Every finding on record at Macclenny Nursing and Rehab Center

Based on observations, staff interviews, and record review, the facility failed to ensure each resident had the right to personal privacy and confidentiality for all aspects of care and services, specifically concerning dietary orders and personal care posted in public areas for 12 (Residents #17, #30, #7, #76, #18, #23, #32, #68, #6, #33, #82, and #2) out of a total of 35 sampled residents. The findings include: On October 19, 2021 at 8:20 a.m., a piece of paper was observed taped to a white board in the East Wing hallway. It was across from nurses station in public view and read, 10-18-2021 Dining Room. For staff information: The following residents will be eating in the East Wing Dining Room for lunch and dinner only. Seven residents were listed by first and last name, room number, and diet order, including Resident #32. Other residents observed on this dining list included Residents #17, #30, #7, #76, #18, and #23. (Photographic evidence obtained) On October 20, 2021 at 12:20 p.m., the same piece of paper was observed taped to the same white board in the East Wing hallway. On October 20, 2021 at 12:35 p.m., during an interview with Certified Nursing Assistant (CNA) A, she was asked whether she knew what the list taped to the white board was for, and why it was taped to the the whiteboard in the hallway. She stated, It's a list of the feeders since the dining room re-opened. That's new, I had to ask what it was, too. It's the residents who need to be in the dining room for lunch and dinner, so they can be assisted with their meals. On October 20, 2021 at 12:40 p.m., during an interview with CNA B, she was asked whether she knew what the list taped to the white board was for, and why it was taped to the whiteboard in the hallway. She stated, It's the people that need to go to the dining room, because they need help with their meals. See, on here it's their name and room number and what kind of diet they eat. They put it here so we know who needs to go to the dining room to be helped with their meals. On October 20, 2021 at 12:45 p.m., during an interview with Licensed Practical Nurse (LPN) C, she was asked whether she knew what the list taped to the whiteboard was for, and why it was taped to the whiteboard in the hallway. She stated, It's taped there because it's important information. It's the list of residents who need to get to the dining room for meals, for assist or supervision. She was asked whether she would expect to see resident names and information taped to the whiteboard in the hallway where anyone walking by could read the information. She replied, Oh, maybe I should take it down. She began peeling the tape off, then she put it back and stated, I should ask the Unit Manager about it. She stated she wasn't sure whether it should be there or not. On October 21, 2021 at 10:15 a.m., during an interview with LPN E/East Wing Unit Manager, she was asked whether she knew why there was a list of residents with their names, room numbers, and diet orders taped to the hallway whiteboard. She stated, That's a list of the residents who need to be taken to the dining room for assistance with meals. It probably should be taken down though, it doesn't have to be there. When she was asked whether that information being taped up in the hallway was a privacy issue, she stated Yes, it is with the names, room numbers and diet orders. On October 17, 2021 at 2:51 p.m., an observation was made of the whiteboard on the West Wing hallway across from nurses' station. An area on the whiteboard was marked Night Shift Get Ups. The following residents were listed by first and last name: Residents #68, #6, and #33. (Photographic evidence obtained) On October 19, 2021 at 9:45 a.m., an observation was made of the same whiteboard on the West Wing hallway. Two additional residents (#82 and #2) had been added to the Night Shift Get Ups. (Photographic evidence obtained) On October 20, 2021 at 9:30 a.m., an observation was made of the same whiteboard on the West Wing hallway. The same five residents' (#68, #6, #33, #82, and #2) first and last names were listed. On October 21, 2021 at 10:09 a.m., an observation was made of the same whiteboard on the West Wing hallway. The same five residents' (#68, #6, #33, #82, and #2) first and last names were listed. On October 21, 2021 at 10:12 a.m., during an interview with Registered Nurse (RN) D, she was asked whether she knew why there was a list of residents with first and last names listed on the West Wing hallway whiteboard. She observed the whiteboard and stated, I'm not really sure why that would be on this board. Those are the residents who get up early and need the night staff to help them, but that list is posted in the nutrition room. She opened the nutrition room door directly across from the hallway whiteboard and the same list was observed posted on the cork board. She was asked if having the names on the whiteboard was a privacy issue. She replied, Yes, it is because it's nobody else's business who is scheduled to get up early. A review of the facility's policy titled Resident Dignity and Personal Privacy (revised 4/4/2019) read, Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity and right to personal privacy. Each resident's right to personal privacy includes confidentiality of his or her personal and clinical affairs. A review of the facility's policy titled HIPAA's Do's and Don't's read, Under HIPAA (Health Insurance Portability and Accountability Act), protected health information (PHI) is individually identifiable health information that is oral, electronic, or on paper and relates to: 2. Health care provided to an individual. .

Based on observations, staff interviews, clinical record reviews and policy and procedure reviews, the facility failed to provide a clean and homelike environment for one (Resident #65) of three residents with enteral feedings (nutrition provided via feeding tube through the gastrointestinal tract) from a total of 35 sampled residents. Specifically, enteral food product was observed splattered on the resident's feeding pump, the pole, the floor, the wall, the mattress, and the resident's bed frame. The findings include: On 10/20/2021 at 2:59 p.m., Resident #65's enteral feeding pump and pole were observed beside her bed. A large amount of different shades of a beige substance was splattered on the pump, the pole, the floor, the wall, the mattress, and the bed frame. (Photographic evidence obtained) The tube feeding was running at the prescribed amount with today's date on the feeding bottle and bagged syringe. During an interview with the Director of Nursing (DON) on 10/20/2021 at 3:10 p.m., he was asked who who was responsible for cleaning the tube feeding pumps. He stated housekeeping wiped them down. Housekeeping staff were responsible for cleaning the pump, the pole, the floor, the walls, the bedframe, and the mattress. He was asked if nursing could clean them as well. He stated, Yes, nursing can clean them when tube feeding product spills on them, but the task is usually done by housekeeping. He confirmed that the mess should have been cleaned up. On 10/21/2021 at 3:08 p.m., Resident #65's enteral feeding product was observed to be splattered on the walls and floors next to the bed, as well as on the mattress and bed frame. (Photographic evidence obtained) A review of Resident #65's medical record revealed that the physician's order sheets dated 10/01/2021 through 10/31/2021 read, Resident was was admitted on [DATE] with diagnoses including: cerebral infarction due to [CONDITION(S)] of other cerebral artery, pneumonia, acute chronic [CONDITION(S)] with [CONDITION(S)], Corona Virus -19, pressure ulcer of sacral region Stage III, acute kidney failure, diabetes mellitus type II, urinary tract infection ([CONDITION(S)]), hypertension, muscle spasms, metabolic [CONDITION(S)], [CONDITION(S)], Vitamin D deficiency, [CONDITION(S)] and muscle weakness. A review of the physician's order sheets dated 10/01/2021 through 10/31/2021 read, Administer Glucerna 1.5 at 25 cubic centimeters (cc) per hour x 22 hours per day via feeding pump. Ensure in place and infusing per physician's orders. On at 1400 and off at 1200 two times a day. Check tube for placement every shift, before medications and before flushes. Every day and night shift. Flush peg tube with 250 cc every 6 hours. Flush peg tube with 30 cc water before and after medications with 5 cc water between each medication. A review of the Minimum Data Set (MDS) assessment dated [DATE] read: Section K: B. Feeding tube - nasogastric or abdominal (PEG) (Percutaneous Endoscopic Gastrostomy). A review of Resident #65's care plan, dated 09/28/2021, revealed: [Resident #65] is at risk for decreased nutritional status & dehydration related to g-tube/NPO (nothing by mouth). Diagnosis of [CONDITION(S)] requiring feeding tube. Interventions included: Check for tube placement and gastric contents/residual volume as ordered. NPO as ordered. Provide site care as ordered. Activities of daily living (ADL) self-care performance: She is requiring total care with activities of daily living. She has a g-tube for feeding. EATING: Total assist; G-tube for feeding/NPO. On 10/21/2021 at 9:48 a.m., during an interview with the Housekeeping Supervisor, he confirmed that the housekeeping staff were responsible for cleaning up any enteral food product that was splattered on the resident's feeding pump, pole, walls, floors, furniture, bedframe, or mattresses. He stated in other places he'd worked, it was always the nursing staff who cleaned the pumps, but here the housekeeping staff were expected to do it. A review of the facility's policy and procedure entitled Infection Control (revised July 2014) revealed: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to: b: Maintain a safe, sanitary, and comfortable environment for residents, f: Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment, 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. A review of the facility's policy and procedure entitled Daily Patient Room Cleaning (revised 6/2016) revealed: Every room to be cleaned is that resident's home - treat it as such. The goal of cleaning is infection control. 3. Spot clean. With a cloth and disinfectant spot clean all vertical surfaces. 5. Damp mop floor with germicide solution damp mop floor working from back corner to door.

Based on observation, staff interviews, and medical record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #12) of 35 residents in the sample. The findings include: A review of Resident #12's medical record revealed a history of venous ulcers on her right lower extremity (leg) which required wound care two times per week and as needed. On 10/19/2021 at 10:30 a.m., wound care was observed for Resident #12 in her room. Wound care was performed by Licensed Practical Nurse (LPN) I/Wound Care Nurse. She was asked how long she had been the facility's wound care nurse and she replied, About two weeks, but I've been an LPN for a couple of years. She was asked if she had performed wound care for Resident #12 before today and she stated, Yes, yesterday (10/18) was the first time I performed her wound care, so today is the second time. She was asked what the wound care would include and she replied, After the old dressing is removed, the wounds are cleansed with normal saline. The open areas will have [MEDICATION(S)] Cream 1% put on them, and then calcium alginate is placed over those areas. An absorbent pad is placed over each wound area and then wrapped with gauze followed by ace wraps for compression. The current wound care order was verified through a review of the resident's medical record and was dated 7/23/2021. LPN I was asked whether she had worked with [MEDICATION(S)] Cream 1% before. She stated she had. When asked whether she knew how it worked, she stated, I know it helps stop the growth of bacteria. LPN I began the wound care treatment. Hand hygiene was performed with each glove change, and gloves were changed between each task throughout the provision of wound care. LPN I removed the resident's ace wraps, then the gauze wraps. She placed the ace wraps and gauze wraps in a red biohazard bag which was on the resident's bed. Large absorbent pads were removed, and a small amount of light tan drainage was observed on each pad. Those pads were also placed in the red biohazard bag on the resident's bed. Under the pads was 4 x 4 gauze which also showed small amounts of light tan drainage. That was also placed in the red biohazard bag on the resident's bed. No odors were noted. No calcium alginate was observed on any part of the right lower extremity during the dressing removal. LPN I then cleansed the wounds with 4 x 4 gauze soaked in normal saline and patted each area dry. She applied [MEDICATION(S)] Cream 1% with a freshly opened wooden spatula/tongue depressor. She applied a heavy amount of the cream to several wound areas on the right lower leg. The amounts applied were observed to be thick and overlapping the wound area onto the intact skin. LPN I applied the first cut piece of calcium alginate on top of one area of the [MEDICATION(S)] Cream 1%. She was asked to stop what she was doing and was then asked how much [MEDICATION(S)] Cream 1% she should use on each wound area. She stopped what she was doing, but did not answer the question. It was explained to her that a minimal amount of [MEDICATION(S)] Cream 1% with no more than 1-2 millimeters in depth should be used on each wound, and the [MEDICATION(S)] Cream 1% should not extend onto the intact skin. She stated, Thank you, okay and then removed the thickness of the [MEDICATION(S)] Cream 1% from each wound area and from the intact skin. She proceeded with wound care as ordered, and covered each wound area with calcium alginate followed by large absorbent pads followed by gauze wrap and then ace wraps. On 10/20/2021 at 8:55 a.m., during an interview with LPN I, she was asked if calcium alginate had been used on the wound dressing change for Resident #12 when she changed the dressing on Monday, 10/18/21. She paused and stated, Yes, I think so. Yes, I used calcium alginate on the wound Monday. It was explained that during the dressing change on Tuesday, 10/19/21, there was no calcium alginate on the wound that LPN undressed before treating and redressing the leg. That would have been Monday's dressing you removed. She stated, I did put calcium alginate on the wound Monday. When I removed the dressing on Tuesday, I took the calcium alginate off and showed you the drainage. I said her (the resident's) drainage and swelling were less than the day before. It was explained that large abdominal pads and 4 x 4 gauze were all that was removed from the leg on Tuesday. She replied, I'm pretty sure there was calcium alginate, too. .

Based on observation, staff interview, clinical record review, and facility policy and procedure review, the facility failed to ensure appropriate catheter care was provided to one (Resident #65) of six residents with indwelling urinary catheters from a total of 35 residents in the sample. Failure to ensure proper catheter care is provided, creates a potential for urinary tract infections and negative health outcomes for the resident. The findings include: On 10/20/2021 at 2:59 p.m., Resident #65 was observed resting in bed with her eyes closed. She did not respond to her name being called or open her eyes. Resident #65's urinary catheter tubing and bag were hanging from the side of the bed frame. The bag, exposed at the bottom, was resting on the floor. The catheter bag had no date on it. The catheter tubing was observed with a large amount of rust/orange-colored sediment inside the tubing, and the same rust/orange color coated the inside of the catheter tubing. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 10/20/2021 at 3:10 p.m., he was asked if the catheter bag should be resting on the floor. He replied No, it should not be on the floor. He was asked how often urinary catheter bags were changed, and he replied once a month. He was asked if they could also be changed as needed, and he replied yes. He was asked if the catheter bag should be dated when changed, and he stated yes. He was asked to observe the condition of the current catheter bag for Resident #65. He observed it and stated, It should have been changed. A review of Resident #65's clinical record revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) Further review of Resident #65's clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change drainage bag with catheter change as needed. Change foley catheter 18fr on the 20th of each month and document every night shift starting on the 20th and ending on the 21st every month related to [CONDITION(S)] and kidney failure. (Copy obtained) A review of the Minimum Data Set (MDS) assessment dated [DATE] read: Section H: Indwelling catheter. (Copy obtained) A review of Resident #65's care plan, dated 09/28/2021, revealed: [Resident] has indwelling catheter with [CONDITION(S)], multiple pressure ulcers with terminal condition. Interventions included: Catheter care as ordered. Change catheter as ordered and as needed. Ensure proper positioning of drainage tube at all times, keep drainage bag below waist level at all times. Keep drainage bag covered at all times. Monitor signs/symptoms of infection: pain burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, change in behavior, change in eating patterns. Position/secure tubing to prevent traumatic removal (Copy obtained). A review of the facility's policy and procedure for Catheter Care revealed: Routine catheter care helps prevent infections and other complications. Maintenance: Inspect the catheter and tubing to detect compression or kinking that could obstruct urine flow. Keep the drainage tube and collection bag lower than the bladder. Empty the collection bag every shift and as needed. Monitoring: 20. Report the following to the nurse responsible for the resident's care: a. Signs or symptoms of urinary tract infection ([CONDITION(S)]): change in urine such as a foul odor, bloody or cloudy urine and appearance. (Copy obtained)

Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #101) of a total of 35 residents in the sample. The findings include: On October 18, 2021 at 1:08 p.m., Resident #101 was observed sitting in his wheelchair in his room with the television on. He was asked how he was doing, and he replied, My back hurts. He was asked whether he had made anyone aware of that, and he replied No, net yet. He was encouraged to ring his call bell to let the staff know he was in pain. He rang the call bell at 1:10 p.m. Certified Nursing Assistant (CNA) K entered the resident's room at 1:28 p.m. Resident #101 let her know his back hurt and he wanted to get back to bed. Another CNA was summoned to assist with getting the resident back to bed. CNA K told Resident #101 that she would let the nurse know his back was hurting him. On October 19, 2021 at 8:15 a.m., Resident #101 was observed sitting up in bed eating breakfast. He was asked if his back hurt this morning, and he replied, Yes, it hurts. He was asked whether he let the nurse know that his back hurt. He stated, Well, shouldn't they know? CNA F entered the room. Resident #101 was asked whether he wanted to share anything with CNA F. He looked at CNA F and stated, Yes, my back hurts. I'm in pain. CNA F stated she would let the nurse know. On October 20, 2021 at 9:30 a.m., an interview was conducted with CNA G in Resident #101's room. She was asked if she was caring for Resident #101 on her assignment today. She stated, Yes, I am. She was asked whether Resident #101 ever complained to her of pain. She stated, Yes, all the time. She was asked what she did when the resident told her he was in pain. She stated I go tell the nurse I think he has scheduled pain medicine. On October 20, 2021 at 12:25 p.m., Resident #101 was observed sitting up in his wheelchair in his room. His lunch tray was in front of him on his overbed table. He was asked if he was having any pain. He stated Yes, I am. He was asked where his pain was located. He stated, Like where my belt would go, but in the back. He was asked if he had let the nurse know, and he replied, I've let them know two or three times. It don't make no damn difference. Nobody does anything about it. He was asked if he had received any pain medication today. He stated No, none. Can I get back in bed? That helps a little at least. On October 20, 2021 at 1:05 p.m., an interview was conducted with Licensed Practical Nurse (LPN) E/East Wing Unit Manager. She was asked whether Resident #101 had ever complained of pain. She replied, Yes, as a matter of fact, the Tylenol hasn't been working, so the APRN (Advanced Practice Registered Nurse) wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The family mentioned he was having trouble sleeping too, so she wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN E was asked how it was determined that the Tylenol and [MEDICATION(S)] orders were not effective for the resident's pain and [CONDITION(S)] if they had not been given since his admitted [DATE]. She stated, He's had the PRN Tylenol. The [MEDICATION(S)], I think he used that at home and he said it made him groggy in the morning, so he probably never requested it here. The Unit Manager was advised that no PRN doses of Tylenol or [MEDICATION(S)] had been signed out on the MAR (Medication Administration Record) since the resident was first admitted . She stated, I know we just had an in-service on signing out PRN medicines. She was asked how recently that in-service was. She stated, I don't remember the date, but it was recent. She was asked if she would expect to see as needed doses of medication signed out as given on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #101's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his Care Plan, dated 9/30/2021 (revised 10/5/2021), revealed: Focus: (Resident #101) is at risk for pain related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: (Resident #101) should voice level of comfort on a scale of 1-10 through the review date. Interventions: Administer analgesics as ordered. Monitor for side effects of pain medication. Observe for signs of relief/effectiveness with interventions. Utilize non-medication interventions for pain relief. A review of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9/30/2021: Pain evaluation: scale 0-10 every shift 9/30/2021: Tylenol 325mg: give 2 tablets by mouth every 6 hours as needed for pain 1-4 or fever (do not exceed 3 grams) 10/1/2021: [MEDICATION(S)] 250mg/10ml: inject 0.9ml SQ every Friday (d/c 10/19/21) arthritis 10/1/2021: [MEDICATION(S)] 2.5mg: give one tablet by mouth daily (OA) 10/4/2021: [MEDICATION(S)] 3mg: give one tablet by mouth every 24 hours as needed for [CONDITION(S)] 10/19/2021: [MEDICATION(S)] Tablet 5/325: give 1 tablet by mouth every 4 hours as needed for non acute pain 10/19/2021: [MEDICATION(S)] 250mg/10ml: inject 0.9 IM every Friday (start 10/22/21) arthritis 10/19/2021: Trazadone 25mg: give one tablet by mouth at bedtime ([CONDITION(S)]) 10/19/2021: VS (vital signs) every shift A review of Resident #101's October 2021 MAR (Medication Administration Record) revealed: No doses of PRN Tylenol were documented as having been adminsitered between 10/1 and 10/20/21. No doses of PRN [MEDICATION(S)] were documented as having been adminsitered between 10/1 and 10/20/21. A new order for [MEDICATION(S)] 5/325 (milligrams) mg: Give one tablet by mouth every 4 hours as needed for non-acute pain - written 10/19/21 at 2:00 p.m. A new order for Trazadone 25 mg: Give one tablet by mouth every day at bedtime for [CONDITION(S)] - written 10/19/21 at 9:00 p.m. A pain evaluation scale 0-10 (zero indicating no pain at all and 10 indicating the worst possible pain) showed that from October 1st through October 7th, all spaces were signed off, but levels were all marked as X. From October 7th (evening shift) through October 19th, all spaces were signed off and marked as zero, indicating the resident had no pain. .

Based on observations, interview and record review, the facility failed to 1) Assist residents in obtaining needed dental care, and 2) Provide or obtain from an outside source, dental services to meet the needs of each resident for one (Resident #82) of a total of 35 residents in the sample. Specifically, the facility failed to obtain dental care for oral pain noted on 2/8/21 per the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: On 10/17/21 at 3:00 p.m., Resident #82 was observed in bed. An odor was coming from the resident's mouth. Secretions were also observed coming out of the right side of his mouth. On 10/18/21 at 10:40 a.m., Resident #82 was observed seated in a Geri chair. His lips were dry and cracked, and he could not open his mouth when asked. On 10/21/21 at 9:16 a.m., during an interview with Registered Nurse (RN) D, she stated the certified nursing assistant (CNA) had just helped the resident into the Geri chair. She stated oral care was provided during the morning care routine. When asked whether the resident could open his mouth, she replied no. She added that staff used oral care swabs for oral hygiene. She confirmed that even after oral care had been provided, the resident still had bad breath. A review of Resident #82's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also ordered was [MEDICATION(S)] 0.12%, give 15 milliliters by mouth every shift to prevent gingivitis. (Copies obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/24/21, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating that resident did not participate in the cognitive status screening. He was noted as totally dependent on staff for bed mobility, transfers, eating and toilet use. A review of his current care plan revealed that Resident #82 had a potential for alteration in nutrition/hydration due to requiring enteral nutritional to meet 100% of his nutritional/fluid needs. He received no nutrition or hydration orally. Interventions included oral care and dental consults as ordered. A review of the Oral Hygienist's note, dated 06/10/21, indicated the resident had limited communication, access and cooperation. He presented with slightly pursed lips and the oral hygiene was fair, generally heavy plaque, food, bleeding and calculus present. Another Oral Hygienist's note, dated 08/05/21, indicated the resident had limited communication, access and cooperation. He presented with slightly pursed lips and the oral hygiene was poor with generally heavy plaque, food, bleeding and calculus present. On 10/21/21 at 2:44 p.m., during an interview with the Regional Nurse Consultant, she was asked about the resident's order for a consultation with the outside dentist due to oral pain on 2/8/21. She stated the resident was insured through Medicaid, so the only outside provider would be through a particular acute care hospital. She added that the waiting list was too long, and the resident had not seen the outside dentist as ordered. She was then asked for evidence of notification of the outside dentist. She confirmed that there was nothing documented to verify that the outside dentist had been contacted. She added that the in-house dental hygienist was still seeing Resident #82. She confirmed that he had poor oral hygiene and was offered pain medication. A review of the facility's policy and procedure entitled Dental Services (Revised 08/29/2017), revealed that the facility provided each resident with access to dental services. Resident will be referred to dentist based on assessed need. Facility staff will assess dental status through the interdisciplinary resident assessment process and daily provision of care. The physician, residents and family/responsible party may request dental services at any time. .

Based on observations, interviews, and record reviews, the facility failed to thoroughly investigate an allegation of abuse by failing to conduct thorough interviews with staff who were present during the alleged abuse, as well as staff who interacted with the resident immediately following the alleged abuse, for one (Resident #1) of one resident reviewed for compliance with abuse investigations. The findings include: A review of Resident #1's medical record revealed a readmitted [DATE]. His primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/24/21, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating moderate cognitive impairment. Resident #1 required extensive to total assistance with activities of daily living (ADLs). A review of the resident's comprehensive care plans revealed a focus area for ADL self-care performance. The care plan directed staff to utilize 1-2 person assistance for personal hygiene and toileting. A facility report dated 6/9/21, revealed that Employee C, Certified Nursing Assistant (CNA) reported she witnessed Employee A, CNA, and Employee B, Patient Care Associate (PCA), physically abuse Resident #1. The report further explained that Employee C reported the incident to the Administrator and a head-to-toe assessment of the resident was completed. The report alleged that Resident #1 was interviewed, and he stated no one had struck him at any point during the day. The report indicated the facility had determined Employee C's allegation of abuse was unsubstantiated. On 7/1/21 at 11:30 AM, an interview was attempted with Resident #1. He was lying in bed with his eyes closed. His upper extremities were visible. There were two areas of bruising observed to the resident's left hand. Both areas were light purple in color and were approximately two centimeters in size with irregular borders. There were no other areas of skin impairment observed. On 7/1/21 at 2:10 PM an interview was conducted with Employee C, CNA. Employee C confirmed that she was assigned to Resident #1 at the time of the alleged incident. Employee C stated she observed Employees A and B strike Resident #1 during care that was provided in the resident's room. She stated the resident was receiving incontinent care, and during care, he became agitated and began swinging his fists at Employees A and B during care. Employee C stated Employees A and B responded by striking the resident in the face and chest. She further stated he was screaming/yelling during this time. Employee C stated she then told Employees A and B that she had it from here and both employees left the room. Employee C immediately reported the incident to the Administrator. There were no other witnesses in the room and the door was closed at the time of the alleged incident. On 7/1/21 at 2:49 PM an interview was conducted with the Social Services Manager. She confirmed that she was the facility's Abuse Coordinator, and she was responsible for the reporting and investigation of the alleged incident involving Resident #1 on 6/9/21. She explained that she interviewed Resident #1 on the date of the alleged abuse along with a former Unit Manager. She observed the resident with a knot on his forehead but that the resident was not able to state where the injury had come from. She further explained that she asked the resident whether anyone had mistreated him, and he stated, No. The Social Services Manager went on to say that the Director of Nursing (DON) interviewed the resident separately, and the resident stated he scratched himself on the forehead. When asked whether she had spoken to Employee C during the investigation, she acknowledged she had. The Social Services Manager provided copies of the facility's investigative materials. A typed statement dated 6/9/21 was reviewed. The statement had Employee A's name and position typed at the top of the form. On the signature line, a written statement read, Interview conducted by phone. The statement failed to address the question of whether Employee A or Employee B struck Resident #1. (Photographic Evidence Obtained). A second typed statement dated 6/9/21 was reviewed. The statement had Employee B's name and position typed at the top of the form. On the signature line, a written statement read, Interviewed by phone. The statement failed to address the question of whether Employees A or B struck Resident #1. (Photographic Evidence Obtained). On 7/1/21 at 4:20 PM an interview was conducted with the Wound Care Nurse. She explained that she was familiar with Resident #1 and confirmed that she had assessed the resident on the day of the alleged abuse. She explained that she observed a raised area on the resident's forehead that measured approximately 1cm by 1cm (centimeter). She described the area as raised and red. Immediately beneath this area, she observed broken skin (scratch) measuring 0.3cm by 0.3cm. When the Wound Care Nurse asked the resident what happened, the resident stated, I got in a fight with nurses. On 7/1/21 at 5:30 PM, the Administrator and Regional Nurse entered the room and stated they were reopening the investigation because they had received information from the wound care nurse that had not previously been reported. On 7/28/21 at 11:40 AM an interview was conducted with the Administrator regarding the facility's continued investigation. She explained that the facility had been unable to prove or disprove that the alleged abuse had actually occurred. On 7/28/21 at 1:41 PM, an interview was conducted with the Administrator, DON, and Regional Nurse. The DON was asked why the facility determined a continued investigation was necessary. He explained that the facility had been alerted to the Wound Care Nurse's interview with the resident, and they were not previously aware of the resident's statement. When asked why the facility was not aware, the DON explained that the Wound Care Nurse felt she was only responsible for the resident's skin concerns and didn't think about it. When asked about the outcome of the continued investigation, the Regional Nurse explained that all of the employee interviews had been conducted again, and the facility identified conflicting statements between Employee A and Employee B, however, continued investigation by facility management was unable to verify that abuse of Resident #1 had occurred. The facility's abuse prohibition policy titled, Abuse and Neglect Prohibition was reviewed. The policy was revised on 5/23/2017. The policy defined abuse as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The policy defined physical abuse as, hitting, slapping, pinching, and kicking. It also included controlling behavior through corporal punishment. Page four of the policy read, The facility will investigate patterns, trends, or incidents that suggest the possible presence of abuse, neglect, or misappropriation of property or psychosocial harm, with intervention, reporting, or policy/procedure modification conducted as appropriate.

Based on record reviews and interviews the facility failed to supply pharmacy services according to physician orders [REDACTED].#36). The findings include: Record review for Resident #36 revealed that she was admitted to the facility on [DATE]. She had multiple [DIAGNOSES REDACTED]. Further review of the record revealed the Advanced Registered Nurse Practitioner (ARNP) had ordered Lonhala Magnair (asthma/[MEDICAL CONDITION] medication) on 9/20/19; however, the facility failed to obtain the medication, due to it not being on their formulary and/or covered by the resident's insurance. On 11/7/19 at 1:02 PM an interview was conducted with the Medical Director who stated that he did not know why his ARNP had ordered the Lonhala Magnair; that it was not covered by insurance and she should not have ordered it. He stated that Resident #36 has been on [MEDICATION NAME], which is the equivalent medication, so she had not missed anything. However, after reviewing the resident's medication administration record (MAR), [MEDICATION NAME] had not been ordered. He was asked if Lonhala Magnair should have remained on order and he confirmed that it should have been discontinued. He was informed of documentation that staff had signed off that it had been administered and he stated, That is incorrect, how can they do that when it was not even available. On 11/7/19 at 1:05 PM, the Director of Nursing (DON) reviewed Resident #36's Medication Administration Records (MAR) for September, October, and (MONTH) 2019 and confirmed that staff had signed off that the Lonhala had been administered. She stated, I noticed that. That is incorrect. They never had any to give. Regarding the [MEDICATION NAME] order, she stated that she would have to check on that, but they were going to order it today. A further review was completed of Resident #36's MAR and it revealed the facility ordered the [MEDICATION NAME] (asthma/[MEDICAL CONDITION] medication) on 11/7/19. The facility had failed to obtain the Lonhala as ordered and/or an order for [REDACTED].

Based on observation, interview and record review the facility failed to ensure that the drug regimen was free from unnecessary drugs for one of 37 residents sampled. (Resident #13) The findings include: Record review for Resident #13 revealed that she was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. ER Tablet Extended Release 24 hour 1 tablet daily for Hypertension; monitoring for [MEDICAL CONDITION] medication use every shift; wanderguard check each shift; behavior monitoring every shift On 11/04/2019 at 2:28 pm, Resident #13 was observed sitting in her wheelchair at the nurses station. She was alert and oriented and interacted with members of the survey team upon greeting. On 11/07/2019 at 10:58 am, Resident #13 was observed lying in bed with her eyes closed. A male who identified himself as the resident's grandson was seated at the foot of her bed. The resident did not respond to a greeting and appeared to be heavily sedated. The grandson stated that he comes to the facility daily and that this is not usual behavior for Resident #13. He referred to the resident as being out of it and so drugged out and that she had been in the current state since 11/04/2019. He stated that when he came in on 11/07/2019 he found the resident covered in vomit. He informed staff immediately and they came to clean her up. Staff reported that the resident had had two episodes of vomiting. Resident #13 has not been able to eat breakfast or lunch because she has been drugged out. The grandson was concerned about the resident being on too much medication. The family has made attempts to speak with the facility regarding the medications that the resident is receiving. Neither the doctor nor his assistant were present at the last Care Plan meeting to answer the questions. The facility acknowledged this and rescheduled the Care Plan meeting for 11/12/2019 to allow the family the opportunity to address their concerns with the doctor. An interview was held on 11/07/2019 at 11:07 am with the Medical Director, who stated that he had not seen the resident. He was informed by the facility that the resident had some changes in her mental status which started 11/05/2019. He stated that the resident had not had any changes in the recent past and that he would be assessing her on 11/07/2019. A second interview was held with the Medical Director on 11/07/2019 at 11:29 am. Regarding Resident #13, he stated, Her baseline is that she's very combative. On 11/04/2019 staff reported that the resident was very lethargic. The resident had an order for [REDACTED]. After an evaluation, the psychiatrist determined that the resident was taking too much medication and discontinued the evening dose of [MEDICATION NAME]. The Medical Director stated that the psychiatrist sent an order to stop the night time dose of the [MEDICATION NAME]. Resident #13 was sent out for labs the week of 10/28/2019 and that the results were normal. The Medical Director stated that he was advised by staff that the resident had not received any of the psychiatric medications since 11/5/2019. In response to this, he was provided a copy of the Medication Administration Record [REDACTED]. They told me that the meds weren't given. Regarding the status of Resident #13 on 11/07/2019, the Medical Director said, Her condition change is due to medication build up. We're thinking it's medication induced. An interview was conducted on 11/07/2019 at 1:28 pm with Employee D, a Licensed Practical Nurse (LPN) who stated that she was familiar with Resident #13. She stated that Resident #13 can be pleasant sometimes and identified her as an extreme fall risk. She confirmed that Resident #13 was lethargic and that they (the psychiatrists) attributed this to the medications. During an interview on 11/07/2019 at 3:54 pm with the Psychiatric Advanced Registered Nurse Practitioner, she stated that she issued an order on 11/5/2019 to decrease the frequency of the dose of the [MEDICATION NAME] and to hold the next day's dose (11/6/2019). She confirmed that the behavior the resident displayed on 11/07/2019 was out of her norm.

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% for 3 of 6 sampled residents (Residents #8, #48, and #70) for medication administration. There were 4 medication errors with 50 opportunities, for a medication error rate of 8%. The findings include: 1. On 11/6/19 at 9:02 am medication observation was conducted with Employee C, Licensed Practical Nurse (LPN), for Resident #8. The LPN administered all of the ordered medications to Resident #8, including his [MEDICATION NAME] (Iron) 325 mg tablet and his Potassium 20 mEq (milliequivalent) tablet. She crushed all of his medications and administered them in applesauce. [MEDICATION NAME] and Potassium should not be crushed. 2. On 11/6/19 at 9:51 am observation was conducted of medication pass with Employee B, Licensed Practical Nurse (LPN), for Resident #48. The resident had an order for [REDACTED]. Employee B removed a pill cutter from the cart and cut the pill in half. The pill cut; however, it also crumbled making it impossible to get half of the tablet. Employee B picked up a piece of the medication and administered it to the resident. An interview was immediately conducted with Employee B regarding the correct dose for Resident #48. Employee B stated that she would call the pharmacy, because she did not know the pills needed to be scored in order to be able to cut them in half. 3. On 11/6/19 at 12:07 pm observation was conducted with Employee A, Licensed Practical Nurse (LPN), for Resident #70. Employee A had to administer 2 units of [MEDICATION NAME] to Resident #70 via an insulin pen. She obtained the pen, applied the needle to the pen, and drew up the dial to 2 units. Next, she turned to administer the insulin, but was asked about priming the needle. She stated she had never primed a needle and/or heard about that. Employee A was asked to prime the needle prior to administering to ensure is received. 4. On 11/6/19 at 11:02 am interview was conducted with Employee C, Licensed Practical Nurse (LPN) regarding the crushed medications for Resident #8. She confirmed that she should not crush the medications, but if she tried to just break the tablets in half, the resident would choke on them. She would notify the physician and get an order for [REDACTED].>

Based on observations, staff interviews, and review of the facility policy and procedure, the facility failed to ensure glucometers were clean and disinfected prior use on residents to prevent the spread of communicable disease for 2 of 8 glucometers, while observing a blood glucose monitoring check for 1 resident. (Resident # 71) The findings include: On 11/06/19 at 11:25 AM, Employee A, Licensed Practical Nurse (LPN), was observed preparing to perform blood glucose monitoring for Resident #71 at the East Wing Nursing Station on the medication cart. Employee A stated the glucometer was already cleaned, using Micro-Kill Bleach Wipes. Employee A donned gloves without performing hand hygiene. Employee A grabbed a styrofoam tray holding the glucometer (a device used to monitor glucose), glucometer strips, alcohol wipes, and gauze and then turned to enter the room. There was a visible, red colored spot on the front of the glucometer. Employee A was stopped prior to entrance of the room and asked about the visible spot on the glucometer. Employee A replied, It's probably blood. I need to clean it. (Photographic evidence obtained) Employee A wiped the glucometer with bleach wipes for 20 seconds and wrapped the glucometer in a second wipe, stating she needed to keep it covered for 2 minutes. An interview with Employee A on 11/06/19 at 11:30 AM, confirmed the soiled glucometer would have been used to perform a blood glucose check, if not stopped prior to entrance of the resident room. A second medication cart on the East Wing was observed with Employee B, LPN, on 11/06/19 at 11:55 AM. There were two glucometers on the cart. Employee B stated both glucometers were clean. One glucometer in the drawer was observed to be soiled. (Photographic evidence was obtained) Employee B confirmed the glucometer was soiled and stated the glucometer would be re-cleaned. Review of the Facility Policy and Procedure for Cleaning and Disinfecting Blood Glucose Meter revealed the following steps: 1. Wash hands with soap and water and dry thoroughly. 2. Apply gloves. 3. Assemble equipment & place on barrier. -Blood glucose meter -Germicidal wipes 4. Cleaning the Blood Glucose Meter (when visibly soiled). -Clean the meter with a germicidal wipe. -Wipe all external areas of the meter until visibly clean. -Avoid wetting the meter test strip port. 5. Disinfecting the Blood Glucose Meter (before and after each use). -Disinfect the meter with a germicidal wipe. -Place Glucose Meter on clean barrier and allow to air dry for a full 3 minutes. -Remove gloves and perform hand hygiene. Note: Always refer to and follow the manufacturer's recommendations for usage and cleaning instructions

Based on record reviews and staff interviews, the facility failed to provide treatment and care in accordance with professional standards of practice by failing to obtain physician's orders [REDACTED]. The facility failed to monitor and observe for skin breakdown, and it failed to prevent the development of a Stage 4 pressure ulcer for one (Resident #1) of one resident in the facility with pressure ulcers. The findings include: A record review for Resident #1 revealed an [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. The resident was alert with confusion, and required extensive assistance with all activities of daily living except eating. The resident had a urinary catheter and was incontinent of bowel. He was ordered Physical and Occupational therapy, and was non-weight bearing on his right leg. At the time of the survey, Resident #1 was on contact isolation [MEDICAL CONDITION] (methycillin-resistant staphylococcus aureus) in the urine. The initial wound care physician assessment, dated 9/7/18, revealed the following: multiple wounds of six days duration to the medial sacrum measuring 1.5 x 1.0 cm (centimeters) with light exudate (drainage) and 100% granulation. Unstageable area deep tissue injury (DTI) to the right buttock, pressure, measuring 5.5 x 5.0 cm. Surrounding DTI purple/maroon, light exudate and 100% granulation. Treatment included silver [MEDICATION NAME] (ointment) twice daily. Recommended low air loss mattress and gel cushion for wheelchair, nutritional supplements, and explained importance of repositioning and off-loading the wound. Wound report, dated 9/28/18, revealed medial sacral wound improving measured 0.5 x 0.5 cm. Right buttock, unstageable due to necrosis, measured 10.5 x 9.5 cm, moderate exudate, and thick adherent necrotic tissue, 10% granulation tissue, wound deteriorated. Wound was debrided. On 10/12/18, the medial sacrum wound was documented as healed. The right buttock wound measured 11 x 10 cm, per the wound doctor with odor, moderate exudate, and 100% devitalized tissue. A new area was detected - unstageable necrotic area right lateral calf, less than 6 days' duration measuring 2.0 x 2.0 cm with moderate serous exudate and 100% necrotic. Area debrided. The Wound Report, dated 10/19/18, found the right calf wound was a Stage 4, measured 3.0 x 2.0 x 0.2 cm with 20% thick necrotic tissue, 70% granulation and 10% tendon exposed. A review of the nursing progress notes for (MONTH) and (MONTH) (YEAR) found no documentation regarding a wound or wound care to the right calf. A review of the weekly skin checks for (MONTH) and (MONTH) (YEAR) found no documentation regarding any new skin issues. A review of the weekly wound progress note written by the wound care nurse on 10/12/18, found no documentation of a necrotic wound to the right lateral leg. The only documentation found in the record was authored by the wound care physician on 10/12/18. An interview was conducted with the wound care nurse on 11/28/18 at 1:35 p.m. She was asked when the unstageable wound to the right calf was discovered, and she replied that it was found on 10/12/18 during wound care rounds with the physician. When asked whether she had been notified by the nurses or certified nursing assistants (CNAs) of changes in the resident's skin condition to the right calf, she stated no. She was asked about the condition of the wound when observed on 10/12/18. She stated the wound physician documented an unstageable necrosis of the right lateral calf measuring 2.0 x 2.0 cm with a moderate amount serous exudate, less than six days' duration and 100% necrotic. The wound was debrided and a new treatment was ordered. When asked what the cause of the pressure ulcer to the right calf was, she stated it was from the use of the knee immobilizer. When asked who applied the knee immobilizer, she stated that the nurses did. She was asked what the orders were for the use of the knee immobilizer. She stated she would need to review the record. After reviewing the record, she stated she could find no orders for the use of the immobilizer. When asked why the resident required the knee immobilizer, she stated the resident was admitted with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the nursing progress notes found the knee immobilizer was applied on the following dates: 9/1, 9/3, 9/4, 9/5, 9/6, 9/7. 9/8, 9/9, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/24, 9/26, 9/27, 9/29, 10/2, 10/3, 10/4, 10/5, 10/6, 10/8, 10/10, 10/11, 10/15, 10/18, 10/22, 10/23, 10/24, and 10/25/18. There were no assessments performed regarding observation and monitoring of skin condition under the device, circulation, evidence of swelling, pain or color of extremity. An interview was conducted with CNA D on 11/28/18 at 3:23 p.m. She confirmed that Resident #1 had a knee brace and it was on all the time. She did not remember whether it was removed and did not recall it ever being placed back on. She was asked about the resident's bath schedule, and she stated it was scheduled on the day shift. She stated she provided a bed bath and she avoided bathing the area of the knee brace. She washed around the area, but never removed the immobilizer. An interview was conducted with the Physical Therapist (PT) on 11/28/18 at 2:26 p.m. She was asked whether Resident #1 had received PT. She stated there were orders to evaluate and treat. She reported the resident had a knee immobilizer when he entered the facility and there were no orders. The resident had the immobilizer on both in and out of bed, and it was in place every time there was therapy. She stated she never had to remove it or make adjustments. An interview was conducted with the Therapy Director on 11/28/18 at 2:35 p.m. When asked if there was an order for [REDACTED]. She reported that orders normally filtered from the doctor to the nurse and then they were relayed to therapy. A review of the care plan did not include the use of a knee immobilizer for a fractured right lower leg or an unstageable pressure ulcer as a result of the use of the immobilizer.

Based on record reviews and staff interviews, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #1) of one sampled residents with pressure ulcers by failing to obtain orders for the use of a knee immobilizer, and by failing to monitor and assess the condition of the skin beneath the immobilizer, resulting in a Stage 4 pressure ulcer. The findings include: A record review for Resident #1 revealed an [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. The resident was alert with confusion, and required extensive assistance with all activities of daily living except eating. The resident had a urinary catheter and was incontinent of bowel. The resident was ordered Physical and Occupational therapy, and was non-weight bearing on his right leg. At the time of the visit, Resident #1 was on contact isolation [MEDICAL CONDITION] (methycillin-resistant staphylococcus aureus) in the urine. The initial wound care physician assessment, dated 9/7/18, revealed the following: multiple wounds of six days duration to the medial sacrum measuring 1.5 x 1.0 cm (centimeters) with light exudate (drainage) and 100% granulation. Unstageable area deep tissue injury (DTI) to the right buttock, pressure, measuring 5.5 x 5.0 cm. Surrounding DTI purple/maroon, light exudate and 100% granulation. Treatment included silver [MEDICATION NAME] (ointment) twice daily. Recommended low air loss mattress and gel cushion for wheelchair, nutritional supplements, and explained importance of repositioning and off-loading the wound. Wound report, dated 9/28/18, revealed medial sacral wound improving measured 0.5 x 0.5 cm. Right buttock, unstageable due to necrosis, measured 10.5 x 9.5 cm, moderate exudate, and thick adherent necrotic tissue, 10% granulation tissue, wound deteriorated. Wound was debrided. On 10/12/18, the medial sacrum wound was documented as healed. The right buttock wound measured 11 x 10 cm, per the wound doctor with odor, moderate exudate, and 100% devitalized tissue. A new area was detected - unstageable necrotic area right lateral calf, less than 6 days' duration measuring 2.0 x 2.0 cm with moderate serous exudate and 100% necrotic. Area debrided. The Wound Report, dated 10/19/18, found the right calf wound was a Stage 4, measured 3.0 x 2.0 x 0.2 cm with 20% thick necrotic tissue, 70% granulation and 10% tendon exposed. A review of the nursing progress notes for (MONTH) and (MONTH) (YEAR) found no documentation regarding a wound or wound care to the right calf. A review of the weekly skin checks for (MONTH) and (MONTH) (YEAR) found no documentation regarding any new skin issues. A review of the weekly wound progress note written by the wound care nurse on 10/12/18, found no documentation of a necrotic wound to the right lateral leg. The only documentation found in the record was authored by the wound care physician on 10/12/18. An interview was conducted with the wound care nurse on 11/28/18 at 1:35 p.m. She was asked when the unstageable wound to the right calf was discovered, and she replied that it was found on 10/12/18 during wound care rounds with the physician. When asked whether she had been notified by the nurses or certified nursing assistants (CNAs) of changes in the resident's skin condition to the right calf, she stated no. She was asked about the condition of the wound when observed on 10/12/18. She stated the wound physician documented an unstageable necrosis of the right lateral calf measuring 2.0 x 2.0 cm with a moderate amount serous exudate, less than six days' duration and 100% necrotic. The wound was debrided and a new treatment was ordered. When asked what the cause of the pressure ulcer to the right calf was, she stated it was from the use of the knee immobilizer. When asked who applied the knee immobilizer, she stated that the nurses did. She was asked what the orders were for the use of the knee immobilizer. She stated she would need to review the record. After reviewing the record, she stated she could find no orders for the use of the immobilizer. When asked why the resident required the knee immobilizer, she stated the resident was admitted with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the nursing progress notes found the knee immobilizer was applied on the following dates: 9/1, 9/3, 9/4, 9/5, 9/6, 9/7. 9/8, 9/9, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/24, 9/26, 9/27, 9/29, 10/2, 10/3, 10/4, 10/5, 10/6, 10/8, 10/10, 10/11, 10/15, 10/18, 10/22, 10/23, 10/24, and 10/25/18. There were no assessments performed regarding observation and monitoring of skin condition under the device, circulation, evidence of swelling, pain or color of extremity. An interview was conducted with CNA D on 11/28/18 at 3:23 p.m. She confirmed that Resident #1 had a knee brace and it was on all the time. She did not remember whether it was removed and did not recall it ever being placed back on. She was asked about the resident's bath schedule, and she stated it was scheduled on the day shift. She stated she provided a bed bath and she avoided bathing the area of the knee brace. She washed around the area, but never removed the immobilizer. An interview was conducted with the Physical Therapist (PT) on 11/28/18 at 2:26 p.m. She was asked whether Resident #1 had received PT. She stated there were orders to evaluate and treat. She reported the resident had a knee immobilizer when he entered the facility and there were no orders. The resident had the immobilizer on both in and out of bed, and it was in place every time there was therapy. She stated she never had to remove it or make adjustments. An interview was conducted with the Therapy Director on 11/28/18 at 2:35 p.m. When asked if there was an order for [REDACTED]. She reported that orders normally filtered from the doctor to the nurse and then they were relayed to therapy.

Based on record reviews and staff interviews, the facility failed to develop a care plan to address the use of a knee immobilizer for the treatment of [REDACTED].#1) of one resident sampled for pressure ulcers out of one resident in the facility with pressure ulcers. The findings include: A record review for Resident #1 revealed an [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. He was alert with confusion. He required extensive assistance with all activities of daily living except eating. He had a urinary catheter and was incontinent of bowel. He was ordered Physical and Occupational therapy. He was non-weight bearing on the right leg. At the time of the survey, Resident #1 was on contact isolation [MEDICAL CONDITION] (methycillin-resistant staphylococcus aureus) in the urine. The initial nursing assessment dated [DATE] revealed that Resident #1 had a knee immobilzer in place. The initial skin assessment performed on 9/1/18 revealed an unstageable area to the resident's right buttock. On 10/12/18 a new pressure ulcer was discovered by the facility. The wound was an unstageable, necrotic (blackened, dead tissue) area to the right lateral calf. It was identified as with a duration of less than six days and measured 2.0 x 2.0 cm (centimeters). It had a moderate amount of serous exudate (drainage) and was 100 % necrotic. The wound was debrided (To remove dead, contaminated, or adherent tissue and/or foreign material. To debride a wound is to remove all materials that may promote infection and impede healing.) by the wound care physician. The Wound Report dated 10/19/18 found the right calf wound was a stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.), measured 3.0 x 2.0 x 0.2 cm, 20% thick necrotic tissue, 70 % granulation and 10 % tendon exposed. An interview was conducted with the wound care nurse on 11/28/18 at 1:35 p.m. She was asked when the unstageable wound to right calf was discovered, and she replied that it was found on 10/12/18 during wound care rounds with the physician. When asked whether she had been notified by the nurses or certified nursing assistants (CNA) of changes in skin condition to the right calf, she stated no. She was asked about the condition of the wound when observed on 10/12/18. She stated the wound care physician documented an unstageable necrosis of the right lateral calf, measuring 2.0 x 2.0 cm with a moderate amount serous exudate. It was of less than six days' duration and was 100% necrotic. The wound was debrided and a new treatment was ordered. When asked what the cause of the pressure ulcer to the right calf had been, she replied that it resulted from the use of the resident's knee immobilizer. When asked who applied the knee immobilizer, she stated the nurses did. She was asked what the orders were for the use of the knee immobilzer. She stated she would need to review the record. After reviewing the record, she stated she could find no orders for the use of the immobilizer. When asked why the resident required the knee immobilizer, she stated he was admitted with a [DIAGNOSES REDACTED]. He was also non-weight bearing. A review of the physician's orders [REDACTED]. A review of the nursing progress notes found the knee immobilizer was applied on the following dates: 9/1, 9/3, 9/4, 9/5, 9/6, 9/7. 9/8, 9/9, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/24, 9/26, 9/27, 9/29, 10/2, 10/3, 10/4, 10/5, 10/6, 10/8, 10/10, 10/11, 10/15, 10/18, 10/22, 10/23, 10/24 and 10/25/18. There were no assessments performed regarding observation and monitoring of the skin's condition under the device, circulation, evidence of swelling, pain or color of the extremity. A review of the care plan did not include use of a knee immobilzer or an unstageable pressure ulcer as a result of the use of the immobilzer, and this was confirmed by the wound care nurse on 11/28/18 at 1:35 p.m.

Based on observations, record review, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for 1 (Resident #2) of 12 residents in the facility receiving continuous oxygen therapy, by not adhering to physicians' orders related to the number of liters to be administered per hour or maintaining the head of the bed in an elevated position at all times. The findings include: Resident #2 had [DIAGNOSES REDACTED]. A review of Resident #2's History and Physical revealed that the resident had been in the hospital on [DATE] with complaints of progressively worsening [MEDICAL CONDITION], shortness of breath, and an elevated heart rate. Resident #2 was subsequently admitted on [DATE] to the facility. During a tour of the facility on 7/29/2017 at 9:45 AM, the resident was heard calling out for help. After a knock on the door and entry into the room, Resident #2 was seen lying in bed with the oxygen concentrator running at 4 liters per minute, but the nasal cannula was observed lying on the bed. Resident #2 was asked if he needed help, and he replied 'yes'. The resident's face appeared flushed; his breathing was rapid, and no oxygen signs were posted outside or inside of his room. The certified nursing assistant (CNA) was observed in the corridor, and was told the resident was calling for help. She replied, Yes, we know. He is always doing that. Nurse #C was observed at her medication cart, then went into another resident's room. No staff were observed responding to Resident #2's call light at that time. The surveyor was returning past Resident #2's room on 7/29/2017 at 10 AM and saw Resident #2 was now sitting in a wheelchair in the corridor just outside of his door. Upon re-entry into the resident's room, the oxygen concentrator was still running at 4 liters per minute. The surveyor looked again, and no oxygen signs were posted inside or outside of the room. A review of physicians' orders for Resident #2 revealed that the resident was ordered oxygen via nasal cannula at 2 liters per minute every shift; oxygen saturation as needed; notify the physician if saturations were less than 90%, and keep head of bed up 45 degrees at all times to facilitate adequate ventilation. (Evidence obtained) Review of Resident #2's vital signs record showed no documentation of any pulse oximetry readings, despite the resident's history and being admitted with an oxygen order. Review of Resident #2's care plan revealed, Head of bed to be elevated 45 degrees, oxygen sats as ordered and prn, give oxygen therapy as ordered. During an interview with Nurse D at 3PM on 7/29/2017, she was asked to accompany the surveyor to the resident's room. The resident was lying flat in bed, and his face was flushed. Nurse D was asked to read the concentrator as to how much oxygen the resident was receiving at that time. Nurse D looked at the concentrator and stated Resident #2 was receiving 4 liters of oxygen per minute. Nurse D was asked to describe the position the resident was lying in, and stated the resident was lying flat on his back in the supine position. Nurse D was asked to describe his physical appearance, and stated his face looks a bit red and flushed, then she proceeded to ask the resident if he was comfortable and did he want to sit up in the bed more, to which the resident replied, 'yes'. Nurse D went and got a CNA and instructed her to help Resident #2 sit up more, and then returned and proceeded to review Resident #2's record. Resident #2's care plans and physician orders [REDACTED]. Nurse D read the orders, stating he should be receiving 2 liters of oxygen per minute. Then she stated that it must have been a mistake, proceeded to look through all of Resident #2's previous orders. She stated that he should have been on oxygen at 2 liters per minute, and she did not know what had happened. When asked about positioning orders, she stated the physician had ordered the head of the bed be elevated at 45 degrees at all times to facilitate ventilation. When asked what she had seen while in the resident's room, she stated that the bed had not been positioned as ordered. It was flat. At 3:40 PM on 7/29/2017, standing outside of Resident #2's room with the Interim Director of Nursing (DON), she was asked where the oxygen warning sign was posted for both residents in the room, as both of the residents were on continuous oxygen. The DON looked at the door of the room, then went into the room and looked behind the door. She went to the roommate's side of the room, and looked at the window, then stated, We must have missed it. The DON was observed posting an oxygen warning sign on the resident's doorway a few minutes later, then staff were observed checking other residents' rooms for signage. A review of the facility's Oxygen Administration policy, SHCRC .02, stated in part, Post an oxygen precaution (no smoking sign) on the resident's door. Number 12 stated in part Monitor the resident's response to Oxygen therapy. (Evidence obtained)

Based on observations, record reviews, and staff interview during an observation of the holding food temperatures in the kitchen on 5/31/2017 at 12:08 PM, the facility failed to serve cold food at palatable, safe temperatures. The findings include: During observation of the food temperatures on 05/31/2017 at 12:07:56 PM in the kitchen, this surveyor observed two tall open food carts with trays of salad, trays of pumpkin pies, and trays of sliced peaches. The service line started at 11:15 AM. The temperature of the hot beef stew was 150 degrees Fahrenheit, but the pumpkin pie was 80 degrees F. Peaches were 70 degrees Fahrenheit, and the tossed salad was 80 degrees F. The french fries were 100 F. The holding temperature of cold food should not exceed 40 degrees Fahrenheit for food safety. The CDM (Certified Dietary Manager) stated at 12:10 PM that the staff should not have brought out all of the salad trays and the other cold food from the refrigerator into the hot kitchen all at the same time. The staff should have brought out one tray at a time.

Based on observations, staff interviews, and policy and procedure review, the facility failed to ensure medications were stored and labeled correctly for three randomly sampled residents (Residents #38, #110, and #68), in two medication rooms (East and West Wings), a treatment room (East Wing), and on one medication cart (West Wing). This could potentially cause medication errors and use of supplies such as catheters and dressings that may no longer be sterile, which could detrimentally affect the residents. The findings include: The medication storage room on the West Wing was observed on [DATE] at 11:30 AM. In the first medication cart, a container of bleach germicidal wipes was found with the expiration date [DATE]. In the refrigerator, three sterile single use insulin needles were found in the emergency kit with expiration dates of ,[DATE], lot number 26, ,[DATE], lot number 22 and ,[DATE], lot number 97. The treatment storage room on the West Wing was observed on [DATE] at 12:10 PM. A urinary catheter was found in a drawer with no expiration date on the label. The medication storage room on the East Wing was observed on [DATE] at 12:40 PM. A plastic bag labeled Serevent Diskus inhalation powder for Resident #38 was found to have two different 'date opened' dates on it. The storage bag had the date of [DATE], and the vial itself had the date of [DATE]. A plastic bag labeled Serevent Diskus inhalation powder for Resident #110 was found to have two different 'date opened' dates on it. The storage bag had the date of [DATE], and the vial had the date of [DATE]. A box of Umeclidinium inhalation powder for Resident #68 was found to have a different open date of [DATE], and the package inside was dated [DATE]. The treatment room on the East Wing was observed on [DATE] at 12:55 PM. A plastic storage drawer on the counter top was found to have 20 rolls of gauze bandages with no expiration dates on the label. A box containing 20 abdominal pads was found in the cabinet with no expiration date on it. A box containing eight non-woven drain sponges was found in the cabinet with no expiration date on it. During an interview with Employee I, Licensed Practical Nurse (LPN), on [DATE] at 11:33 AM, she stated that she was unaware that the germicidal wipes in her cart were expired. During an interview with Employee D, LPN, on [DATE] at 11:40 AM, she stated that the germicidal wipes were out of date and she would discard them. She was not aware that the three sterile single use insulin needles were in the emergency kit in the refrigerator. During an interview with Employee E, LPN Charge Nurse, on [DATE] at 12:40 pm, she stated that she was not sure why the inhalation powders for Resident #110 and Resident #38 were found to have two different date opened dates on them. She stated that they should have only one date. Review of the policy and procedure entitled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles' dated [DATE] with revision date of [DATE]' revealed in number 4: Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines. Number 5 read once any medication or biological package is opened, Facility should follow manufacturer/ supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Number 16 read: Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biological in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication).

Based on observations, staff interviews, and record reviews, the facility failed to consult with the resident's physician and notify the resident representative/interested family member when 1 resident (Resident #120) sustained two injuries which resulted in the need for physician intervention out of 36 sampled residents. The facility also failed to consult with the resident's physician and notify the resident's representative / interested family member in a timely manner when 1 (Resident #133) refused medication (antibiotics for a wound infection) on multiple occasions. The findings include: 1. On June 2, 2017 at 10:52 AM, Resident #120 was observed in the hallway in his wheelchair. This surveyor noticed a dressing on Resident #120's dorsal (top) left hand with a date of May 30, 2017, 7:00 AM. The dressing was soiled, and looked as though it needed to be changed. A clinical record review revealed that Resident #120 was a [AGE] year-old male with [DIAGNOSES REDACTED]. Further review of the chart revealed no documentation related to skin impairment on the gentleman's left hand or left forearm. There were no treatment orders, no nurses' notes, and no indication that contact was made with the physician, the resident's representative for an interested family member. On June 2, 2017 at 11:37 AM, an interview was conducted with Employee F, Registered Nurse/ Unit Manager West (RN/UMW), regarding the dressing on Resident #120's left hand. Employee F was not sure why the dressing was there or what the current order was. Employee F and this surveyor went to the nurses station and asked Employee E, Licensed Practical Nurse (LPN), to check the computer for treatment orders for Resident #120's left hand. Employee E confirmed that Resident #120 did not have an ordered treatment in the computer for the injury to his left hand. Employee F then asked Employee G, Licensed Practical Nurse (LPN), to assess Resident #120's left hand. On June 2, 2017 at 11:42 AM, Employee G and this surveyor entered Resident #120's room to look at his left hand injury. Employee G confirmed that the dressing in place was dated May 30, 2017 at 7:00 AM (photographic evidence obtained after dressing removed). Employee G attempted to remove the large Band-Aid with gauze underneath it; however, the gauze was imbedded in Resident #120's wound. Employee G had to use her scissors to cut the dressing, leaving gauze imbedded in the wound until she could get supplies to soak it off. Employee G then removed a second Band-Aid with no date or time on it from Resident #120's left forearm. Resident #120 had a skin tear under the Band-Aid. On 6/2/17 at 11:47 AM, the Director of Nursing (DON) was interviewed regarding new treatment orders for residents with skin tears or other injuries. The DON stated that the nurse was supposed to write a treatment order, call the doctor, and notify the family. They have to complete an incident report if they are not sure how the injury occurred. The DON was then asked about using Band-Aids on residents with skin concerns. The DON stated, We don't use Band-Aids, and they should have obtained an order for [REDACTED]. 2. Resident #133 was a [AGE] year-old female admitted to the facility with [DIAGNOSES REDACTED]. Resident #133 was ordered a wound culture for her Stage 4 pressure ulcer on March 11, 2017. The wound culture was positive for extended spectrum beta lactamase (ESBL) resistance, heavy growth. Resident #133 was ordered antibiotics for wound infection. Resident #133 had multiple refusals of her antibiotics; however, the staff did not document in nursing notes the refusals or notify the physician or family of the refusals. Per the resident's medication administration records (MARs), the resident refused on March 12, 2017, March 13, 2017, April 4, 2017, April 7, 2017 (2 doses), April 11, 2017 (2 doses), April 18, 2017 (2 doses), April 19, 2017 (3 doses), April 21, 2017 (2 doses), April 28, 2017, May 5, 2017, May 8, 2017, and May 9, 2017. Resident #133's progress notes and nurses' notes were reviewed for all of the above-mentioned dates, and there was no documentation of Resident #133 ever having refused her antibiotics. On 6/2/17 at 11:03 AM, an interview was conducted with the Director of Nursing (DON) regarding how many times a resident was allowed to refuse their medication before the physician was notified. The DON stated that they could refuse their medication three (3) times before the physician had to be notified. The DON was asked if that was for all medications, and she replied, Yes, all medications. On 6/2/17 at 12:07 PM, an interview was conducted with Resident #133's Advanced Registered Nurse Practitioner (ARNP) regarding her sacral wound. The ARNP was asked if she was notified of Resident #133's refusals of antibiotic therapy (ABT) on multiple occasions, and she replied that she was notified of maybe 1 or 2 occasions, but she was only on call Monday through Friday. The ARNP was asked about the wound infection, and the isolation precautions that Resident #133 was on. The ARNP stated that she could not answer whether Resident #133 was still infected or not, without a follow-up culture, and it was not standard procedure to complete a follow-up culture. Resident #133 was also being treated for [REDACTED]. Resident #133's sister did not want the resident to go out for a biopsy. The ARNP stated that she had not seen Resident #133's wound in at least 2 months, because she was not following it anymore. She last saw Resident #133 on May 9, 2017, and that was when they discontinued the IV and recommended Hospice. The resident had received 8-9 weeks of ABT, but she had no idea how much of the ABT the resident actually received. Upon review of the facility's policy and procedure Refusal of Treatment SHC 3.07, Reviewed: 05/19/2015, Revised: 11/08/2008, page 2, #8: If the resident refuses to accept treatment, the resident's surrogate and the attending physician must be notified of such refusal; and #10: Detailed information relating to the refusal must be entered into the resident's medical record, via Interdisciplinary Progress Note and/or resident/Family Education form. A non-compliance care plan shall be developed to address behaviors. According to the policy and procedure on pages 2 and 3 under the heading of documentation, the facility must: 1. At a minimum, the following must be recorded in the Interdisciplinary Progress Notes and non-compliance care plan: - the date and time the treatment was attempted - the treatment attempted - the resident's response and reason(s) for refusal; - documentation that the resident or surrogate was informed of the purpose of the treatment and the consequences of not receiving the treatment; - documentation each time the resident refused his or her treatment, the resident's condition and any adverse effects due to such refusals; - the date and time the physician was notified as well as the physicians response; - all pertinent observations; - the signature and title of the person recording the data.

Based on resident and staff interviews, observations and record reviews, the facility failed to ensure one resident (Resident #2) out of 36 sampled residents was afforded the right to choose activities and schedules consistent with her interests when a caregiver refused to assist her to get out bed and get dressed to go to a church service. The findings include: During an interview with Resident #2 on 05/30/2017 at 2:32 PM, she stated that she liked to go to the church services offered in the facility on Fridays. She would get up out of bed for that and some other activities if they appealed to her. On 06/02/2017 at 8:21 AM, the resident was observed lying in bed on her back. The head of the bed was elevated at a 45-degree angle. The resident's breakfast tray was on the tray table. She appeared to be watching television. At 8:22 AM, Employee N, Certified Nursing Assistant (CNA), went into the resident's room. The call light was on above the door. The call light was shut off, and the resident was heard to say, I want to get up. The CNA replied, Not now. The CNA asked the resident if she was finished eating her breakfast, and if the CNA could take the tray away. The resident gave consent, and the CNA left the room with the breakfast tray at 8:24 AM. For the next hour and 15 minutes, the CNA was observed walking around on the unit talking to other residents and staff. He was not observed involved in resident care during this time. During an interview with Resident #2 at 8:24 AM, she repeated what the CNA told her, and stated she wanted to be assisted up so she could go to the church service that day. At 9:35 AM, she was observed lying in bed on her back. The head of the bed was lowered, and the resident appeared to be asleep. During an interview with Employee E, Charge Nurse, on 06/02/2017 at 9:40 am, she stated she was not aware that Resident #2 had requested to get up and the CNA had refused to get her up. She stated that the CNA should have gotten the resident up. Employee L, MDS Coordinator, was also involved in the interview and stated that Resident #2 got up for church on Fridays, and that the service started at 10:00 AM. A review of the May 2017 Treatment Administration Records (TARs) for Resident #2, revealed the resident attended the church services each Friday of the month. (Photographic evidence obtained) A review of the care plan, dated 05/16/2017, revealed a focus area that read, I prefer my own daily activity pursuit pattern according to my past/present interest. The goal read: I will attend/participate in activities of my choice at least 1-2 times weekly according to my past/present interest by next review date. The interventions read: I will have assistance/escorted by all staff/volunteers and family activity functions to assure attendance. I will have weekly church services, Bible study group, sing-alongs, gospel music concerts offered according to my religious preference. (Photographic evidence obtained)

Based on observations, staff interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with professional standards of practice when a resident sustained [REDACTED].#120) of 36 sampled residents. The findings include: A clinical record review revealed that Resident #120 was a [AGE] year-old male with [DIAGNOSES REDACTED]. Further review of the chart revealed no documentation related to skin impairment on the gentleman's left hand or left forearm. There were no treatment orders, no nurses' notes, and no indication that contact was made with the physician, the resident's representative for an interested family member. On June 2, 2017 at 10:52 AM, Resident #120 was observed in the hallway in his wheelchair. This surveyor observed a dressing on Resident #120's dorsal (top) left hand with a date of May 30, 2017, 7:00 AM. The dressing was soiled, was coming loose, and looked as though it needed to be changed. On June 2, 2017 at 11:37 AM, an interview was conducted with Employee F, Registered Nurse/ Unit Manager West (RN/UMW), regarding the dressing on Resident #120's left hand. Employee F was not sure why the dressing was there or what the current order was. Employee F and this surveyor went to the nurses station and asked Employee E, Licensed Practical Nurse (LPN), to check the computer for treatment orders for Resident #120's left hand. Employee E confirmed that Resident #120 did not have an ordered treatment in the computer for the injury to his left hand. Employee F then asked Employee G, Licensed Practical Nurse (LPN), to assess Resident #120's left hand. On June 2, 2017 at 11:42 AM, Employee G and this surveyor entered Resident #120's room to look at his left hand injury. Employee G confirmed that the dressing in place was dated May 30, 2017 at 7:00 AM (photographic evidence obtained after dressing removed). Employee G attempted to remove the large Band-Aid with gauze underneath it; however, the gauze was imbedded in Resident #120's wound. Employee G had to use her scissors to cut the dressing, leaving gauze imbedded in the wound until she could get supplies to soak it off. Employee G then removed a second Band-Aid with no date or time on it from Resident #120's left forearm. Resident #120 had a skin tear under the Band-Aid. On 6/2/17 at 11:47 AM, the Director of Nursing (DON) was interviewed regarding new treatment orders for residents with skin tears or other injuries. The DON stated that the nurse was supposed to write a treatment order, call the doctor, and notify the family. They have to complete an incident report if they are not sure how the injury occurred. The DON was then asked about using Band-Aids on residents with skin concerns. The DON stated, We don't use Band-Aids, and they should have obtained an order for [REDACTED].

Based on clinical record review, facility policy and procedure review, and staff interviews, the facility failed to follow a resident's advance directive for 1 (Resident #1) of 3 residents sampled for resident rights of 66 residents who were a full code. Resident #1 had an advance directive that did not include withholding of CPR. The facility neglected to provide Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1, and failed to call 911 per the facility policy and procedure for CPR, and the resident died . Failure to provide proper CPR resulted in denial of any chance of successful resuscitation for the resident, which was immediate jeopardy. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. The findings include: A closed record review conducted for Resident #1 found he was admitted to the facility on [DATE] for rehabilitation post-hospitalization for a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). He was an [AGE] year-old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. There was no DNR (do not resuscitate) paperwork in his record. On [DATE] at 9:15 p.m., Employee A, Licensed Practical Nurse (LPN), completed a Change in Condition nursing note. She documented that the doctor was called at 9:30 p.m. due to inability to obtain blood pressure, temperature, pulse, respirations, or oxygen level on the resident. Employee A noted she was unable to arouse the resident when she entered the room to administer his medications. A review of Emergency Medical Services (EMS) records, dated [DATE], revealed a call was received at 9:40 p.m. with the nature of the call noted as death. EMS personnel found nurses were doing CPR on the resident on the floor upon their arrival at 9:41 p.m. EMS noted the resident on the floor was unresponsive, pulseless, not breathing, cyanotic (bluish color), and pale. An electro-cardiogram revealed no heart rhythm. A review of written statements by the staff dated [DATE], revealed that between 9:00 p.m. and 9:15 p.m. on [DATE], Employee A, LPN, discovered that Resident #1 was unresponsive and without measurable vital signs. Employee A left Resident #1 to request that Employee B, LPN, begin Cardiopulmonary Resuscitation (CPR). A review of the Macclenny NRC CPR: One-Person Rescue policy, review date [DATE], required the staff member discovering the victim to open the resident's airway, check for breathing, assess for circulation, and call for help before beginning compressions. The procedures included calling for help, sending someone someone to contact the Emergency Medical Service (911), and sending someone to call a code. The staff member should begin CPR after determining the resident is unresponsive and breathing. A review of a written statement by Employee A (no date noted) revealed that Employee H, Certified Nursing Assistant (CNA), approached her at 6:40 p.m. on [DATE], and stated that Resident #1 was acting funny. Employee A wrote that she responded by assessing the resident who she found to be Resting comfortable and no acute distress. Respiration even and unlabored. No vital signs were documented during this time. No other healthcare provider (i.e. Registered Nurse or physician) was consulted to check the resident. A few hours later at 9:15 p.m., as per the Change in Condition note by Employee A, the resident was found unresponsive, with no pulse and no respirations. A review of a written statement dated [DATE] by Employee B, LPN, revealed that at 9:00 p.m. on [DATE], Employee A needed her immediate assistance to perform CPR. Employee A stated, I will call rescue if you will do CPR. At 9:05 p.m., Employee B and Employee F, CNA, proceeded to the resident's room. Employee B wrote, We tried to lift the resident to the floor, but we couldn't lift him by ourselves. Another CNA came to assist so the resident could be placed on the floor. His body was cold, his lips were blue, and his eyes were open and fixated. Employee B asked Employee G, CNA, to see whether Employee A called EMS. When Employee G returned, she stated, (Employee A) said she has to complete her paperwork first, and laughed stating, I bet she is still doing compressions isn't she. Employee B then asked Employee F, CNA, to call rescue on her personal phone. According to the statement, at approximately 9:50 p.m. EMS arrived. Employee A never went back to the resident's room. Paramedics questioned Employee B regarding the resident and she stated, I was not his nurse and wasn't familiar with his medical history. Paramedics had to get information from Employee A. At the end of the statement, Employee B stated that Employee H, CNA, reported that she made Employee A aware that the resident was not responding at 6:30 p.m., and the CNA asked Employee A to check on him. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on [DATE] at 11:00 a.m. She stated she was on the other wing of the facility, and heard that a code was happening. She responded at approximately 9:30 p.m. She never went to the room where Employee B was performing CPR on the resident. She went to the nursing station, and saw that Employee A was sitting there doing paperwork. She stated that Employee A told her she forgot to call 911. An interview was conducted with Employee I, LPN, Unit Manager, on [DATE] at 2:00 p.m. She stated she had to come in and work at midnight on [DATE] because Employee A was suspended pending investigation. She confirmed the CNAs and nurses familiar with the incident stated Employee A did not call 911 as required. An interview was conducted with Employee B, LPN, on [DATE] at 2:40 p.m. She confirmed that what was written on her own statement was correct. She stated, I'm still upset about it. I wear a Fitbit (physical activity tracker), and I did CPR for a long time, over 20 minutes, my heartrate was fast. His dinner tray was still in his room untouched. An interview was conducted with the director of nursing (DON) on [DATE] at 3:00 p.m. The DON confirmed that Employee A did not call 911 when she should have. The DON confirmed that Employee A left Resident #1, and requested that Employee B begin CPR. The DON said Employee B stopped administering medication when she was notified by Employee A at 9:15 p.m. Employee B immediately started CPR on the resident. An interview was conducted with the administrator on [DATE] at 4:33 p.m. He stated he was notified immediately after the incident (10:00 p.m.) on [DATE]. He stated the times on the statements written by staff were conflicting. It was unclear why the nurse who performed CPR documented the time CPR began was between 9:00 p.m. and 9:05 p.m. He also stated Employee H, CNA, did see the resident around 6:30 p.m., and reported his condition (unresponsive) to the nurse (Employee A). Employee A checked on Resident #1 right away, and found the resident resting comfortably and breathing. He explained that Employee A enlisted assistance from Employee B at 9:15 p.m. Employee B began CPR immediately after Employee A verified Resident #1's code status at the desk. Employee A went to the nursing station and did paperwork. The administrator stated that Employee A failed to call 911 at that time. A CNA stopped and asked her if she had called 911, and she said that she had forgotten to call 911. The administrator stated that Employee F, CNA, called 911 on her personal cell phone. On [DATE] at 1:00 p.m., Employee B was asked again to explain what happened on the night of [DATE]. She stated, I was in the middle of med (medication) pass, and (Employee A) said she needed my help. I asked her to let me finish what I was doing, and she replied that she needed my help right away. She said, 'I need you to do CPR on a full code dead man.' I locked my cart and went to help. On [DATE] at 1:17 p.m., Employee J, Registered Nurse (RN) stated that she worked full-time, 12-hour shifts. She stated that she had completed multiple CPR drills; she had worked one on one with the nurse educator, and that she was CPR certified. She remembered participating in a mock CPR drill on [DATE] and again in mid-February. Training included all of the steps taken when performing CPR, and she appropriately recited those steps to the surveyor. On [DATE] at 1:30 p.m., Employee B, LPN, stated that the administrator had just contacted her regarding the time she wrote on her statement. They wanted to clarify with Employee B the time she responded to the resident. She confirmed that her documented time was accurate. She did not make any changes to her statement. She explained that her time documented on the Medication Administration Record (MAR) on [DATE] did not reflect the actual time that the medication was given, because it allowed you to sign it at a different time. She explained that she was sure of the time she responded and performed CPR for Resident #1 at 9:05 p.m. On [DATE] at 1:50 p.m., Employee K, Certified Nursing Assistant (CNA) stated that she was a full-time employee. When she was asked what should be done if a resident was discovered unresponsive and not breathing, she was able to recite the appropriate steps to take according to the facility's policy for initiation of CPR. On [DATE] at 2:15 p.m., the Minimum Data Set (MDS) Coordinator (LPN), explained that an audit was completed for every resident in the facility to ensure that their DNR status was documented clearly in their clinical records. The facility also initiated daily CPR drills for 7 days to ensure that all staff participated. Afterward, CPR drills would be conducted monthly. The crash carts were checked to ensure that all potentially needed supplies were available, and all CPR certification cards were reviewed. She stated that the facility had been conducting CPR drills randomly each month prior to this incident. During an interview on [DATE] at 3:18 p.m. with the Social Services Director (SSD), she stated that she discussed advance directives with residents and/or their representatives upon admission. If the resident did not wish to have a DNR (do not resuscitate), the facility identified the chart using a black marker, and if the resident wished to be a DNR, the chart was marked with a red marker for quick identification. The facility administrator was made aware of Resident #1's death at 10:00 p.m. on [DATE]. The director of nursing and unit manager were made aware by 10:30 p.m. on [DATE]. The administrator started an investigation on [DATE] by suspending Employee A, and assigning another nurse to take over Employee A's assignment. Facility-wide training in CPR, activation of EMS services, and changes in condition for all staff was initiated on [DATE]. Staff involved were interviewed. An audit was completed of all residents' clinical records to ensure that their DNR status was clearly documented. An audit of all deaths within the last 6 months was conducted to identify any additional educational needs. The administrator initiated random code simulations daily for all nursing staff for 7 days, then to continue monthly thereafter. He developed a plan for the Quality and Assurance Assessment (QA&A) committee to track the progress of the corrective action plan monthly until resolved. An audit was completed of all nursing staff to ensure that there would be a CPR certified staff member on all shifts. The administrator terminated Employee A and reported her to the State Nursing Board.

Based on clinical record review, facility policy and procedure review, and staff interviews, the facility failed to protect residents from neglect for 1 (Resident #1) of 3 residents sampled for resident rights of 66 residents who were a full code. Resident #1 had an advance directive that did not include withholding of CPR. The facility neglected to provide Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1, and failed to call 911 per the facility policy and procedure for CPR, and the resident died . Failure to provide CPR resulted in denial of any chance of successful resuscitation for the resident, which was immediate jeopardy. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. The findings include: A review of the facility abuse/neglect report to the agency revealed the facility's Social Services Director (SSD) reported an incident involving Resident #1 that occurred on [DATE] at 10:30 p.m., as per the report, and was identified as neglect. The SSD documented that she notified the resident's representative, law enforcement, and the Florida State Abuse Registry on [DATE]. A closed record review conducted for Resident #1 found he was admitted to the facility on [DATE] for rehabilitation post-hospitalization for a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). He was an [AGE] year-old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. There was no DNR (do not resuscitate) paperwork in his record. On [DATE] at 9:15 p.m., Employee A, Licensed Practical Nurse (LPN), completed a Change in Condition nursing note. She documented that the doctor was called at 9:30 p.m. due to inability to obtain blood pressure, temperature, pulse, respirations, or oxygen level on the resident. Employee A noted she was unable to arouse the resident when she entered the room to administer his medications. A review of Resident #1's 14-day Minimum Data Set (MDS) assessment revealed that he was oriented only to himself. His Brief Interview for Mental Status (BIMS) score was 5 out of 15, indicating significant cognitive impairment. He required extensive assistance of ,[DATE] persons for all of his activities of daily living except eating. He used a walker and wheelchair for mobility. A review of Emergency Medical Services (EMS) records, dated [DATE], revealed a call was received at 9:40 p.m. with the nature of the call noted as death. EMS personnel found nurses were doing CPR on the resident on the floor upon their arrival at 9:41 p.m. EMS noted the resident on the floor was unresponsive, pulseless, not breathing, cyanotic (bluish color), and pale. An electro-cardiogram revealed no heart rhythm. A review of written statements by the staff dated [DATE], revealed that between 9:00 p.m. and 9:15 p.m. on [DATE], Employee A, LPN, discovered that Resident #1 was unresponsive and without measurable vital signs. Employee A left Resident #1 to request that Employee B, LPN, begin Cardiopulmonary Resuscitation (CPR). A review of the Macclenny NRC CPR: One-Person Rescue policy, review date [DATE], required the staff member discovering the victim to open the resident's airway, check for breathing, assess for circulation, and call for help before beginning compressions. The procedures included calling for help, sending someone someone to contact the Emergency Medical Service (911), and sending someone to call a code. The staff member should begin CPR after determining the resident is unresponsive and breathing. A review of a written statement by Employee A (no date noted) revealed that Employee H, Certified Nursing Assistant (CNA), approached her at 6:40 p.m. on [DATE], and stated that Resident #1 was acting funny. Employee A wrote that she responded by assessing the resident who she found to be Resting comfortable and no acute distress. Respiration even and unlabored. No vital signs were documented during this time. No other healthcare provider (i.e. Registered Nurse or physician) was consulted to check the resident. A few hours later at 9:15 p.m., as per the Change in Condition note by Employee A, the resident was found unresponsive, with no pulse and no respirations. A review of a written statement by Employee B, LPN, dated [DATE] revealed that at 9:00 p.m. on [DATE], Employee A needed her immediate assistance to perform CPR. Employee A stated, I will call rescue if you will do CPR. At 9:05 p.m., Employee B and Employee F, CNA, proceeded to the resident's room. Employee B wrote, We tried to lift the resident to the floor, but we couldn't lift him by ourselves. Another CNA came to assist so the resident could be placed on the floor. His body was cold, his lips were blue, and his eyes were open and fixated. Employee B asked Employee G, CNA, to see whether Employee A called EMS. When Employee G returned, she stated, (Employee A) said she has to complete her paperwork first, and laughed stating, I bet she is still doing compressions isn't she. Employee B then asked Employee F, CNA, to call rescue on her personal phone. According to the statement, at approximately 9:50 p.m. EMS arrived. Employee A never went back to the resident's room. Paramedics questioned Employee B regarding the resident and she stated, I was not his nurse and wasn't familiar with his medical history. Paramedics had to get information from Employee A. At the end of the statement, Employee B stated that Employee H, CNA, reported that she made Employee A aware that the resident was not responding at 6:30 p.m., and the CNA asked Employee A to check on him. An interview was conducted with Employee D, Physical Therapy Assistant, on [DATE] at 10:35 a.m. He stated Resident #1 was a frail guy, tall, thin, and quiet. I had him for 30 minutes on [DATE]. He finished rehab at 2:00 - 3:00 p.m. He did all the activities. We ambulated a short distance. He rode a bike and transferred. We went to his room. He was alert and he was good. He answered appropriately and had no complaints. During the day he did occupational therapy as well. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on [DATE] at 11:00 a.m. She stated she was on the other wing of the facility, and heard that a code was happening. She responded at approximately 9:30 p.m. She never went to the room where Employee B was performing CPR on the resident. She went to the nursing station, and saw that Employee A was sitting there doing paperwork. She stated that Employee A told her she forgot to call 911. An interview was conducted with Employee I, LPN, Unit Manager, on [DATE] at 2:00 p.m. She stated she had to come in and work at midnight on [DATE] because Employee A was suspended pending investigation. She confirmed the CNAs and nurses familiar with the incident stated Employee A did not call 911 as required. An interview was conducted with Employee B, LPN, on [DATE] at 2:40 p.m. She confirmed that what was written on her own statement was correct. She stated, I'm still upset about it. I wear a Fitbit and I did CPR for a long time, over 20 minutes, my heartrate was fast. His dinner tray was still in his room untouched. An interview was conducted with the director of nursing (DON) on [DATE] at 3:00 p.m. The DON confirmed that Employee A did not call 911 when she should have. The DON confirmed that Employee A left Resident #1, and requested that Employee B begin CPR. The DON said Employee B stopped administering medication when she was notified by Employee A at 9:15 p.m. Employee B immediately started CPR on the resident. An interview was conducted with the Social Services Director (SSD) on [DATE] at 3:27 p.m. She stated that in-services were provided to staff which included information about resident abuse/neglect and burn out. She stated that department heads were made aware promptly if there was a concern about an employee's stress level. Staff are taught to make their supervisors aware immediately if they are concerned about abuse/neglect. An interview was conducted with the administrator on [DATE] at 4:33 p.m. He stated he was notified immediately after the incident (10:00 p.m.) on [DATE]. He stated the times on the statements written by staff were conflicting. It was unclear why the nurse who performed CPR documented the time CPR began was between 9:00 p.m. and 9:05 p.m. He also stated Employee H, CNA, did see the resident around 6:30 p.m., and reported his condition (unresponsive) to the nurse (Employee A). Employee A checked on Resident #1 right away, and found the resident resting comfortably and breathing. He explained that Employee A enlisted assistance from Employee B at 9:15 p.m. Employee B began CPR immediately after Employee A verified Resident #1's code status at the desk. Employee A went to the nursing station and did paperwork. The administrator stated that Employee A failed to call 911 at that time. A CNA stopped and asked her if she had called 911, and she said that she had forgotten to call 911. The administrator stated that Employee F, CNA, called 911 on her personal cell phone. On [DATE] at 1:17 p.m., Employee J, Registered Nurse (RN) stated that she worked full-time, 12-hour shifts. She stated that she had completed multiple CPR drills; she had worked one on one with the nurse educator, and that she was CPR certified. She remembered participating in a mock CPR drill on [DATE] and again in mid-February. Training included all of the steps taken when performing CPR, and she appropriately recited those steps to the surveyor. On [DATE] at 1:30 p.m., Employee B, LPN, stated that the administrator had just contacted her regarding the time she wrote on her statement. They wanted to clarify with Employee B the time she responded to the resident. She confirmed that her documented time was accurate. She did not make any changes to her statement. She explained that her time documented on the Medication Administration Record (MAR) on [DATE] did not reflect the actual time that the medication was given, because it allowed you to sign it at a different time. She explained that she was sure of the time she responded and performed CPR for Resident #1 at 9:05 p.m. On [DATE] at 1:50 p.m., Employee K, Certified Nursing Assistant (CNA) stated that she was a full-time employee. When she was asked what should be done if a resident was discovered unresponsive and not breathing, she was able to recite the appropriate steps to take according to the facility's policy for initiation of CPR. On [DATE] at 2:15 p.m., the Minimum Data Set (MDS) Coordinator (LPN), explained that an audit was completed for every resident in the facility to ensure that their DNR status was documented clearly in their clinical records. The facility also initiated daily CPR drills for 7 days to ensure that all staff participated. Afterward, CPR drills would be conducted monthly. The crash carts were checked to ensure that all potentially needed supplies were available, and all CPR certification cards were reviewed. She stated that the facility had been conducting CPR drills randomly each month prior to this incident. During an interview on [DATE] at 3:18 p.m. with the Social Services Director (SSD), she stated that she discussed advance directives with residents and/or their representatives upon admission. If the resident did not wish to have a DNR (do not resuscitate), the facility identified the chart using a black marker, and if the resident wished to be a DNR, the chart was marked with a red marker for quick identification. The facility administrator was made aware of Resident #1's death at 10:00 p.m. on [DATE]. The director of nursing and unit manager were made aware by 10:30 p.m. on [DATE]. The administrator started an investigation on [DATE] by suspending Employee A, and assigning another nurse to take over Employee A's assignment. Facility-wide training in CPR, activation of EMS services, and changes in condition for all staff was initiated on [DATE]. Staff involved were interviewed. An audit was completed of all residents' clinical records to ensure that their DNR status was clearly documented. An audit of all deaths within the last 6 months was conducted to identify any additional educational needs. The administrator initiated random code simulations daily for all nursing staff for 7 days, then to continue monthly thereafter. He developed a plan for the Quality and Assurance Assessment (QA&A) committee to track the progress of the corrective action plan monthly until resolved. An audit was completed of all nursing staff to ensure that there would be a CPR certified staff member on all shifts. The administrator terminated Employee A and reported her to the State Nursing Board.

Based on clinical record review, facility policy and procedure review, and staff interviews, the facility failed to provide services that met professional standards for 1 out of 3 sampled residents who expired in the facility (Resident #1) by failing to initiate Cardiopulmonary Resuscitation (CPR) after finding Resident #1 unresponsive. The facility failed to immediately determine the resuscitation code of Resident #1, and failed to call 911 per the facility policy and procedure for CPR, and the resident died . The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. According to the 2015 American Heart Association Handbook of Emergency Cardiovascular Care for Healthcare Providers, The following sequence is intended for a single healthcare provider rescuer. If additional rescuers are available, the first rescuer feels for a pulse for no more than 10 seconds and starts chest compressions if pulse is not definitely palpated. A second rescuer activates the emergency response number and obtains an automated external defibrillator (AED), and a third rescuer opens the airway and provides ventilation. Recognition: The victim is not responsive and not breathing or only gasping (i.e. not breathing normally). Check for breathing and pulse. Activation: Activate the emergency response system and send someone to retrieve emergency equipment. Pulse Check: Check pulse for no more than 10 seconds (carotid in adult). If pulse is absent provide CPR until advanced life support providers arrive. If pulse is present, but breathing is absent, open the airway and provide rescue breathing. Recheck the pulse every two minutes. Continue CPR until advanced life support providers arrive or the victim starts to move. According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) State Statute, Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgement, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured or infirmed; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) Nursing diagnosis means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment, and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. (f) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. The practice of practical nursing is defined as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance of health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, or a licensed dentist. The findings include: A review of the facility abuse/neglect report to the agency revealed the facility's Social Services Director (SSD) reported an incident involving Resident #1 that occurred on [DATE] at 10:30 p.m., as per the report, and was identified as neglect. The SSD documented that she notified the resident's representative, law enforcement, and the Florida State Abuse Registry on [DATE]. A closed record review conducted for Resident #1 found he was admitted to the facility on [DATE] for rehabilitation post-hospitalization for a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). He was an [AGE] year-old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. There was no DNR in his record. On [DATE] at 9:15 p.m., Employee A, Licensed Practical Nurse (LPN), completed a Change in Condition nursing note. She documented that the doctor was called at 9:30 p.m. due to inability to obtain blood pressure, temperature, pulse, respirations, or oxygen level on the resident. Employee A noted she was unable to arouse the resident when she entered the room to administer his medications. A review of Resident #1's 14-day Minimum Data Set (MDS) assessment revealed that he was oriented only to himself. His Brief Interview for Mental Status (BIMS) score was 5 out of 15, indicating significant cognitive impairment. He required extensive assistance of ,[DATE] persons for all of his activities of daily living except eating. He used a walker and wheelchair for mobility. A review of Emergency Medical Services (EMS) records, dated [DATE], revealed a call was received at 9:40 p.m. with the nature of the call noted as death. EMS personnel found nurses were doing CPR on the resident on the floor upon their arrival at 9:41 p.m. EMS noted the resident on the floor was unresponsive, pulseless, not breathing, cyanotic (bluish color), and pale. An electro-cardiogram revealed no heart rhythm. A review of written statements by the staff dated [DATE], revealed that between 9:00 p.m. and 9:15 p.m. on [DATE], Employee A, LPN, discovered that Resident #1 was unresponsive and without measurable vital signs. Employee A left Resident #1 to request that Employee B, LPN, begin Cardiopulmonary Resuscitation (CPR). A review of the Macclenny NRC CPR: One-Person Rescue policy, review date [DATE], required the staff member discovering the victim to open the resident's airway, check for breathing, assess for circulation, and call for help before beginning compressions. The procedures included calling for help, sending someone someone to contact the Emergency Medical Service (911), and sending someone to call a code. The staff member should begin CPR after determining the resident is unresponsive and breathing. A review of a written statement by Employee A (no date noted) revealed that Employee H, Certified Nursing Assistant (CNA), approached her at 6:40 p.m. on [DATE], and stated that Resident #1 was acting funny. Employee A wrote that she responded by assessing the resident who she found to be Resting comfortable and no acute distress. Respiration even and unlabored. No vital signs were documented during this time. No other healthcare provider (i.e. Registered Nurse or physician) was consulted to check the resident. A few hours later at 9:15 p.m., as per the Change in Condition note by Employee A, the resident was found unresponsive, with no pulse and no respirations. A review of a written statement by Employee B, LPN, dated [DATE] revealed that at 9:00 p.m. on [DATE], Employee A needed her immediate assistance to perform CPR. Employee A stated, I will call rescue if you will do CPR. At 9:05 p.m., Employee B and Employee F, CNA, proceeded to the resident's room. Employee B wrote, We tried to lift the resident to the floor, but we couldn't lift him by ourselves. Another CNA came to assist so the resident could be placed on the floor. His body was cold, his lips were blue, and his eyes were open and fixated. Employee B asked Employee G, CNA, to see whether Employee A called EMS. When Employee G returned, she stated, (Employee A) said she has to complete her paperwork first, and laughed stating, I bet she is still doing compressions isn't she. Employee B then asked Employee F, CNA, to call rescue on her personal phone. According to the statement, at approximately 9:50 p.m. EMS arrived. Employee A never went back to the resident's room. Paramedics questioned Employee B regarding the resident and she stated, I was not his nurse and wasn't familiar with his medical history. Paramedics had to get information from Employee A. At the end of the statement, Employee B stated that Employee H, CNA, reported that she made Employee A aware that the resident was not responding at 6:30 p.m., and the CNA asked Employee A to check on him. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on [DATE] at 11:00 a.m. She stated she was on the other wing of the facility, and heard that a code was happening. She responded at approximately 9:30 p.m. She never went to the room where Employee B was performing CPR on the resident. She went to the nursing station, and saw that Employee A was sitting there doing paperwork. She stated that Employee A told her she forgot to call 911. An interview was conducted with Employee I, LPN, Unit Manager, on [DATE] at 2:00 p.m. She stated she had to come in and work at midnight on [DATE] because Employee A was suspended pending investigation. She confirmed the CNAs and nurses familiar with the incident stated Employee A did not call 911 as required. An interview was conducted with Employee B, LPN, on [DATE] at 2:40 p.m. She confirmed that what was written on her own statement was correct. She stated, I'm still upset about it. I wear a Fitbit and I did CPR for a long time, over 20 minutes, my heartrate was fast. His dinner tray was still in his room untouched. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:00 p.m. The DON confirmed that Employee A did not call 911 when she should have. The DON confirmed that Employee A left Resident #1, and requested that Employee B begin CPR. The DON said Employee B stopped administering medication when she was notified by Employee A at 9:15 p.m. Employee B immediately started CPR on the resident. An interview was conducted with the administrator on [DATE] at 4:33 p.m. He stated he was notified immediately after the incident (10:00 p.m.) on [DATE]. He stated the times on the statements written by staff were conflicting. It was unclear why the nurse who performed CPR documented the time CPR began was between 9:00 p.m. and 9:05 p.m. He also stated Employee H, CNA, did see the resident around 6:30 p.m., and reported his condition (unresponsive) to the nurse (Employee A). Employee A checked on Resident #1 right away, and found the resident resting comfortably and breathing. He explained that Employee A enlisted assistance from Employee B at 9:15 p.m. Employee B began CPR immediately after Employee A verified Resident 31's code status at the desk. Employee A went to the nursing station and did paperwork. The administrator stated that Employee A failed to call 911 at that time. A CNA stopped and asked her if she had called 911, and she said that she had forgotten to call 911. The administrator stated that Employee F, CNA, called 911 on her personal cell phone. On [DATE] at 1:17 p.m., Employee J, Registered Nurse (RN) stated that she worked full-time, 12-hour shifts. She stated that she had completed multiple CPR drills; she had worked one on one with the nurse educator, and that she was CPR certified. She remembered participating in a mock CPR drill on [DATE] and again in mid-February. Training included all of the steps taken when performing CPR, and she appropriately recited those steps to the surveyor. On [DATE] at 1:30 p.m., Employee B, LPN, stated that the administrator had just contacted her regarding the time she wrote on her statement. They wanted to clarify with Employee B the time she responded to the resident. She confirmed that her documented time was accurate. She did not make any changes to her statement. She explained that her time documented on the Medication Administration Record (MAR) on [DATE] did not reflect the actual time that the medication was given, because it allowed you to sign it at a different time. She explained that she was sure of the time she responded and performed CPR for Resident #1 at 9:05 p.m. On [DATE] at 1:50 p.m., Employee K, Certified Nursing Assistant (CNA) stated that she was a full-time employee. When she was asked what should be done if a resident was discovered unresponsive and not breathing, she was able to recite the appropriate steps to take according to the facility's policy for initiation of CPR. On [DATE] at 2:15 p.m., the Minimum Data Set (MDS) Coordinator (LPN), explained that an audit was completed for every resident in the facility to ensure that their DNR status was documented clearly in their clinical records. The facility also initiated daily CPR drills for 7 days to ensure that all staff participated. Afterward, CPR drills would be conducted monthly. The crash carts were checked to ensure that all potentially needed supplies were available, and all CPR certification cards were reviewed. She stated that the facility had been conducting CPR drills randomly each month prior to this incident. The facility administrator was made aware of Resident #1's death at 10:00 p.m. on [DATE]. The director of nursing and unit manager were made aware by 10:30 p.m. on [DATE]. The administrator started an investigation on [DATE] by suspending Employee A, and assigning another nurse to take over Employee A's assignment. Facility-wide training in CPR, activation of EMS services, and changes in condition for all staff was initiated on [DATE]. Staff involved were interviewed. An audit was completed of all residents' clinical records to ensure that their DNR status was clearly documented. An audit of all deaths within the last 6 months was conducted to identify any additional educational needs. The administrator initiated random code simulations daily for all nursing staff for 7 days, then to continue monthly thereafter. He developed a plan for the Quality and Assurance Assessment (QA&A) committee to track the progress of the corrective action plan monthly until resolved. An audit was completed of all nursing staff to ensure that there would be a CPR certified staff member on all shifts. The administrator terminated Employee A and reported her to the State Nursing Board.

Based on observation, record review and staff interview, the facility failed to ensure each resident was free from harm due to falls for 1 ( Resident #49) of 28 sampled residents. The facility failed to demonstrate effective fall prevention measures, or revise the plan of care when the current plan of care proved ineffective as demonstrated by multiple falls and the eventual injury the resident sustained [REDACTED]. Furthermore, the facility failed to ensure all safety alarms are responded to in a timely manner for 1 (Resident #74) of 28 sampled residents. The findings include: 1. A review of the Resident #49's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded for falls and coded for having memory problems and being moderately impaired for decision making. A review of the resident's Care plan for falls initiated 2/4/11 revealed the resident fell on [DATE] and 12/6/10. The "Need" section of the care plan stated the resident required extensive to total assist with activities of daily living, transfers, toileting and mobility. The "Goal" of the care plan was for the resident to be free from injury. The "Approach" section of the care plan listed the following: 1. Keep bed in lowest position; 2. Provide assistance of 1-2 during transfers; 3. Reinforce instructions on correct/safe transfer techniques prn (as needed); 4. Report falls/injury to MD and treatment as prescribed; 5. Keep call bell within easy reach; 6. Keep pathways clean, neat and free from clutter; 7. Assist/ensure resident to wear nonskid sole shoes, socks, or slippers, assess shoes for proper fit, secure and strings tied; 8. Assess and accommodate need for rest; 9. Toilet at frequent intervals per toileting schedule as resident may allow; 10. Provide adequate lighting to minimize glare; 11. Use of bed/chair alarms for decrease in safety awareness; 12. Use of seatbelt to wheelchair, release for care and services. Further review of the care plan revealed the resident fell on [DATE] with no injuries. A review of the physician's orders [REDACTED]. Discontinue w/c (wheelchair) seatbelt." A review of the Fall Risk Care Plan revealed the care plan was revised on 4/4/11 to include "lap tray to w/c to promote upright positioning " and discontinuing the seat belt. Facility provided documents titled, "Macclenny Nursing & Rehab's Education for the Day" dated 4/6/11, 4/13/11 and 4/14/11 listed several residents, including Resident #49. The information regarding Resident #49 directed staff to keep the lap tray secure. The Care Plan for Fall Risk further revealed the resident fell on [DATE], with no revision to the care plan. Further review of the clinical record revealed a document titled, "Rehabilitation Service Interdisciplinary Screening Form" dated 5/9/11 stated, "Observed on floor of assisted dining room by w/c - lap tray had been removed for resident to sit at table for meal - cont with lap tray to w/c." A review of the resident's nurses notes revealed an entry dated 5/9/11 stated, "IDT (Interdisciplinary Team) reviewing res (resident) fall on 5/8/11. Res was observed sitting on floor in assisted dining room. No injuries obtained...Will continue lap tray on w/c for positioning." A nurses note dated 5/11/11 stated, "Focus meeting to review fall on 5/8/11. She was observed on floor in rehab dining room. No injuries sustained. Family and MD notified. Cont with lap tray on w/c for positioning. Resident conts (continues) on Seroquel for psychosis. Behaviors include pacing in w/c, hallucinations, fidgeting. Saw on 4/4/11 with no change. Followed by (physician name) psych services." A review of documents provided by the facility titled, "Macclenny Nursing & Rehab Education for the Day" dated 5/9/11, 5/10/11 and 5/11/11 revealed several residents were listed, including Resident #49. The information regarding Resident #49 directed staff to keep the lap tray secure. The documentation did not provide instruction on how to keep the resident safe or what supervision was needed when the lap tray was removed. A nurse's note dated 6/27/11 revealed the resident slid out of her wheelchair and was observed sitting on the floor. Review of the care plan for Fall Risk revealed it was revised on 6/28/11 to include a chair pressure alarm. A review of documents provided by the facility titled, "Macclenny Nursing & Rehab Education for the Day" dated 6/28/11, 6/29/11 and 6/30/11 revealed several residents were listed, including Resident #49. The information regarding Resident #49 directed staff to keep the lap tray secure, but failed to include instructions for the chair pressure alarm. A therapy screen dated 6/28/11 was reviewed and indicated a chair alarm was placed by nursing. A nurse's note dated 7/7/11 at 1:10 PM revealed, "heard alarm sound down hall. Observed res lying on floor in front of w/c lap tray off w/c. No injury noted, MD & family made aware." A nurses note dated 7/8/11 stated, "IDT mtg (meeting) to review res fall of 7/7/11 at 12:50 PM. Res was observed lying in front of her wheelchair, lap tray noted on floor also. Chair alarm sounding appropriately...IDT reviewed use of lap tray. Staff education/evaluation of application initiated and ongoing. Will cont (continue) to evaluate for use of lap tray with MD, family, res, and Hospice services. Will also continue with ongoing review and revision of her POC (Plan of Care)." A review of the care plan for Fall risk revealed a revision dated 7/7/11 adding, "staff education on application of lap tray for positioning." A review of documents provided by the facility titled, "Macclenny Nursing & Rehab Education for the Day" dated 7/7/11 revealed several residents were listed, including Resident #49. The information regarding Resident #49 directed staff to keep the lap tray secure. An observation of Resident #49 on 7/19/11 at 9:30 AM, revealed the resident sitting in her wheelchair with a lap tray secured to the wheelchair. A large bandage was on her forehead and her entire face appeared discolored and blue. An interview with a Certified Nursing Assistant (CNA) on 7/19/11 at 9:30 AM revealed the resident had fallen the day before and had gone to an emergency room and returned with stitches to her forehead. On 7/21/11 at 8:21 AM an interview with the CNA working with Resident #49 when the fall occurred on 7/18/11, revealed the resident was taken into the assisted dining room and the CNA took off the lap tray from Resident #49's wheelchair. She stated she turned away from resident to put the lap tray on counter and although the resident was sitting up when tray was there, when she turned away the resident fell out of chair to floor. The CNA also stated the lap tray was used because the resident leans forward, and the lap tray was to prevent falls. A review of the nurse's notes dated 7/18/11 at noon stated, "Resident in assisted dining where lap tray was removed for more comfort and ease of eating, resident then fell forward out of w/c and on the floor. Resident observed with bruise over nose and large laceration on forehead. Bleeding observed from laceration. MD notified. Orders received to send resident to ER for evaluation." A nurses note dated 7/18/11 at 3:15 PM stated, "Resident returned to facility with bandage on head, bruises on bilateral knees, and open area on nose." A nurse's note dated 7/19/11 at 10:15 AM stated, "IDT meeting in place to review fall on 7/18/11. She was in assisted dining when lap tray was removed for more comfort /ease of eating when she fell forward out of w/c onto floor. She had a bruise on nose and a laceration approx (approximately) 1 1/2 inches on forehead. bleeding. MD called and ordered her to be sent to ER for evaluation. Res -c/o pain...cont with current POC." A review of documents provided by the facility titled, "Macclenny Nursing & Rehab Education for the Day" dated 7/19/11 revealed several residents were listed, including Resident #49. The information regarding Resident #49 instructed staff to, "be sure lap tray is secured." A review of the care plan for Fall Risks revealed the care plan was revised 7/20/11 to include, "counter weights placed on back of w/c for additional safety measures." A review of the Rehabilitation Service Interdisciplinary screening form dated 7/18/11 stated, "res fell from w/c in assisted dining room with lap tray removed. Staff present - Counter weights placed on back of w/c for additional safety measure - cont with lap tray for positioning." An interview with the Director of Nursing (DON) on 7/21/11 at 10:15 AM revealed the counter weights on the back of the wheelchair were put on the wheelchair as the resident had very , very swollen lower legs and they may cause the wheelchair to tip. 2. An observation on 7/18/11 at 10:17 AM, in the West wing, revealed an alarm going off in the bedroom of Resident #74, which was the last room on the wing, furthest from the nurses station. The door to the room was observed to be closed. At 10:18 AM the room was entered and Resident #74 was observed standing at the bathroom door. The resident was observed to walk into the bathroom. At 10:21 AM the resident was observed to walk out of the bathroom and walk toward her bed, the alarm still sounding. The resident then sat on the edge of her bed. At 10:22 AM the surveyor sought out a staff member and alerted them the alarm was sounding. A review of the clinical record for Resident #74 revealed the resident was admitted on [DATE]. Further review of the clinical record revealed a physician's orders [REDACTED]. An interim care plan for the resident dated 6/24/11 revealed a care plan for risk for falls that included bed and wheelchair alarms. An interview with the Director of Nursing (DON) on 7/21/11 at 10:16 AM revealed a chair/bed alarm in Resident #74's room, with the door closed, would not be heard at the nurse's station. .