluation with effective date of [DATE] revealed the resident's initial admission was on [DATE] and showed the resident was alert with some forgetfulness, oxygen device/delivery was by trach, and nutrition was via tube feed. The Respiratory Therapy Treatment Note with Clinical Assessment date of [DATE] revealed the resident arrived at the facility with a trach and was alert and stable. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complications, and notify the physician of abnormal findings. A progress note documented by RN A dated [DATE] at 11:59 PM, revealed the resident took off his trach two times and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by RN A on ,d+[DATE]/ 23 at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM, revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM, revealed the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level was obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. Clinical record review revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions were taken after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Review of resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence that nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM, and found resident #1's body still on the floor, face up. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM, and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder and kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of Epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her statement to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 11:47 AM, the B Wing Licensed Practical Nurse (LPN) Unit Manager (UM) stated resident #1 was admitted to the B Wing on [DATE] between 1:00 PM and 2:00 PM. She recalled the Respiratory Therapist (RT) was at the facility to ensure all the required equipment and devices were set up correctly. She stated the resident's trach was in place and intact and he was calm. The UM verbalized that on Friday [DATE] at 2:31 AM, she received a notification via email that the resident was sent to the hospital via 911. She recalled when she came to work later that morning, she was made aware the resident decannulated himself and although staff attempted to reinsert the trach, resident #1 was resisting and 911 had to be called. She stated the resident returned to the facility with a new trach but a short time after his return, at about 7:00 AM, he was sent out to the hospital again for the same reason. The UM stated he returned to the facility at about 12:30 PM or 1:00 PM, with a newly inserted trach and a prescription for Lorazepam 0.5 mg via his G-tube. She stated resident #1 received the antianxiety medication in the hospital prior to returning to the facility. The UM stated that on [DATE] at 7:33 PM, she received another email indicating 911 was again called from the B Wing nurses' station for resident #1. She said she was notified the following day, on [DATE], that the resident had fallen out of bed and passed away. She was told the family was called, the Medical Examiner was involved, and the police and EMS came. On [DATE] at 12:40 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). They confirmed they were knowledgeable of the sequence of events related to resident #1's admission and two transfers to the hospital for emergency services after self-decannulation. The DON stated on [DATE] at about 7:30 PM, he was informed the resident coded or stopped breathing, when EMS personnel were in the facility. The Administrator stated the Weekend Supervisor notified him of the incident. He verbalized after interviewing the Weekend Supervisor and reviewing the resident's medical chart, it appeared the resident coded after EMS personnel entered the facility. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the DON, and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and did not need a dose of the newly ordered Lorazepam. He validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. They explained residents were re-evaluated for fall risk and the Regional Consultant Nurse conducted audits of skin assessment for newly admitted residents and reviewed wound treatment orders for the month of February 2023. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received emergency care; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:32 PM, in a telephone interview, the RN Weekend Supervisor stated that on [DATE], he was not aware resident #1 fell until he saw the EMS crew entering the building. He stated he followed them to the B Wing, where additional EMS personnel were already in the resident's room. The Weekend Supervisor recalled one of the nurses told him the resident fell from his bed, was still breathing, and 911 was called. The Weekend Supervisor stated when EMS personnel left the facility he attempted to enter resident #1's room, but a police officer told him he could not go in as it was the scene of an active investigation. The Weekend Supervisor explained the facility's usual post-fall process was for a staff member to locate him and he would assess the resident. The Weekend Supervisor stated he was informed the resident had a trach, used supplemental oxygen, and had anxiety. He acknowledged he was not sure if the resident got any anti-anxiety medication, and he was not aware that increased observation was initiated for the resident, except that the assigned nurse and CNA continued to round and check on the resident. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. On [DATE] at 3:29 PM, in a telephone interview, the Medical Director stated he was notified of the incident with resident #1 after the fact. He was aware the resident was sent to the hospital a couple times, and recalled he was told the resident had stable vital signs when he was on the floor. The Medical Director verbalized that when the resident was lying face down, his airway would not necessarily be compromised. He explained the resident could have been compromised for several reasons. The Medical Director acknowledged he had lots of questions but thought everything was done to the scope of the ability and training of staff. He stated staff had basic competencies. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM, revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. The facility's policy for Tracheostomy Care implemented in [DATE] and reviewed/revised on [DATE] read, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice.The facility will ensure staff responsible for providing tracheostomy care.are trained and competent according to professional standards of practice. The facility's policy for Medical Emergency Response implemented in [DATE], and reviewed/revised on [DATE] read, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance.A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident.If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. Review of the Facility assessment dated [DATE], indicated services and care offered was based on the residents' needs and special care needs included tracheostomy care. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: * On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. * On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, six CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other oxygen-dependent residents with tracheostomies. The resident sample was expanded to include additional residents who were at risk for falls, utilized oxygen and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition. A concern was identified related to oxygen use for resident #2 that resulted in noncompliance that was not Immediate Jeopardy. 2. Review of the medical record revealed resident #2 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including encephalopathy, acute respiratory failure, and traumatic subdural hemorrhage. The resident had a physician order dated [DATE] for oxygen therapy at 2 Liters per minute (LPM) continuously via nasal cannula. On [DATE] at 9:50 AM and 11:30 AM, resident #2 was seated in his wheelchair close to the nurses' station. He wore oxygen that infused at 3 LPM via nasal cannula that was connected to an oxygen concentrator. On [DATE] at 11:37 AM, the resident's oxygen flow rate was observed with the A Wing LPN UM. She confirmed the Oxygen flow rate was set at 3 LPM, and she confirmed it should be set at 2 LPM. The resident's physician orders were reviewed with the UM, and she validated the resident was admitted on [DATE], and his physician ordered oxygen at 2 LPM. The A Wing LPN UM stated the resident's assigned nurses should check his oxygen settings every shift to ensure oxygen therapy was administered as ordered. On [DATE] at 3:24 PM, the DON stated oxygen therapy required a physician order and she expected nurses to verify flow rates when they conduct residents' assessments, during medication administration, and when they obtained vital signs. The DON confirmed the oxygen order directed nurses to provided oxygen at 2 LPM continuously. Resident #2 had a care plan for respiratory complications related to diagnoses of chronic obstruc [TRUNCATED]

Based on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to adequately conduct assessments, and develop and implement interventions to provide routine care and emergency services for an oxygen-dependent resident with a tracheostomy for 1 of 1 resident reviewed for tracheostomy status, of a total sample of 7 residents, (#1). A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to develop and implement an appropriate plan of care to prevent decannulation, and failure to conduct a thorough assessment with proper response to a medical emergency contributed to resident #1's death and placed all residents with tracheostomies at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross Reference F600, F684, and F695. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and gastrostomy tube or feeding tube. A progress note documented by RN A dated [DATE] at 11:59 PM revealed the resident took off trach two times and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by RN A on ,d+[DATE]/ 23 at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 2:02 PM, in a telephone interview, RN B stated she saw resident #1 on the floor and alerted his assigned nurse, RN A. She recalled RN A entered the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She stated RN A left the room to call 911, and when CNA C arrived she left the CNA with the resident, who was still face down on the floor. RN B acknowledged she did not remain in the room to monitor the resident's respiratory, cardiac, or neurological status while RN A called for assistance. She confirmed she did not wait with the resident until EMS personnel arrived, instead she left to take care of her assigned residents. On [DATE] at 3:05 PM, RN D stated she was assigned to resident #1 on the 11:00 PM to 7:00 AM shift on [DATE], his first night in the facility. RN D recalled the resident pulled out his trach and she attempted to reinsert the device. She explained resident #1 was resistant to her efforts and she had to arrange for him to be transferred to the hospital for replacement of the trach. RN D stated she rarely took care of residents with tracheostomies and felt she needed more training in that area. RN D did not recall receiving education, attending in-services, or completing a post-test regarding tracheostomy care on [DATE]. On [DATE] at 4:43 PM, and on [DATE] at 2:50 PM, the DON stated verbal education on tracheostomy care was provided to nurses on [DATE] during the 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts. When informed RN D could not recall participating in any such in-service even though her name was on the attendance sheet, the DON declined to comment. When asked about staff competency, the DON verbalized the facility's last competency exercises for tracheostomy care were done in [DATE]. He stated licensed nurses had their competency assessed by return demonstration method and/or pre-tests and post-tests. The DON stated he contacted the Respiratory Therapist regarding documentation of the training and competencies done in [DATE] but none were found. He explained there was no evidence of competencies for tracheostomy care in the education folders he reviewed. The DON stated he had been on staff since [DATE], and resident #1 was the first resident admitted to the facility with a tracheostomy since [DATE]. Review of the resident's clinical record revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions were taken after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Nursing progress notes showed assigned nurses did not collaborate with the Weekend Nursing Supervisor or other members of nursing management to adjust staffing to meet resident #1's need for increased supervision. Review of resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. The job description for the Director of Nursing dated [DATE] revealed the DON was to manage the overall operations of the Nursing Department in accordance with.standards of nursing practices.to maintain excellent care of all residents' needs. The policy for Tracheostomy Care implemented in [DATE], and reviewed/revised on [DATE] read, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice.The facility will ensure staff responsible for providing tracheostomy care.are trained and competent according to professional standards of practice. Review of the Facility assessment dated [DATE], revealed the assessment was completed to determine the resources necessary to care for the residents competently during the day-to- day operations of the facility and during emergencies. The assessment addressed staff competencies necessary to provide the level and types of care needed for the resident population, and indicated the facility considered the clinical characteristics of the resident population to determine the skills and competencies required to meet the resident needs. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. *On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. *On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse, and neglect, responding to medical emergencies and the facility fall prevention program policy. Post tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with post-tests. Remaining facility and newly hired staff will be educated during orientation, and agency nurses will be educated prior to accepting nursing assignments. *On [DATE], licensed nurses were educated on the facility oxygen administration policy with post-test to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstration completed to validate nurse competency. *On [DATE], there were no residents currently residing in the facility with a tracheostomy. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Medical Emergency Response, Abuse/Neglect, and Fall Prevention Program with evidence of post-tests. On [DATE], interviews were conducted with six RNs and two LPN. They verbalized understanding of the education provided.

Based on record review and interview, the facility failed to arrange a safe and orderly discharge home with home health services and reasonable access to medication and pharmacy for 1 of 6 residents reviewed for discharge status of a total sample of 14 residents, (#2). Finding: A review of resident #2's hospital records revealed on 1/14/22, the resident was found at his home without electricity or running water. At the hospital, the resident was diagnosed with acute [CONDITION(S)] with [CONDITION(S)] and uncontrolled diabetes. During his hospitalization , resident #2 showed improvement in his status, and he was discharged to an Assisted Living Facility (ALF) on 2/09/22. Upon arrival at the ALF, the resident refused to stay and the ALF staff drove him back to the hospital. He was readmitted to the hospital, where he was subsequently diagnosed with [CONDITION(S)], an infection that required treatment with intravenous (IV) antibiotics. [CONDITION(S)] is the clinical name for blood poisoning by bacteria. It is a medical emergency that can lead to organ failure and death if not treated appropriately (retrieved on 4/13/22 from www.hopkinsmedicine.org). Resident #2 was discharged from the acute care hospital to the nursing home on 3/10/22 for skilled nursing care, therapy and continuation of IV antibiotics to treat his infection. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #2's nursing home medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician noted the IV antibiotic should have a completion or stop date of 4/04/22. Review of the facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 3/20/22 revealed resident #2's IV catheter was removed and he was discharged home that morning without completing the antibiotic regimen. On 3/28/22 at 11:50 AM, in a telephone interview, the Hospital Physician who treated resident #2 expressed his concerns regarding resident#2 not completing IV antibiotic therapy at the nursing home. He confirmed the resident was due to complete IV antibiotic therapy on 4/04/22 but the nursing home discharged him to his house prior to the completion date. The Hospital Physician explained he was very concerned about the resident's health and well-being as he had not completed the antibiotic therapy for a severe infection. He added the nursing home did not inform him of the resident's discharge nor that the antibiotic was changed to an oral medication. The Hospital Physician added the living conditions at the resident's house were very unsafe as there was no electricity or running water. He stated resident #2 had no way to get into his house and was found outside by a church member. He noted resident #2 was readmitted to the hospital after he was found by the church member and the Hospital Case Manager was currently arranging placement at another nursing facility. Review of the Minimum Data Set (MDS) 5-day Medicare assessment dated [DATE] revealed resident #2's Brief Interview for Mental Status score was 12, which indicated his cognition was moderately impaired. The MDS assessment noted the resident required extensive assistance from one person for Transfers, Dressing, Personal Hygiene and was totally dependent for Bathing. The resident's Baseline Care Plan indicated he required assistance with Activities of Daily Living (ADLs) and IV Antibiotic Therapy. The Baseline Care Plan neither included the IV Antibiotic stop date of 4/04/22 nor addressed the resident's discharge from the facility. On 3/28/22 at 4:35 PM, the Social Worker (SW) and her assistant discussed resident #2's discharge home. They stated he was insured by a Managed Medicare Plan and the resident initiated the discharge. They explained the resident did not have a Power of Attorney, Health Care Surrogate or Health Care Proxy and he was responsible for himself. They indicated the facility received a 2-day notice from the resident's insurance company on 3/17/22 at 4:30 PM that showed he was cut from the facility's skilled nursing services. The SW and her assistant provided a Notice of Medicare Non-Coverage (NOMNC) form that showed skilled nursing service would end on 3/19/22. They explained they did not want to miss the deadline for notification of discharge in 2 days so they called the resident's sister in Miami on 3/17/22. They recalled the sister approved her brother's discharge to his home on Sunday, 3/20/22. The SW and her assistant validated the resident was not deemed incapacitated, and they could not explain why they did not involve the resident in the discharge planning process. The SW stated she later informed resident #2 about the discharge, but during review of the NOMNC form revealed it was not signed by resident #2. The SW identified the original discharge plan was for resident #2's son to provide transportation home or to meet him at the house on Sunday, 3/20/22. The SW conveyed she arranged a meal delivery service and home health services, but acknowledged she never received confirmation from the Home Health Agency (HHA) to indicate the resident was accepted for services. She explained on the day after the resident's discharge home, Monday 3/21/22, she discovered the HHA was not able provide services for resident #2 due to staffing issues. The SW explained on 3/21/22, she also found out the resident was not at his house as a church member saw him outside the house, picked him up and took him to a hotel. The SW and her assistant reported they did not complete a home visit prior to discharging the resident, and they acknowledged the resident's home needed to be fixed up and described it as not an ideal situation. The SW stated the facility determined the discharge to be safe as the resident wanted to be discharged Against Medial Advice (AMA). However, the SW was not able to show any documentation in the medical record related to resident #2 requesting a discharge AMA. On 3/28/22 at 5:35 PM, the Director of Nursing (DON) recalled the Weekend Nursing Supervisor called the facility's on-call physician on Sunday 3/20/22 and received an order to remove resident #2's Peripherally Inserted Central Catheter (PICC) line used to administer his IV antibiotics, and a new order to start an oral antibiotic. She noted a prescription for the oral antibiotic was sent to a pharmacy near the resident's home prior to discharge. A map search revealed the selected pharmacy location was 9.3 miles away from resident #2's home although another branch of the same pharmacy was located 1.5 miles from his home, approximately five minutes away by car. The DON spoke about the resident's PICC line and acknowledged he would have been able to continue IV antibiotic therapy at home if HHA services were arranged. On 3/29/22 at 12:45 PM, the MDS Coordinator and her assistant stated the resident had a Managed Medicare Insurance that initially authorized a 7-day stay in the facility. They explained on the 7th day of the resident's stay they submitted information including therapy notes, skilled nursing services notes and a medication list to the insurance company for extension of his stay in the facility. The Assistant MDS Coordinator said, I screwed up on this one. She acknowledged she did not submit the Occupational Therapy (OT) notes initially, but faxed the OT notes by 2:00 PM on 3/17/22. The MDS Coordinators explained the insurance company sent a NOMNC form that indicated it would no longer pay for skilled nursing services. The Assistant MDS Coordinator provided the Skilled Nursing/Acute Rehab Monitoring Tool form that the facility sent to the insurance company. The form noted ADLs such has Bed Mobility, Transfers, and other skilled nursing care and services the resident required. However, the section on the form designated for documentation of IV antibiotics was left blank. The Assistant MDS Coordinator explained she thought the IV antibiotics were discontinued. The MDS Coordinators indicated they were aware of the living conditions in the resident's home environment as they noted the information during review of his hospital record. They confirmed lack of electricity and running water was problematic.

Based on interview and record review, the facility failed to permit a long-term care resident to return to the facility after being hospitalized for 1 of 6 residents reviewed for discharge status, of a total sample of 14 residents, (#1). Findings: Review of resident #1's medical record showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #1 had severe cognitive impairment, exhibited physical and verbal behaviors that interfered with his care but did not put the resident or others at risk for physical injury. The assessment revealed he rejected care and wandered for 1 to 3 days during the 7-day look-back period. Resident #1 required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene, and used a wander/elopement alarm daily. The MDS Discharge assessment dated [DATE] documented an unplanned transfer to an acute hospital with return anticipated. Review of the resident's nursing home care plan included risk for elopement, communication problems related to Alzheimer's, dementia, anxiety, and impaired cognition. The care plan was updated on 1/21/22 to include behavior problems. The discharge plan read, The resident's family wishes for resident to reside in this facility long-term care. The Discharge Plan Interventions included, Encourage resident to engage in favorite activities. Encourage family and friends to visit often. Administer medications as ordered. Review of the Advanced Practice Registered Nurse (APRN) Initial Psychiatry Evaluation dated 12/21/21 revealed the facility staff reported resident #1 was aggressive and exit seeking since admission. The APRN documented the resident exhibited agitation, restlessness, combativeness and resistance to care and to follow up as needed. The APRN recommended utilizing [MEDICATION(S)] PRN (as needed) for aggressive anxiety and stop after a 14-day period. The APRN wrote, Patient will likely have improved behaviors and restlessness as he settles into the new facility. The APRN's visit note dated 1/18/22 read, Patient appears to be psychiatrically stable at this time. The APRN's recommendations included discontinue [MEDICATION(S)] PRN as patient had not required any doses in the last 30 days, discontinue [MEDICATION(S)] (anti-psychotic medication), and start [MEDICATION(S)] to prevent rebound [CONDITION(S)] that can occur from prolonged use of [MEDICATION(S)]. The note included the intent to follow up in two weeks or earlier if necessary. Review of resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 1 mg every 6 hours PRN was ordered for anxiety but never given during the resident's stay in the facility. Review of the Nursing Progress Notes revealed on 1/31/22 at 11:09 AM, resident #1 wandered into other residents' rooms and urinated on the floor. A second progress note dated 1/31/22 at 11:15 AM showed the resident tried to enter another resident's room and the staff attempted to redirect him, but the resident became aggressive with staff and punched a nurse on the arm. The note read, resident grabbed a pen and [was] swinging in a way to cause harm to staff. Resident #1 was evaluated by the physician who initiated the Baker Act. The progress note showed law enforcement was called and the resident was transferred to an acute hospital for evaluation. Florida's Baker Act is the law that allows police, doctors, and family members to have someone committed for an involuntary 72-hour mental health examination. (Retrieved on 4/02/22 from www.parrislaw.org). The Agency for Health Care Administration (AHCA) Nursing Home Transfer and Discharge Notice dated 1/31/22 revealed the facility contacted the resident's representative via telephone regarding the transfer to the hospital. The form included signatures of the physician and Social Services Director. The selected reason for resident #1's discharge or transfer was The safety of other individuals in the facility is endangered. The Certificate of Professional Initiating Involuntary Examination was completed on 1/31/22 at 11:25 AM, by the facility's Medical Director and included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The form's Supportive Evidence section read, resident attempting to stab others with pen. The Non-Compliance with Involuntary Outpatient Placement Order section read, Attempts to give medications not successful due to aggressive behavior. Review of the hospital's Consultation Report dated 2/02/22 at 12:16 PM revealed the patient was accepted in a hospital in the city of Lake [NAME] for inpatient psychiatric care. The note indicated resident #1 was alert, confused, cooperative with exam but nursing staff reported he was aggressive when they attempted to draw labs and they were unable to collect samples. Review of the hospital's Progress Note date 2/07/22 revealed the case manager contacted the resident's son and the tentative discharge plan was to return the resident to the nursing home. Review of the hospital's PT [Physical Therapy] Evaluation and Treatment note dated 2/08/22 revealed discharge to skilled nursing facility. Review of the communication log between the nursing home's admission staff and the hospital's case managers revealed the nursing home declined two requests to readmit resident #1, citing Behavioral/Mental Health Concerns. On 2/16/22 the referral was declined a third time with a note that read, Does not meet admission criteria. On 3/28/22 at 4:12 PM, the Social Services Director (SSD) explained the physician initiated the Baker Act because resident #1 tried to stab someone with a pen that he grabbed from a nurse. The SSD indicated this was the first time resident #1 exhibited such an extreme behavior. She noted resident #1 received psychiatric services while at the facility and was doing well prior to the incident with the pen. The SSD stated resident #1 was transported to the closest hospital and when the facility last checked, he was in the psychiatric unit at that hospital. According to the SSD, they checked the status of the resident a few weeks after the discharge. The SSD explained resident #1 would return to the facility after he received the care the facility could not provide at the time. The SSD indicated the facility looked at transfers to hospitals as discharges and noted the resident was given a 30-day notice. The SSD reported any time a resident was transferred to the hospital, they used the AHCA transfer form as the 30-day notice of discharge. The SSD explained since the resident did not return within the 30 days, he was discharged . On 3/28/22 at 6:16 PM, the Administrator and Director of Nursing (DON) explained resident #1 was discharged from the facility when he was transferred to the hospital to be evaluated for aggressive behaviors. The Administrator stated the facility's Admissions Department would have informed him if the resident was returning to the facility, but he did not recall getting that information. The DON explained resident #1 did not hurt anyone and he never showed aggression towards others prior to the incident on 1/31/22. On 3/29/22 at 11:32 AM, the nursing home's Business Development Director explained she was the admission liaison between the facility and the hospitals. She indicated she and the Admission Director reviewed the referrals from hospitals. She indicated before deciding to accept a referral, she reviewed the physician and emergency department notes, medication list, and other documentation. She explained the company standard was to respond to the hospitals' referrals in less than 30 minutes. The Business Development Director explained she did not contact the hospital or the resident to follow up after a transfer to the hospital and thought nursing did that. She added once the hospital notified them of a resident's return to the facility, she was involved in the readmission process. She stated the facility did not decline referrals for long-term residents. On 3/29/22 at 9:15 AM, during a telephone interview, the hospital's Case Manager and Social Worker from the psychiatric unit explained resident #1 was transferred to the medical floor on 2/19/22. The Case Manager stated their discharge planning process included sending the referral to the nursing home where the resident previously resided, but the nursing home refused readmission. On 3/29/22 at 2:05 PM, during a telephone interview, the hospital's Operational Manager explained resident #1 was no longer exit seeking and did not exhibit aggressive behaviors. She reported the hospital expanded the search to find a facility that would accept resident #1 and he was ready to be transferred to a nursing home that was a 2-hour drive away from the resident's son. The Operational Manager stated the nursing home where the resident resided informed the hospital they would not readmit the resident. On 3/29/22 at 9:24 AM, during a telephone interview, resident #1's son and Power of Attorney, explained his father was a long-term resident at the nursing home and was transferred to the hospital due to an incident involving aggressive behavior. He said he was never told of his father being aggressive. He recalled he received a few calls from the facility when his father would not take his medications or refuse care. He said he would speak to his father on the phone and his father would then take the medications and accept care. He stated he learned about his father's transfer to the hospital in Lake [NAME] after the transfer was completed. He remembered he received a phone call from the nursing home asking him to pick up his father's belongings. I was told if I didn't pick them up by the end of the week, they would be discarded. They did not even ask how my father was doing or when he would return. Resident #1's son noted the hospital called the nursing home so many times but they refused to take his father back. He said he was so upset when he found out the facility would not let his father return. He tried to get someone in management to explain why they denied his return but they would not return his calls. The son reported he visited his father at least 3-4 times weekly at the nursing home as it was just 20 minutes drive from home. He said he would see his Dad before going to work on the evening shift. The hospital had a hard time finding placement and they placed him in a nursing home in [NAME] which is a 2 hour drive from my home each way. I love my Dad and he knows me more than anyone else. He often asks for me. Now I can only see him once a week because of the distance. Last weekend I had to stay in a hotel to visit my Dad as the drive is so exhausting. My Dad was never left alone, always had family around him. The son spoke of the hardship of visiting his father because of the long distance from his home. He said his father's placement at the new facility was hard on his father and him, it's very distressing. Review of resident #1's medical record revealed no progress notes or documentation by facility staff of attempts to communicate with the hospital related to concerns about evaluation or medical justification of specific care and services that could not be provided by the facility. There was no evidence of discussions based on resident #1's needs and the rationale for not allowing resident #1 to return to the facility. Review of the facility's policy titled Transfer and Discharge (including AMA), (undated) read, It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. The policy defined a Facility initiated transfer or discharge as a transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request and/or is in alignment with the resident's stated goals for care and preferences. Review of the Facility Assessment, dated 2/14/2022, indicated the facility provided services for residents with Psychiatric/Mood Disorders: [CONDITION(S)], Impaired Cognition, Mental Disorder .Anxiety Disorder, Behavior that needs interventions. The document also listed Neurological System which included Alzheimer's Disease and Non-Alzheimer's Disease among other conditions.

Based on observation, interview and record review, the facility failed to provide care and services to identify, monitor and treat pressure ulcers for 1 of 2 residents reviewed for pressure ulcers, of a total sample of 33 residents, (#45). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #45 was identified with 3 new facility acquired unstageable pressure ulcers by the surveyor from 1/13-1/14/21. The resident had 1 unstageable pressure ulcer to the coccyx and 1 on the left ankle and 1 unstageable deep tissue injury to the right heel. The facility failed to do weekly skin checks and failed to apply skin prep to the resident's heels for prevention as ordered in the month prior to the survey. The facility failed to identify wounds at an early stage and failed to initiate timely treatment and preventive measures. Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), There are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury (SDTI) .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed .A Deep Tissue Pressure Injury: is a persistent non-blanchable deep red, maroon or purple discoloration .Pain and temperature change often precede skin color changes .This injury results from intense and/or prolonged pressure . (The National Pressure Injury Advisory Panel website at www.npiap.com accessed on 1/17/21). Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she had moderate cognitive impairment, was totally dependent on 1-2 persons for all her activities of daily living, was bedbound, unable to turn herself in bed and always incontinent of urine and occasionally incontinent of bowel. The MDS assessment showed resident #45 did not .reject evaluation or care necessary to achieve the resident's goals for health and wellbeing . and had no pressure ulcers. Review of resident #45's medical record revealed a care plan revised on 12/10/20 for skin breakdown related to being admitted with excoriation to buttocks. Interventions directed nurses to complete weekly skin assessments and Certified Nursing Assistants (CNAs) to monitor skin during bathing daily, especially over bony prominences, and report abnormalities to nurse. Nursing staff were to provide incontinence care after each episode and as needed, check residents skin when assisting with daily care on shower/bathing days, report any redness, sores, skin tears, bruises, blisters, rashes .to nurse. Resident #45 also had care plan for potential for pressure ulcer development related to immobility and incontinence that was initiated on 12/10/20. The goals were that resident would have intact skin, free of redness, blister or discoloration. Interventions included; administer treatments as ordered and monitor for effectiveness, and follow facility policies and protocols for prevention and treatment of [REDACTED]. On 1/12/21 at 12:02 PM, the Nursing Home Administrator (NHA) said that since care concerns were identified during the survey, staff were instructed to do head to toe assessments of all residents today. The NHA stated, not acceptable for nurses to just be looking at orders in the electronic health record, they should be looking at the resident too. On 1/13/21 at 9:35 AM, resident #45's door was closed but she could be heard from the hallway crying out. The assigned Licensed Practical Nurse (LPN) A was standing outside of the resident's room at the medication cart. Upon entry to the room, resident #45's roommate said the resident was yelling like this all night. The resident was observed in bed on a regular mattress with her eyes closed. She could not answer any questions but repeated, God help me, what am I going to do. LPN A exited the room and then returned. She said she would give the resident Tylenol for pain. She administered the crushed medication in apple sauce to the resident by mouth. LPN A was requested to remove the sheets off the resident for an observation of the resident's skin. The resident's legs were contracted and bent with no pillows between her knees and her lower extremities. The resident's ankles were rubbing together. The LPN then moved the resident's legs apart. The left medial ankle had plum size area of brownish eschar with redness around the wound. The right medial heel had a prune sized dark purplish/red area. LPN A indicated no prior knowledge of the wounds on the resident's lower extremities. On 1/13/21 at 10:10 AM, the Director of Nursing (DON) entered resident #45's room and acknowledged the wounds on resident #45's lower extremities. The DON said since all residents had a head to toe assessment by a nurse yesterday, the wounds should have been assessed at that time. The resident was not currently able to tolerate an observation of her bottom as she yelled out that she was hurting all over. On 1/13/21 at 12 PM, Certified Nursing Assistant (CNA) C was observed sitting at the bedside feeding resident #45 her lunch meal. The resident was sitting up approximately 60 degrees and was lying on a regular mattress. The resident repeatedly yelled out, please let me go, this is awful. CNA C said that yelling out was the resident's usual behavior. CNA C said that she had not observed any open areas to the resident's buttock area when she provided care to her this morning. She added that there was only redness and she applied barrier cream. CNA C added that she was not the resident's usual care giver. She revealed it was her first time caring for the resident in 2 1/2 weeks. CNA C denied seeing any skin breakdown on the resident's ankles or heels 2 1/2 weeks ago, when she last cared for the resident. On 1/14/21 at 10:48 AM, CNA D said she was assigned to resident #45's care on Monday 1/11/21 and Tuesday 1/12/21 of this week on the day shift. She said she gave the resident a complete bed bath and did not see any wounds on her lower extremities. She added that she saw a dime sized open area on her bottom which she reported to the nurse, (LPN B). She was not aware what LPN B did after she reported the skin breakdown to her. CNA D added the open area on the resident's bottom was present when she provided care on 1/11 and 1/12/21. She stated she did not see a dressing on the open area. CNA D added that one can identify if the resident was in pain when she moaned. On 1/14/21 at 1:06 PM, a telephone call was made to LPN B but she did not return the call by the end of survey on 1/15/21. Review of resident #45's medical record revealed orders dated 11/18/20 for nurses to do weekly skin checks on Thursdays 7-3 shift. Another order dated 11/19/20 was to apply skin prep and offload heels every shift. It was noted that the last skin check was completed on 12/10/20, 33 days ago. The last application of skin prep and offloading of heels was done on 12/18/20, 25 days ago. On 1/13/21 at 4:28 PM, the B Wing Unit Manager (UM) said that she obtained orders on 12/10/20 for skin prep to residents #45's heels and did not see any breakdown of her inner ankle/heel areas at that time. She checked the resident's medical record and could not find any nursing documentation of weekly skin checks since December 2020. She acknowledged the weekly skin checks and skin prep treatments orders to the resident's heel did not get entered into the facility's electronic system when the facility switched from paper to electronic medical records (EMR) on 12/18/20-12/19/20. She said she saw the eschar on residents #45's left ankle and the discolored purplish area to right medial heel but she had not put her skin observation in the EMR. UM B did not indicate during this interview that she saw any breakdown on the resident's buttocks/coccyx. The UM did not provide an answer when asked about the process when CNAs identified new areas of skin concern. She acknowledged that CNAs should do a head to toe observation of the resident's skin every time they gave a bath. She said that if any skin issues are identified, the nurse should be notified. She added the nurse should then do a head to toe assessment of the residents' skin and report and new areas of breakdown/wounds to the physician and obtain orders for treatment. The UM verified that resident #45's eschar wound to left inner ankle did not happen overnight and stated, all I know is that it was not there when I did skin prep to her heels on 12/10/20. The UM acknowledged the wound would not have become so advanced if the orders had been entered in the EMR. She added that if the nurses had applied the skin prep to the heels as ordered 3 times per day, they may have identified skin breakdown sooner. On 1/14/21 at 8:57 AM, interviews were conducted with the DON, Regional Nurse and NHA. The following surveyor findings were discussed with the administrative team: 1.) CNA D who was assigned to the resident on 1/11 and 1/12/21 identified new breakdown on the resident's bottom. CNA D said she reported the breakdown to LPN B. There was no evidence that LPN B assessed the resident's skin breakdown, notified the physician or obtained new treatment orders. 2.) The facility did a whole house skin audit of all residents the night of 1/12/21. The B wing UM did not call the physician or obtain treatment orders for new areas of concern on the resident's bottom or lower extremities. 3.) Resident #45 was heard hollering through closed doors out in the hallway on 1/13/20. The surveyor and LPN A entered the resident's room and observed resident with eschar to wound on the left inner ankle and discolored area to right medial heel. An observation of the resident's buttock area could not be done at this time because she was in too much distress/discomfort. 4.) An interview with the B wing UM revealed that orders for skin checks and skin prep to the heels were not entered in the EMR when the facility switched from paper records to electronic records in the middle of December 2020. The orders for weekly skin checks were not entered for resident #45 and the nurses failed to identify skin breakdown. CNAs did not report any new areas of breakdown to the nurses when they provided care to the resident. The DON said the wound physician had been contacted and had seen the resident this morning. She stated that in addition to wounds of the lower extremities, an unstageable wound on the sacrum was identified this morning. The DON noted that CNAs were to complete a Stop and Watch tool if they observed any skin issues during resident care. The Regional Nurse stated, there is no excuse, the staff should have identified and treated breakdown sooner. She said the facility switched from paper to EMR and the nurse managers were responsible for entering the orders into the electronic medical record on 12/7/21. The EMR went live on 12/17/20. The previous DON was responsible and should have validated all orders were entered correctly. She said the previous DON no longer worked at the facility. On 1/12/21 at 9:56 AM, the NHA said that UM B Wing was suspended pending neglect investigation as she failed to complete a thorough head to toe skin assessment of resident #45 and failed to notify the physician or obtain treatment orders for skin breakdown. The NHA added that nurses were responsible for providing the needed care to residents. The UM did not get any treatment orders for resident #45's wounds on her coccyx, inner ankle and heel wounds. Review of the Initial Wound Evaluation and Management Summary note by the wound care physician dated 1/14/21 revealed that resident #45 had the following wounds all due to pressure of greater than 2 days duration: Site #1 Unstageable (due to necrosis) left medial ankle wound measured 1.4 centimeters (cm.) by 1.7 cm. by unmeasurable depth. Wound has moderate amount of serous drainage, 30% slough (dead tissue) and 70% other viable tissue. Site #2 Unstageable Deep Tissue Injury (DTI) of the right medial heel measured 1.9 cm. by 1 cm. by unmeasurable depth. Wound presents as blood filled blister. Site #3 Unstageable (due to necrosis) medial coccyx wound measured 3 cm. by 2.8 cm. by unmeasurable depth. Wound presents with 75% thick adherent devitalized necrotic tissue and 25% viable tissue. The Wound MD's recommendations read, Float heels in bed, obtain consent for debridement, reposition per facility protocol, turn side to side and front to back in bed every 1-2 hours if able, low air loss mattress .Dressing treatment plan . On 1/14/21 at 2:13 PM, a telephone interview was conducted with the wound care medical doctor. He said he saw resident #45 this morning and she had 3 unstageable pressure ulcers; 1 on the sacrum, 1 on the left medial ankle and 1 on the right medial heel. He stated the cause of the 3 wounds was pressure. He said her left ankle had been rubbing against her other ankle which caused the breakdown. The wound MD stated, they missed it. The Wound MD acknowledged that resident #45 suffered 3 facility acquired unstageable pressure ulcers. The wound doctor acknowledged the facility's failure to identify wounds timely and implement appropriate treatment contributed to advanced wound stage which may have been prevented if the skin areas had been identified and treated sooner. Review of the Pressure Injury Prevention and Management policy and procedure dated 11/7/20 revealed, The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing injuries .Avoidable means the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risks factors; define and implement interventions that are consistent with resident needs resident goals, and professional standards of practice; monitor and evaluate the impact of interventions; or revise the interventions as appropriate .The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment .Licensed nurses will conduct a full body skin assessment on all resident upon admission/re-admission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .The RN (registered nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risk, progression towards healing an compliance at least weekly .The attending physician will be notified : The presence of new pressure injury upon identification .