Every finding on record at Madison Pointe Care Center

Based on observations, interviews, and record review, the facility failed to ensure two residents (#210 and #211), assisted with care by a Certified Nursing Assistant (CNA), was free from verbal/psychosocial abuse. out of twelve residents sampled for abuse. Findings included: During an interview on 04/15/24 12:00 p.m., Resident #210 stated Staff A, CNA this weekend started using the F bomb and stated she was just not doing it over the weekend. Resident #210 stated Staff A, CNA also was on her phone with the earbuds talking to someone about threesomes. Resident #210's Family Representative (FR), present during the interview, also stated I didn't even go to work today, I came in because I am worried about my mom and her care. Resident #210's FR stated when she and Resident #210 reported Staff A, CNA over the weekend to Staff E, Licensed Practical Nurse (LPN) , Staff A, CNA ,after being reassigned, came back into Resident #210's room and asked what she did wrong. Resident #210 stated she felt very uncomfortable and even a little threatened. Resident #210's FR informed Staff A they felt very uncomfortable and Staff A left the room. During an interview on 04/15/24 at 12:15 p.m., Resident #211's family member stated he was certainly grateful for Resident #210 and the FR who spoke up to ensure Staff A, CNA was no longer able to work with Resident #211. Resident #211's family member stated he was not present during the time Staff A, CNA was being disrespectful and verbally aggressive towards Resident #211 but all the information could be obtained by speaking with Resident #210 and Resident #210's FR. Review of the Admission Record showed Resident #210 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of femur subsequent encounter for closed fracture with routine healing, cerebellar ataxia in diseases classified elsewhere, polyneuropathy, heart failure and spinal stenosis. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #210 had a BIMS score of 14 (cognitively intact. During a second interview on 04/15/24 at 2:50 p.m. Resident #210 stated the incident occurred on Sunday 04/14/24. Resident #210 recalled it all started when the roommate (Resident #211) had to go to the bathroom. Resident #210 stated she heard Staff A, CNA yell at Resident #211 saying Don't do that, you are going to make me have to clean {expletive} off the call light pull string. Resident #210 stated Staff A, CNA took Resident #211's wheelchair, shoved it out of the bathroom door and It hit my bed. Resident #210 stated she heard Staff A, CNA state, I don't feel like this {expletive} crap today. Resident #210 stated her FR walked in to visit about that time and was also present in the room. Resident #210 stated Staff A, CNA was on the phone and was talking about :threesomes and cussing. Resident #210 stated both she and Resident #210's FR talked with Staff E, LPN about it and she stated Staff A, CNA would not be coming back into the room. Resident #210 stated after lunch Staff A, CNA came back in to the room to pick up the lunch tray and began interrogating and asking why she was reassigned. Resident #210 stated, It was like she was going to get one more dig in. Resident #210 stated the FR spoke up and informed Staff A the conversation was getting very uncomfortable and Staff A, CNA left the room. Review of the facility's actual working schedule for 04/14/24 revealed Staff A, CNA was assigned to both Resident #210 and Resident #211 for the 6:45 a.m.-3:15 p.m. shift. During an interview on 04/15/24 at 3:12 p.m., the Staffing Coordinator (SC) identified Staff A, CNA as the CNA assigned to Resident #210 and Resident #211's room on 04/14/24. Review of the facility's reportable's for April 2024 showed no reportable for the date of 04/14/24. During an interview on 04/15/24 at approximately 3:20 p.m., the Administrator stated there were no additional reportable's for April. During an interview on 04/15/24 at 3:30 p.m., Staff A, CNA stated she provided care for Resident #210 and #211 on Sunday 04/14/24 until she was reassigned from the room. Staff A, CNA stated she really did not know why she got reassigned and no one gave her any specific reason for the reassignment. Staff A, CNA stated Staff E, LPN came to her and told her she would no longer be working with Resident #210 and Resident #211. Staff A, CNA stated she tried to inquire about why she was reassigned but no one would give her answers. Staff A, CNA stated no one told her she could not go back into Resident #210 and Resident #211's room. Staff A, CNA stated later in the day she was picking up lunch trays and went back into Resident #210 and Resident #211's room when the residents and Resident #210's family representative (FR) acted as if they were stunned and uncomfortable. Staff A, CNA stated the response gave her an uncomfortable feeling as well. Staff A, CNA stated at the time of tray pick, she asked Resident #210 and Resident #210's FR if there was a problem, but Resident's 210's FR stated this was making them very uncomfortable, so she left the room. Staff A, CNA stated no one ever told her she was not allowed to go back into the room, so she apologized to Resident #210 and Resident #210's FR but she still did not understand why everyone felt so uncomfortable. Staff A, CNA stated she tried to inquire a couple more times with staff as to why she was reassigned but no supervisor ever gave her any other information. Staff A, CNA stated she still knows nothing about why her room assignments got changed. During an interview on 04/15/24 at 3:46 p.m., Staff E, Licensed Practical Nurse (LPN) stated on Sunday 04/14/24 she was addressed by both Resident #210 and Resident #211 about Staff A, CNA being on her phone with ear buds and cursing. Staff E, LPN stated she decided to just go ahead and remove Staff A,CNA from Resident #210 and Resident #211's room and replace her with another CNA. Staff E, LPN stated she reported this to the supervisor Staff F, Registered Nurse (RN) who stated she would have a talk with Staff A, CNA. Staff E, LPN stated later Sunday afternoon Staff A, CNA took it upon herself to go back into Resident #210 and Resident #211's room . Staff E, LPN stated she never told Staff A, CNA why she was reassigned because she reported it to the supervisor on duty Staff F, RN. Staff E, LPN stated Staff F, RN was the supervisor and told her she would take care of it. Staff E, LPN stated she reported to Staff F, RN the information about Staff A, CNA cursing and all the actions that Staff A, exhibited towards Resident #210 and Resident #211. Staff E, LPN stated when she spoke with Resident #210 and Family Representative (FR) she was informed Staff A, CNA was cussing, using the F word and talking about threesomes. Staff E, stated she apologized for Staff A, CNA's behavior and informed Resident #210 and Resident #211 that Staff A, CNA would not go back into the room. Staff E, LPN stated she told all this information to Staff F, RN. Staff E, LPN stated that she would have reported this incident but respecting the chain of command she reported it to Staff F, RN who was the supervisor to take the information from there. During an interview on 04/15/24 at 4:20 p.m., Staff F, RN stated on Sunday 04/14/24 Staff A, CNA was reassigned from Resident #210 and Resident #211's room . Staff F, RN stated Staff E, LPN reported concerns that Resident #210 and Resident #211 had about Staff A, CNA. Staff F, ,RN stated she heard there were personality conflicts and since personalities do not always mesh Staff A, CNA's assignment was reassigned. Staff F, RN stated it was reported to her Resident #210 and Resident #211 were unhappy, so Staff E, LPN tried to smooth things over by removing Staff A, CNA from Resident #210 and Resident #211's room. Staff F, RN stated Staff A, CNA was Loud with a Big Personality but stated that is just Staff A, CNA's personality. Staff F, RN stated Staff E, LPN told her about a wheelchair that may have been pushed out of the bathroom while assisting Resident #211 and hit the wall or something and the Residents didn't care for that behavior. Staff F, RN stated she did not follow up with Resident #210 and Resident #211 about Staff A, CNA because she was under the impression Staff E, LPN took care of it. Staff F, RN stated she was never told about Staff A, CNA ever being on the phone or using any profanity. Staff F, RN stated she was a mandated reporter so if Staff E, LPN would have reported anything to her about Staff A, CNA using profanity directed towards residents that behavior would have required her to report it. Staff F, RN stated Staff E, LPN stated that she took care of it. During an interview on 04/15/24 at 4:35 p.m., with the Administrator and the DON, the DON stated she just spoke with Staff F, RN about 20 minutes before meeting with the survey team. The DON stated Staff F, RN just reported to her that Staff A, CNA was reassigned from Resident #210 and Resident #211's room on Sunday 04/14/24 because the Residents didn't care for Staff A, CNA. The DON stated Staff F, RN told DON Staff E, LPN talked with both Resident #210, Resident #210's Family Representative(FR) and Resident #211 and answered a ton of questions and everything seemed fine after that. The DON stated the chain of command for reporting would be for Staff E, LPN to report to Staff F, RN and then Staff F, RN should report to the DON who also identified herself as the Risk Manager. The DON stated if anything was reported to her related to abuse then Staff A, CNA would have been suspended immediately and an investigation would have been initiated. The DON stated that she had not even heard of any concerns related to Staff A, CNA and Residents #210 and #211 until 20 minutes prior to meeting with the survey team. During an interview on 04/15/24 at 4:45 p.m., Resident #211 stated on Sunday 04/14/24 Staff A, CNA was cussing. Resident #211 stated she could hear Staff A, CNA talking to someone on the phone. Resident #211 stated she could hear Staff A, CNA Talking about me. Resident #211 stated It didn't make me feel very good but what could I do? Resident #211 stated, I am blind with 1% vision in one eye and only about 7% in the other eye (legally blind). Resident #211 stated, I was afraid when Staff A, CNA was acting like that. Review of the Admission Record revealed Resident #211 was admitted to the facility on [DATE] with diagnoses that included acute bronchitis, weakness, unspecified falls, unspecified visual loss, depression and anxiety disorder. Review Resident #211's care plan showed the following: Focus: Resident has experienced a traumatic event that could lead to manifestation of Post Traumatic Stress Disorder (PTSD) or other psychosocial issues change in health status, loss of past roles. The goal included: Resident will have minimum negative changes in thinking and mood through next review. The Interventions included: Allow resident to make decisions, encourage resident participation in activities of choice, encourage resident to express emotions in a safe, private environment, provide reassurance and reorientation to facility, staff, and current situation as needed and refer to counseling/psych as needed. Focus: Resident #211 has an alteration in visual function diagnoses of glaucoma, diagnosis legally blind. Resident #211is at increased risk for falls with visual deficiencies at risk for malnutrition with visual deficiency. The goal showed, Resident will remain safe in the surrounding environment thru the next review date with assist form staff. The interventions included: administer medication as ordered, administer eye gtts (drops) as ordered, provide adequate lighting, provide assist with ADL tasks as needed, maintain a safe environment; notify resident of changes in environment as needed, provide verbal cues to locate objects or navigate in the environment, read written material to resident as needed. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #211 had a BIMS score of 13 (cognitively intact). During an interview on 04/16/24 at 4:35 p.m., The Regional Nurse Consultant (RNC) stated she thought Staff A, CNA's behavior was unprofessional and inappropriate, but she did not see it as abuse. The RNC stated she would have handled it differently than this administration and would have fired Staff A, CNA for the behavior. Review of the facility's policy Identifying Types of Abuse revised date 09/2022 showed, Mental and Verbal Abuse 1. Mental abuse is the use of verbal and non-verbal conduct which cause (or has the potential to cause) the resident to experience humiliation, intimidation, fear , shame, agitation and degradation. 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Psychosocial Outcomes 1. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not to be immediately apparent. 2. Abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: a. Fear of a person or place of being left alone, of being in the dark, and/or disturbed sleep and nightmares. Review of facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised date 2021 showed, Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation 3. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigation.

Based on observations, interviews, and record review, the facility failed to ensure four dependent residents (#45, #43, #69, and #72) were provided with activities out of ten residents sampled. Findings Include: Multiple observations were made on 4/15/2024 at 10:00 a.m., 1:00 p.m., and 4:00 p.m., showing Resident #45 laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident # 45 was not able to communicate his needs. During an observation made on 04/16/204 at 10:30 a.m., and at 3:00 p.m., and on 4/17/2024 at 11:00 a.m. Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident # 45 was not able to communicate his needs. Review of the medical record showed Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Autistic Disorder, Chronic Kidney Disease Stage 3, other mechanical complication of other Urinary Devices and Implants, Sequelae, and Down Syndrome, Unspecified. Review of a Quarterly Minimum Data Set (MDS) ARD/ Target Date 2/20/2024, showed in section C0100 no was answered indicting Resident #45 is rarely/never understood and a Brief Interview for Mental Status should not be conducted. Further review of section C100 showed Resident #45 was severely impaired. Review of Resident #45's care plan showed the following: Focus: The resident is at risk for decreased social interaction/ activity participation, due to severe cognitive impairment, fluctuating responses to external stimuli do to (d/t) down syndrome, autistic, limited verbalization, impaired physical mobility, dependent on staff for all needs. Interventions: to provide cues and assist to complete tasks while in activity programs as needed. Activity staff to provide in room [ROOM NUMBER]:1 visit, including sunshine visits, various tactile activities. During an interview on 4/18/2024 at 2:00 p.m., with the Activities Director, he stated he creates his activity program from the information he gathers from residents upon admission and from resident council meetings. He stated room visits are done every day for wellness checks around 4 or 4:15 p.m. every day. He stated he had not provided any activities or room visit for Resident #45 all week because he was too busy. 43453 During multiple facility tours on 04/15/24 from 09:58 a.m. to 2:30 p.m. Resident #72 was observed in the dining room sitting at a table by himself. The resident was not interacting with anyone. The resident was not participating in any activities. On 04/15/24 at 02:21 p.m. Resident #72 was observed still sitting in the dining room at the same spot. The resident was observed growing restless, noted standing, looking around and then sitting down. Resident was noted to be confused. Review of the admission record showed Resident #72 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of resident #72's Care Plan, dated 03/20/24, showed a focus indicating Resident #72 was at risk for decreased social interaction/activity participation related to dementia with interventions to include assist with television programs, provide monthly activity calendar in room, encourage social interactions with staff and peers and to encourage family/loved ones to ring music, television etc. for stimulation. A focus in the care plan showed Resident 372 has severe cognitive deficits and does not respond to verbal or tactile stimuli with interventions for activities' staff to provide in room [ROOM NUMBER]:1 visits, music etc. Resident #72 has an alteration in communication ability related to does not communicate needs at all, does not speak English; primary language is: Polish Interventions: included to ask resident yes/no questions, provide interpreter as needed, ask family to interpret as able and for staff to anticipate need and verify with resident as able. On 04/15/24 at 02:35 p.m. an interview was conducted with Staff G, Certified Nursing Assistant (CNA). She stated the resident spoke Polish. She said, He is hard to understand. I did not ask him if he wanted to leave the dining room or if he needed to use the restroom. He is sometimes resistive. Residents should be checked on at least every 2 hours. On 04/15/24 at 2:40 p.m. an interview was conducted with Staff J, Registered Nurse (RN). She confirmed seeing Resident #72 in the dining area all morning. She stated she had seen him since 11 a.m. On 04/15/24 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON). She stated their residents should be attended to at least three times per shift. During multiple tours on 04/16/24 and 04/17/24 Resident #72 was observed in the dining room seated at a table by himself without interaction. The resident was not engaged in any activities. During multiple tours on 04/15/24, 04/16/24, and 04/17/24, Residents #69 and #43 were observed laying in their beds without a television or radio on. The residents were observed in their room without activities or social interactions. Review of the admission record showed Resident #69 was admitted to the facility on [DATE] an initial admitted [DATE] with diagnoses of blindness right and left eye category 5, and Cerebral Vascular Accident (CVA). Review of a care plan, dated 05/16/22, revealed Resident #69 was at risk for decreased social interaction/activity participation related to being legally blind. Activity preferences indicated Resident #69 had impaired physical mobility and enjoyed listening to fishing shows, national geographic, music and family visits. Interventions included providing assistance with television programs of choice. Providing monthly activity calendar in room, encourage social interactions with staff and peers and to encourage family/loved ones to bring in music, television for increased stimulation. Review of the admission record showed Resident #43 was admitted to the facility 11/21/23 an initial admitted [DATE] with diagnoses of dementia. Review of a care plan, dated 02/28/24, showed Resident #43 was capable of pursuing his own activities with motivation and encouragement. Resident prefers to watch television, spend time with families and listening to music. Interventions included determining which individual activities [Resident #43] preferred and provide any related materials, to provide monthly calendar in room, invite to daily activities of choice and encourage resident to voice needs and concerns related to independent leisure tasks as needed. On 04/18/24 at 1:20 p.m. an interview was conducted with the Activities Director. He stated a lot of times he tried to conduct 1:1 activities in the afternoons. He stated the wellness check in the activity's calendar meant 1:1 activities. He stated he would see the ones who would like an activity brought to them such as magazines or books or just a conversation. The Activities Director said, I have a spreadsheet with listed name of the residents. I don't write the specific names of the residents who participated. I am not charting an individual's participation. I just tally the count. He stated he had an assistant but would normally be by himself on Mondays and Tuesdays. He stated the assistant worked weekends by herself. The Activities Director said, It can be a lot. The Activities Director confirmed he had not checked on Residents #69, #43 and #72 all week. He said, [Resident #69] enjoys just being in his room watching TV or listening to the radio. It should be on. You are right. I did not check on him this week. [Resident #43] does come out. When is out, he participates in activities with encouragement. I have not seen him this week. A family member visits and gets him out. I have not seen him this week. I did not get around to see him. I could have asked the CNAs to get him up. I did not get to it. [Resident #72] is in the dining room a lot. I have not seen him participate in any activities. I tried to get him into Polish activities like music. I have not figured him out yet. I know he has a language barrier. He sits and watches people. It is not realistic to engage all the residents. I have quite a few that do not come out of the rooms. I try my best. Review of the facility policy titled, Activity Programs, revised June 2018, showed Activity programs are designed to meet the interest of and support the physical, mental and psychological well-being of each resident. 1. The activity program is provided to support the well-being of residents and to encourage both independence and community interaction

Based on observation, record review, and interviews, and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a relicensure and complaint survey that was conducted on 4/15 - 4/18/24 and was cited at F880. On 6/11/24 a revisit survey was conducted, and the facility was recited at F880. The facility had developed a Plan of Correction with a completion date of 5/18/22. During the revisit survey the facility failed to 1. ensure staff members observed transmission-based precautions correctly related to the use of Personal Protective Equipment (PPE) for one (#1) out of 18 residents diagnosed with COVID-19, failed to appropriately dispose of PPE after assisting one (#2) out of 18 residents with transferring, failed to appropriately clean and disinfect a mechanical lift used for multiple residents, and 2. failed to ensure the catheter drainage bag of one (#45) out of three residents sampled for the implementation of privacy bags was stored in a clean and sanitary manner. Findings included: 1. The facility developed a plan of correction that included: The facility identified residents on transmission based precautions on 4/16/2024 and 4/17/2024 verified signage and Personal Protective Equipment (PPE) on door. The facility developed a plan of correction that included: Staff education PPE for transmission-based precautions provided by DON/Designee 5/10/2024. Isolation audits before and after resident contact will be completed daily for 1 week, weekly for 4 weeks, and monthly for two months or until the QAPI committee determines substantial compliance. On 6/11/24 at 10:02 a.m., an observation was made on one of four hallways of room [ROOM NUMBER] with an open lidded trash bin, containing blue precaution gowns, and a three-drawer storage unit located outside the room and in the hallway. The observation revealed room [ROOM NUMBER] was posted (on the door) for Enhanced Barrier Precautions (EBP). Photographic evidence was obtained. On 6/11/24 at 10:04 a.m., an observation was made of a healthcare professional dressed in gray scrubs standing against the bed of Resident #1. The observation revealed the door to Resident #1's room was posted with a red sign showing Droplet Precautions and in the hallway next to the doorway of the room was a trash bin containing blue precaution gowns and a three-drawer storage unit containing procedural masks and blue precaution gowns. The staff member was standing next to an over-bed table which a clipboard and a tablet which the staff member was observed utilizing with bare hands. Photographic evidence was obtained. During an observation on 6/11/24 at 10:04 a.m., Staff A, Certified Nursing Assistant was seen leaving room [ROOM NUMBER] (across hall from Resident #1's room). The staff member was observed [NAME] up a blue precaution gown, walked across the hallway, and disposed the gown into the trash bin next to Resident #1's room. The door to room [ROOM NUMBER] was posted with a red sign Droplet Precautions with a trash bin inside the room next to the door. A few moments later Staff A and Staff B, CNA, dressed in gown, gloves, and masks then entered room [ROOM NUMBER]. On 6/11/24 at 10:15 a.m., Staff B pushed a mechanical (Hoyer) lift from room [ROOM NUMBER] into the hallway. The staff member stated the lift had been cleansed with hand sanitizer prior to bringing it into the hallway and had to get bleach wipes from the nurse for Staff A to clean it. Staff C, Registered Nurse (RN), removed a bleach wipe from the medication cart and handed the wipe to Staff B, who hung it on the handle of the lift. Staff A was seen in the room making Resident #2's bed. On 6/11/24 at 10:18 a.m., the healthcare professional, Staff D, dressed in gray was observed into the bathroom of room [ROOM NUMBER] as running water could be heard. The staff member came out of the bathroom, wiped her hands with a brown paper towel, she placed the clipboard and tablet in her arms and held them against her torso while she spoke with Resident #1. Staff D, left room [ROOM NUMBER] and revealed self as a (named) physician's Registered Nurse (RN) and not a staff member of the facility. Staff D reported not knowing the room was posted for Droplet Precautions and should have been wearing (a) gown and gloves. Staff D stated next time I'll pay attention. On 6/11/24 at 10:24 a.m., Staff C stated it was not appropriate to clean the mechanical lift with hand sanitizer. The staff member stated the lift should have been left in the room, staff members should have gotten a bleach wipe to clean it (before leaving room) as they could not leave bleach wipes in the hallway. Staff C reported not seeing if Staff D had been wearing PPE or not but should have been. On 6/11/24 at 10:26 a.m., Staff A came out of room [ROOM NUMBER] dressed in a blue PPE gown, took the gown off in the hallway, crossed the hall, and placed it in the trash bin outside of room [ROOM NUMBER]. An interview was conducted with Staff A on 6/11/24 at 10:28 a.m., the staff member stated the reason for throwing PPE away in the bin across the hall (next to room [ROOM NUMBER]) was they did not have a bin in room [ROOM NUMBER]. The staff member viewed the trash bin next to the door in room [ROOM NUMBER] and stated they did not use that one for isolation, they used the one outside of room [ROOM NUMBER]. The facility revealed an outbreak of COVID was ongoing and currently had 18 positive residents. The floor map, provided by the facility, where observations were made had 12 rooms, which had 6 rooms with Droplet precautions, one room with consequent Contact, one room with Enhanced Barrier precautions, and three additional rooms with Enhanced Barrier Precautions (EBP). The map showed 9 out of the 12 rooms had assigned precautions. Review of the list of COVID positive residents included Resident #1 and Resident #2. Review of Resident #1's Admission Record showed the resident was admitted on [DATE] and diagnoses included acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, and acute pulmonary edema. The physician order summary for the resident revealed an order for Maintain Droplet Precautions for COVID+ for 10 days, every shift for COVID + for 10 days, started on 6/3 and to end on 6/13/24. Review of Resident #2's Admission Record showed the resident was admitted on [DATE] and diagnoses included chronic diastolic (congestive) heart failure, localized edema, and nasal congestion. The review of Resident #2's physician order summary revealed an order for Droplet isolation for COVID 19 one time only until 6/13/24, started on 6/3/24 and Enhanced Barrier precaution for Infection control intervention related to (r/t) wounds, started on 4/18/24. The facility provided signage for Droplet Precautions and Enhanced Barrier Precautions. The Droplet sign revealed STOP ATTENTION STOP Please carefully review the instructions Below. EVERYONE MUST: Clean their hands, including before entering and when leaving the room with Alcohol-based Hand Rub (ABHR). PPE Requirements: Gown and (&) Gloves, Face Shield or Goggles, N95 or higher-level respirator must be worn at all times while in patient room. The Enhanced Barrier sign revealed STOP ENHANCED BARRIER PRECAUTIONS STOP EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care of use: central line, urinary catheter, feeding tube, tracheostomy, (and/or) Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview, on 6/11/24 at 12:44 p.m., the Infection Preventionist (IP) stated N95's (mask), gown, gloves, and eye protection were to be worn for Droplet precautions and glasses were not considered eye protection, a face shield or goggles should be worn. The IP stated the observation of Staff D wearing a surgical mask and no other PPE (in room [ROOM NUMBER]) was not appropriate, PPE should be thrown away inside the room, and trash bins were inside the room. The IP reviewed photos taken of the trash bins in the hallway outside of room [ROOM NUMBER] and 49 then stated they should not be in the hallway, staff should remove everything (PPE) before coming into the hallway and while outside to use hand sanitizer. The IP stated the expectation was for staff to take off PPE while in the room and garbage bins were to be inside the room to dispose of the PPE. Regarding the process for cleaning the mechanical lift, the staff member stated staff were to remove PPE, leave the lift in the room, get wipes, don PPE, clean the lift, and then remove it from the room. The IP stated hand sanitizer was absolutely not to clean equipment. The IP reported educating (staff) on COVID outbreak, the education contained don/doffing PPE and did not put in writing but did tell them to doff (remove) inside the room and all trash bins were to be kept in the room. The IP stated the facility had completed audits for use of PPE. During an interview on 6/11/23 at 3:20 p.m., the Director of Nursing (DON) stated she had spoken with the Medical Director regarding Staff D, his nurse who was observed on the unit. The DON stated Staff D needed to wear PPE appropriately according to Transmission Based Precautions (TBP). She said all garbage cans were to be inside the rooms. Originally the garbage cans were outside the room because the facility did not have enough when the EBP were started. The only explanation for trash bins outside in the hallway was to get residents or lifts out of the room. The DON stated hand sanitizer was not appropriate to use to clean a mechanical lift. The policy- Infection Control, revised October 2018, 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. The interpretation and implementation of this policy included the following: 1. The facilities infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, in the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control for infections in the facility; b. Maintaining safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; e. Maintain records of incidents and corrective actions related to infections; and f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. 3. The quality assurance and performance improvement committee, through the infection control committee, shall establish, review, and revised infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 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. 5. The administrator or governing board, through the quality assurance and performance improvement and the infection control committees, has adopted the infection control policies and practices. Inquiries concerning our infection control policies in the facility practices should be referred to the infection preventionist or director of nursing services. The policy, Isolation-Categories of Transmission-based Precautions, revised September 2022, revealed Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The interpretation and implementation of the policy showed: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2. Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door, and on the front of the chart so that the personnel and visitors are aware of the need for in the type of precaution. a. The signage informs the staff of what type of centers for Disease Control and prevention (CDC) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If reuse of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. The section of policy, Droplet Precautions explained Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [larger than five microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 3. Are worn when entering the room. 4. Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, showed resident care equipment, including reasonable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 6. Reusable resident care equipment is decontaminated and/ or sterilize between residents according to manufacturer's instructions. 9. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. 2. On 6/11/24 at 11:16 a.m., Resident #45 was observed in bed with multiple magazines/newspapers, an empty catheter privacy bag was hanging from the side of bed facing the door. The observation revealed the resident's catheter bag appeared to be lying on the floor on the opposite side of the bed. The resident did not engage verbally with this writer. The resident's room was posted for Droplet precautions and resident was included on list of COVID+ residents. On 6/11/24 at 11:30 a.m., Staff E, Occupational Therapist (OT) was observed dressed in PPE in hallway standing next to the door of the room next to Resident #45. The catheter bag for Resident #45 was observed lying in the same area previously viewed at 11:16 a.m. on 6/11/24. The OT stated it did appear the catheter bag was on the floor, the staff member entered the room and picked the drainage bag off the floor and moved it, saying it must have fallen. Staff E stated it (drainage) bag appeared to be on the floor but had a privacy bag. An interview was conducted on 6/11/24 at 12:03 p.m. with Staff F, Licensed Practical Nurse/Unit Manager (LPN/UM) and Staff G, Certified Nursing Assistant (CNA). Staff F stated Resident #45 moved around a lot and (the drainage bag) must have fallen off during that time. Staff F reported no the catheter bag should not be on the floor. Review of Resident #45's Admission Record revealed the resident was admitted on [DATE]. The review revealed the resident's diagnoses included COVID-19, Autistic disorder, sequela other neuromuscular dysfunction of bladder, and other mechanical complication of other urinary devices and implants. A review of Resident #45's care plan on 6/11/24 at 12:13 p.m., revealed: -Resident #45 had an alteration in elimination as evidence by (AEB): is incontinent of bowel, cognitive impairment related to (r/t) diagnosis (dx) of autism, Down Syndrome. Has a suprapubic catheter r/t urinary retention neurogenic bladder. Requires staff assist with toileting/incontinence care needs, has history (hx) recurrent Urinary Tract Infections (UTI). Hx of Nephrolithiasis/Chronic Kidney Disease. This history showed the care plan changes prior to completion of last review, dated 2/28/24. The history showed Staff H, MDS Coordinator, revised the above focus on 6/11/24 to include Noted to touch and reposition foley catheter bag. Photographic evidence obtained. The interventions related to the resident's suprapubic catheter revealed care instructions and to Maintain closed drainage system and keep drainage bag below level of the bladder, provide catheter privacy bag. - Resident had a self-care deficit and at times refused Activities of Daily Living (ADL) care with changing clothes, continent care, can try to hit when ADLs are being done, refuses to have anyone but sister shave (pronoun), (and) prefers to stay in bed, revised on 1/26/23. This focus did not show a behavior related to repositioning catheter bag to the floor. -Resident prefers to deviate from plan of care regarding refusal of ADL care, may try to hit staff providing care, refusing medications, refusing to get out of bed (OOB) and was not capable of understanding risks of deviating from the plan of care, revised 12/11/23. - Use of indwelling suprapubic urinary catheter related to dx of urinary retention secondary to neurogenic bladder, created and revised on 3/5/23. The interventions instructed staff to keep drainage bag below urinary bladder., monitor position of bag and tubing during transfers to avoid tugging and pulling, watch for kinks in tubing which may obstruct urinary flow and to monitor for signs/symptoms of UTI. The focus or interventions did not reveal the resident had history of placing drainage bag on floor. - Resident has the potential to exhibit following behaviors: may strike out at care during are d/t dx of autism and has been noted to put finger in mouth to try to throw up, revised on 1/25/23. Review of this focus did not show the resident had a behavioral history of touching or repositioning catheter drainage bag to the floor. Review of Resident #45's physician orders did not reveal an order instructing staff to monitor for any behaviors. The orders revealed the resident was not receiving any psychotropic medications related to any mental illness or intellectual disability. Review of Resident #45's Behavioral task documentation showed in the past 30 days (5/13 to 6/9/24) the resident had one episode of kicking/hitting and two episodes of rejection of care. The behavioral symptoms did not address the resident touching or repositioning catheter drainage bag to the floor. Review of the most recent written Daily Skilled Note, effective 6/7/24, showed Resident #45 had not exhibited any behaviors. The comments reported the resident was alert, staff anticipated needs, the resident was resting comfortably in bed, and mood (was) pleasant. Review of Resident #45's progress notes dated 5/13 to 6/11/24 did not reveal the resident had exhibited the behavior of touching or repositioning catheter drainage bag on the floor. A care plan meeting note, dated 5/15/24, showed the resident's responsible party/family attended the meeting via telephone conference and the resident's plan of care was discussed and the care plan remains current. The note did address the resident's resistiveness to get out of bed but did not mention the resident was noted to touch and reposition catheter drainage bag. An interview was conducted with Staff H, Registered Nurse/MDS Coordinator, on 6/11/24 at 3:34 p.m. State H stated Resident #45 had a history of playing with magazines and had to look back at it (care plan). Staff H reported adding that the resident touched and repositioned the foley catheter bag because the resident had taken it or played with the catheter or maneuvered it. Staff H stated Staff E said the bag was in a privacy bag and he must have done it (moved it to the floor). Staff H reported believing Staff E had seen the resident do it. During an interview on 6/11/24 at 4:34 p.m., the Director of Nursing stated the facility was able to purchase drainage bags with privacy flaps. The policy - Urinary Catheter Care, revised August 2022, showed the purpose of this procedure was to prevent urinary catheter-associated complications, including urinary tract infections. The procedure of infection control related to the use of catheter revealed staff were to use aseptic technique when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag were kept below level of bladder. Review of Cleveland Clinic's guidance on the care of urine drainage bags, last reviewed on 12/3/20, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor. The policy - Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of clear and quality of life. 2. Providing means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Established systems through which to monitor and evaluate corrective actions. The implementation of the policy revealed: 1. The QAPI committee overseas implementation of our QAPI plan, which is a written component describing the specifics of the QAPI program, how the facility will conduct its Q API functions, and the activities of the QAPI committee. 2. The Q API plan describes the process for identifying and correcting quality deficiencies key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. The coordination of the policy showed: 1. The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/ or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as liaison between the QAPI committee and individuals, services, and/or departments regarding QAPI activities.

Based on observation, record review, and interviews, and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a relicensure and complaint survey that was conducted on 4/15 - 4/18/24 and was cited at F880. On 6/11/24 a revisit survey was conducted, and the facility was recited at F880. The facility had developed a Plan of Correction with a completion date of 5/18/22. During the revisit survey the facility failed to 1. ensure staff members observed transmission-based precautions correctly related to the use of Personal Protective Equipment (PPE) for one (#1) out of 18 residents diagnosed with COVID-19, failed to appropriately dispose of PPE after assisting one (#2) out of 18 residents with transferring, failed to appropriately clean and disinfect a mechanical lift used for multiple residents, and 2. failed to ensure the catheter drainage bag of one (#45) out of three residents sampled for the implementation of privacy bags was stored in a clean and sanitary manner. Findings included: 1. The facility developed a plan of correction that included: The facility identified residents on transmission based precautions on 4/16/2024 and 4/17/2024 verified signage and Personal Protective Equipment (PPE) on door. The facility developed a plan of correction that included: Staff education PPE for transmission-based precautions provided by DON/Designee 5/10/2024. Isolation audits before and after resident contact will be completed daily for 1 week, weekly for 4 weeks, and monthly for two months or until the QAPI committee determines substantial compliance. On 6/11/24 at 10:02 a.m., an observation was made on one of four hallways of room [ROOM NUMBER] with an open lidded trash bin, containing blue precaution gowns, and a three-drawer storage unit located outside the room and in the hallway. The observation revealed room [ROOM NUMBER] was posted (on the door) for Enhanced Barrier Precautions (EBP). Photographic evidence was obtained. On 6/11/24 at 10:04 a.m., an observation was made of a healthcare professional dressed in gray scrubs standing against the bed of Resident #1. The observation revealed the door to Resident #1's room was posted with a red sign showing Droplet Precautions and in the hallway next to the doorway of the room was a trash bin containing blue precaution gowns and a three-drawer storage unit containing procedural masks and blue precaution gowns. The staff member was standing next to an over-bed table which a clipboard and a tablet which the staff member was observed utilizing with bare hands. Photographic evidence was obtained. During an observation on 6/11/24 at 10:04 a.m., Staff A, Certified Nursing Assistant was seen leaving room [ROOM NUMBER] (across hall from Resident #1's room). The staff member was observed [NAME] up a blue precaution gown, walked across the hallway, and disposed the gown into the trash bin next to Resident #1's room. The door to room [ROOM NUMBER] was posted with a red sign Droplet Precautions with a trash bin inside the room next to the door. A few moments later Staff A and Staff B, CNA, dressed in gown, gloves, and masks then entered room [ROOM NUMBER]. On 6/11/24 at 10:15 a.m., Staff B pushed a mechanical (Hoyer) lift from room [ROOM NUMBER] into the hallway. The staff member stated the lift had been cleansed with hand sanitizer prior to bringing it into the hallway and had to get bleach wipes from the nurse for Staff A to clean it. Staff C, Registered Nurse (RN), removed a bleach wipe from the medication cart and handed the wipe to Staff B, who hung it on the handle of the lift. Staff A was seen in the room making Resident #2's bed. On 6/11/24 at 10:18 a.m., the healthcare professional, Staff D, dressed in gray was observed into the bathroom of room [ROOM NUMBER] as running water could be heard. The staff member came out of the bathroom, wiped her hands with a brown paper towel, she placed the clipboard and tablet in her arms and held them against her torso while she spoke with Resident #1. Staff D, left room [ROOM NUMBER] and revealed self as a (named) physician's Registered Nurse (RN) and not a staff member of the facility. Staff D reported not knowing the room was posted for Droplet Precautions and should have been wearing (a) gown and gloves. Staff D stated next time I'll pay attention. On 6/11/24 at 10:24 a.m., Staff C stated it was not appropriate to clean the mechanical lift with hand sanitizer. The staff member stated the lift should have been left in the room, staff members should have gotten a bleach wipe to clean it (before leaving room) as they could not leave bleach wipes in the hallway. Staff C reported not seeing if Staff D had been wearing PPE or not but should have been. On 6/11/24 at 10:26 a.m., Staff A came out of room [ROOM NUMBER] dressed in a blue PPE gown, took the gown off in the hallway, crossed the hall, and placed it in the trash bin outside of room [ROOM NUMBER]. An interview was conducted with Staff A on 6/11/24 at 10:28 a.m., the staff member stated the reason for throwing PPE away in the bin across the hall (next to room [ROOM NUMBER]) was they did not have a bin in room [ROOM NUMBER]. The staff member viewed the trash bin next to the door in room [ROOM NUMBER] and stated they did not use that one for isolation, they used the one outside of room [ROOM NUMBER]. The facility revealed an outbreak of COVID was ongoing and currently had 18 positive residents. The floor map, provided by the facility, where observations were made had 12 rooms, which had 6 rooms with Droplet precautions, one room with consequent Contact, one room with Enhanced Barrier precautions, and three additional rooms with Enhanced Barrier Precautions (EBP). The map showed 9 out of the 12 rooms had assigned precautions. Review of the list of COVID positive residents included Resident #1 and Resident #2. Review of Resident #1's admission Record showed the resident was admitted on [DATE] and diagnoses included acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, and acute pulmonary edema. The physician order summary for the resident revealed an order for Maintain Droplet Precautions for COVID+ for 10 days, every shift for COVID + for 10 days, started on 6/3 and to end on 6/13/24. Review of Resident #2's admission Record showed the resident was admitted on [DATE] and diagnoses included chronic diastolic (congestive) heart failure, localized edema, and nasal congestion. The review of Resident #2's physician order summary revealed an order for Droplet isolation for COVID 19 one time only until 6/13/24, started on 6/3/24 and Enhanced Barrier precaution for Infection control intervention related to (r/t) wounds, started on 4/18/24. The facility provided signage for Droplet Precautions and Enhanced Barrier Precautions. The Droplet sign revealed STOP ATTENTION STOP Please carefully review the instructions Below. EVERYONE MUST: Clean their hands, including before entering and when leaving the room with Alcohol-based Hand Rub (ABHR). PPE Requirements: Gown and (&) Gloves, Face Shield or Goggles, N95 or higher-level respirator must be worn at all times while in patient room. The Enhanced Barrier sign revealed STOP ENHANCED BARRIER PRECAUTIONS STOP EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care of use: central line, urinary catheter, feeding tube, tracheostomy, (and/or) Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview, on 6/11/24 at 12:44 p.m., the Infection Preventionist (IP) stated N95's (mask), gown, gloves, and eye protection were to be worn for Droplet precautions and glasses were not considered eye protection, a face shield or goggles should be worn. The IP stated the observation of Staff D wearing a surgical mask and no other PPE (in room [ROOM NUMBER]) was not appropriate, PPE should be thrown away inside the room, and trash bins were inside the room. The IP reviewed photos taken of the trash bins in the hallway outside of room [ROOM NUMBER] and 49 then stated they should not be in the hallway, staff should remove everything (PPE) before coming into the hallway and while outside to use hand sanitizer. The IP stated the expectation was for staff to take off PPE while in the room and garbage bins were to be inside the room to dispose of the PPE. Regarding the process for cleaning the mechanical lift, the staff member stated staff were to remove PPE, leave the lift in the room, get wipes, don PPE, clean the lift, and then remove it from the room. The IP stated hand sanitizer was absolutely not to clean equipment. The IP reported educating (staff) on COVID outbreak, the education contained don/doffing PPE and did not put in writing but did tell them to doff (remove) inside the room and all trash bins were to be kept in the room. The IP stated the facility had completed audits for use of PPE. During an interview on 6/11/23 at 3:20 p.m., the Director of Nursing (DON) stated she had spoken with the Medical Director regarding Staff D, his nurse who was observed on the unit. The DON stated Staff D needed to wear PPE appropriately according to Transmission Based Precautions (TBP). She said all garbage cans were to be inside the rooms. Originally the garbage cans were outside the room because the facility did not have enough when the EBP were started. The only explanation for trash bins outside in the hallway was to get residents or lifts out of the room. The DON stated hand sanitizer was not appropriate to use to clean a mechanical lift. The policy- Infection Control, revised October 2018, 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. The interpretation and implementation of this policy included the following: 1. The facilities infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, in the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control for infections in the facility; b. Maintaining safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; e. Maintain records of incidents and corrective actions related to infections; and f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. 3. The quality assurance and performance improvement committee, through the infection control committee, shall establish, review, and revised infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 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. 5. The administrator or governing board, through the quality assurance and performance improvement and the infection control committees, has adopted the infection control policies and practices. Inquiries concerning our infection control policies in the facility practices should be referred to the infection preventionist or director of nursing services. The policy, Isolation-Categories of Transmission-based Precautions, revised September 2022, revealed Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The interpretation and implementation of the policy showed: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2. Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door, and on the front of the chart so that the personnel and visitors are aware of the need for in the type of precaution. a. The signage informs the staff of what type of centers for Disease Control and prevention (CDC) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If reuse of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. The section of policy, Droplet Precautions explained Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [larger than five microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 3. Are worn when entering the room. 4. Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, showed resident care equipment, including reasonable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 6. Reusable resident care equipment is decontaminated and/ or sterilize between residents according to manufacturer's instructions. 9. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. 2. On 6/11/24 at 11:16 a.m., Resident #45 was observed in bed with multiple magazines/newspapers, an empty catheter privacy bag was hanging from the side of bed facing the door. The observation revealed the resident's catheter bag appeared to be lying on the floor on the opposite side of the bed. The resident did not engage verbally with this writer. The resident's room was posted for Droplet precautions and resident was included on list of COVID+ residents. On 6/11/24 at 11:30 a.m., Staff E, Occupational Therapist (OT) was observed dressed in PPE in hallway standing next to the door of the room next to Resident #45. The catheter bag for Resident #45 was observed lying in the same area previously viewed at 11:16 a.m. on 6/11/24. The OT stated it did appear the catheter bag was on the floor, the staff member entered the room and picked the drainage bag off the floor and moved it, saying it must have fallen. Staff E stated it (drainage) bag appeared to be on the floor but had a privacy bag. An interview was conducted on 6/11/24 at 12:03 p.m. with Staff F, Licensed Practical Nurse/Unit Manager (LPN/UM) and Staff G, Certified Nursing Assistant (CNA). Staff F stated Resident #45 moved around a lot and (the drainage bag) must have fallen off during that time. Staff F reported no the catheter bag should not be on the floor. Review of Resident #45's admission Record revealed the resident was admitted on [DATE]. The review revealed the resident's diagnoses included COVID-19, Autistic disorder, sequela other neuromuscular dysfunction of bladder, and other mechanical complication of other urinary devices and implants. A review of Resident #45's care plan on 6/11/24 at 12:13 p.m., revealed: -Resident #45 had an alteration in elimination as evidence by (AEB): is incontinent of bowel, cognitive impairment related to (r/t) diagnosis (dx) of autism, Down Syndrome. Has a suprapubic catheter r/t urinary retention neurogenic bladder. Requires staff assist with toileting/incontinence care needs, has history (hx) recurrent Urinary Tract Infections (UTI). Hx of Nephrolithiasis/Chronic Kidney Disease. This history showed the care plan changes prior to completion of last review, dated 2/28/24. The history showed Staff H, MDS Coordinator, revised the above focus on 6/11/24 to include Noted to touch and reposition foley catheter bag. Photographic evidence obtained. The interventions related to the resident's suprapubic catheter revealed care instructions and to Maintain closed drainage system and keep drainage bag below level of the bladder, provide catheter privacy bag. - Resident had a self-care deficit and at times refused Activities of Daily Living (ADL) care with changing clothes, continent care, can try to hit when ADLs are being done, refuses to have anyone but sister shave (pronoun), (and) prefers to stay in bed, revised on 1/26/23. This focus did not show a behavior related to repositioning catheter bag to the floor. -Resident prefers to deviate from plan of care regarding refusal of ADL care, may try to hit staff providing care, refusing medications, refusing to get out of bed (OOB) and was not capable of understanding risks of deviating from the plan of care, revised 12/11/23. - Use of indwelling suprapubic urinary catheter related to dx of urinary retention secondary to neurogenic bladder, created and revised on 3/5/23. The interventions instructed staff to keep drainage bag below urinary bladder., monitor position of bag and tubing during transfers to avoid tugging and pulling, watch for kinks in tubing which may obstruct urinary flow and to monitor for signs/symptoms of UTI. The focus or interventions did not reveal the resident had history of placing drainage bag on floor. - Resident has the potential to exhibit following behaviors: may strike out at care during are d/t dx of autism and has been noted to put finger in mouth to try to throw up, revised on 1/25/23. Review of this focus did not show the resident had a behavioral history of touching or repositioning catheter drainage bag to the floor. Review of Resident #45's physician orders did not reveal an order instructing staff to monitor for any behaviors. The orders revealed the resident was not receiving any psychotropic medications related to any mental illness or intellectual disability. Review of Resident #45's Behavioral task documentation showed in the past 30 days (5/13 to 6/9/24) the resident had one episode of kicking/hitting and two episodes of rejection of care. The behavioral symptoms did not address the resident touching or repositioning catheter drainage bag to the floor. Review of the most recent written Daily Skilled Note, effective 6/7/24, showed Resident #45 had not exhibited any behaviors. The comments reported the resident was alert, staff anticipated needs, the resident was resting comfortably in bed, and mood (was) pleasant. Review of Resident #45's progress notes dated 5/13 to 6/11/24 did not reveal the resident had exhibited the behavior of touching or repositioning catheter drainage bag on the floor. A care plan meeting note, dated 5/15/24, showed the resident's responsible party/family attended the meeting via telephone conference and the resident's plan of care was discussed and the care plan remains current. The note did address the resident's resistiveness to get out of bed but did not mention the resident was noted to touch and reposition catheter drainage bag. An interview was conducted with Staff H, Registered Nurse/MDS Coordinator, on 6/11/24 at 3:34 p.m. State H stated Resident #45 had a history of playing with magazines and had to look back at it (care plan). Staff H reported adding that the resident touched and repositioned the foley catheter bag because the resident had taken it or played with the catheter or maneuvered it. Staff H stated Staff E said the bag was in a privacy bag and he must have done it (moved it to the floor). Staff H reported believing Staff E had seen the resident do it. During an interview on 6/11/24 at 4:34 p.m., the Director of Nursing stated the facility was able to purchase drainage bags with privacy flaps. The policy - Urinary Catheter Care, revised August 2022, showed the purpose of this procedure was to prevent urinary catheter-associated complications, including urinary tract infections. The procedure of infection control related to the use of catheter revealed staff were to use aseptic technique when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag were kept below level of bladder. Review of Cleveland Clinic's guidance on the care of urine drainage bags, last reviewed on 12/3/20, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor. The policy - Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of clear and quality of life. 2. Providing means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Established systems through which to monitor and evaluate corrective actions. The implementation of the policy revealed: 1. The QAPI committee overseas implementation of our QAPI plan, which is a written component describing the specifics of the QAPI program, how the facility will conduct its Q API functions, and the activities of the QAPI committee. 2. The Q API plan describes the process for identifying and correcting quality deficiencies key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. The coordination of the policy showed: 1. The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/ or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as liaison between the QAPI committee and individuals, services, and/or departments regarding QAPI activities.

Based on observation, interviews, and record review, the facility failed to ensure an effective infection control program was implemented related to 1) the use of personal protective equipment (PPE) for two of three designated transmission based precaution (TBP) rooms, 2) no hand hygiene provided to residents prior to meals for four of four hallways, and 3) the Infection Preventionist (IP) conducting appropriate surveillance for influenza. Findings included: During an interview on 04/15/24 at 1:20 p.m., Resident #209's Family Representative (FR) stated Resident #209 tested negative for influenza and the droplet precautions sign was placed on the door for his roommate who went out to the hospital. Resident #209's FR stated she did not know why the droplet precaution sign remained on Resident #209's door when he tested negative for influenza. (Photographic evidence obtained). An observation on 04/15/24 at 1:25 p.m., revealed Staff A, Certified Nursing Assistant (CNA) walked into Resident #209's room, past Droplet Precaution sign and PPE, and entered the room without donning PPE. Staff A, CNA was observed taking Resident #209 out of the room and began to wheel him down the hall. An immediate interview on 04/15/24 at 1:25 p.m., was conducted. Staff A, CNA stated Resident #209 was good and not on precautions because he did not have a blue band on his wrist to show that she needed to don a gown and glove to assist him. During an interview on 04/15/24 at 1:30 p.m., Staff B Licensed Practical Nurse (LPN) stated Resident #209 had an active order for droplet precautions and Staff A, CNA should have appropriately donned PPE for any droplet precaution rooms. Staff B, LPN stated Resident #209 should not be out of his room and being wheeled down to the hall to the shower room right now due to being on droplet precautions. Review of the Admission Record showed Resident #209 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, anemia, Type II Diabetes, ventricular tachycardia, and acute chronic systolic (congestive) heart failure. A physician order, dated 04/12/24 revealed, Follow Droplet isolation related to active Flu A + status. All cares to be provided in room only. During an interview on 04/16/24 at 3:00 p.m., the Infection Preventionist (IP) stated blue bands were used in the facility to only alert therapists and our staff a resident is on enhance precautions because of a peripherally inserted central catheter (PICC) line or other catheters. The IP stated the blue bands are only used for enhanced precaution rooms. The IP stated blue bands had nothing to do with droplet precautions and all PPE should be worn in droplet precaution rooms. An observation on 04/15/24 at 12:30 p.m., revealed seven residents sitting in the front dining room located near the facility lobby. Staff C, CNA was observed passing hydration to the residents. Staff C, CNA was not observed providing hand hygiene to the residents during the passing of hydration. Additional observations of tray pass in the facility revealed the following: - On 04/17/24 at 12:00 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 18 to 30. - On 04/17/24 at 12:15 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 1 to 17. - On 04/17/24 at 12:22 p.m., there was no hand hygiene offered to 13 residents during hydration pass in the front dining room near the lobby. - On 04/17/24 at 12:30 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 41 to 52. - On 04/17/24 at 12:40 p.m., there was no hand hygiene offered to 13 residents during tray pass in the front dining room near the lobby. During an interview on 04/17/24 at 1:15 p.m., Resident #210 stated No staff never offer hand hygiene. Resident #210 stated, I actually had my daughter bring me some hand hygiene wipes from home. Review of the Admission Record showed Resident #210 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of the neck of left femur, subsequent encounter for closed fracture with routine healing, cerebellar ataxia in disease, polyneuropathy, heart failure, and spinal stenosis. Review of the Brief Interview For Mental Status (BIMS) evaluation, dated 04/14/24, revealed Resident #210 had a BIMS score of 14 (cognitively intact). During an interview on 04/17/24 at 1:20 p.m., Resident #65 stated, No, I have never been offered any hand sanitizer from staff and actually I have never heard staff offer hand hygiene to anyone. Review of the Admission Record showed Resident #65 was admitted to the facility on [DATE] with diagnoses that included Sepsis, Hyperlipidemia, Cystitis without hematuria and urinary tract infection. Review of Resident #65's quarterly Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns revealed a BIMS of 11 (moderately impaired). During an interview on 04/17/24 at 5:16 p.m., Resident #205 stated, No and they never do. regarding hand hygiene. A review of the Admission Record showed Resident #205 was admitted to the facility on [DATE] with diagnoses that included Syncope and collapse, hyperthyroidism, dehydration, hypokalemia, depression and Parkinson's. Review of Resident #205's quarterly Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns revealed a BIMS of 13 (cognitively intact). During an interview on 04/17/24 at 1:25 p.m., Staff C, CNA stated she did not carry around hand sanitizer to provide to residents for hand hygiene. Staff C, CNA stated if Residents needed hand hygiene, they could use the sink or any of the two hand sanitizer stations located on the walls of the dining room. Staff C, CNA stated she was picky about her hands, and she washed, and hand sanitized all the time. Review of the facility's policy Influenza, Prevention and Control of Season, revised date March 2022, showed, Infection Precautions 1. Contact and Droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement. Review of the facility's policy Handwashing/Hand Hygiene, dated August 2019, showed, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and/or other written material provided at the time of admission and/or posted throughout the facility. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .o. Before and after eating or handling food. 46234 An observation was made on 4/15/24 at 10:51 p.m. of Resident #89 going to lunch in the dining room. The resident had black debris under her fingernails. When asked if staff helped her clean her hands or nails, she said no. The resident was observed eating her lunch with her hands and nails dirty. Her nails remained dirty on 4/16/24. (Photographic evidence obtained) An observation was made on 4/16/24 at 8:58 a.m. of Staff B, Licensed Practical Nurse (LPN) during medication administration. Staff B, LPN donned PPE to enter a room on isolation precautions. When exiting the room, she went to the medication cart with PPE still on, prior to performing hand hygiene, opened the drawer and placed items in the cart. She then removed her PPE in the hall and threw it in the trash can placed in the hallway. An observation was made on 4/16/24 at 9:13 a.m. of Staff N, LPN during medication administration. Staff N administered an inhaler to a resident, exited the room, opened the medication cart, and placed the inhaler inside without performing hand hygiene. An interview was conducted on 4/16/24 at 2:58 p.m. with the Assistant Director of Nursing (ADON). The ADON said PPE should be removed inside the room and placed in the trash before exiting. She said the health department came to the facility a week prior and told them PPE should be removed and thrown away in the room. She said changes could not be implemented overnight and they needed to get big trash cans for the rooms. The PPE trash cans remained in the hallway on 4/17 and 4/18/24. The ADON confirmed staff should perform hand hygiene after each resident, prior to touching the medication cart. Review of the facility's policy Handwashing/Hand Hygiene, dated August 2019, showed, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and/or other written material provided at the time of admission and/or posted throughout the facility. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .o. Before and after eating or handling food.

Based on observations, interviews and record review, the facility 1) failed to provide access to quality care related to a dignified meal service for three residents (# 69, #43, and #89) out of 13 residents reviewed for dining, and 2) failed to ensure a catheter was stored in a privacy bag for one resident (#43) out of 29 sampled residents. Findings included: On 4/15/24 at 10:00 a.m. Resident #69 was observed in his room in bed. The resident was observed with food on his chest area and beard from his breakfast meal, and a small flying insect on his beard. The resident stated he fed himself. He stated the staff clean him up When they get around to it. During the interview, the resident confirmed he did not know he had food pieces on his beard, chest, and clothing. He said, I am blind I can't see. The resident stated he had oatmeal for breakfast. He did not know how long ago. The food remnants were noted to be mushy in texture. An interview was conducted with Staff I, Certified Nursing Assistant (CNA) on 4/15/24 at 10:12 a.m. She stated breakfast was served at 7:45 a.m. and Resident #69 ate independently. She stated the CNAs clean the residents up as soon as they are done with the meal. She observed Resident #69 with food on himself and stated she would clean the resident. Resident #69 was readmitted to the facility on ,d+[DATE] with diagnoses to include Type 2 Diabetes Mellitus (DM), unspecified malnutrition, blindness right and left eye category 5, Cerebral Vascular Accident (CVA), dysphagia and dehydration. A care plan for Resident #69, dated 5/31/23, revealed the resident had an alteration in visual function with interventions to provide Activities of Daily Living (ADL) tasks as needed and to provide verbal cues to locate objects or navigate in the environment. A self-care focus showed the resident had a grooming deficit related to generalized weakness, DM, CVA ,and chronic pain. Interventions included to provide hands on assistance with grooming. On 4/15/24 at 12:40 p.m., Resident # 69 was observed in his bed after lunch. The resident was observed with food spilled all over his shirt, chest area and his left shoulder as he leaned to the side of the bed. During an observation on 4/16/24 at 02:00 p.m., Resident #69 was observed in his room, he was noted licking a bowl. The resident's tray was removed from the room. The resident said, I can't see in this bowl. I am trying to feel for the pudding. The resident was observed with a towel on his chest area with food dropped on himself during the meal. The resident's beard and nails were observed with redness from meal sauce and brown color from the pudding. It was noted the other residents had finished their meal and trays had been removed from the halls. Resident #69 was not cleaned up from lunch which was served at 12:00 p.m. Review of a document titled, Documentation Survey Report, also known as CNA task log, dated April 2024, showed daily entries of 05 under eating, indicating the resident required set up or clean up assistance - Helper sets up or cleans up. Under personal hygiene, the documentation showed 01 documented daily indicating the resident was dependent - Helper does all of the effort, meaning resident does none of the effort to complete the activity. On 4/17/24 at 1:03 p.m., an interview was conducted with Staff K, CNA. She stated she assisted residents who eat in their rooms and cleans them up when she removes trays or right after they were done with their meals. She stated the residents should not wait hours to be cleaned up after meals. An interview was conducted on 4/17/24 at 1:06 p.m. with Staff G, CNA regarding Resident #69 being observed with food after the meal. She said, [Resident #69] refuses care. He has [small flying insects] on his beard and on himself all the time. She stated if the resident refused care, they let the nurse know. She stated she had not notified the nurse of any refusals that day. During dining observation on 4/17/24 at 12:40 p.m., Resident #43 was observed laying on his bed. His roommate was presented with his tray while this resident was not. An immediate interview was conducted with Staff G, CNA. She said to this surveyor, [Resident # 43] is a feed, that's why I didn't pass his tray. During a dining observation on 4/17/24 at 12:41 p.m., The Regional Nurse Consultant (RNC) asked Staff J, Registered Nurse (RN) if they needed help passing trays. She said, Yes, Resident #69 is not a feed. He needs cues. His roommate [Resident #43] is a feed. During a facility tour on 4/15/24 at 10:11 a.m., Resident #43 was observed in his bed. The resident was not interviewable. His catheter was observed hanging below his bed, visible to bystanders. His catheter was not stored in a privacy bag. (Photographic evidence was obtained.) On 4/18/24 at 10:50 a.m., an interview was conducted with the Assistant Director of Nursing (ADON) she stated, It is bad to leave the resident soiled after a meal. She stated if a resident refused care, she would have another staff try. She stated she would step away and come back and try again. She said regarding Resident #69, it is care planned. Sometimes you have to leave him and come back. Sometimes he refuses, but not all the time. The ADON stated the CNAs should report to the nurses and there should be documented re-attempts. She stated they should not wait a long time before returning to the resident. She stated the CNAs should document if a resident refused care and the attempts they made should be documented. A follow -up interview was conducted on 4/18/24 at 12:35 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated Resident #69 refuses care. She asked, How long was he waiting? When notified breakfast was served at 7:30 a.m. and at 10:12 a.m. the resident still had food on him, she said, Oh, okay. The DON stated regarding the catheter not being in a privacy bag I'm surprised. What room was that? 46234 An observation was conducted on 4/15/24 at 12:16 p.m. in the Unit 7 dining room. Four residents were sitting at a table for lunch. One resident had their tray and was eating, and the other three residents did not have a tray. At 12:18 p.m. the second resident was served their lunch tray, at 12:23 p.m. the third resident was served their lunch tray and at 12:27 p.m. the fourth and final resident at the table was served their lunch tray. (Photographic evidence obtained.) Review of a facility policy titled Dignity, dated February 2021, showed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Under policy interpretation and implementation, (1.) Residents are treated with dignity and respect at all times. 5. (e.) provided with a dignified dining experience. (8.) Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice not labeling or referring to the resident by his or her room number, diagnosis, or care needs. (12.) Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents keep urinary bags covered.

Based on observations, record review, and interviews, the facility failed to ensure a grievance was filed related to a resident's room changed for one resident (#87), out of eight residents sampled. Findings Include: During an observation made on 04/15/2024 at 10:45 AM., Resident #87 was observed laying down in her bed with her call light within reach. The Resident said she would like to have a room change because she doesn't get along with her roommate. She said she spoke to the Social Services Assistant multiple times about wanting to move to another room, but nothing has been done about it. During an observation made on 04/16/2024 at 12:00 PM., Resident #87 was observed sitting up in her wheelchair with a blanket placed over her lap. She stated she and her roommate got into a verbal fight last night and she really wants her room to change. She said she was not made aware of the facility grievance process. Review of the medical record showed Resident #87 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, unspecified, major depressive disorder, recurrent, mild, acute kidney failure unspecified. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident had a Brief Interview Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. During an interview on 4/17/2024 at 4: 37 p.m., with Staff P, Social Service Assistant, SSA, she stated Resident #87 spoke with her about wanting to have a room changed a few times because she was not getting along with her roommate. She stated Resident #87 told her a few weeks ago that she and her roommate do not get along with each other and she wants a room change. Staff P stated she told Resident #87 when a room becomes available, she will work on moving her to another room. During an Interview on 4/17/2024 at 4:37 p.m., with the Social Service Director, SSD, she stated her assistant told her about Resident #87 wanting to have a room change but they did not have any rooms available at this time. Resident #87 has an infection, and we were not able to change her out of that room but when a room becomes available, we told her that we will do our best to change her to another room. She stated Resident #87 likes to fixate on things and will not let some things go once she gets it in her head. We did not document the conversation we had with the resident about the room change and the reason we were not able to move her out of the room she is in at this time. My assistant should have put a progress note in the system showing that she spoke with the resident about the room change and a grievance should have been filed on the resident's behalf if we were not able to accommodate her need. Review of the facility policy titled, Grievance/ Complaint, Filing, ,revised April 2017, showed the following: Policy statement: Resident and their representatives have the right to file grievance, either orally or in writing, to the facility staff or to the agency designated to hear grievance (e.g., thee State Ombudsman) The administrator and staff will make prompt effort to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation: 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Action on such issues will be responded to in writing, including a rationale for the response.

Based on observations, interviews, and record review, the facility failed to report an allegation of verbal/psychosocial abuse for two residents (#210 and #211) out of twelve residents. Findings included: Review of the facility's policy Identifying Types of Abuse revised date 09/2022 showed, Mental and Verbal Abuse 1. Mental abuse is the use of verbal and non-verbal conduct which cause (or has the potential to cause) the resident to experience humiliation, intimidation, fear , shame, agitation and degradation. 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Psychosocial Outcomes 1. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not to be immediately apparent. 2. Abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: a. Fear of a person or place of being left alone, of being in the dark, and/or disturbed sleep and nightmares. During an interview on 04/15/24 12:00 p.m., Resident #210 stated Staff A, CNA this weekend started using the F bomb and stated she was just not doing it over the weekend. Resident #210 stated Staff A, CNA also was on her phone with the earbuds talking to someone about threesomes. Resident #210's Family Representative (FR), present during the interview, also stated I didn't even go to work today, I came in because I am worried about my mom and her care. Resident #210's FR stated when she and Resident #210 reported Staff A, CNA over the weekend to Staff E, Licensed Practical Nurse (LPN) , Staff A, CNA ,after being reassigned, came back into Resident #210's room and asked what she did wrong. Resident #210 stated she felt very uncomfortable and even a little threatened. Resident #210's FR informed Staff A they felt very uncomfortable and Staff A left the room. During an interview on 04/15/24 at 12:15 p.m., Resident #211's family member stated he was certainly grateful for Resident #210 and the FR who spoke up to ensure Staff A, CNA was no longer able to work with Resident #211. Resident #211's family member stated he was not present during the time Staff A, CNA was being disrespectful and verbally aggressive towards Resident #211 but all the information could be obtained by speaking with Resident #210 and Resident #210's FR. Review of the Admission Record showed Resident #210 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of femur subsequent encounter for closed fracture with routine healing, cerebellar ataxia in diseases classified elsewhere, polyneuropathy, heart failure and spinal stenosis. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #210 had a BIMS score of 14 (cognitively intact. During a second interview on 04/15/24 at 2:50 p.m. Resident #210 stated the incident occurred on Sunday 04/14/24. Resident #210 recalled it all started when the roommate (Resident #211) had to go to the bathroom. Resident #210 stated she heard Staff A, CNA yell at Resident #211 saying Don't do that, you are going to make me have to clean {expletive} off the call light pull string. Resident #210 stated Staff A, CNA took Resident #211's wheelchair, shoved it out of the bathroom door and It hit my bed. Resident #210 stated she heard Staff A, CNA state, I don't feel like this {expletive} crap today. Resident #210 stated her FR walked in to visit about that time and was also present in the room. Resident #210 stated Staff A, CNA was on the phone and was talking about :threesomes and cussing. Resident #210 stated both she and Resident #210's FR talked with Staff E, LPN about it and she stated Staff A, CNA would not be coming back into the room. Resident #210 stated after lunch Staff A, CNA came back in to the room to pick up the lunch tray and began interrogating and asking why she was reassigned. Resident #210 stated, It was like she was going to get one more dig in. Resident #210 stated the FR spoke up and informed Staff A the conversation was getting very uncomfortable and Staff A, CNA left the room. Review of the facility's actual working schedule for 04/14/24 revealed Staff A, CNA was assigned to both Resident #210 and Resident #211 for the 6:45 a.m.-3:15 p.m. shift. During an interview on 04/15/24 at 3:12 p.m., the Staffing Coordinator (SC) identified Staff A, CNA as the CNA assigned to Resident #210 and Resident #211's room on 04/14/24. Review of the facility's reportable's for April 2024 showed no reportable for the date of 04/14/24. During an interview on 04/15/24 at approximately 3:20 p.m., the Administrator stated there were no additional reportable's for April. During an interview on 04/15/24 at 3:30 p.m., Staff A, CNA stated she provided care for Resident #210 and #211 on Sunday 04/14/24 until she was reassigned from the room. Staff A, CNA stated she really did not know why she got reassigned and no one gave her any specific reason for the reassignment. Staff A, CNA stated Staff E, LPN came to her and told her she would no longer be working with Resident #210 and Resident #211. Staff A, CNA stated she tried to inquire about why she was reassigned but no one would give her answers. Staff A, CNA stated no one told her she could not go back into Resident #210 and Resident #211's room. Staff A, CNA stated later in the day she was picking up lunch trays and went back into Resident #210 and Resident #211's room when the residents and Resident #210's family representative (FR) acted as if they were stunned and uncomfortable. Staff A, CNA stated the response gave her an uncomfortable feeling as well. Staff A, CNA stated at the time of tray pick, she asked Resident #210 and Resident #210's FR if there was a problem, but Resident's 210's FR stated this was making them very uncomfortable, so she left the room. Staff A, CNA stated no one ever told her she was not allowed to go back into the room, so she apologized to Resident #210 and Resident #210's FR but she still did not understand why everyone felt so uncomfortable. Staff A, CNA stated she tried to inquire a couple more times with staff as to why she was reassigned but no supervisor ever gave her any other information. Staff A, CNA stated she still knows nothing about why her room assignments got changed. During an interview on 04/15/24 at 3:46 p.m., Staff E, Licensed Practical Nurse (LPN) stated on Sunday 04/14/24 she was addressed by both Resident #210 and Resident #211 about Staff A, CNA being on her phone with ear buds and cursing. Staff E, LPN stated she decided to just go ahead and remove Staff A,CNA from Resident #210 and Resident #211's room and replace her with another CNA. Staff E, LPN stated she reported this to the supervisor Staff F, Registered Nurse (RN) who stated she would have a talk with Staff A, CNA. Staff E, LPN stated later Sunday afternoon Staff A, CNA took it upon herself to go back into Resident #210 and Resident #211's room . Staff E, LPN stated she never told Staff A, CNA why she was reassigned because she reported it to the supervisor on duty Staff F, RN. Staff E, LPN stated Staff F, RN was the supervisor and told her she would take care of it. Staff E, LPN stated she reported to Staff F, RN the information about Staff A, CNA cursing and all the actions that Staff A, exhibited towards Resident #210 and Resident #211. Staff E, LPN stated when she spoke with Resident #210 and Family Representative (FR) she was informed Staff A, CNA was cussing, using the F word and talking about threesomes. Staff E, stated she apologized for Staff A, CNA's behavior and informed Resident #210 and Resident #211 that Staff A, CNA would not go back into the room. Staff E, LPN stated she told all this information to Staff F, RN. Staff E, LPN stated that she would have reported this incident but respecting the chain of command she reported it to Staff F, RN who was the supervisor to take the information from there. During an interview on 04/15/24 at 4:20 p.m., Staff F, RN stated on Sunday 04/14/24 Staff A, CNA was reassigned from Resident #210 and Resident #211's room . Staff F, RN stated Staff E, LPN reported concerns that Resident #210 and Resident #211 had about Staff A, CNA. Staff F, ,RN stated she heard there were personality conflicts and since personalities do not always mesh Staff A, CNA's assignment was reassigned. Staff F, RN stated it was reported to her Resident #210 and Resident #211 were unhappy, so Staff E, LPN tried to smooth things over by removing Staff A, CNA from Resident #210 and Resident #211's room. Staff F, RN stated Staff A, CNA was Loud with a Big Personality but stated that is just Staff A, CNA's personality. Staff F, RN stated Staff E, LPN told her about a wheelchair that may have been pushed out of the bathroom while assisting Resident #211 and hit the wall or something and the Residents didn't care for that behavior. Staff F, RN stated she did not follow up with Resident #210 and Resident #211 about Staff A, CNA because she was under the impression Staff E, LPN took care of it. Staff F, RN stated she was never told about Staff A, CNA ever being on the phone or using any profanity. Staff F, RN stated she was a mandated reporter so if Staff E, LPN would have reported anything to her about Staff A, CNA using profanity directed towards residents that behavior would have required her to report it. Staff F, RN stated Staff E, LPN stated that she took care of it. During an interview on 04/15/24 at 4:35 p.m., with the Administrator and the DON, the DON stated she just spoke with Staff F, RN about 20 minutes before meeting with the survey team. The DON stated Staff F, RN just reported to her that Staff A, CNA was reassigned from Resident #210 and Resident #211's room on Sunday 04/14/24 because the Residents didn't care for Staff A, CNA. The DON stated Staff F, RN told DON Staff E, LPN talked with both Resident #210, Resident #210's Family Representative(FR) and Resident #211 and answered a ton of questions and everything seemed fine after that. The DON stated the chain of command for reporting would be for Staff E, LPN to report to Staff F, RN and then Staff F, RN should report to the DON who also identified herself as the Risk Manager. The DON stated if anything was reported to her related to abuse then Staff A, CNA would have been suspended immediately and an investigation would have been initiated. The DON stated that she had not even heard of any concerns related to Staff A, CNA and Residents #210 and #211 until 20 minutes prior to meeting with the survey team. During an interview on 04/15/24 at 4:45 p.m., Resident #211 stated on Sunday 04/14/24 Staff A, CNA was cussing. Resident #211 stated she could hear Staff A, CNA talking to someone on the phone. Resident #211 stated she could hear Staff A, CNA Talking about me. Resident #211 stated It didn't make me feel very good but what could I do? Resident #211 stated, I am blind with 1% vision in one eye and only about 7% in the other eye (legally blind). Resident #211 stated, I was afraid when Staff A, CNA was acting like that. Review of the Admission Record revealed Resident #211 was admitted to the facility on [DATE] with diagnoses that included acute bronchitis, weakness, unspecified falls, unspecified visual loss, depression and anxiety disorder. Review Resident #211's care plan showed the following: Focus: Resident has experienced a traumatic event that could lead to manifestation of Post Traumatic Stress Disorder (PTSD) or other psychosocial issues change in health status, loss of past roles. The goal included: Resident will have minimum negative changes in thinking and mood through next review. The Interventions included: Allow resident to make decisions, encourage resident participation in activities of choice, encourage resident to express emotions in a safe, private environment, provide reassurance and reorientation to facility, staff, and current situation as needed and refer to counseling/psych as needed. Focus: Resident #211 has an alteration in visual function diagnoses of glaucoma, diagnosis legally blind. Resident #211is at increased risk for falls with visual deficiencies at risk for malnutrition with visual deficiency. The goal showed, Resident will remain safe in the surrounding environment thru the next review date with assist form staff. The interventions included: administer medication as ordered, administer eye gtts (drops) as ordered, provide adequate lighting, provide assist with ADL tasks as needed, maintain a safe environment; notify resident of changes in environment as needed, provide verbal cues to locate objects or navigate in the environment, read written material to resident as needed. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #211 had a BIMS score of 13 (cognitively intact). During an interview on 04/16/24 at 4:35 p.m., The Regional Nurse Consultant (RNC) stated she thought Staff A, CNA's behavior was unprofessional and inappropriate, but she did not see it as abuse. The RNC stated she would have handled it differently than this administration and would have fired Staff A, CNA for the behavior. During an interview on 04/17/24 at 8:23 a.m., the DON stated all the staff know they are to report accurate information up the chain, so as the Risk Manager she is able to obtain accurate information to report an allegation and it can be handled properly. The DON stated she believed this was not abuse just a case of bad customer service. Review of facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised date 2021 showed, Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation 3. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigation.

Based on observations, interviews, record review, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to one resident (#45) out of ten residents sampled. Finding Include: On 4/15/2024 at 10:30 AM., Resident #45 was observed laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident #45 was not able to communicate his needs. On 04/16/204 and 4/17/2024, at 11:00 AM., Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident #45 was not able to communicate his needs. Review of the medical record showed Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include but not limited to Autistic Disorder, Chronic Kidney Disease Stage 3, other mechanical complication of other Urinary Devices and Implants, Sequelae, and Down Syndrome, unspecified. Review of a Quarterly Minimum Data Set (MDS) ARD/ Target Date 2/20/2024, showed in section C0100 no was answered indicting Resident #45 is rarely/never understood and a Brief Interview for Mental Status should not be conducted. Further review of section C100 showed Resident #45 was severely cognitively impaired. Review of Resident #45's care plan showed the following: Focus: Resident having a self-care deficit with dressing, grooming, bathing related to r/t: cognitive deficit, diagnoses of down syndrome, autism, generalized weakness, limited endurance visional limitations, Resident requires staff assistance/ cueing to participate with ADL's (Activity of Daily Living). Date initiated: 08/08/2018 and revised on: 01/26/2023. Interventions for providing hands-on assistance with dressing, grooming, bathing as needed, observed for decline in ADL function; report to the physician as indicated. Date initiated 08/08/2024 and revised on 01/26/2024. Review of the medical record showed no documentation to support Resident #45 had an ADL decline or behaviors with refusing ADL care. During an interview on 04/17/2024 at 11:00 AM., with Staff M, Certified Nursing Assistant, (CNA), she stated she stated at the facility two weeks ago and she was caring for Resident #45. She stated she had not completed full ADLs on Resident #45 because she really doesn't know all his care needs. She stated she had emptied his catheter and did not change the resident shirt from the night because she thought the night shift staff took care of dressing the resident. She stated she did not know what type of care the resident needed. She stated, I usually work on the other hall. During an interview on 04/17/2024 at 11:20 AM., with Staff N, License Practical Nurse (LPN), she stated when she first starts her shift at 7:00 AM., she does rounds to ensure all her residents are safe, and their beds are in low positions. If a resident is awake, she asks them if they are experiencing any pain. She said she checks on residents who are incontinent to make sure they are dry and clean. She stated she had been assigned to Resident #45 for the last three days but was not aware that he had the same shirt on for three days in a roll. She stated it was an oversight on her behalf and she will assist the resident immediately with his care. She stated her expectations are CNA's should make sure that ADL care is provided to their residents every day and residents are provided with clean clothes. If a CNA is experiencing problems with a resident they should notify her so she can assist them by using a different approach to provide care for the resident. She stated Resident #45 has not had any behavior reported to her during the days she has worked with him as his nurse. During an interview on 04/18/2024 at 2:00 PM., with the Director of Nursing, DON, she stated her expectation is that residents have ADL's performed on them every day. If staff are dealing with a resident refusing ADL care, then they report it to their nurse so the nurse can document the resident's behavior and provide further assistance. She stated no resident should be left in the same shirt for three days. Review of the facility policy titled, Activities of Daily Living (ADL's) Supporting, revised 03/2018 showed the following: Resident will be provides with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) has a debilitating diseases with known functional decline; (2) has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or (3) refuses care and treatment to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative intervention to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. 4. If resident with cognitive impairment or dementia care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care.

Based on observation, interview, and record review the facility failed to ensure proper orders and documentation were in the medical record for two residents (#10 and #255) out of twenty-nine sampled residents. Findings included: Review of Resident #10's care plan showed she was receiving hospice services. Review of Resident #10's physician orders did not show an active order in place for hospice services. There was a previous order for hospice, dated 5/31/22, which was discontinued on 6/6/22. Review of admission records showed Resident #10 was admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, psychotic disturbance, anxiety, and malnutrition. Review of Resident #10's hard chart and electronic medical record showed no documentation or notes from hospice services. An interview was conducted on 4/17/24 at 10:05 a.m. with Staff Q, Licensed Practical Nurse (LPN). She said Resident #10 was receiving hospice services. She pulled out the resident's hard chart and showed the hospice team and contact information noted on Resident #10's chart. When asked if the resident had an order for hospice she said Oh it's there she has been on hospice a long time. Staff Q reviewed Resident #10's medical record and confirmed there was no order for hospice services. Staff Q said maybe Resident #10 was disenrolled from hospice because she didn't meet the criteria any longer. When asked where notes are from hospice visits, Staff Q said she isn't sure hospice leaves any notes. An interview was conducted on 4/17/24 at 10:21 a.m. with Staff H, LPN/Unit Manager (UM). She said Resident #10 is hospice but she wasn't sure where hospice notes are. She said they may be in the Director of Nursing's (DON) office. An interview was conducted on 4/17/24 at 10:28 a.m. with the DON. She confirmed Resident #10 was on hospice. The DON said hospice notes should be scanned into the medical record. She reviewed the record and was unable to find any hospice notes or documentation for Resident #10. The DON also confirmed there was no physician order for hospice for Resident #10. The DON checked the facility's previous charting system in case the information didn't transfer to the new system. She said she could only find the order that was discontinued in 2022. The DON said an order should be in Resident #10's medical record. She also said hospice notes should be in the record, so the resident's nurses are able to view them. Review of lab results for Resident #255 showed he had a critically low hemoglobin level on 4/9/24. The Lab Results Report showed the lab was collected on 4/9/24 at 7:02 p.m. and the facility's laboratory servicing company was notified of the critical lab result on 4/9/24 at 8:57 p.m. The lab results showed they were faxed to the facility on [DATE] at 9:08 p.m. Review of the Admission Record showed Resident #255 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the kidney, history of transient ischemic attach and cerebral infarction, and anemia. Review of Resident #255's progress notes did not show any documentation a provider was notified of the critical lab values on 4/9/24. There was a progress note dated 4/10/24 at 7:08 a.m. showing the lab called about critical lab results for Resident #255, the resident's primary care nurse practitioner (NP) was notified, and she gave orders for the resident to be sent to the hospital. An interview was conducted on 4/18/24 at 10:50 a.m. with the DON. The DON reviewed Resident #255's medical record and noted the order for STAT (immediate) labs was placed on 4/9/24 at 10:42 a.m. When asked why it took almost 8 1/2 hours for STAT labs to be drawn, the DON stated, STAT labs have been challenging at times. She said STAT labs should have results within 4-6 hours of being ordered. The DON confirmed there was no documentation showing a provider was notified of the critical lab values. She said she knows the nurse spoke with the NP but there should be documentation in the record. An interview was conducted on 4/18/24 at 11:25 a.m. with Staff R, Medical Records. She confirmed all facility records for Resident #255 had been scanned into his electronic medical record and there are no additional closed records or hospice notes. An interview was conducted on 4/18/24 at 11:59 a.m. with Resident #255's primary care NP. She said she didn't know what the deal was with the labs, but STAT orders should be drawn within 4 hours and results are typically back within two hours after that. Review of a facility policy titled Hospice Program, revised July 2017, showed the following: Policy Statement Hospice services are available to residents at the end of life. Policy Interpretation and Implementation 9. In general, it is the responsibility of the hospice to manage the resident's care as it related to the terminal illness and related conditions, including: . c. Providing medical direction, nursing, and clinical management of the terminal illness. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriate based on the individual resident's needs. Review of a facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, reviewed November 2018, showed the following: Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis,etc. Review of a facility policy titled Charting and Documentation, revised July 2017, showed the following: Policy Statement All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care

Based on observations, interviews and record review, the facility did not ensure foot care was provided when needed for one resident (#69) out of one residents sampled. Findings included: During a facility tour on 04/15/24 at 10:10 a.m., Resident #69 was observed in his bed. His toe nails were observed with dark nail beds and black residue around the toe nails. An immediate interview was conducted with the resident who did not know what was wrong with his feet or toenails. He asked this surveyor what they looked like. He said, Lady, I am blind. I have not seen my feet or nails. He stated he did not know if the staff were applying anything to his feet. Review of a Primary Care Physician (PCP) progress note, dated 02/07/24, showed Resident #69 had a follow up visit chief complaint, At risk patient with long thickened painful nails. Patient is seen today for treatment of painful and thickened toenails bilateral feet. Patient has pain secondary to thickening and dystrophy of the infected (mycotic) nail plate. Thickening and dystrophic nail has been present for many months. Debridement of the nails has helped previously to control pain and inflammation of periungual nail borders. The patient has a reoccurrence of pain as the nail grows and becomes thickened . The plan note showed Nursing staff to contact me immediately if any erythema, purulence, or other signs of infection be present, otherwise patient is to be seen in 6-8 weeks. Review of the Electronic Medical Record (EMR) for Resident #69 did not show the physician had been contacted or had seen this resident since the visit in February. Review of April 2024 physician orders for Resident #69 conducted on 04/15/24 at 11:00 a.m. showed the resident did not have active treatment orders for his skin condition. Review of the admission record showed Resident #69 was admitted to the facility on [DATE] an initial admitted [DATE] with diagnoses of Type 2 Diabetes Mellitus (DM), unspecified malnutrition, blindness right and left eye category 5,and Cerebral Vascular Accident (CVA). Review of a care plan for Resident #69, dated 05/31/23, revealed the resident had an alteration in visual function, with interventions to provide ADL tasks as needed and to provide verbal cues to locate objects or navigate in the environment. A self-care focus showed the resident had a grooming deficit with .grooming related to generalized weakness, DM, CVA and chronic pain. Interventions included providing hands-on assistance with dressing, grooming, and bathing. Review of Resident #69's weekly skin assessments for the months of March and April 2024 showed four documents were completed indicating the resident's skin condition was normal. On 04/13/24 skin condition is normal, dry, flaky, and fragile. On 04/06/24 skin condition is normal, dry, flaky, and fragile. On 03/30/24 skin condition is normal. On 03/23/24 skin condition is normal, dry, flaky, and fragile. On 03/16/24 skin condition is normal, dry, and fragile. On 04/18/24 at 09:18 a.m., an interview was conducted with Staff L, Registered Nurse (RN) she observed Resident #69's feet and stated the resident should be getting skin prep. She stated she would review his chart. Staff L followed up with this surveyor at 09:54 a.m. and stated they just ordered a cream for his feet. She stated the physician ordered Ammonium Lactate External Cream 12% to be applied to bilateral legs and feet every shift. She stated Resident #69 was on the list to be seen by the podiatrist next time he was in the building. Staff L, RN reviewed the electronic medical record and confirmed she could not find podiatry notes for this resident. An interview was conducted on 04/18/24 at 10:02 a.m., with Staff H Licensed Practical Nurse (LPN) She stated the resident was seen by his PCP on 02/7/24. The UM stated she did not know if he had been seen by a podiatrist since his admission. She stated she had not seen the resident's feet and did not know the condition they were in. She stated she was not aware there were any concerns. On 04/18/24 at 10:59 A.m. an interview was conducted with the Assistant Director of Nursing (ADON). She said, As a nurse they [nurses] should do skin checks and report any concerns, or the CNAs to report any skin impairments. The ADON reviewed residents skin assessments with surveyor and noted they indicated normal skin. She stated if a resident had any kind of skin impairment, it should be documented. She stated she would assess the resident herself. On 04/18/24 at 12:59 p.m. an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON stated the resident should have been seen by podiatrist. She said, There should be notes. She reviewed the skin assessments with surveyor showing normal skin assessments were documented without any noted impairments. She stated she would follow-up. Review of a facility policy titled, Fingernails/Toenails, Care of, dated February 2018, showed the purpose of this procedure are to clean the nail bed, to keep nails trimmed, to prevent infections. Under general guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulator impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on observations, interviews and record reviews, the facility did not accommodate dietary preferences related to alternate meal requests for four residents (#351, #18, #352, and #86) out of 13 sampled residents. Findings included: 1. On 04/15/24 at 10:31 a.m. an interview was conducted with Resident #351 who stated food was not palatable. He said sometimes the food is cold. He described the supper last night, which was lima beans, carrots, and what he described as broth (but was supposed to be soup), fruit from a can, and no bread/crackers. He stated dietary comes by to get choices, but they never bring what he wants. He said follow up is nonexistent. On 04/15/24 at 12:52 p.m. resident #351 said, The food {expletive}. I don't like anything. He stated the food has no seasoning/salt. He described the lunch as very bland. The resident stated he was not offered an alternative even though he doesn't like the options. During the interview the roommate stated nobody asked if he wanted an alternate meal choice and he didn't know he could ask for an alternative. Review of the admission record showed Resident #351 was admitted to the facility on [DATE] with a diagnoses of dehydration, and dysphagia. Review of Resident #351's Admission Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 12, intact cognition. Review of April 2024 physician orders for Resident #351 showed the resident received a regular texture diet, thin consistency, large portions with breakfast and fortified foods with meals for nutrition. Review of Resident #351's care plan, dated 03/29/24, under the nutrition focus showed the resident has an alteration in nutrition related to a variable PO (by mouth) intake. The goal, revised on 04/12/24, showed honoring resident's food preferences. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 2. On 04/17/24 at 12:42 p.m. Resident #18 was observed during lunch service. The resident stated to Staff G, Certified Nursing Assistant (CNA) that was not what he wanted. He said, I don't want the soup. I wanted two sandwiches. I ordered this last night. During the observation, the resident's tray was noted without sandwiches. Resident #18 stated he put in his request the night before. Resident#18 said, It happens all the time. During the interview Staff H, Licensed Practical Nurse (LPN)/ Unit Manager (UM) stated she would get him a sandwich. She said, It should have been on the tray if he asked the night before. Review of the Admission Record for Resident #18 showed the most recent admitted [DATE] and an initial original admitted [DATE], with a diagnoses morbid severe obesity and Type 2 Diabetes Mellitus. Review of Resident #18's MDS, dated [DATE], revealed in Section C-Cognitive and Patterns BIMS score of 15, intact cognition. Review of the April 2024 physician orders for Resident #18 did not show the resident's dietary orders. Review of resident #18's care plan, initiated on 08/25/20 under the focus of nutrition showed the resident has an alteration in nutrition related to a therapeutic diet with a history of changing dislikes and preferences often. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 3. An interview was conducted with Resident #352 on 04/15/24 at 12:48 p.m. Resident #352 stated he doesn't like the food as it's not food he normally would eat. He said, When I request food as an alternate choice, I do not get what I want. Review of Resident #352's meal ticket, dated 04/29/24 sic (04/15/24), revealed the resident was served mushroom gravy, steamed summer squash, pureed black-eyed peas, dinner roll buttered, mechanical/altered ground orange gelatin (photographic evidence was obtained). During the observation, the resident stated this is not what he ordered and he did not like any of these meal items. Review of the Admission Record showed Resident #352 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease stage 4. Review of the April 2024 physician orders for Resident #352 showed the resident received a mechanical soft texture diet, thin consistency, no straws for nutrition. Review of Resident #352's care plan, dated 04/15/24, under the focus of nutrition showed the resident has an alteration in nutrition related to a variable oral (PO) intake. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 4. An interview was conducted on 04/15/24 at 10:50 a.m. with Resident #86. Resident #86 stated she generally likes the food; however, she doesn't ask for an alternate if she doesn't like the option. Resident #86 stated, She did not know she could ask for an alternate option. Review of the Admission Record for Resident #86 showed an admitted [DATE] with diagnoses to include noninfective gastroenteritis and colitis and constipation. Review of Resident #86's Quarterly MDS, dated [DATE], revealed in Section C-Cognitive and Patterns a BIMS score of 99, indicating the resident was not interviewable. Review of the April 2024 physician orders for Resident #86 showed the resident received a regular texture diet, thin consistency, and super cereal with breakfast for nutrition. Review of Resident #86's care plan, dated 08/26/23, under the focus of nutrition showed the resident has an alteration in nutrition related to a variable PO intake. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. An interview was conducted on 4/18/24 at 6:09 p.m. with the Dietary Manager (DM). The DM stated she was responsible for interviewing residents and collecting their food preferences. The DM stated during the 3pm-11pm shift, the CNAs collect the food preferences from the residents. The DM stated she gives the food preferences interview to the Registered Dietitian (RD-1), who puts the information into the meal tracker system. The DM stated the meal tracker system is a new system. She stated the meal tracker system is not interfaced completely, therefore, there have been some issues with residents not getting their preferences and alternate choices. The DM stated she was aware there was an issue, which was identified a month and a half ago. She stated she was aware residents have been reporting they were not receiving the options they wanted, despite being asked the day prior by staff. She stated she brought this concern up during their morning staff meetings. She said, I am keeping the food preferences and substitute paper from the residents who are saying they are not getting the food choices they want. The DM stated she was monitoring their process. Review of the facility's policy titled, Dining and Food Preferences, dated October 2019, showed it is a center policy that individual dining, food, and beverages preferences are identified for all residents/patients. Under action steps, (6.) The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal pan into the plan of care, (7.) The individual tray assembly ticket will identify allergies, food and beverage preferences or special requests, and adaptive equipment as appropriate, (8.) Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value, (9.) The alternate meal and/or beverage will be provided in a timely manner.

Based on observation, facility staff interviews, record review and policy and procedure review, the facility failed, during assistance with bed mobility by three staff members (C, B and E), to prevent a 0.5 cm abrasion to the head to one resident (#1), who was also being administered anticoagulants, and failed to provide supervision to prevent falls and failed to follow facility policy and procedures to follow up after a fall for three residents (#1, #4 and #5) of three sampled residents. Findings included: 1. Review of a Grievance/Concern Report for the dates of 08/03/22 and 08/04/22 showed the resident's [family member] stated on 08/03 the resident was injured by staff and received a wound to the head. She met him at an appointment and the wound bandage was dirty and no notes with records for doctor. The DON documented on 08/04 that an investigation would be initiated. She spoke with [family member] over the phone and explained the process of investigation and possible corrective action for staff if deemed necessary. Apologized on behalf of the nurse for any indiscretion on her behalf. The family member stated she was not satisfied with resolution and was calling AHCA (Agency for Health Care Administration). Review of the Admission Record revealed Resident #1 was admitted on [DATE] and discharged on [DATE]. The Admission Record showed diagnoses to include amputation of left toes, adjustment disorder, mixture of anxiety and depressed mood, obesity, right below the knee amputation, weakness, and history of venous [CONDITION(S)] (blood clots). Review of the Admission Minimum Data Set (MDS), dated [DATE], showed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired). Section G Functional Status showed he required extensive assistance of two for bed mobility (how resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture), was totally dependent on two persons for transfers and totally dependent on one person for toileting. Resident #1 had functional limitation of range of motion of both lower extremities. Section J Health Conditions showed the resident had two falls, one with no injury and one with injury (except major). Record review of the August 2022 physician orders, Medication Administration Records (MAR) and Treatment Administration Records (TAR) for July 2022 and August 2022 showed bilateral 1/4 side rails up while in bed as enabler as of 07/21; monitor for the following signs and symptoms (s/s) of bleeding gums, unusual bruising, bleeding wounds. Notify Medical Doctor (MD) if any symptoms present every shift as of 07/21/22; encourage resident to maintain bed in lowest position at all times when resident is in bed, may elevate bed for the provision of care for safety as of 07/26; Floor mat to exit side of bed when resident is in bed for safety as of 07/26; [MEDICATION(S)]-Acetaminophen 10-325 mg (milligrams) every 6 hours as needed for pain; [MEDICATION(S)] ([MEDICATION(S)]) 5 mg by mouth two times a day for [CONDITION(S)] (CAD). This medication is an anticoagulant used to treat and prevent blood clots, it may take longer than usual to stop bleeding if cut or injured; May cause bruising or bleeding more easily. Call doctor right away if bleeding or bruising is unusual, severe, or cannot be controlled found at www.National Library of Medicine. Medlineplus.gov. The MARs and TARs for July 2022 and August 2022 showed [MEDICATION(S)] was given twice a day. They showed documentation for low bed every shift and floor mats in place every shift. They showed monitoring for signs/symptoms of bleeding every shift. Review of progress notes showed: On 07/22 at 15:26 (3:26 p.m.), the nurse left the room for 3 minutes after adjusting the wound vac (vacuum), and within seconds the resident was found sitting on the floor in his room. No injury was noted. He was confused, as when he was admitted . MD made aware of confusion. Labs ordered for a.m. A floor pad was placed at bedside. The resident stated he was going to get up and go behind the bar. On 07/22 at 16:37 (4:37 p.m.), the nurse was notified by the Certified Nursing Assistant (CNA) that the resident had fallen onto the side of the bed. Resident stated he was trying to walk to the bathroom. Reminded him he had a [indwelling catheter] catheter and did not need to attempt to urinate in toilet. Resident complained he was an [CONDITION(S)] so it's hard to walk. Advised resident to not try to walk because of recent surgery. No injuries were present during the initial skin sweep, immediately after incident. Called and let family and MD know. Family advised they would be in later. Applied a bed alarm to resident's bed as a fall intervention, as he had fallen on previous shift as well. On 07/22 at 21:52 (9:52 p.m.), called into resident's room by family member who was upset with resident's condition. Family pointed out that he was bleeding on top of his hand. A small skin tear was observed on right knuckles. Area was cleansed with normal saline and steri-strips applied (no orders found for care). Family member talked about still not feeling comfortable with father and she was afraid he would fall again. After brainstorming for a while, we came to the conclusion that after 8 p.m. med-pass we would switch out [resident's] bed with a bed with different rails. After waiting some time family member became impatient with how long med-pass was taking so an aide and nurse moved resident during the 8 pm. med-pass instead. The family member expressed contention afterwards and no other concerns voiced. On 07/25 at 23:10 (11:10 p.m.), called MD on call number, and left a message with name of patient and a brief description of incident (fall from his wheelchair in his room that day). Waited for a call back, and yet to at this time, still no response. Also notified the resident's wife about the incident. Neuro-checks were initiated, and he continued to be monitored with 0 injuries noted at this time. He did complain of pain and was treated for pain with positive results. Staff C Licensed Practical Nurse (LPN) On 07/26 at 01:55 (1:55 a.m.) showed no ill effects from recent fall. On 07/23, 7/24, and 7/25; no documentation was documented related to post fall protocol. Neuro checks were not documented. On 08/04 at 16:02 (4:02 p.m.), Notified by MD's office that resident will go to hospital due to some issues currently. The nurse will communicate to Nurse Practitioner (NP). Wife was with husband. Progress Notes lacked any documentation on 08/03 regarding incident with three staff members (C, B, and E) assisting Resident #1 up in bed and hitting his head on the headboard. Or of any assessment, care needs or monitoring, informing of change in condition. Review of a facility report with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 08/15/22 at 11:14 a.m. showed on 07/22/22 at 1455 (2:55 p.m.) in resident's room he was found sitting on floor at bedside. No injury noted. He stated he was getting up going behind the bar. Full vital signs, all stable. No injury noted currently. MD and family made aware. Resident was not taken to the hospital. Resident was oriented to person. Predisposing environmental factors: other. Predisposing Physiological Factors: confused, gait imbalance, impaired memory. Predisposing Situation Factors: ambulating without assistance. No witnesses found. MD notified on 07/22 at 15:06 (3:06 p.m.). Family notified on 07/22 at 15:08 (3:08 p.m.). Review of another facility report with the NHA and DON on 08/15/22 at 11:14 a.m. showed on 07/22/22 at 21:12 (9:12 p.m.) walked into resident room and found resident lying on floor mat next to bed. Resident was trying to go to the bathroom. Reminded resident he has an [indwelling catheter] and doesn't need to get up. Small skin tear on knuckles of resident. Applied steri strips and applied a bed alarm to resident's bed. Resident was not taken to the hospital. No injuries observed at time of incident. Skin tear to back of right hand. Resident was alert and bedridden. He was oriented to person and place. Predisposing Physiological Factors: confused. Predisposing Situation Factors: ambulating without assist. No witnesses found. MD notified on 07/22 at 21:14 (9:14). Family notified on 07/22 at 15:14 (3:14 p.m.). This happened at 4:00 p.m. on the dot. When asked how the family was notified before the incident, received no comment. Review of another facility report with the NHA and DON on 08/15/22 at 11:14 a.m. showed on 07/25/22 at 23:02 (11:02 p.m.) in resident's room, resident attempted to stand up out of his wheelchair. His call light was not turned on, and he stated that he was trying to go over there. I was trying to get up and go over there. Assessed, neuro-checks initiated, placed resident in bed at lowest level, floor mats in place, call light in reach. Called out to on call at physician office, awaiting return phone call. Notified his wife and treated him for pain, with positive results. No injuries observed at time of incident. Level of pain was 2. He was oriented to person and place. He was lucid throughout most of the evening, yet at times appeared to be somewhat confused. For example, he couldn't explain to writer why he did not use his call light for help. Next, he stated that the doesn't want to go to the same hospital. Predisposing Physiological Factors: confused, recent illness, gait imbalance. Predisposing Situation Factors: ambulating without assist. He is also currently being treated for [CONDITION(S)] via midline. With his infection, some confusion may be noted. No witnesses found. Notified MD on 07/25 at 23:10 (11:23 p.m.). No documentation that family was notified. Review of the facility forms related to fall incidents with the NHA and DON showed Staff C, LPN failed to accurately chart or document pertinent information concerning a resident. A resident had an incident on Staff C's floor on 08/03, resident was boosted by staff and his head was hit causing a head laceration. No Facility Form was started, no supporting documentation on incident anywhere in computer system. Staff C was suspended pending investigation. Record review of hospital records dated 08/04/22 at 11:27 a.m. showed Resident #1 presented with lightheadedness and neck pain that occurred after being pulled up in his bed at the nursing home and was slid into the wall last night, headfirst. He reports a wound to his head that will not stop bleeding. He denies headache or loss of consciousness. He takes [MEDICATION(S)] for a previous DVT. He was noted to have a 0.5 cm abrasion to the top of head with minimal bleeding (ooze). CT of the spine showed no evidence of acute cervical spinal fracture or spondylolisthesis. CAT scan showed no evidence of acute infarct, [CONDITION(S)], or mass lesion. Dermabond was applied to the abrasion on top of his head with resolution of bleeding. Will be discharged home. Review of the Fall Risk Evaluation, dated 07/22/22 15:29 (3:29 p.m.), showed he did not have a change in cognition. He does have behaviors present. He has a fall risk of 14 (a score of 10 or higher indicates risk for falls). A Pain Evaluation, dated 07/22/22 at 15:31 (3:51 p.m.), showed no pain. Review of the Fall Risk Evaluation, dated 07/26/22 at 23:02 (11:02 p.m.), showed he had 3 or more falls, had no change in cognition. He does have behaviors present. He has a fall risk of 20 (a score of 10 or higher indicates risk for falls). Documented as if the fall occurred on 07/26 rather than 07/25 and was created on 08/02/22, 8 days after fall by Staff G LPN/Unit Manager (UM). Record Review of the Neurological Flowsheet dated 07/25 (third fall) showed neuro checks performed from 19:30 (7:30 p.m.) until 22:00 (10:00 p.m.) only. Record review of the care plans showed Resident #5 was at risk for falls and/or fall related injury related to generalized weakness, was non-ambulatory, was impulsive, attempted transfers, uses wheelchair as primary mode of locomotion, use of anticoagulants, required [mechanical] lift for transfers. Increased risk for fracture with falls due to diagnosis of osteopenia. On 07/22/22 he was found sitting on floor at beside. No injury noted. On 07/22/22 walked into patient room and found patient lying on floor mat next to bed. On 07/25/22 attempted to stand up out of his wheelchair and lost balance. Goals included resident will minimize risk of fall related injuries with staff intervention. Interventions included but were not limited to ¼ side rails up in bed as an enabler as of 07/22; floor mat to exit side as of 07/25; switched bed as of 07/22; Labs as of 07/25; observe for unsteadiness / dizziness when changing positions, provide assist as needed; perform frequent checks on resident; utilize total mechanical lift with staff assist of 2 for transfers; observe for use of appropriate footwear and assist as needed; educate / remind resident to request assistance prior to ambulation/transfers as needed; administer medications as ordered, observe for effectiveness and for side effects; keep bed in low position; bed alarm on while in bed as of 07/22; keep call light within reach; provide incontinence care / toileting per resident's needs; report falls to physician and responsible party as needed. Another focus was [Resident #1] was at risk for abnormal bleeding and increased bruising related to use of anticoagulants for treatment of history of Deep Vein [CONDITION(S)] (DVT). Goal for resident was to remain free of complications from anticoagulant therapy. Interventions included administer medications as ordered, observe for effectiveness; educate resident or responsible party on risk and benefits of anticoagulants use as needed; observe for blood in urine, stool, emesis, nosebleeds, bleeding from gums, abnormal bruising and report to physician if noted. Another focus was [Resident #1] exhibits the following behaviors, irritable, can be resistant to care. Patient stated to psych that he was falling because he would like to be put back to bed. Interventions include but not limited to anticipate care needs and provide them before becomes overly stressed. No documentation of an Interdisciplinary Team meeting was found in the medical record. During an interview on 08/15/22 at 11:08 a.m. the DON stated they do a daily review in the morning meeting. It included the IDT including MDS. They review the interventions put into place, etc. They document falls in the internal section of the computer. The surveyor does not have access to that section of the computer. The DON stated she did not know if this documentation was part of the medical record or not. She stated they do not document what was discussed at this meeting elsewhere. She verified they only have a SOC (Standards of Care) Summary in Resident #1's medical record and it was not complete. Review of the Standards of Care (SOC) Summary, effective 07/28/22, showed the following care area requires review by the IDT: falls. He has had a history of falls in the last 180 days. His current fall prevention interventions in place: bed is in low position when in bed and floor mats beside bed. His Fall Risk Score is above 10. Care plan/Kardex (CNA tasks) reflect current fall interventions. Date and score of most recent Fall Risk Evaluation was on 07/25/22 and a score of 20. IDT Comments / Recommendations was blank. Factors increasing risk of falls included safety judgment is impaired, attempts to stand/ambulate without assistance, has episodes of incontinence, displaced generalized weakness. ADL (activities of daily living) decline showed current ADL function as blank. The DON documented on the form on 08/16/22 that the SOC Summary was not complete due to unplanned discharge. Record review of the Psych Nurse Practitioner note dated 08/01/22 showed the chief complaint is mood symptoms increased confusion with multiple falls per facility staff. Staff states the patient is having increased episodes of confusion and has had several falls recently. Patient is very irritable during evaluation. He states that he is falling because he wants to be put back in bed from his wheelchair. He states that this leg slides off the leg board for his wheelchair and that he wants to be in his bed. Patient states in a loud tone if I don't get put back in the bed right now, I am going to fall onto the floor. I want to be back in bed. Patient also stated that he was very upset because he wants to go back home. Patient is alert and oriented x 4. Patient is asked by this writer to stay in his wheelchair while staff is notified in regards for his need for assistance. Staff is notified of patient's needs and writer stays at patient's bedside until staff return. Patient does present with increased symptoms of agitation and irritability. Patient appears frustrated and restless at this time. Review of the staff statements related to the 08/03/22 fall were as follows: Staff I, Registered Nurse (RN) wrote on 08/04/22 that on Wednesday, 08/03/22, I was working with nurse Staff C, LPN. During my shift she had mentioned her, and a CNA had boosted Resident #1 up in bed and bumped his head. She did not mention any injury to me regarding the incident. Staff A, CNA, wrote on 08/04, I [Staff A], CNA, was sitting in [Staff G, LPN/UM's] office charting when I overheard [Staff C, LPN] talking out loud about how she helped an aide boost [Resident #1] and they hit his head on the headboard. Staff B, CNA documented a statement without a date, on 08/03/22 [Staff C, LPN] for 3-11 shift asked if myself and an orientee to boost [Resident #1's room number]. As we were boosting his head came in contact with the headboard. I left. A spot-on top of his head was bleeding. [Staff C] was in room and told the resident she will be back with a bandage. Was told to not write any report regarding incident. Was notified the next day by [Staff G], to write report. Reviewed statement by Staff E, CNA that was taken over the phone by the DON on 08/15/22 (day of survey). Interview was conducted with [Staff E, CNA] regarding incident with Resident #1 on 08/03/22 during the 3-11 shift. [Staff E] was orienting with [Staff B, CNA]. She was asked to assist [Staff B] and [Staff C]. [Staff E] stated that [Staff C, LPN] and [Staff B, CNA] felt like he required an additional person to be pulled up and when they did his head was accidentally bumped on the headboard. [Staff E, CNA] also stated that [Staff C, LPN] it (head wound) was bleeding but the injury itself was less than half the size of the tip of her finger. She continued to say [Staff C, LPN] did put a wound dressing on the area afterwards. The DON obtained a statement from Staff J, CNA on 08/15/22 (day of survey). To whom it may concern I was the 7-3 CNA for Resident #1 on 08/04/22. As I was getting him ready for doctor's appointment that morning, I observed a gauze, band-aid on top of his head. He mentioned his head had been bumped on the wall when being pulled up in bed on 11-7 shift. I was under the impression that the nurse was already notified due to the dressing being in place already. Reviewed a statement written on 08/15/22 by Staff K, LPN, who worked 7-3 shift on 08/04/22, showed while hanging [Resident #1's] IV he stated he hit his head while being boosted up. There was a small island bandage on his head. I did not get any information in report and no documentation in computer. During an interview on 08/15/22 at 11:14 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated that Resident #1 was admitted on ,d+[DATE]. The DON stated he started to have some issues with falls. They switched his bed because he had shorter side rails and they wanted to put ¼ side rails which are easier to grab. He already had the bed alarm put on his bed. The DON stated the family was in her office between 8:00 p.m. and 9:00 p.m. on 07/25 about the bed being changed. She reviewed with the family they had placed bed mats at his bedside. The NHA and DON reviewed Resident #1's medical record and verified the documentation post falls lacked vital signs, neuro checks, assessment performed at time of incident, range of motion, exact time of incident, who found resident, etc. They stated the nurse documented the information in the facility form which was not part of the medical record. Review of the facility forms with the NHA and DON at this time for the first 07/22 fall showed it lacked vital signs, neuro checks, complete assessment including range of motion, exact time of incident, describing the resident and the environment at the time of the discovery of the resident. Review of the second fall on a 07/22 facility form. Again, there was no documentation of vital signs, neuro checks, complete assessment including range of motion, describing the resident and the environment at the time of the discovery of the resident. It did include the interventions put into place including a bed alarm and new bed. Review of the progress note documentation in the medical record of the incident on 07/25 which lacked what the incident even was. The documentation lacked details of how the resident was found, who found him, his appearance, his environmental details. There was no documentation of vital signs, neuro checks, complete assessment including range of motion, and time of incident/fall. There was no documentation the physician was ever made aware of the fall. During the continued interview with the NHA and DON, they stated on 08/03/22 two aides, Staff B, CNA and Staff A, CNA (not the aide at the scene discovered during the investigation) and Staff C, LPN were boosting Resident #1 in bed. The DON stated she was not aware of the incident until after the fact. She stated the physician's office called her and stated the resident had a band-aid on his head and it was bleeding. She stated she started investigating. The DON stated that all three (Staff A[not correct CNA it was Staff E], Staff B, Staff C) were pulling him up in bed and he decided to push himself up and had some sort of laceration. The DON stated she does not know why he decided to push himself up due to being non-weight bearing on the foot. She stated he never returned from the physician's visit. The incident happened on 08/03 on the 3-11 shift and he went to the physician on 08/04. She stated the 11-7 shift nurse, Staff K, LPN had nothing to say. She said he was asleep and had no issues with him during the shift and does not remember the band-aid. She said she spoke with the 7-3 shift nurse, Staff L, LPN, and she did not see it either. She stated he was sent to the hospital by the physician's office. The [family member] called the DON on the phone, and she tried to explain to her they were doing an investigation. She told the [family member] she did not have a lot of information for her at that time. She explained the investigation process. The [family member] told the DON she was calling the State Agency. Another State Agency showed up that afternoon, 08/04. This State Agency employee asked the DON to fax her the nursing notes, August MAR and last Nurse Practitioner note. The DON stated the State Agency employee later called and stated she was pursing the nursing license of [Staff C, LPN], and reporting to an additional State Agency. The DON stated the Social Service Director (SSD) wrote it up as a grievance, we spoke with the [family member] together. Staff C, LPN was suspended and has not come back to work. DON stated, The CNAs involved were not suspended because it was not a matter of them doing their jobs or not; it was the nurse did not do her job. The nurse did not do the documentation of the incident. The DON stated again that Staff C, LPN was still suspended due to still being investigated. They have not reinstated the nurse. They did educate the nurses on risk reporting documentation and who they have to report to. It should have been reported to the DON, physician, family. None was documented. The DON stated, Did not do a reportable. Reviewed the care plans with them related to falls. On 08/15/22 at 1:15 p.m. in an interview with Staff A, CNA she stated she was at the nursing station and overheard Staff C, LPN talking about bumping the head of Resident #1. She stated that she was not present during the incident. Staff C, LPN stated she and Staff B, CNA said they hit his head on the headboard. Staff B, CNA stated the nurse stated, she did not know how much force she had, to do that (move him up and hit his head). The nurse was small. She did not hear about it on the 3-11 shift that night, she was charting. She did not see the resident that evening. They just told her to write a note the next day. She gave it to Staff G, LPN/UM. She did not talk to anyone nor interview with anyone about the incident. An interview with Staff C, LPN was conducted on 08/15 at 1:55 p.m. She stated she had been taking care of him (Resident #1) for several weeks. He asked to be boosted up. She stated he was about 300 pounds. She asked an aide to assist because he can be difficult. He bent his knee to help us. We boosted him and he hit his head on the headboard. He was not bleeding much. There was a scant amount of blood. I provided First Aid to stop the bleeding. There were other emergencies going on that evening. She stated, She called the doctor's office, she did not get a call back, and did not know who to call. She stated, Should have called the DON. She stated she placed gauze on his head and cleaned it up. She took his vital signs. She stated she had to do an event on him, but it was after 11:30 p.m. She stated she had to go home because she worked the next day at her other job, and she said she could come in tomorrow early to do the event. She did talk to the DON the next day. She came in at 1:00 p.m. the next day (08/04) and wanted to do the event. The DON told her she was suspended. She stated the lady from the state agency came in. The residents were not lacking, not at all. She stated there was not much blood. He was on blood thinners. She stated again she cleaned him up and put a band-aid on him. She stated she had four or five IVs that evening and had emergencies on the floor. She stated one resident was going in and out of other resident's rooms. She had to prioritize. She stated she wanted to do the paperwork and told them she could come in the next day. She stated she thought she had 24 hours to put in the paperwork. The DON told her he was discharged to the hospital and was discharged out of the system. She would not be able to document in the medical record because he was discharged . She stated again she thought she could put it in later. She stated she was told the resident was bleeding heavily. By the time I left, changed the band-aid to a larger band-aid. He went to sleep. She stated she gave him a pain pill. She stated she could not stay late. She talked to the DON and told her that morning she could come in at 1:00 p.m. and the DON said come in and we will talk. She stated the DON talked to her in front of other staff in the day room. She stated, Did not do intentional. There were three of us, [Staff B, Staff E, CNA] that was with [Staff B]. [Resident #1] can be very heavy and difficult. She stated, He hit it pretty hard. She stated, Don't recall if reported to next nurse. She stated she checked his neuro checks a couple of times. He told us to leave him alone. She stated again, she intended to do the documentation the next day, within 24 hours in the computer. She stated the incident happened between 8:00 and 9:00 p.m. During an interview on 08/15/22 at 2:18 p.m. with Staff E, CNA (orientee) she stated she was on her third day of orientation. [Staff C, LPN] asked [Staff B, CNA] and me to help to pull [Resident #1] up. We pulled him all together and he went into the headboard. It was too much force. He wasn't as heavy as the nurse thought. She stated she was on one side by herself, and Staff B, CNA and Staff C LPN were on the other side. She was on the right side of the bed. She stated she did not know he was an [CONDITION(S)]. She stated, No, he did not push with his foot he had an injury on top of his foot. The head injury was bleeding. She stated it was a small area about the half size of her pinky tip, but it was bleeding. She stated she put a washcloth on it. She stated she did come back, and the washcloth was still there. She stated, Staff C, LPN was going to come back but don't know if she got distracted or not. She stated her trainer (Staff B, CNA) did go in and check on him. The facility staff talked to my trainer (Staff B, CNA) and the nurse (Staff C, LPN) but they did not talk to me about the incident. She stated, Don't know if the DON knew or not. Staff B told her she had written a report, but no one said anything to her at that point. Staff B asked her if I written a statement and I told her no one had asked me to do one. It was a busy night and think she was frustrated (Staff C, LPN). In an interview with Staff B, CNA on 08/16/22 at 10:49 a.m., she stated she worked on August 3rd, Wednesday. She stated she was not on that set of residents. The nurse, Staff C, LPN, came out of the room and asked if we could help to boost the resident. He hit his head on the headboard of the bed. The nurse stated she would be right back with a dressing for his head. We put a washcloth on his head. She stated Staff C, LPN stated she would take care of it. Staff G, LPN/UM asked her to write something about the incident the next day. She thinks she did it on Saturday or Sunday of that week. She stated she reported it to the aide, which was assigned to him, Staff D, CNA. She stated she also told the other nurse on the floor, Staff F. She stated Staff C, LPN was their direct report, and she was there during the incident. In an interview on 08/16/22 at 11:31 a.m. with Staff F, LPN, she stated she does not remember the resident. She stated she was not aware of the incident. She stated, If had been aware, would have gone to the nurse as to what have happened and went in and assessed the patient and made sure the nurse followed the protocol. She stated she works a lot of facilities, and the protocol was the same, assess the resident, report, and document. 2. Review of the Admission Record for Resident #4 showed Resident #4 was admitted on [DATE] and readmitted on [DATE]. The diagnoses included [CONDITION(S)], dementia, [CONDITION(S)], [CONDITION(S)] (TIA), heart failure, hypertension, [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) and falls. Review of the Admission MDS, dated [DATE], showed a BIMS score of 04 out of 15 (severe impairment). Section G Functional Status showed he required extensive assistance of one for bed mobility and toileting, and extensive assistance of two for transfers. Record review of the August 2022 physician orders and MARs for July 2022 and August 2022 showed bilateral ¼ side rails up while in bed as enabler as of 06/28/22; floor mats to the exit side of bed as of 07/28/22; [MEDICATION(S)] ([MEDICATION(S)]) 20 mg daily for pulmonary embolism (blood thinner); monitor for s/s of bleeding every shift. Record review of progress notes showed: On 07/26/22 at 11:30 a.m. resident found lying on the floor near the bedside by the Speech Therapist. Called the writer. Noted no pain or abnormalities on skin. Resident at bedside on the floor head elevated. Resident was able to move extremities. He voiced no pain. Two assisted him to bed. Call light placed within reach. Head of Bed elevated and bed in low position. On 07/26 at 12:01 p.m. notified physician's office. Call placed to family and left message with call back phone number. On 07/26 at 13:54 (1:54 p.m.) found by therapy staff. Resident on the floor. Writer noticed resident lying on the floor beside the bed. the resident denied hitting his head. He was alert and oriented. No complaint of pain. Able to move extremities. He was assisted to bed with two assists. No skin abnormalities. Vital signs B/P (blood pressure) 110/56, temper (temperature) 97.1, pulse was 90, respirations were 19 and pulse ox (level of oxygen) was 93%. Call placed to daughter and left message for her. Notified physician office. On 07/27 at 10:36 a.m. resident status post fall day 2.

Based on facility staff interview, record review and review of facility policies and procedures the facility failed to report to the appropriate State Agencies an incident of alleged neglect related to 0.5 cm abrasion to the head to one resident (#1) of three sampled residents. Findings included: Review of the facility's policy titled, Risk Management Incident Guidelines, dated May 2021, revealed: Purpose: all incidents occurring in the facility or on facility property will be recorded on an Incident Report. Resident Management: any employee witnessing an incident involving a resident, employee, or visitor must report such occurrence to his or her immediate supervisor as soon as practical. * Assess the resident or visitor for injury * Inform the attending physician of the incident and document notification and any receipt of orders for treatment in the resident's clinical record * Notify the resident's responsible party of the incident and status of the resident and document notification in the clinical record * Document the incident, conduct a head-to-toe clinical condition review of the resident, treatment, and interventions, and ongoing monitoring of the resident's status in the clinical record * If necessary, transfer the resident to the hospital. Documentation in Resident Record: an incident and its effect on the resident must be documented in the resident's medical record. Documentation in the medical record should include: * Factual statement of the event. * Resident assessment findings. * Clinical condition of the resident * Immediate actions taken, such as timely notification of the physician and treatments implemented * Physician orders received * Documentation of the resident's condition on each shift for 72 hours post incident, when applicable * Discussions with the resident * Resident's comments should be recorded using quotes whenever possible. Incident Investigation: an investigation is completed by the Director of Nursing, charge nurse, or nursing supervisor and the Facility Risk Manager. The goal of the investigation is to identify the underlying cause, referred to as the root cause analysis. Understanding the cause of the event may assist in making necessary system changes and/or promote actions needed to address human error. Incident investigations should include: * Evaluation of the environment * Review of pertinent records * Review the event follow-up including review and modification of the resident's care plan, staff in-servicing, report to regulatory agency if required, and counseling. * Review of related policies and procedures for compliance. * Obtain statements of residents involved (as appropriate), and witnesses. * Interviewing of resident involved and witnesses with findings documented by the interviewer * Interview of witnesses will be completed as soon as practicable after the event, so the information may be clearly recalled * The interviewing technique should include the basic questions of who, what, when, where, and how. Reportable Incidents: the facility Risk Manager will review all incidents and if a Reportable Event is determined Federal 2-Hour/Immediate/5-Day Report should be completed for all incidents that are categorize as allegations of abuse, neglect, injuries of unknown origin or misappropriation of property. The facility is required to submit a Federal 2-Hour/Immediate/5-Day Report for all incidents which meet the definition of alleged abuse, neglect The facility is also required to submit a State Adverse Incident Report within 15 (fifteen) calendar days of the event to the Agency for Health Care Administration (AHCA) for: a. all incidents which meet the definition of an Adverse Incident, or b. a potential Adverse Incident if the results of the investigation have not ruled out being an Adverse Incident prior to the required deadline for report the incident to AHCA. Review of the Admission Record revealed Resident #1 was admitted on [DATE] and discharged on [DATE]. The Admission Record showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], showed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired). Section G Functional Status showed he required extensive assistance of two for bed mobility (how resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture), was totally dependent on two persons for transfers and totally dependent on one person for toileting. Resident #1 had functional limitation of range of motion of both lower extremities. Section J Health Conditions showed the resident had two falls, one with no injury and one with injury (except major). Record review of the August 2022 physician orders, Medication Administration Records (MAR) and Treatment Administration Records (TAR) for July 2022 and August 2022 showed bilateral 1/4 side rails up while in bed as enabler as of 07/21; monitor for the following signs and symptoms (s/s) of bleeding gums, unusual bruising, bleeding wounds. Notify Medical Doctor (MD) if any symptoms present every shift as of 07/21/22; encourage resident to maintain bed in lowest position at all times when resident is in bed, may elevate bed for the provision of care for safety as of 07/26; Floor mat to exit side of bed when resident is in bed for safety as of 07/26; [MEDICATION(S)]-Acetaminophen 10-325 mg (milligrams) every 6 hours as needed for pain; [MEDICATION(S)] ([MEDICATION(S)]) 5 mg by mouth two times a day for [CONDITION(S)] (CAD). This medication is an anticoagulant used to treat and prevent blood clots, it may take longer than usual to stop bleeding if cut or injured; May cause bruising or bleeding more easily. Call doctor right away if bleeding or bruising is unusual, severe, or cannot be controlled found at www.National Library of Medicine. Medlineplus.gov. The MARs and TARs for July 2022 and August 2022 showed [MEDICATION(S)] was given twice a day. They showed documentation for low bed every shift and floor mats in place every shift. They showed monitoring for signs/symptoms of bleeding every shift. The progress notes revealed on 08/04 at 16:02 (4:02 p.m.), Notified by MD's office that resident will go to hospital due to some issues currently. The nurse will communicate to Nurse Practitioner (NP). [Family member] was with [Resident #1]. Review of the progress notes showed lack of documentation on 08/03 regarding an incident with three staff members (C, B and E) who assisted Resident #1 up in bed resulting in the resident hitting his head on the headboard causing a laceration to his head. The medical record lacked an assessment, care needs or monitoring, and communication for a change in condition. Record review of the care plans showed Resident #5 was at risk for abnormal bleeding and increased bruising related to use of anticoagulants for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal for resident was to remain free of complications from anticoagulant therapy. Interventions included administer medications as ordered, observe for effectiveness; educate resident or responsible party on risk and benefits of anticoagulants use as needed; observe for blood in urine, stool, emesis, nosebleeds, bleeding from gums, abnormal bruising and report to physician if noted. Review of a Grievance/Concern Report for the dates of 08/03/22 and 08/04/22 showed the resident's [family member] stated on 08/03 the resident was injured by staff and received a wound to the head. She met him at an appointment and the wound bandage was dirty and no notes with records for doctor. The DON documented on 08/04 that an investigation would be initiated. She spoke with [family member] over the phone and explained the process of investigation and possible corrective action for staff if deemed necessary. Apologized on behalf of the nurse for any indiscretion on her behalf. The family member stated she was not satisfied with resolution and was calling AHCA (Agency for Health Care Administration). Record review of hospital records dated 08/04/22 at 11:27 a.m. showed Resident #1 presented with lightheadedness and neck pain that occurred after being pulled up in his bed at the nursing home and was slid into the wall last night, headfirst. He reports a wound to his head that will not stop bleeding. He denies headache or loss of consciousness. He takes [MEDICATION(S)] for a previous DVT. He was noted to have a 0.5 cm (centimeter) abrasion to the top of head with minimal bleeding (ooze). CT (Computed tomography) of the spine showed no evidence of acute cervical spinal fracture or spondylolisthesis. CAT (Computed tomography) scan showed no evidence of acute infarct, [CONDITION(S)], or mass lesion. Dermabond was applied to the abrasion on top of his head with resolution of bleeding. Will be discharged home. On 08/15/22 at 11:14 a.m. a review of facility forms with the Nursing Home Administrator (NHA) and Director of Nursing (DON) showed Staff C, Licensed Practical Nurse (LPN) failed to accurately chart or document pertinent information concerning Resident #1. Resident #1 had an incident on Staff C's floor on 08/03, the resident was boosted by staff and his head was hit causing a head laceration. It was confirmed that no Facility Form was started, no supporting documentation on the incident was anywhere in the computer system or medical record and that Staff C, LPN was suspended pending investigation. Review of the staff statements were as follows: Staff I, Registered Nurse (RN) wrote on 08/04/22 that on Wednesday, 08/03/22, I was working with nurse [Staff C, LPN]. During my shift she had mentioned her, and a CNA (Certified Nursing Assistant) had boosted [Resident #1] up in bed and bumped his head. She did not mention any injury to me regarding the incident. Staff A, CNA, wrote on 08/04, I [Staff A, CNA], was sitting in [Staff G, LPN, UM's] office charting when I overheard [Staff C, LPN] talking out loud about how she helped an aide boost [Resident #1] and they hit his head on the headboard. Staff B, CNA documented a statement without a date, on 08/03/22 [Staff C, LPN] for 3-11 shift asked if myself and an orientee to boost [Resident #1's room number]. As we were boosting his head came in contact with the headboard. I left. A spot-on top of his head was bleeding. [Staff C] was in room and told the resident she will be back with a bandage. Was told to not write any report regarding incident. Was notified the next day by [Staff G], to write report. Reviewed statement by Staff E, CNA, that was taken over the phone by the DON on 08/15/22 (day of survey) and showed: Interview was conducted with [Staff E, CNA] regarding incident with [Resident #1] on 08/03/22 during the 3-11 shift. [Staff E] was orienting with [Staff B, CNA]. She was asked to assist [Staff B] and [Staff C]. [Staff E] stated that [Staff C, LPN] and [Staff B, CNA] felt like he required an additional person to be pulled up and when they did his head was accidentally bumped on the headboard. [Staff E, CNA] also stated that [Staff C, LPN] it (head wound) was bleeding but the injury itself was less than half the size of the tip of her finger. She continued to say [Staff C, LPN] did put a wound dressing on the area afterwards. The DON obtained a statement from Staff J, CNA on 08/15/22 (day of survey). To whom it may concern I was the 7-3 CNA for Resident #1 on 08/04/22. As I was getting him ready for doctor's appointment that morning, I observed a gauze, band-aid on top of his head. He mentioned his head had been bumped on the wall when being pulled up in bed on 11-7 shift. I was under the impression that the nurse was already notified due to the dressing being in place already. Reviewed a statement written on 08/15/22 by Staff K, LPN, who worked the 7-3 shift on 08/04/22, and it showed while hanging [Resident #1's] IV he stated he hit his head while being boosted up. There was a small island bandage on his head. I did not get any information in report and no documentation in computer. During the continued interview with the NHA and DON, they stated on 08/03/22 two aides, Staff B, CNA and Staff A, CNA (not the aide at the scene discovered during the investigation) and Staff C, LPN were boosting Resident #1 in bed. The DON stated she was not aware of the incident until after the fact. She stated the physician's office called her and stated the resident had a band-aid on his head and it was bleeding. She stated she started investigating. The DON stated that all three (Staff A[not correct CNA it was Staff E], Staff B, Staff C) were pulling him up in bed and he decided to push himself up and had some sort of laceration. The DON stated she does not know why he decided to push himself up due to being non-weight bearing on the foot. She stated he never returned from the physician's visit. The incident happened on 08/03 on the 3-11 shift and he went to the physician on 08/04. She stated the 11-7 shift nurse, Staff K, LPN had nothing to say. She said he was asleep and had no issues with him during the shift and does not remember the band-aid. She said she spoke with the 7-3 shift nurse, Staff L, LPN, and she did not see it either. She stated he was sent to the hospital by the physician's office. The [family member] called the DON on the phone, and she tried to explain to her they were doing an investigation. She told the [family member] she did not have a lot of information for her at that time. She explained the investigation process. The [family member] told the DON she was calling the State Agency. Another State Agency showed up that afternoon, 08/04. This State Agency employee asked the DON to fax her the nursing notes, August MAR and last Nurse Practitioner note. The DON stated the State Agency employee later called and stated she was pursing the nursing license of [Staff C, LPN], and reporting to an additional State Agency. The DON stated the Social Service Director (SSD) wrote it up as a grievance, we spoke with the [family member] together. Staff C, LPN was suspended and has not come back to work. DON stated, The CNAs involved were not suspended because it was not a matter of them doing their jobs or not; it was the nurse did not do her job. The nurse did not do the documentation of the incident. The DON stated again that Staff C, LPN was still suspended due to still being investigated. They have not reinstated the nurse. They did educate the nurses on risk reporting documentation and who they have to report to. It should have been reported to the DON, physician, family. None was documented. The DON stated, Did not do a reportable. Reviewed the care plans with them related to falls. On 08/15/22 at 1:15 p.m. in an interview with Staff A, CNA she stated she was at the nursing station and overheard Staff C, LPN talking about bumping the head of Resident #1. She stated that she was not present during the incident. Staff C, LPN stated she and Staff B, CNA said they hit his head on the headboard. Staff B, CNA stated the nurse stated, she did not know how much force she had, to do that (move him up and hit his head). The nurse was small. She did not hear about it on the 3-11 shift that night, she was charting. She did not see the resident that evening. They just told her to write a note the next day. She gave it to Staff G, LPN/UM. She did not talk to anyone nor interview with anyone about the incident. In an interview with Staff G, LPN/UM on 08/15/22 at 1:22 p.m., she stated she knew Resident #1. She was not working the evening of the headboard incident. She heard about it the next day. She gave the note from Staff A, CNA to the DON the next day. No one asked her anything. An interview with Staff C, LPN was conducted on 08/15 at 1:55 p.m. She stated she had been taking care of him (Resident #1) for several weeks. He asked to be boosted up. She stated he was about 300 pounds. She asked an aide to assist because he can be difficult. He bent his knee to help us. We boosted him and he hit his head on the headboard. He was not bleeding much. There was a scant amount of blood. I provided First Aid to stop the bleeding. There were other emergencies going on that evening. She stated, She called the doctor's office, she did not get a call back, and did not know who to call. She stated, Should have called the DON. She stated she placed gauze on his head and cleaned it up. She took his vital signs. She stated she had to do an event on him, but it was after 11:30 p.m. She stated she had to go home because she worked the next day at her other job, and she said she could come in tomorrow early to do the event. She did talk to the DON the next day. She came in at 1:00 p.m. the next day (08/04) and wanted to do the event. The DON told her she was suspended. She stated the lady from the state agency came in. The residents were not lacking, not at all. She stated there was not much blood. He was on blood thinners. She stated again she cleaned him up and put a band-aid on him. She stated she had four or five IVs that evening and had emergencies on the floor. She stated one resident was going in and out of other resident's rooms. She had to prioritize. She stated she wanted to do the paperwork and told them she could come in the next day. She stated she thought she had 24 hours to put in the paperwork. The DON told her he was discharged to the hospital and was discharged out of the system. She would not be able to document in the medical record because he was discharged . She stated again she thought she could put it in later. She stated she was told the resident was bleeding heavily. By the time I left, changed the band-aid to a larger band-aid. He went to sleep. She stated she gave him a pain pill. She stated she could not stay late. She talked to the DON and told her that morning she could come in at 1:00 p.m. and the DON said come in and we will talk. She stated the DON talked to her in front of other staff in the day room. She stated, Did not do intentional. There were three of us, [Staff B, Staff E, CNA] that was with [Staff B]. [Resident #1] can be very heavy and difficult. She stated, He hit it pretty hard. She stated, Don't recall if reported to next nurse. She stated she checked his neuro checks a couple of times. He told us to leave him alone. She stated again, she intended to do the documentation the next day, within 24 hours in the computer. She stated the incident happened between 8:00 and 9:00 p.m. During an interview on 08/15/22 at 2:18 p.m. with Staff E, CNA (orientee) she stated she was on her third day of orientation. [Staff C, LPN] asked [Staff B, CNA] and me to help to pull [Resident #1] up. We pulled him all together and he went into the headboard. It was too much force. He wasn't as heavy as the nurse thought. She stated she was on one side by herself, and Staff B, CNA and Staff C LPN were on the other side. She was on the right side of the bed. She stated she did not know he was an [CONDITION(S)]. She stated, No, he did not push with his foot he had an injury on top of his foot. The head injury was bleeding. She stated it was a small area about the half size of her pinky tip, but it was bleeding. She stated she put a washcloth on it. She stated she did come back, and the washcloth was still there. She stated, Staff C, LPN was going to come back but don't know if she got distracted or not. She stated her trainer (Staff B, CNA) did go in and check on him. The facility staff talked to my trainer (Staff B, CNA) and the nurse (Staff C, LPN) but they did not talk to me about the incident. She stated, Don't know if the DON knew or not. Staff B told her she had written a report, but no one said anything to her at that point. Staff B asked her if I written a statement and I told her no one had asked me to do one. It was a busy night and think she was frustrated (Staff C, LPN). In an interview with Staff B, CNA on 08/16/22 at 10:49 a.m., she stated she worked on August 3rd, Wednesday. She stated she was not on that set of residents. The nurse, Staff C, LPN, came out of the room and asked if we could help to boost the resident. He hit his head on the headboard of the bed. The nurse stated she would be right back with a dressing for his head. We put a washcloth on his head. She stated Staff C, LPN stated she would take care of it. Staff G, LPN/UM asked her to write something about the incident the next day. She thinks she did it on Saturday or Sunday of that week. She stated she reported it to the aide, which was assigned to him, Staff D, CNA. She stated she also told the other nurse on the floor, Staff F. She stated Staff C, LPN was their direct report, and she was there during the incident. In an interview on 08/16/22 at 11:31 a.m. with Staff F, LPN, she stated she does not remember the resident. She stated she was not aware of the incident. She stated, If had been aware, would have gone to the nurse as to what have happened and went in and assessed the patient and made sure the nurse followed the protocol. She stated she works a lot of facilities, and the protocol was the same, assess the resident, report, and document. An interview was conducted on 08/16/22 at 12:03 p.m. with the DON, the SSD, and the NHA. The NHA stated he was on vacation. The SSD was in charge of reporting, per the DON. The DON and the SSD were in charge. The DON stated she heard about it (abrasion to head) from the physician's office on 08/04/22. She stated she started an investigation to see who the nurse was, see what happened, there was no description. The [family member] called and left a voice mail for the SSD. The SSD stated she filled out a grievance. The DON and the SSD called the [family member] back and the [family member] stated she was calling the State Agency. The DON stated she was going to do an investigation, by pulling the schedule. apologize and investigate. She stated she tried to reach Staff C, LPN. She stated she got a copy of the schedule to see who was caring for him [Resident #1]. She was told Staff B, CNA and her orientee was caring for him by Staff G, LPN/UM or Staff J, CNA. They stated they were pulling him up and bumped his head .Within an hour, the State Agency was here. The State Agency spoke with the SSD and the DON and wanted clinical information. They told the State Agency person he bumped his head, and he was on a blood thinner. The DON told her she was still trying to get a hold of people to interview. She was trying to reach people. Staff C, LPN came in because the DON asked her to come in early, she was supposed to work the 3-11 shift. She stated we had already covered the shift. Staff G, LPN/UM had a disciplinary action written and Staff G, ADON (Assistant Director of Nursing) and the DON spoke with her when she came in. The DON stated we asked her what happened. She gave us a verbal of what happened and appeared to be agitated. The DON stated we informed her he was already at the hospital, and she was suspended pending an investigation. The DON stated she told Staff C, LPN they were going to have to wait to speak with the NHA about this further. The DON stated we asked her to write a statement. Write the facts, but she did not do it. The DON stated she called Staff K, LPN, the 11-7 shift nurse, was away for a few days after the incident. The DON stated she just spoke with her this morning (08/16/22), she said it was in her office. (Requested the statement and it was not provided.) The DON stated Staff K wrote the nurse (Staff C) did not report anything to her, she was not aware it happened. Staff K stated that sometime in the night he told her they bumped his head during boosting. He had a dressing on his head and since she did not get it during report, she was not sure what had happened because sometimes he says bizarre things. The DON stated Staff K wrote, the dressing looked okay, and it was a small island dressing. The DON stated that was the extent of Staff K, LPN's interaction with the resident. When asked why they did not report the incident, the SSD stated they discussed this today (08/16). They need to report neglect. The NHA stated because the State Agency was here, the SSD thought that was reporting and enough. The NHA stated if done; the reporting would have been done as an immediate and then a 5-day reporting of the investigation. He stated the investigation would have been completed within the 5-day investigation. The DON stated they would have interviewed everyone involved, reviewed the chart, and reporting. The SSD stated she was not involved with the whole investigation. The DON stated she reviewed the chart and printed out the orders, care plans, psych notes, and did a chart review. She stated she continued to try to collect statements. The DON stated, I talked to them but did not document the interviews. No, documentation on follow-up on the statements. The DON stated the Root Cause Analysis should have shown, the nurse was being over cautious and overzealous; she was distracted, and it was a difficult boost; her lack of respect of license; and documents when she feels like it. The DON stated they do late entries here; within 24 hours was recommended. The DON stated if Staff C, had done the required documentation and report, it would have been on the 24-hour report. The SSD stated due to the NHA being gone she took it as a grievance. The SSD stated it was reported to a State Agency and felt it was going through them and did not need reporting. Review of the facility's policy titled, Resident Mistreatment, Neglect, and Abuse Prohibition Guidelines, dated May 2021, showed the facility is committed to protecting the physical and emotional well-being and personal possessions of every resident. Each facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect and compassion for residents. Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .neglect .is strictly prohibited. All allegations will be reported immediately and investigated per state and federal regulations. Investigation: each facility will thoroughly investigate injuries of unknown origin and any suspected or alleged .neglect in accordance with federal and state regulations. An Incident Report and investigation should be completed for all incidents of suspected .neglect. Facility guidelines for incident management and incident reporting should be followed including requirements for Federal 2-Hour/Immediate/5-Day and Adverse Incident fifteen Day reporting requirements. Reporting/ Response: regulations require employees that provide services to elderly person or dependent adults to report instances of .neglect .to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if alleged violate involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and / or Director of Nursing, so that facility responsibilities to protect resident and promptly investigate occurrences may be met. Review of the facility policy titled, Incident Report and Investigation Guidelines, dated May 2021, showed all falls, injuries of unknown origin, alleged neglect occurring in the facility or on facility property will be documented and investigated and recorded on the Incident Report. Procedure: 1. An Incident Report should be completed for all incidents on the shift that the incident occurred, by the person who observed or discovered the event, under the supervision of the Charge Nurse. 2. it shall be complete and shall contain only observed facts. 6. Documentation of the incident, resident assessments, treatment and interventions, notifications to the physician and family/responsible party and ongoing monitoring of the resident's status should be recorded in the nursing notes of the clinical record. 7. A thorough investigation of each incident should be completed by the Director of Nursing, Charge Nurse or Supervisor and the Facility Risk Manager. 8. Interview should be conducted with the resident and witnesses. 12. The findings of the investigation, along with corrective action will be reported as required by Federal and State law. 13. The Risk Manager is responsible for ensuring the timely and accurate reporting and for recording such reporting as appropriate.

Based on facility staff interview, record review and review of facility policies the facility failed to perform a complete, accurate and timely investigation of an incident related to a 0.5 cm abrasion to the head to one resident (#1), who was also being administered anticoagulants, of three sampled residents. Findings included: Review of the Admission Record revealed Resident #1 was admitted on [DATE] and discharged on [DATE]. The Admission Record showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], showed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired). Section G Functional Status showed he required extensive assistance of two for bed mobility (how resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture), was totally dependent on two persons for transfers and totally dependent on one person for toileting. Resident #1 had functional limitation of range of motion of both lower extremities. Section J Health Conditions showed the resident had two falls, one with no injury and one with injury (except major). Record review of the August 2022 physician orders, Medication Administration Records (MAR) and Treatment Administration Records (TAR) for July 2022 and August 2022 showed bilateral 1/4 side rails up while in bed as enabler as of 07/21; monitor for the following signs and symptoms (s/s) of bleeding gums, unusual bruising, bleeding wounds. Notify Medical Doctor (MD) if any symptoms present every shift as of 07/21/22; encourage resident to maintain bed in lowest position at all times when resident is in bed, may elevate bed for the provision of care for safety as of 07/26; Floor mat to exit side of bed when resident is in bed for safety as of 07/26; [MEDICATION(S)]-Acetaminophen 10-325 mg (milligrams) every 6 hours as needed for pain; [MEDICATION(S)] ([MEDICATION(S)]) 5 mg by mouth two times a day for [CONDITION(S)] (CAD). This medication is an anticoagulant used to treat and prevent blood clots, it may take longer than usual to stop bleeding if cut or injured; May cause bruising or bleeding more easily. Call doctor right away if bleeding or bruising is unusual, severe, or cannot be controlled found at www.National Library of Medicine. Medlineplus.gov. The MARs and TARs for July 2022 and August 2022 showed [MEDICATION(S)] was given twice a day. They showed documentation for low bed every shift and floor mats in place every shift. They showed monitoring for signs/symptoms of bleeding every shift. The progress notes revealed on 08/04 at 16:02 (4:02 p.m.), Notified by MD's office that resident will go to hospital due to some issues currently. The nurse will communicate to Nurse Practitioner (NP). [Family member] was with [Resident #1]. Review of the progress notes showed lack of documentation on 08/03 regarding an incident with three staff members (C, B and E) who assisted Resident #1 up in bed resulting in the resident hitting his head on the headboard causing a laceration to his head. The medical record lacked an assessment, care needs or monitoring, and communication for a change in condition. Record review of the care plans showed Resident #5 was at risk for abnormal bleeding and increased bruising related to use of anticoagulants for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal for resident was to remain free of complications from anticoagulant therapy. Interventions included administer medications as ordered, observe for effectiveness; educate resident or responsible party on risk and benefits of anticoagulants use as needed; observe for blood in urine, stool, emesis, nosebleeds, bleeding from gums, abnormal bruising and report to physician if noted. Review of a Grievance/Concern Report for the dates of 08/03/22 and 08/04/22 showed the resident's [family member] stated on 08/03 the resident was injured by staff and received a wound to the head. She met him at an appointment and the wound bandage was dirty and no notes with records for doctor. The DON documented on 08/04 that an investigation would be initiated. She spoke with [family member] over the phone and explained the process of investigation and possible corrective action for staff if deemed necessary. Apologized on behalf of the nurse for any indiscretion on her behalf. The family member stated she was not satisfied with resolution and was calling AHCA (Agency for Health Care Administration). Record review of hospital records dated 08/04/22 at 11:27 a.m. showed Resident #1 presented with lightheadedness and neck pain that occurred after being pulled up in his bed at the nursing home and was slid into the wall last night, headfirst. He reports a wound to his head that will not stop bleeding. He denies headache or loss of consciousness. He takes [MEDICATION(S)] for a previous DVT. He was noted to have a 0.5 cm (centimeter) abrasion to the top of head with minimal bleeding (ooze). CT (Computed tomography) of the spine showed no evidence of acute cervical spinal fracture or spondylolisthesis. CAT (Computed tomography) scan showed no evidence of acute infarct, [CONDITION(S)], or mass lesion. Dermabond was applied to the abrasion on top of his head with resolution of bleeding. Will be discharged home. On 08/15/22 at 11:14 a.m. a review of facility forms with the Nursing Home Administrator (NHA) and Director of Nursing (DON) showed Staff C, Licensed Practical Nurse (LPN) failed to accurately chart or document pertinent information concerning Resident #1. Resident #1 had an incident on Staff C's floor on 08/03, the resident was boosted by staff and his head was hit causing a head laceration. It was confirmed that no Facility Form was started, no supporting documentation on the incident was anywhere in the computer system or medical record and that Staff C, LPN was suspended pending investigation. Review of the staff statements were as follows: Staff I, Registered Nurse (RN) wrote on 08/04/22 that on Wednesday, 08/03/22, I was working with nurse [Staff C, LPN]. During my shift she had mentioned her, and a CNA (Certified Nursing Assistant) had boosted [Resident #1] up in bed and bumped his head. She did not mention any injury to me regarding the incident. Staff A, CNA, wrote on 08/04, I [Staff A, CNA], was sitting in [Staff G, LPN, UM's] office charting when I overheard [Staff C, LPN] talking out loud about how she helped an aide boost [Resident #1] and they hit his head on the headboard. Staff B, CNA documented a statement without a date, on 08/03/22 [Staff C, LPN] for 3-11 shift asked if myself and an orientee to boost [Resident #1's room number]. As we were boosting his head came in contact with the headboard. I left. A spot-on top of his head was bleeding. [Staff C] was in room and told the resident she will be back with a bandage. Was told to not write any report regarding incident. Was notified the next day by [Staff G], to write report. Reviewed statement by Staff E, CNA, that was taken over the phone by the DON on 08/15/22 (day of survey) and showed: Interview was conducted with [Staff E, CNA] regarding incident with [Resident #1] on 08/03/22 during the 3-11 shift. [Staff E] was orienting with [Staff B, CNA]. She was asked to assist [Staff B] and [Staff C]. [Staff E] stated that [Staff C, LPN] and [Staff B, CNA] felt like he required an additional person to be pulled up and when they did his head was accidentally bumped on the headboard. [Staff E, CNA] also stated that [Staff C, LPN] it (head wound) was bleeding but the injury itself was less than half the size of the tip of her finger. She continued to say [Staff C, LPN] did put a wound dressing on the area afterwards. The DON obtained a statement from Staff J, CNA on 08/15/22 (day of survey). To whom it may concern I was the 7-3 CNA for Resident #1 on 08/04/22. As I was getting him ready for doctor's appointment that morning, I observed a gauze, band-aid on top of his head. He mentioned his head had been bumped on the wall when being pulled up in bed on 11-7 shift. I was under the impression that the nurse was already notified due to the dressing being in place already. Reviewed a statement written on 08/15/22 by Staff K, LPN, who worked the 7-3 shift on 08/04/22, and it showed while hanging [Resident #1's] IV he stated he hit his head while being boosted up. There was a small island bandage on his head. I did not get any information in report and no documentation in computer. During the continued interview with the NHA and DON, they stated on 08/03/22 two aides, Staff B, CNA and Staff A, CNA (not the aide at the scene discovered during the investigation) and Staff C, LPN were boosting Resident #1 in bed. The DON stated she was not aware of the incident until after the fact. She stated the physician's office called her and stated the resident had a band-aid on his head and it was bleeding. She stated she started investigating. The DON stated that all three (Staff A[not correct CNA it was Staff E], Staff B, Staff C) were pulling him up in bed and he decided to push himself up and had some sort of laceration. The DON stated she does not know why he decided to push himself up due to being non-weight bearing on the foot. She stated he never returned from the physician's visit. The incident happened on 08/03 on the 3-11 shift and he went to the physician on 08/04. She stated the 11-7 shift nurse, Staff K, LPN had nothing to say. She said he was asleep and had no issues with him during the shift and does not remember the band-aid. She said she spoke with the 7-3 shift nurse, Staff L, LPN, and she did not see it either. She stated he was sent to the hospital by the physician's office. The [family member] called the DON on the phone, and she tried to explain to her they were doing an investigation. She told the [family member] she did not have a lot of information for her at that time. She explained the investigation process. The [family member] told the DON she was calling the State Agency. Another State Agency showed up that afternoon, 08/04. This State Agency employee asked the DON to fax her the nursing notes, August MAR and last Nurse Practitioner note. The DON stated the State Agency employee later called and stated she was pursing the nursing license of [Staff C, LPN], and reporting to an additional State Agency. The DON stated the Social Service Director (SSD) wrote it up as a grievance, we spoke with the [family member] together. Staff C, LPN was suspended and has not come back to work. DON stated, The CNAs involved were not suspended because it was not a matter of them doing their jobs or not; it was the nurse did not do her job. The nurse did not do the documentation of the incident. The DON stated again that Staff C, LPN was still suspended due to still being investigated. They have not reinstated the nurse. They did educate the nurses on risk reporting documentation and who they have to report to. It should have been reported to the DON, physician, family. None was documented. The DON stated, Did not do a reportable. Reviewed the care plans with them related to falls. On 08/15/22 at 1:15 p.m. in an interview with Staff A, CNA she stated she was at the nursing station and overheard Staff C, LPN talking about bumping the head of Resident #1. She stated that she was not present during the incident. Staff C, LPN stated she and Staff B, CNA said they hit his head on the headboard. Staff B, CNA stated the nurse stated, she did not know how much force she had, to do that (move him up and hit his head). The nurse was small. She did not hear about it on the 3-11 shift that night, she was charting. She did not see the resident that evening. They just told her to write a note the next day. She gave it to Staff G, LPN/UM. She did not talk to anyone nor interview with anyone about the incident. In an interview with Staff G, LPN/UM on 08/15/22 at 1:22 p.m., she stated she knew Resident #1. She was not working the evening of the headboard incident. She heard about it the next day. She gave the note from Staff A, CNA to the DON the next day. No one asked her anything. An interview with Staff C, LPN was conducted on 08/15 at 1:55 p.m. She stated she had been taking care of him (Resident #1) for several weeks. He asked to be boosted up. She stated he was about 300 pounds. She asked an aide to assist because he can be difficult. He bent his knee to help us. We boosted him and he hit his head on the headboard. He was not bleeding much. There was a scant amount of blood. I provided First Aid to stop the bleeding. There were other emergencies going on that evening. She stated, She called the doctor's office, she did not get a call back, and did not know who to call. She stated, Should have called the DON. She stated she placed gauze on his head and cleaned it up. She took his vital signs. She stated she had to do an event on him, but it was after 11:30 p.m. She stated she had to go home because she worked the next day at her other job, and she said she could come in tomorrow early to do the event. She did talk to the DON the next day. She came in at 1:00 p.m. the next day (08/04) and wanted to do the event. The DON told her she was suspended. She stated the lady from the state agency came in. The residents were not lacking, not at all. She stated there was not much blood. He was on blood thinners. She stated again she cleaned him up and put a band-aid on him. She stated she had four or five IVs that evening and had emergencies on the floor. She stated one resident was going in and out of other resident's rooms. She had to prioritize. She stated she wanted to do the paperwork and told them she could come in the next day. She stated she thought she had 24 hours to put in the paperwork. The DON told her he was discharged to the hospital and was discharged out of the system. She would not be able to document in the medical record because he was discharged . She stated again she thought she could put it in later. She stated she was told the resident was bleeding heavily. By the time I left, changed the band-aid to a larger band-aid. He went to sleep. She stated she gave him a pain pill. She stated she could not stay late. She talked to the DON and told her that morning she could come in at 1:00 p.m. and the DON said come in and we will talk. She stated the DON talked to her in front of other staff in the day room. She stated, Did not do intentional. There were three of us, [Staff B, Staff E, CNA] that was with [Staff B]. [Resident #1] can be very heavy and difficult. She stated, He hit it pretty hard. She stated, Don't recall if reported to next nurse. She stated she checked his neuro checks a couple of times. He told us to leave him alone. She stated again, she intended to do the documentation the next day, within 24 hours in the computer. She stated the incident happened between 8:00 and 9:00 p.m. In an interview with the DON on 08/15/22 at 2:06 p.m. she verified that Staff B, CNA did have a trainee that night. The DON stated that she did not have her information. She stated she just talked to Staff J, CNA who had him the next morning (08/15). The DON stated, I had not interviewed the orientee. During an interview on 08/15/22 at 2:18 p.m. with Staff E, CNA (orientee) she stated she was on her third day of orientation. [Staff C, LPN] asked [Staff B, CNA] and me to help to pull [Resident #1] up. We pulled him all together and he went into the headboard. It was too much force. He wasn't as heavy as the nurse thought. She stated she was on one side by herself, and Staff B, CNA and Staff C LPN were on the other side. She was on the right side of the bed. She stated she did not know he was an [CONDITION(S)]. She stated, No, he did not push with his foot he had an injury on top of his foot. The head injury was bleeding. She stated it was a small area about the half size of her pinky tip, but it was bleeding. She stated she put a washcloth on it. She stated she did come back, and the washcloth was still there. She stated, Staff C, LPN was going to come back but don't know if she got distracted or not. She stated her trainer (Staff B, CNA) did go in and check on him. The facility staff talked to my trainer (Staff B, CNA) and the nurse (Staff C, LPN) but they did not talk to me about the incident. She stated, Don't know if the DON knew or not. Staff B told her she had written a report, but no one said anything to her at that point. Staff B asked her if I written a statement and I told her no one had asked me to do one. It was a busy night and think she was frustrated (Staff C, LPN). In an interview with Staff B, CNA on 08/16/22 at 10:49 a.m., she stated she worked on August 3rd, Wednesday. She stated she was not on that set of residents. The nurse, Staff C, LPN, came out of the room and asked if we could help to boost the resident. He hit his head on the headboard of the bed. The nurse stated she would be right back with a dressing for his head. We put a washcloth on his head. She stated Staff C, LPN stated she would take care of it. Staff G, LPN/UM asked her to write something about the incident the next day. She thinks she did it on Saturday or Sunday of that week. She stated she reported it to the aide, which was assigned to him, Staff D, CNA. She stated she also told the other nurse on the floor, Staff F. She stated Staff C, LPN was their direct report, and she was there during the incident. In an interview on 08/16/22 at 11:31 a.m. with Staff F, LPN, she stated she does not remember the resident. She stated she was not aware of the incident. She stated, If had been aware, would have gone to the nurse as to what have happened and went in and assessed the patient and made sure the nurse followed the protocol. She stated she works a lot of facilities, and the protocol was the same, assess the resident, report, and document. In an interview on 08/16/22 at 11:38 a.m. with Staff D, CNA. She stated, My DON called me 20-30 minutes ago. (about) Incident that happened August 3rd in [Resident #1's room number]. She stated, I know who you are talking about. They boosted him up, they hit his head.She stated the resident stated they boosted me up and hit my head . She stated she walked out of the room and to the nurses' station. She stated she went to Staff C, LPN and she was like, yeah, but I have to hang these IVs. I am so busy. She stated she gave him a bath, cleaned him up and put a towel over the pillow and extra towels. She wet one towel and placed it on his head like packed it on his head. She used a towel like a bandage, with his head back. She stated she notified Staff C, LPN again and she never came. She stated no one has spoken to her about this incident until today (08/16). An interview was conducted on 08/16/22 at 12:03 p.m. with the DON, the SSD, and the NHA. The NHA stated he was on vacation. The SSD was in charge of reporting, per the DON. The DON and the SSD were in charge. The DON stated she heard about it (abrasion to head) from the physician's office on 08/04/22. She stated she started an investigation to see who the nurse was, see what happened, there was no description. The [family member] called and left a voice mail for the SSD. The SSD stated she filled out a grievance. The DON and the SSD called the [family member] back and the [family member] stated she was calling the State Agency. The DON stated she was going to do an investigation, by pulling the schedule. apologize and investigate. She stated she tried to reach Staff C, LPN. She stated she got a copy of the schedule to see who was caring for him [Resident #1]. She was told Staff B, CNA and her orientee was caring for him by Staff G, LPN/UM or Staff J, CNA. They stated they were pulling him up and bumped his head .Within an hour, the State Agency was here. The State Agency spoke with the SSD and the DON and wanted clinical information. They told the State Agency person he bumped his head, and he was on a blood thinner. The DON told her she was still trying to get a hold of people to interview. She was trying to reach people. Staff C, LPN came in because the DON asked her to come in early, she was supposed to work the 3-11 shift. She stated we had already covered the shift. Staff G, LPN/UM had a disciplinary action written and Staff G, ADON (Assistant Director of Nursing) and the DON spoke with her when she came in. The DON stated we asked her what happened. She gave us a verbal of what happened and appeared to be agitated. The DON stated we informed her he was already at the hospital, and she was suspended pending an investigation. The DON stated she told Staff C, LPN they were going to have to wait to speak with the NHA about this further. The DON stated we asked her to write a statement. Write the facts, but she did not do it. The DON stated she called Staff K, LPN, the 11-7 shift nurse, was away for a few days after the incident. The DON stated she just spoke with her this morning (08/16/22), she said it was in her office. (Requested the statement and it was not provided.) The DON stated Staff K wrote the nurse (Staff C) did not report anything to her, she was not aware it happened. Staff K stated that sometime in the night he told her they bumped his head during boosting. He had a dressing on his head and since she did not get it during report, she was not sure what had happened because sometimes he says bizarre things. The DON stated Staff K wrote, the dressing looked okay, and it was a small island dressing. The DON stated that was the extent of Staff K, LPN's interaction with the resident. The DON stated she did not get anything from Staff F, due to her being an agency nurse. When asked why they did not report the incident, the SSD stated they discussed this today (08/16). They need to report neglect. The NHA stated because the State Agency was here, the SSD thought that was reporting and enough. The NHA stated if done; the reporting would have been done as an immediate and then a 5-day reporting of the investigation. He stated the investigation would have been completed within the 5-day investigation. The DON stated they would have interviewed everyone involved, reviewed the chart, and reporting. The SSD stated she was not involved with the whole investigation. The DON stated she reviewed the chart and printed out the orders, care plans, psych notes, and did a chart review. She stated she continued to try to collect statements. The DON stated, I talked to them but did not document the interviews. No, documentation on follow-up on the statements. The DON stated the Root Cause Analysis should have shown, the nurse was being over cautious and overzealous; she was distracted, and it was a difficult boost; her lack of respect of license; and documents when she feels like it. The DON stated they do late entries here; within 24 hours was recommended. The DON stated if Staff C, had done the required documentation and report, it would have been on the 24-hour report. The SSD stated due to the NHA being gone she took it as a grievance. The SSD stated it was reported to a State Agency and felt it was going through them and did not need reporting. The DON reviewed the education sign-in sheets and stated the education was for nurses only. She stated she did not have documented education with the aides as to who they are to report an incident to. It was observed the Education sign-in sheets do not have a start date; the DON stated she started the education on 08/04 through 08/06 for the nurses. Review of the facility's policy titled, Risk Management Incident Guidelines, dated May 2021, revealed: Purpose: all incidents occurring in the facility or on facility property will be recorded on an Incident Report. Resident Management: any employee witnessing an incident involving a resident, employee, or visitor must report such occurrence to his or her immediate supervisor as soon as practical. * Assess the resident or visitor for injury * Inform the attending physician of the incident and document notification and any receipt of orders for treatment in the resident's clinical record * Notify the resident's responsible party of the incident and status of the resident and document notification in the clinical record * Document the incident, conduct a head-to-toe clinical condition review of the resident, treatment, and interventions, and ongoing monitoring of the resident's status in the clinical record * If necessary, transfer the resident to the hospital. Documentation in Resident Record: an incident and its effect on the resident must be documented in the resident's medical record. Documentation in the medical record should include: * Factual statement of the event. * Resident assessment findings. * Clinical condition of the resident * Immediate actions taken, such as timely notification of the physician and treatments implemented * Physician orders received * Documentation of the resident's condition on each shift for 72 hours post incident, when applicable * Discussions with the resident * Resident's comments should be recorded using quotes whenever possible. Incident Investigation: an investigation is completed by the Director of Nursing, charge nurse, or nursing supervisor and the Facility Risk Manager. The goal of the investigation is to identify the underlying cause, referred to as the root cause analysis. Understanding the cause of the event may assist in making necessary system changes and/or promote actions needed to address human error. Incident investigations should include: * Evaluation of the environment * Review of pertinent records * Review the event follow-up including review and modification of the resident's care plan, staff in-servicing, report to regulatory agency if required, and counseling. * Review of related policies and procedures for compliance. * Obtain statements of residents involved (as appropriate), and witnesses. * Interviewing of resident involved and witnesses with findings documented by the interviewer * Interview of witnesses will be completed as soon as practicable after the event, so the information may be clearly recalled * The interviewing technique should include the basic questions of who, what, when, where, and how. Reportable Incidents: the facility Risk Manager will review all incidents and if a Reportable Event is determined Federal 2-Hour/Immediate/5-Day Report should be completed for all incidents that are categorize as allegations of abuse, neglect, injuries of unknown origin or misappropriation of property. The facility is required to submit a Federal 2-Hour/Immediate/5-Day Report for all incidents which meet the definition of alleged abuse, neglect The facility is also required to submit a State Adverse Incident Report within 15 (fifteen) calendar days of the event to the Agency for Health Care Administration (AHCA) for: a. all incidents which meet the definition of an Adverse Incident, or b. a potential Adverse Incident if the results of the investigation have not ruled out being an Adverse Incident prior to the required deadline for report the incident to AHCA. Review of the facility's policy titled, Resident Mistreatment, Neglect, and Abuse Prohibition Guidelines, dated May 2021, showed the facility is committed to protecting the physical and emotional well-being and personal possessions of every resident. Each facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect and compassion for residents. Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .neglect .is strictly prohibited. All allegations will be reported immediately and investigated per state and federal regulations. Investigation: each facility will thoroughly investigate injuries of unknown origin and any suspected or alleged .neglect in accordance with federal and state regulations. An Incident Report and investigation should be completed for all incidents of suspected .neglect. Facility guidelines for incident management and incident reporting should be followed including requirements for Federal 2-Hour/Immediate/5-Day and Adverse Incident fifteen Day reporting requirements. Reporting/ Response: regulations require employees that provide services to elderly person or dependent adults to report instances of .neglect .to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if alleged violate involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and / or Director of Nursing, so that facility responsibilities to protect resident and promptly investigate occurrences may be met. Review of the facility policy titled, Incident Report and Investigation Guidelines, dated May 2021, showed all falls, injuries of unknown origin, alleged neglect occurring in the facility or on facility property will be documented and investigated and recorded on the Incident Report. Procedure: 1. An Incident Report should be completed for all incidents on the shift that the incident occurred, by the person who observed or discovered the event, under the supervision of the Charge Nurse. 2. it shall be complete and shall contain only observed facts. 6. Documentation of the incident, resident assessments, treatment and interventions, notifications to the physician and family/responsible party and ongoing monitoring of the resident's status should be recorded in the nursing notes of the clinical record. 7. A thorough investigation of each incident should be completed by the Director of Nursing, Charge Nurse or Supervisor and the Facility Risk Manager. 8. Interview should be conducted with the resident and witnesses. 12. The findings of the investigation, along with corrective action will be reported as required by Federal and State law. 13. The Risk Manager is responsible for ensuring the timely and accurate reporting and for recording such reporting as appropriate.

Based on observation, interview and record review, the facility failed to ensure one (Resident #250) of twenty residents receiving respiratory (nebulizer) medication was assessed and monitored for self-administration of a respiratory nebulizer treatment. Findings included: An observation of Resident #250 on 11/02/2021 at 12:10p.m. revealed the resident holding respiratory equipment of a nebulizer mouthpiece to her mouth with her left hand, and the nebulizer machine was running. No staff member was in the room or nearby while the resident received the nebulizer medication. An interview was conducted with Resident #250 at that time, and the resident said the nurse had given the medication to her earlier and she did not remember what time. An immediate interview was conducted with the resident's nurse Staff B, Licensed Practical Nurse (LPN) on 11/02/2021 at 12:15p.m. Staff B (LPN) confirmed the resident was self-administering a respiratory (nebulizer) treatment and revealed the resident did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . I signed off the medication, for 12:00 p.m., because we sign it off before we give it here, and I was going to go in her room and give it to her, but she is already getting the medication now. A subsequent interview was conducted with Resident #250, on 11/02/2021 at 12:26 p.m. During the interview the resident revealed she was given the respiratory (nebulizer) treatment on the previous shift and stated, I got it from the nurse last night, I forgot to take it. A record review for Resident #250 revealed a profile sheet which indicated she was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed no active order to self-administer medications. Review of the Minimum Data Set (MDS) dated [DATE], identified in Section C, a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15-point scale, indicating Resident #250 was cognitively intact. On 11/02/21 at 12:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, The nurse must be in the room with the resident during administration of a medication, and until the medication is completed. The DON confirmed Resident #250 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Oral Inhalation Administration, Pharm script Policy #9.8 with revision date of 08/2020, Page 156, 158 and 159, read under Policy Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medications that are orally inhaled. IV. NEBULIZERS: 12. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. 18. Administer Therapy until medication is gone (mist has stopped or until the designated time of treatment has been reached.

Based on observations, interviews and policy review, the facility failed to ensure a clean and sanitary living environment was provided during three (11/02/21, 11/03/21 and 11/04/21) of four days observed, and for two (#39 and #84) of two residents in room #68. Findings included: During a facility tour on 11/02/21 at 10:48 a.m., Resident #39 and #84's room (room #68) was observed with brown stains on wall by trash can with an appearance of human waste matter. The floor around Resident #39's bed was noted with sticky dirt and debris around the fall mats, which were positioned on both sides of the bed. The area in front of Resident #39's bed side table was noted with black spots, stains and dust. A subsequent observation on 11/02/21 at 1:26pm revealed no change in the cleanliness of the resident room. Photographic evidence was obtained. On 11/03/21 at 09:19 a.m., room #68 was observed with the same brown stains on wall, dirt on the floors, stains on floors and an overflowing trash can. A tour of a bathroom inside room #68 revealed a toilet with yellow streak stains and a base covered with brown and yellow debris. The bathroom floors were noted sticky and with dried yellow liquid. A piece of rusted metal pipe extended to the front of the toilet next to Resident #84's walker. A trash can underneath the hand washing sink was noted with overflowing trash. A loose pipe was observed underneath the sink on the floor. Photographic evidence was obtained. A review of the clinical record for Resident #39 revealed she was readmitted to the facility on [DATE] with a primary diagnosis of other [CONDITION(S)] with current pathological fracture, right femur, subsequent encounter for fracture with routine healing. A quarterly MDS (minimum data set) dated 09/20/21, section C showed a BIMS (brief interview for mental status) score of 14, indicating intact cognition. Section G revealed Resident #39 was totally dependent for ADLs (activities of daily living). A review of the clinical record for Resident #84 revealed admission to the facility on [DATE] with a primary diagnosis of unspecified fracture of shaft tibia, subsequent encounter for closed fracture with routine healing. A quarterly MDS dated [DATE], section C showed a BIMS score of 15, indicating intact cognition. Section G showed Resident #84 was totally dependent for ADLs. On 11/03/21 at 09:18 a.m., an interview was conducted with Staff F, Housekeeping. Staff F was observed sweeping the hallway floors outside room #68. Staff F stated that he cleans resident rooms every day. Staff F stated that he was sweeping floors but would be cleaning resident rooms later. Staff F confirmed there are at least four housekeeping staff on duty daily. On 11/03/21 at 09:22 a.m. an interview was conducted with Resident #39. She stated the stains on the wall in front of her bed had been there a while. Resident #39 said, too bad I have to look at that every day. On 11/04/21 at 08:47 a.m., Room #68 was observed in the same condition as the previous observations on 11/02/21 and 11/03/21 showing the same brown stains on the walls, bathroom floors and the bedside floor areas with dirt, dust, and debris. An interview was conducted with Resident #84 on 11/04/21 at 10.22 a.m. Resident #84 stated she uses the bathroom inside her room every day. Resident #84 stated staff assist her with transfers and said she did not know why the floors are never cleaned. On 11/04/21 at 12:25 p.m., Resident #39 was observed laying in her bed, waiting for lunch. The room was noted dirty, with trash overflowing, bathroom floors stained, and drops of brown matter were observed near the trash can, noted extending towards the doorway. An interview was conducted on 11/04/21 at 12:30 p.m. with Staff B, CNA (certified nurse's aide). Staff B looked at Room #68 and said, this room is not clean. At 12:34 pm, Staff C, CNA who was standing outside the door also proceeded to look at room #68. Staff C said, looks like [bowel movement]. The housekeeper should clean it. Staff C stated she saw the stained walls before and forgot to say something. On 11/04/21 at 12:33 p.m., an interview was conducted with Staff E, CNA who worked that hallway during the three days of observation. Staff E said, I would not have my family use that restroom. On 11/04/21 at 12:35 p.m., an interview was conducted with Staff D, LPN (licensed practical nurse). Staff D observed the bathroom and said, the brown stains on wall and floors looks bad. Staff D stated she thought the expectation was that Housekeeping should clean resident rooms daily. A follow-up was conducted on 11/04/21 at 01:00 p.m. with the Housekeeping Director (HD). The HD observed Room #68 and stated, this is absolutely unacceptable, looks like feces on walls and on the floor. The HD stated the CNAs should be wiping off the immediate bowel movement and then Housekeeping staff can disinfect it. The HD stated the resident rooms are cleaned daily, and said, No residents should use a restroom that looks like that. I will clean it myself right after lunch. The HD stated the expectation is for the resident living areas to be cleaned daily. On 11/05/21 at 08:24 a.m. an observation of room #68 confirmed the room and bathroom was clean. A follow -up interview was conducted on 11/05/21 at 08:40 a.m., with the director of nursing (DON). The DON stated she was informed to the condition of room #68, and said it was cleaned right away. The DON said, Residents should live in a clean room. Review of an undated facility policy titled, [company name] Daily resident/patient room cleaning, showed that room cleaning tasks should be performed in the following order: 1. Straighten up resident's room. 2. Dust all surfaces, and spot clean all necessary areas. 3. Dust mop the floor and sweep trash and debris to the door and pick it up with the dust pan. 4. Empty and clean the trashcan and put in a new liner if necessary. 5. Wet mop the room using disinfectant. Under title, Restroom Cleaning the policy showed the restroom cleaning tasks should be performed in the following order: 2. Dust mop the room and spot clean all necessary areas, such as walls. 3. Disinfect the sinks, mirrors, all lights, fixtures, and pipes. 4. Disinfect and clean all parts of the toilet. 5. Damp mop the room using disinfectant. Under title, Method of cleaning, the policy showed to: Move furniture around and clean behind not commonly used furnishings. Restrooms: pay close attention to the sink and commode. Check overall condition of the room Remove all debris from floors, counters, and edges. Remove all trash and replace liners as needed. Mop floors using disinfecting neutral floor cleaner or disinfectant cleaner. Review of an environmental specialist job description titled, Environmental specialist, with a revised date 06/2020, showed that the goal is to create a clean and orderly environment for the residents that will become a critical factor in maintaining and strengthening their reputation. Responsibilities included to: Ensure all clean and soiled rooms are cared for and inspected according to standards.

Based on interview and record review the facility failed to notify resident representatives and families of any occurrence of a single confirmed infection of COVID-19 by 5 p.m. on the next calendar day for four (A, B, E, and G) of five positive staff members reviewed. Findings Included: Review of test results for Staff members with positive results revealed: Staff member E's nasal specimen was collected on 11/5/20 and sent to the lab with a receipt date of 11/7/20 and the lab reported the positive COVID-19 test on 11/8/20 at 9:37 a.m. Staff member G's nasal specimen was collected on 11/5/20 and sent to the lab with a receipt date of 11/7/20 and the lab reported the positive COVID-19 test on 11/8/20 at 9:37 a.m. Staff member A's, nasal specimen was collected on 11/6/20 and sent to the lab with a receipt date of 11/8/20 and the lab reported the positive COVID-19 test on 11/9/20 at 1:18 p.m. Staff member B's nasal specimen was collected on 11/12/20 and sent to the lab with a receipt date of 11/14/20 and the lab reported the positive COVID-19 test on 11/15/20 at 10:02 p.m. During an interview on 11/19/20 at 11:55 a.m. with the Director of Nursing (DON), she said she notified the Administrator as soon as she received the positive COVID-19 results and he sends out the messages to the families. During an interview with the Administrator on 11/19/20 at 11:36 a.m. he confirmed he sent messages out to the resident's families as soon as he was notified. During the interview he compared his notifications to the positive COVID-19 results. The Administrator reported that he sent messages out to family members on 11/6/20, 11/11/20 and 11/17/20. The Administrator confirmed he did not send out the notifications for the positive staff members from 11/8/20, 11/9/20 and 11/15/20 by 5 p.m. the next calendar day.

Based on observation, interview and record review, the facility failed to ensure COVID-19 testing turnaround time met the criteria for reporting of results within 48 hours for 5 Residents (#1, #2, #3, #4, and #5) and 5 Staff members (Staff A, B, C, E, and G) of 13 test results sampled. Findings Included: Review of test results for Residents with positive results revealed: Resident #1's nasal specimen was collected on 10/30/20 at an unknown time and sent to the lab with a receipt date of 11/2/20 at 7:58 a.m., the lab reported the positive COVID-19 test on 11/3/20 at 8:39 a.m. Resident #2's nasal specimen was collected on 10/30/20 at an unknown time and sent to the lab with a receipt date of 11/2/20 and the lab reported the positive COVID -19 test on 11/3/20 at 8:39 a.m. Resident #3's nasal specimen was collected on 10/30/20 at an unknown time and sent to the lab with a receipt date of 11/2/20 and the lab reported the positive COVID -19 test on 11/3/20 at 8:39 a.m. Resident #4's nasal specimen was collected on 10/30/20 at an unknown time and sent to the lab with a receipt date of 11/2/20 and the lab reported the positive COVID -19 test on 11/3/20 at 8:39 a.m. Resident #5's nasal specimen was collected on 10/30/20 at an unknown time and sent to the lab with a receipt date of 11/2/20 and the lab reported the positive COVID -19 test on 11/3/20 at 8:39 a.m. Review of test results for Staff members with positive results revealed: Staff member A's, nasal specimen was collected on 11/6/20 and sent to the lab with a receipt date of 11/8/20 and the lab reported the positive COVID-19 test on 11/9/20 at 1:18 p.m. Staff member B's nasal specimen was collected on 11/12/20 and sent to the lab with a receipt date of 11/14/20 and the lab reported the positive COVID-19 test on 11/15/20 at 10:02 p.m. Staff member C's nasal specimen was collected on 11/12/20 and sent to the lab with a receipt date of 11/10/20 and the lab reported the positive COVID-19 test on 11/16/20 at 4:25 p.m. Staff member E's nasal specimen was collected on 11/5/20 and sent to the lab with a receipt date of 11/7/20 and the lab reported the positive COVID-19 test on 11/8/20 at 9:37 a.m. Staff member G's nasal specimen was collected on 11/5/20 and sent to the lab with a receipt date of 11/7/20 and the lab reported the positive COVID-19 test on 11/8/20 at 9:37 a.m. During an interview on 11/19/20 at 9:45 a.m. with the Director of Nursing (DON), she confirmed the test results take 4 or 5 days to come back. The DON did not confirm with the lab if they tested on the weekend and stated the lab was out of state. She stated that they get results just before they start their next round of testing again. The DON stated they chose to do the weekly testing on Thursday or Friday as they felt that worked best for them. During an interview with the Administrator on 11/19/20 at 11:36 a.m. he confirmed the facility testing was not compliant with receiving test results within 48 hours and stated it would be an easy fix to test staff and residents on another day of the week instead of Thursday and Friday. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-facility-wide-testing.html Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) should be selected for facility-wide testing intended to inform infection prevention initiatives to prevent and limit transmission. -Ideally, one laboratory should be selected to process specimens from both HCP and residents to facilitate data collection and analysis. If the designated laboratory sends results directly to the nursing home, the nursing home and health department should coordinate how all results will be shared with the health department. Review of the facility policy titled Coronavirus Disease (COVID-19)- specimen collection, reporting and documentation for COVID-19 testing, revised 10/20, 4 pages, reflected: General Guidelines 3. Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) are selected for facility wide testing. Review of facility policy Coronavirus Disease (COVID-19) testing residents, revised 10/20, 2 pages reflected: 3. [MEDICAL CONDITION] testing of all residents is conducted if there is an outbreak in the facility. a. An outbreak is defined as any single new onset of [DIAGNOSES REDACTED]-CoV-2 infection in a resident or a single case of infection in healthcare. 4. [MEDICAL CONDITION] tests must be able to detect the [DIAGNOSES REDACTED]-CoV-2 virus with greater than 95% sensitivity, greater that 90% specificity and with results obtained within 48 hours.

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of a communicable diseases. 1)The facility failed to ensure staff followed Centers for Disease Control and Prevention (CDC) guidelines and the facility policy for hand hygiene/hand washing when donning personal protective equipment (PPE) on one (6 East) of one designated Persons Under Investigation (PUI) hall. Findings included: A review of the CMS (Centers for Medicare & Medicaid Services), Guidelines for 3/13/2020, Ref: QSO-20-14-NH, updated: 9/28/20, read as follows. Background: The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring the health and safety of nursing home residents by enforcing the standards required to help each resident attain or maintain their highest level of well-being. In light of the recent spread of COVID-19, we are providing additional guidance to nursing homes to help control and prevent the spread of [MEDICAL CONDITION]. Guidance: Facility staff should regularly monitor the CDC, website for information and resources (links below). They should contact their local health department if they have questions or suspect a resident of a nursing home has COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents, healthcare personnel, and visitors at the facility. Therefore, facilities should continue to be vigilant in identifying any possible infected individuals. Facilities should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day. Furthermore, we encourage facilities to take advantage of resources that have been made available by CDC and CMS to train and prepare staff to improve infection control and prevention practices. Lastly, facilities should maintain a person-centered approach to care. This includes communicating effectively with residents, resident representatives and/or their family, and understanding their individual needs and goals of care. Facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or healthcare personnel should immediately contact their local or state health department for further guidance . A review of the facility policy titled, Policy and Procedure Handwashing/Hand Hygiene, with a revised date of August 2015, documented under Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing and handling medications; i. After contact with the resident's intact skin; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; q. After personal use of the toilet or conducting your personal hygiene. After personal use of the toilet; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: a. Before aseptic techniques; b. When anticipating contact with blood or body fluids; and c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . A review of the facility policy titled, Infection Control, with a revised date of August 2011, documented under Policy Statement, The 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. Under Policy Interpretation and Implementation, 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. During the entrance conference conducted on 10/29/20 at 9:20 a.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) said, We currently do not have any residents in the building who are positive for COVID-19. Our PUI unit is on unit 6 E, rooms 8-17. We also have residents in the building on other types of isolation. An observation of the PUI, transmission-based precautions, hall was conducted on 10/29/20 at 10:33 a.m., Staff B, Certified Nurse's Aide (CNA) was assisting another staff member to move a mechanical lift and replace a plastic cover over the lift. Then Staff B responded to the call light for the resident in room [ROOM NUMBER]. Signage was posted on the resident's door for droplet precautions and the PPE that was required. Staff B, CNA had on a face mask and face shield. She donned gloves and a gown and entered the room. Upon completion of care, Staff B removed her gown and gloves and used hand sanitizer mounted on the wall outside of the room. An interview was conducted with Staff B, CNA at 10:40 a.m., she confirmed that she had not washed or sanitized her hands after helping cover the mechanical lift or before she put gloves and a gown on and entered the resident's room. During an observation outside of resident room [ROOM NUMBER] at 10:43 p.m., Staff C, Licensed Practical Nurse (LPN) was called by Staff B, CNA to assist her to reposition the resident. Staff C, LPN had on a mask and face shield. She put on a gown and gloves. Staff C entered the room and assisted Staff B with resident care. Upon completion of the care, Staff C, LPN was interviewed and confirmed she had put on gloves without using hand sanitizer or washing her hands. During an observation outside of resident room [ROOM NUMBER] at 10:47 p.m., Staff D, Physical Therapy Assistant (PTA) donned a gown and a pair of gloves without washing or using hand sanitizer and entered the room. During an interview conducted at 10:48 a.m., Staff D, PTA said, I just finished working with another resident here. I did not use hand sanitizer. That is why I double glove. An observation was conducted on the PUI hall at 10:49 a.m., Staff E, Occupational Therapist (OT) walked up to resident room [ROOM NUMBER] and pulled out a gown and pair of gloves from the 3 drawer PPE bin outside of the room. Staff E put on her gloves and her gown and entered the room. Staff E did not wash or sanitize her hands before donning PPE. Staff E, OT confirmed she had not washed her hands or used sanitizer before putting on her gloves. An observation was conducted on 10/29/20 at 10:54 a.m., Staff F, Housekeeping was observed cleaning resident room [ROOM NUMBER] on the PUI hall with gloves on. Staff F came out of the room and picked up a rag and a bottle of cleaner and went back into room [ROOM NUMBER] and was observed cleaning the bathroom. Staff F walked back out of the room back to her cart parked in the hall and put the bottle of cleaner back on her cart and the rag in an area on her cart. Then Staff F picked up the broom and dust- pan and re-entered the resident's room. Staff F came out again and put the dustpan and broom back on the cart and picked up the mop. Staff F then mopped the resident room area and then mopped the bathroom. Staff F came out and put the mop back on her cart and moved her cart down the hall to room [ROOM NUMBER]. Staff F did not remove her gloves. Staff F was stopped before entering room [ROOM NUMBER]. Staff F said, You mean I need to change my gloves every time I come out to my cart and change my gloves between each room? An interview was conducted on 10/29/2020 at 2:26 p.m., the Director of Environmental Services said, I actually run the in-services for my department. The housekeeping staff are trained to wear gloves and to wash their hands. We also go over what PPE needs to be worn in and isolation room. I agree if they do not change their gloves, they contaminate everything including their carts. The staff are supposed to clean their housekeeping carts at the end of their shifts. An interview was conducted on 10/29/2020 at 11:30 a.m., the Director of Nurses (DON) said, I expect all staff to wear appropriate PPE when entering and isolation room. Staff are to wash or sanitize their hands before and after putting on gloves. Yes, gloves should be changed, and hands sanitized after touching contaminated surfaces or equipment.

Based on facility and resident record review, interviews with the facility ' s nursing and administrative staff, the resident ' s spouse, the Medical Director, physician, and review of the facility policies, it was determined that the facility failed to implement physician orders for honoring the advance directives related to Cardio-Pulmonary Resuscitation (CPR) for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status, according to the Advance Directives List and verified as current on [DATE]. The facility did not initiate CPR on Resident #1, who was [AGE] years old and previously living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. The resident had a current physician order documenting his code status as Full, meaning that he wanted CPR if found unresponsive. On [DATE], Resident #1 was found unresponsive. The facility did not initiate CPR as per the resident ' s wishes and physician order. The facility failed to honor Resident #1 ' s advance directives and the Resident died without receiving emergency services to potentially prolong his life and enable him to return home with his wife. Failure of the facility staff to follow the physician ' s orders for care and the expressed wishes of the resident to receive CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the hospital on [DATE] for rehabilitative services with a discharge plan to return home with his spouse and receive home health services. Review of the Physician ' s Order Sheet (POS), dated and signed by the physician on [DATE], revealed the resident had multiple [DIAGNOSES REDACTED]. The advance directive section indicated: Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable to provide informed consent for medical treatment and surgical and diagnostic procedures. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. Review of Resident #1 ' s Admission Evaluation dated [DATE], revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. A review of the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Per the nurse ' s notes, dated [DATE] at 5:00 p.m., the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurse ' s notes, dated [DATE] at 2:30 a.m., CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said, at approximately 2:00 a.m. while making rounds, she went back in his room. She stated, He did not look right I put my hand on his hand and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said, ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No . The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA performed the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m.-7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6, going back to station 7, the Licensed Practical Nurse (LPN) (Staff A) was on the phone, covered the mouthpiece, and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code . The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are a full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); who stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes . The DON asked if she initiated CPR and Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) who was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she (herself) did not touch the resident or listen for a pulse. She said she left the room with Staff A. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse is that if a resident is found unresponsive and is a Full code he expects CPR to be initiated. When asked if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive what would his expectation be as far as CPR? He said, I expect them to always follow protocol. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident is found unresponsive is to initiate CPR if the resident is a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. The Policy Interpretation and Implementation read as follows: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives. 2. Each resident will also be informed that our facility ' s policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. 6. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised (as necessary) by his/her legal counsel in this state before the facility may honor such directives. 7. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). 8. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes and/or revocations so that appropriate changes can be made in the resident assessment instrument (MDS) and care plan. 9. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident ' s medical record and plan of care. 10. The Nurse Supervisor will be required to inform emergency medical personnel of a resident ' s advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. 11. The Staff Development Coordinator will be responsible for scheduling advance directive training classes for newly hired staff members as well as scheduling annual Advance Directive In-Service Training Programs to ensure that our staff remains informed about the resident ' s rights to formulate advance directives and facility policy governing such rights. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim responds but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions 5. Open airway 6. Check breathing 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. An interview was conducted on [DATE] at 8:44 a.m. with the Social Service Director, She stated that if the capacity of the resident is in question; they go down the line of appropriate parties to ask (about Advance Directives). The social worker further stated that the status was reviewed quarterly. An interview was conducted on [DATE] at 10:01 a.m. with the DON revealed the following information: When asked if initiating CPR was considered a service that the facility offers, the DON said Yes. When asked if the nurse (Staff A) failed to provide the service of initiating CPR the DON said, Yes. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses. She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. At the time of the complaint investigation there was no evidence that the facility had continued conducting mock code drills since [DATE]. The facility began conducting mock surveys on [DATE] to ensure the staff was knowledgeable about CPR process and their roles. The following measures were taken by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees, that only worked on an as needed basis, had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. (The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work.) The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews from all shifts (30 total) were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on facility and resident record review, interviews with the facility ' s nursing, medical, and administrative staff, the resident ' s spouse, the Medical Director, and review of the facility policies, it was determined that the facility failed to protect the rights of residents to have Cardio-Pulmonary Resuscitation (CPR) initiated in the event of [MEDICAL CONDITION] for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status, according to the Advanced Directives List, dated [DATE], and verified as current on [DATE] and Resident #1 ' s closed record. The facility did not initiate CPR on Resident #1, who was [AGE] years old and had been living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. On [DATE], Resident #1 was found unresponsive. The facility did not initiate CPR as per the resident ' s wishes. The facility failed to honor Resident #1 ' s advanced directives and denied the resident the opportunity to receive emergency lifesaving services to prolong his life and return home with his wife. Failure of the facility staff to honor and carry out the expressed wishes to receive CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the Hospital on [DATE] for rehabilitative services with a discharge plan to return with spouse and receive home health services. Review of the Physician ' s Order Sheet (POS) dated and signed by the physician on [DATE] revealed the resident had multiple [DIAGNOSES REDACTED]. The advanced directive section indicated: Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital) with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. The resident had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and implementation , section 1: Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives. Policy Interpretation and Implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that , in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim response but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions 5. Open airway 6. Check breathing 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. An interview was conducted on [DATE] at 8:44 a.m. with the Social Service Director, she stated that if the capacity of the resident is in question; they go down the line of appropriate party to ask (about Advance Directives). The social worker further stated that the status is reviewed quarterly. A review of the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Review of Resident #1 ' s Admission Evaluation dated [DATE] revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. Per the nurses notes dated [DATE] at 5:00 p.m. the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurses notes dated [DATE] at 2:30 a.m. CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said at approximately 2:00 a.m. while making rounds she went back in his room. She stated, He did not look right I put my hand on his hand and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said ' Oh, he is dead. ' The nurse left the room . Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No . The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA did the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m. -7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6 going back to station 7 the Licensed Practical Nurse (LPN) (Staff A) who was on the phone covered the mouthpiece and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business . About twenty minutes later Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code . The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code . The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); she stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes . The DON asked if she initiated CPR Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) that was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she did not touch the resident or listen for a pulse. She said she left the room with Staff A. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse is that if a resident is found unresponsive and is a Full code him expects CPR to be initiated. The Medical Director was asked what his expectation would be if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive? He said I expect them to always follow protocol. An interview was conducted with the resident primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident is found unresponsive is to initiate CPR if the resident is a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses. She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. At the time of the complaint investigation there is no evidence that the facility had continued conducting mock code drills since [DATE]. The facility began conducting mock surveys on [DATE] to ensure the staff was knowledgeable about CPR process and their roles. The following measures were taken by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities . Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE]. Staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON)verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees that only worked on an as needed basis had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work. The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue . The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist . The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. 100% of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on resident record review, policy and procedure review, and staff and family interview, it was determined that the facility ' s Quality Assessment and Quality Assurance Committee, identified a problem of not protecting the rights of residents to have Cardio-Pulmonary Resuscitation (CPR) initiated in the event of [MEDICAL CONDITION] but failed to put systemic measures in place to ensure that resident ' s advanced directives were honored. The right to have CPR was not honored for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status, according to the Advanced Directives List, dated [DATE], and verified as current on [DATE] and Resident #1 ' s closed record. The facility did not initiate CPR on Resident #1, who was [AGE] years old and had been living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. On [DATE], Resident #1 was found unresponsive. The facility did not initiate CPR as per the resident ' s wishes. The facility failed to honor Resident #1 ' s advanced directives and denied the resident the opportunity to receive emergency services to prolong his life and return home with his wife. The facility ' s Quality Assurance and Performance Improvement (QAPI) committee failed to promote the consistent use of facility systems and processes during the provision of care and services; failed to identify actual and potential negative outcomes relative to resident care and resolve them appropriately; failed to support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems; failed to coordinate the development, implementation, monitoring and evaluation of performance improvement projects to achieve specific goals. The facility QAPI meetings were conducted after the [DATE] event, where Resident #1 was not provided goods and services, related to Cardio [MEDICAL CONDITION] Resuscitation. A review of the Quality Assurance (QA) monthly meeting signature sheets, dated [DATE], [DATE], and ,[DATE] (day was not indicated) reflected the attendance of the required QA members. There was no additional documentation provided by the facility to verify that CPR was discussed in the QA meetings after the [DATE] meeting. After the incident and with knowledge of the incident the facility failed to review their policies and procedures or assess staff knowledge to identify intervention strategies to prevent a reoccurrence. Failure of the facility to respond to this incident with comprehensive review, corrective action and subsequent monitoring resulted in the finding of immediate jeopardy. Failure of the facility staff to honor and carry out the residents expressed wishes to receive CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: A review of the Quality Assurance and Performance Improvement (QAPI) Committee , (2001 MED-PASS, Inc. ([DATE])), policy revealed the following information: Policy Statement: This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation: 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain, and oversee the QAPI program. 2. The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board (body). Goals of the Committee: 1. Establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services. 2. Promote the consistent use of facility systems and processes during provision of care and services. 3. Help identify actual and potential negative out comes relative to resident care and resolve them appropriately. 4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems. 5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care. 6. Coordinate the development, implementation, monitoring and evaluation of performance improvement projects to achieve specific goals. 7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. Committee Audit Process: 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 2. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific timeframes for implementation and follow up. 3. The committee shall track the progress of any active plans of correction. 4. The committee shall advise the administration of the need for policy and procedural changes and, as appropriate, monitor to ensure that such changes are implemented. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses (DON). She said, immediately after the event involving Resident #1, who was a full code, but, did not receive CPR, the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition, mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. The facility was unable to provide any additional documentation to prove that the mock code drills had continued beyond [DATE]. The DON was unable to say why the mock code drills were not offered to the remaining licensed staff to ensure one hundred percent of those staff members were given the opportunity to enhance their knowledge and confidence related to initiation and participation of CPR. On [DATE], at 11:00 a.m. an interview was conducted with the Director of Nurses. She said, on [DATE] a special QA meeting was conducted to review the issue of CPR. She said the team reviewed the event related to Resident #1 not receiving CPR, per his wishes. The team discussed the cause, the plan for correction, and the monitoring process. She said the Medical Director was also present and participated in the discussion. A review of the Quality Assurance (QA) monthly meeting signature sheets, dated [DATE], [DATE], and ,[DATE] (day was not indicated) reflected the attendance of the required QA members. There was no additional documentation provided by the facility to verify that CPR was discussed in the QA meetings after the [DATE] meeting. An interview was conducted with the Administrator on [DATE] at approximately 11:15 a.m. He said he had been made aware of the event (unable to give date) but was not employed at the facility at the time of the event involving Resident #1, who was not provided with C.P.R., despite his full code status. When the NHA was asked if the issue was currently being discussed at the QA meetings, he said, No. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when Resident #1 did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse was that if a resident was found unresponsive and was a Full code, he expected CPR to be initiated. When asked, if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive what would his expectation be as far as CPR? He responded, I expect them to always follow protocol. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse, when a resident was found unresponsive, was to initiate CPR if the resident was a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. The Policy Interpretation and Implementation read as follows: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives. 2. Each resident will also be informed that our facility ' s policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. 6. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised (as necessary) by his/her legal counsel in this state before the facility may honor such directives. 7. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). 8. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes and/or revocations so that appropriate changes can be made in the resident assessment instrument (MDS) and care plan. 9. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident ' s medical record and plan of care. 10. The Nurse Supervisor will be required to inform emergency medical personnel of a resident ' s advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. 11. The Staff Development Coordinator will be responsible for scheduling advance directive training classes for newly hired staff members as well as scheduling annual Advance Directive In-Service Training Programs to ensure that our staff remains informed about the resident ' s rights to formulate advance directives and facility policy governing such rights. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase changes of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim responds but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions. 5. Open airway. 6. Check breathing. 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. 2. File a police report if the victim is not a resident of or patient receiving care at the facility. Per the hospital discharge summary, dated [DATE], for Resident #1: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility on [DATE]. Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the hospital, on [DATE], for rehabilitative services with a discharge plan to return with spouse and receive home health services. Review of the Physician ' s Order Sheet (POS), dated and signed by the physician on [DATE], revealed the resident had multiple [DIAGNOSES REDACTED]. The advanced directive section indicated: Code Status: Full (handwritten). Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. Review of Resident #1 ' s Admission Evaluation, dated [DATE], revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. Per the nurse ' s notes, dated [DATE] at 5:00 p.m., the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurse ' s notes, dated [DATE] at 2:30 a.m., CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep, so, she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said, at approximately 2:00 a.m. while making rounds, she went back in his room. She stated, He did not look right I put my hand on his hand and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said, ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No . The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said, He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said, when she and another CNA performed the post mortem care, the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for Resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m. -7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6, going back to station 7, the Licensed Practical Nurse (LPN) (Staff A) was on the phone, covered the mouthpiece, and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later, Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code. The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); who stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said, Yes. The DON asked if she initiated CPR and Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) who was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she did not touch the resident or listen for a pulse. She said she left the room with Staff A. Interview conducted on [DATE] at 10:01 a.m. with the DON revealed the following information: When asked if initiating CPR was considered a service that the facility offers, the DON said Yes. When asked if the nurse (Staff A) failed to provide the service of initiating CPR the DON said, Yes. The following corrective action measures were initiated by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition, a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled, Code Blue Roles and Responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees that only worked on an as needed basis had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work. The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were restarted on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said, We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition, a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the Administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews (30 total) from all shifts were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on review of clinical records, Nursing Home Administrator (NHA) job description, policy and procedures, and interviews with the resident ' s family, staff, and physicians, it was determined that administration failed to provide resource management to ensure the right to receive emergency services (CPR) and exercise advanced directives were protected for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status, according to the Advance Directives List , dated [DATE], and verified as current on [DATE] and Resident #1 ' s closed record. The facility did not initiate CPR on Resident #1, who was [AGE] years old and had been living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. On [DATE], Resident #1 was found unresponsive. The facility did not initiate CPR as per the resident ' s wishes. The facility failed to honor Resident #1 ' s advanced directives and the resident died without the opportunity to receive emergency services to potentially prolong his life and enable him to return home with his wife. Administration did not ensure that the direct functions and continued operations of the facility, including the right to be free from neglect, were in accordance with current regulations governing long term care facilities related to implementing policies and procedures for Cardiopulmonary resuscitation and abuse prevention. The administration ' s failure to ensure that the resident ' s expressed wishes were honored for advanced directives and Cardiopulmonary Resuscitation led to the findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: An interview was conducted with the Administrator (NHA) on [DATE] at approximately 11:15 a.m. He stated that he had been made aware of the event (unable to give date) involving Resident #1, who was a full code, but, did not receive CPR, consistent with his wishes, however, he was not employed at the facility at that time. When the NHA was asked if the issue was currently being discussed at the QA meetings, he said, No. The Administrator began working at the facility as the Interim Administrator on [DATE]. A review of the QA meeting signature sheets verified that the Administrator was in attendance at the [DATE] and ,[DATE] (day was not indicated) QA meetings. When the NHA was asked if the issue of honoring resident end of life wishes was currently being discussed at the QA meetings, he said No. The Administrator was unable to provide any additional information to show that, even though the event involving Resident #1 did not occur while the Administrator was in charge of the facility, he accepted responsibility to ensure the facility developed a plan, implemented such plan, and monitored the plan to ensure no other resident was denied his or her right to have CPR initiated should they have a [MEDICAL CONDITION]. Though the administrator had been in charge of the facility since [DATE], he did not follow through with the facility ' s policy related to Quality Assurance as follows: The Quality Assurance and Performance Improvement (QAPI) Committee, (2001 MED-PASS, Inc. ([DATE])), policy revealed the following information: Policy Statement: This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation: 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain, and oversee the QAPI program. 2. The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board (body). Goals of the Committee: 1. Establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services. 2. Promote the consistent use of facility systems and processes during provision of care and services. 3. Help identify actual and potential negative out comes relative to resident care and resolve them appropriately. 4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems. 5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care. 6. Coordinate the development, implementation, monitoring and evaluation of performance improvement projects to achieve specific goals. 7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. Committee Audit Process: 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 2. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific timeframes for implementation and follow up. 3. The committee shall track the progress of any active plans of correction. 4. The committee shall advise the administration of the need for policy and procedural changes and, as appropriate, monitor to ensure that such changes are implemented. A review of the Nursing Home Administrator ' s job description (Revision date [DATE]) was provided for review. The document provided the following relevant information: Administrative Functions: 1. Plan, develop, organize, implement, evaluate, direct the Facility ' s programs and activities in accordance with guidelines issued by the VP of Operations. 2. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. 3. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. 4. Ensure that all employees, residents, visitors, and the general public follow the facility ' s established policies and procedures. 5. Ensure that the resident ' s rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are well established and maintained at all times. 6. Assist the HR delegate and department directors in developing written job descriptions and performance-based job evaluations for each staff position. 7. Serve on various committees of the Facility (i.e., Infection Control, Quality Assurance and Assessment, etc.) and provide written and oral reports of such committee meeting to the VP of Operations as directed or as may become necessary. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and implementation, Section 1: Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives. Policy Interpretation and Implementation, Section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes). 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim responds but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions. 5. Open airway. 6. Check breathing. 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. An interview was conducted on [DATE] at 8:44 a.m. with the Social Service Director. She stated that if the capacity of the resident is in question; they go down the line of appropriate parties to ask (about Advance Directives). The social worker further stated that the status is reviewed quarterly. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the Hospital on [DATE] for rehabilitative services with a discharge plan to return with spouse and receive home health services. Review of the Physician ' s Order Sheet (POS) for Resident #1, dated and signed by the physician on [DATE], revealed the resident had multiple [DIAGNOSES REDACTED]. The advanced directive section indicated: Code Status: Full (handwritten). Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. A review of Resident #1 ' s Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Review of Resident #1 ' s Admission Evaluation dated [DATE] revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. Per the nurse ' s notes, dated [DATE] at 5:00 p.m., the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurse ' s notes, dated [DATE] at 2:30 a.m., CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid, unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said at approximately 2:00 a.m., while making rounds, she went back in his room. She stated, He did not look right I put my hand on his hand and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C), she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No. The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said, He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA (Staff I) did the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for Resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m. -7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6 going back to station 7, the Licensed Practical Nurse (LPN) (Staff A), who was on the phone, covered the mouthpiece and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later, Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code. The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); she stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes. The DON asked if she initiated CPR? Staff A said, No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) that was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point, she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she did not touch the resident or listen for a pulse. She said she left the room with Staff A. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse was that if a resident was found unresponsive and was a Full code, he expects CPR to be initiated. When asked if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive what would his expectation be as far as CPR, he said I expect them to always follow protocol. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident was found unresponsive was to initiate CPR if the resident was a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time, he said, I would expect the nurse to follow protocol. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses (DON). She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition mock code drills were completed on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the event, the facility had a total of 32 nurses on staff. The facility was unable to provide any additional documentation to prove that the mock code drills had continued beyond [DATE]. The DON was unable to say why the mock code drills were not offered to the remaining licensed staff to ensure one hundred percent of those staff members were given the opportunity to enhance their knowledge and confidence related to initiation and participation of Advanced Directives and CPR. On [DATE] at 11:00 an interview was conducted with the Director of Nurses. She said, on [DATE], a special QA meeting was conducted to review the issue of CPR. She said the team reviewed the event related to Resident #1 not receiving CPR per his wishes. The team discussed the cause, the plan for correction, and the monitoring process. She said the Medical Director was also present and participated in the discussion. There was no additional documentation provided by the facility, however, to verify that CPR was discussed in the QA meetings after the [DATE], despite that all staff who would be expected to respond, had not participated in re-training. The following measures were taken by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees, that only worked on an as needed basis, had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work. The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews from all shifts (30 total) were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on resident record review, interviews, and review of facility policies and procedures, it was determined that the facility failed to implement its policy and procedure for Abuse and Neglect which resulted in the omission of life saving intervention services for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status. The facility failed to ensure that goods and services of Cardio [MEDICAL CONDITION] Resuscitation (CPR) were provided to Resident #1, [AGE] years old, who was found by Certified Nursing Assistant on [DATE]. The Staff Member communicated concerns of Resident #1 not looking right to a Licensed Practical Nurse. The L.P.N. failed to initiate and provide CPR to Resident #1. Resident #1 died on [DATE]. Resident #1 was a Full Code status and his wishes were to have CPR performed. In addition, the facility failed to ensure that services were provided in accordance with the physician written plan of care for 1 (#1) of 16 sampled residents. The facility staff failed to correctly implement the response policy and procedure for CPR resulting in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: The facility provided an Abuse and Neglect policy and procedure during the survey, which was undated and titled with the Nursing Home Name. On page 1, in the definition area, the term Neglect was defined: Neglect is the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder or self-neglect. On page 4, the document outlined, What Must be Reported : Section A, The facility must ensure that all allegations of abuse, neglect, injuries of unknown origin, and exploitation/misappropriation of resident property are reported immediately to the administrator of the facility, the Agency for Health Care Administration, the Department of Children and Families, the Florida Abuse Hotline, and to other officials in accordance with state law. On page 4, the document outlined Facility Investigation : Federal regulation requires a facility to have evidence that all allegations of abuse, neglect, injuries of unknown origin, and exploitation/misappropriation are thoroughly investigated. In addition, the facility must take action to prevent further potential abuse while the investigation is in process. On page 5, the document outlined Conducting a Thorough Investigation, The federal regulations clearly require the facility to have evidence that all alleged violations are thoroughly investigated. The following represents guidance on those components of an investigation that would constitute a thorough investigation. A. The investigation: 1. Specify the type of allegation that is being reported (i.e. physical, sexual, or verbal abuse, neglect, injury of unknown origin, or exploitation/misappropriation). On page 6, Section 11: If the allegation involves neglect, identify the staff member(s), the length of time involved, and any outcome of the victim. Be specific. Section 14: Review facility procedures if the incident may be related to unsafe technique used by staff. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse was that if a resident is found unresponsive and Full code he expected CPR to be initiated. When asked, if a nurse found a resident unresponsive and had no idea how long the resident had been unresponsive, what would his expectation be as far as CPR, he said, I expect them to always follow protocol. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that , in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim responds but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions. 5. Open airway. 6. Check breathing. 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. A review of Resident #1 ' s clinical chart revealed an admission record that documented admission to the facility on [DATE] from a local hospital. Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the Hospital on [DATE] for rehabilitative services with a discharge plan to return with spouse and receive home health services. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital) with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. Review of a Patient Transfer and Continuity of Care form, signed by a physician, documented a discharge date of [DATE] from the hospital. The type of care recommended was Skilled Nursing. Review of the February, 2015 physician orders, signed and dated on [DATE], documented that the resident code status as FULL. Review of Resident #1 ' s Admission Evaluation dated [DATE] revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. Per the nurse ' s notes, dated [DATE] at 5:00 p.m., the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. A review of Resident #1 ' s admission social service progress note, dated [DATE], document the following information: [AGE] year old male admitted [DATE] from hospital to room. Resident is alert and appears oriented x 3. Verbal and pleasant. Demonstrates ability to make needs known. Lives at home with (family member). Still drives and was independent at home with ADL ' s; uses cane at home, no mood or behaviors noted. Has no concern over care or roommate. Discussed advanced directives. Currently a full code. Has living will and if needed (family member will produce .discharge plan is home with (family member). The document was signed by the Social Service Director. A review was completed of Resident #1 ' s Nurses ' notes, dated [DATE], no time: Resident is alert and oriented, able to make needs known. Resident denies and shows no signs or symptoms of pain or discomfort at this time. Routine medications given according to Medication Administration Record. Resident plus ,[DATE] assist with ADL ' s. Skilled therapy in progress. Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. A review of Resident #1 ' s Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Review of Resident #1 ' s Nurses notes, dated [DATE] at 2:30 p.m. (error, should be a.m.), revealed the following documentation: CNA came up to me and said I think that patient is deceased around 1:50 a.m., upon entering room pt was hunched over, sitting up in bed. Not breathing, no vital signs, no pulse, patient cold, pale, and rigid, unable to move without difficulty. Blood was already pooled to backside. The other nurse, Staff member D, was present and also confirmed patient as deceased . Family notified and given the memorial service request. She will be coming tomorrow at some time to pick up belongings. MD notified of patient deceased . New order to release the body . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said, at approximately 2:00 a.m., while making rounds, she went back in his room. She stated, He did not look right; I put my hand on his hand; and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said, ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No. The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said, He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA performed the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for Resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m. -7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6, going back to station 7, the Licensed Practical Nurse (LPN) (Staff A) was on the phone, covered the mouthpiece, and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later Resident #1 ' s CNA (Staff Member C) came to the supervisor and informed her that the resident who expired was a Full Code. The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); who stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes. The DON asked if she initiated CPR and Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) who was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she did not touch the resident or listen for a pulse. She said she left the room with Staff A. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident is found unresponsive was to initiate CPR if the resident was a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses. She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition, mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. At the time of the complaint investigation, there was no evidence that the facility had continued conducting mock code drills since [DATE]. The facility began conducting mock surveys on [DATE] to ensure the staff was knowledgeable about CPR process and their roles. The facility implemented the following measures to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition, a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator, the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees, with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees that only worked on an as needed basis, had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work. The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said, We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition, a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the Administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews from all shifts (30 total) were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on facility policy review, review of clinical records, interviews with the Medical Director, physician, facility staff, and family member, it was determined that the facility failed to honor the advance directives for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status according to the Advance Directives List, dated [DATE], verified as current on [DATE] and according to review of Resident #1 ' s medical record. The facility did not initiate CPR on Resident #1, who was [AGE] years old and previously living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. The resident had a current physician order documenting his code states as Full , meaning that he wanted CPR if found unresponsive. On [DATE] Resident #1 was found unresponsive. The staff did not fulfill a care taking obligation to provide goods or services necessary to maintain the health and safety of an elder consistent with the definition of Neglect in the Abuse and Neglect Policy and Procedure provided by the facility, did not fulfill the resident ' s expressed wishes to have CPR carried out when necessary and did not carry out a written physician order documenting the resident as a Full code. The facility failed to honor Resident #1 ' s advance directives and the Resident died without receiving emergency services to potentially prolong his life and enable him to return home with his wife. Failure of the facility staff to provide the services necessary to honor and carry out the expressed wishes of the Resident to receive CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the hospital on [DATE] for rehabilitative services with a discharge plan to return home with his spouse and receive home health services. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital) with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. Review of the Physician ' s Order Sheet (POS), dated and signed by the physician on [DATE], revealed the resident had multiple [DIAGNOSES REDACTED]. The advanced directive section indicated: Code Status: Full (handwritten). Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. Review of Resident #1 ' s Admission Evaluation , dated [DATE], revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. A review of Resident #1 ' s Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Per the nurses notes dated [DATE] at 5:00 p.m. the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurses notes dated [DATE], at 2:30 a.m., CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said, at approximately 2:00 a.m. while making rounds, she went back in his room. She stated, He did not look right; I put my hand on his hand; and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said, ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No . The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA performed the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m.-7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6, going back to station 7, the Licensed Practical Nurse (LPN) (Staff A) was on the phone, covered the mouthpiece, and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code. The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); who stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes . The DON asked if she initiated CPR and Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) who was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she (herself) did not touch the resident or listen for a pulse. She said she left the room with Staff A. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse is that if a resident is found unresponsive and is a Full code he expects CPR to be initiated. When asked if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive what would his expectation be as far as CPR? He said, I expect them to always follow protocol. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident is found unresponsive is to initiate CPR if the resident is a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. The facility provided an Abuse and Neglect policy and procedure during the survey, which was undated and titled with the Nursing Home Name. On page 1 in the Definition area, the term Neglect was defined: Neglect is the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder or self-neglect. A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that , in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non- licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation. 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim responds but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions 5. Open airway 6. Check breathing 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. An interview was conducted on [DATE] at 8:44 a.m. with the Social Service Director. She stated that if the capacity of the resident is in question; they go down the line of appropriate parties to ask (about Advance Directives). The social worker further stated that the status is reviewed quarterly. An interview was conducted on [DATE] at 10:01 a.m. with the DON revealed the following information: When asked if initiating CPR was considered a service that the facility offers, the DON said Yes. When asked if the nurse (Staff A) failed to provide the service of initiating CPR the DON said, Yes. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses. She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. At the time of the complaint investigation there was no evidence that the facility had continued conducting mock code drills since [DATE]. The facility began conducting mock surveys on [DATE] to ensure the staff was knowledgeable about CPR process and their roles. The following measures were taken by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees, that only worked on an as needed basis, had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. (The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work.) The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews from all shifts (30 total) were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.

Based on facility policy review, review of clinical records, interviews with the Medical Director, facility staff, physician, and family, it was determined that the facility failed to implement their own policies and procedures for advance directives and Cardiopulmonary Resuscitation (CPR)and failed to carry out the wishes to receive cardiopulmonary resuscitation for one (#1) of 15 sampled residents of 36 residents identified as having Full Code status, according to the Advance Directives List, dated [DATE], verified as current on [DATE] and according to review of Resident #1 ' s medical record. The facility failed to implement their own policies for Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) as the facility did not initiate CPR on Resident #1, who was [AGE] years old and previously living independently at home with his wife. He was admitted to the facility for rehabilitation services with discharge plans to return home. The resident had a current physician order documenting his code states as Full , meaning that he wanted CPR if found unresponsive. On [DATE], Resident #1 was found unresponsive. The facility did not initiate CPR as per the resident ' s wishes. The facility failed to honor Resident #1 ' s advance directives and the Resident died without receiving emergency services to potentially prolong his life and enable him to return home with his wife. Failure of the facility staff to honor and carry out the expressed wishes to receive CPR, resulted in findings of immediate jeopardy which were removed on [DATE], and the severity and scope was reduced to a D. Findings include: A review of the facility policy: Advance Directives, 2001 Med-Pass, Revised [DATE], documented a policy statement: Advance directives will be respected in accordance with state law and facility policy. The Policy Interpretation and Implementation read as follows: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives. 2. Each resident will also be informed that our facility ' s policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. 6. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised (as necessary) by his/her legal counsel in this state before the facility may honor such directives. 7. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). 8. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes and/or revocations so that appropriate changes can be made in the resident assessment instrument (MDS) and care plan. 9. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident ' s medical record and plan of care. 10. The Nurse Supervisor will be required to inform emergency medical personnel of a resident ' s advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. 11. The Staff Development Coordinator will be responsible for scheduling advance directive training classes for newly hired staff members as well as scheduling annual Advance Directive In-Service Training Programs to ensure that our staff remains informed about the resident ' s rights to formulate advance directives and facility policy governing such rights. A review of the facility policy: Cardio [MEDICAL CONDITION] Resuscitation (CPR) and Basic Life Support (BLS), 2001 Med-Pass, Inc. (Revised [DATE]), documented the purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Preparation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. Newly hired employees will be under the direct supervision of a Licensed Nurse in the event of [MEDICAL CONDITION]. 3. Newly hired employees will have 45 days from hire to obtain certification from the American Red Cross or American Heart Association on Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR). 4. Provide periodic Mock Codes (simulations of an actual arrest for training purposes.) 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. General Guidelines: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulseless-ness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of multi-system failure and advanced irreversible or terminal conditions. 4. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 6. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Steps in the Procedure: The facility ' s procedure for administering CPR shall incorporate the steps covered in the American Heart Association Current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. They include the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub). B. Roll the resident on their back. C. If the victim response but is injured, follow facility protocol for first aid or call 911. D. If the victim is unresponsive (no movement or response to stimuli, and no return of pulse and/or respirations), follow steps ,[DATE]. 2. Alert staff and initiate CPR. A. Call a code as designated by facility protocol. B. Designate a staff person to call 911 and then contact the resident ' s attending physician and the resident ' s family. 3. Place backboard under resident ' s upper torso. 4. Start compressions 5. Open airway 6. Check breathing 7. Administer rescue breaths via ambu bag and or mouth shield. 8. Continue CPR until EMS team arrives and takes over. Documentation: 1. Document the following in the resident ' s medical record (if the victim is a resident): A. The condition in which the resident was found or the witnessed event. B. The sequence of resuscitation efforts, including approximate times. C. The victim ' s response to resuscitation efforts. D. The approximate time that the EMS team took over. E. Time of death or time the individual was transported. An interview conducted on [DATE] at 8:44 a.m. with the Social Service Director, She stated that if the capacity of the resident is in question; they go down the line of appropriate parties to ask (about Advance Directives). The social worker further stated that the status was reviewed quarterly. Review of Resident #1 ' s closed medical record, to include the demographic/face sheet, indicated he was admitted to the facility from the hospital on [DATE] for rehabilitative services with a discharge plan to return home with his spouse and receive home health services. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient is a [AGE] year old gentleman admitted to the emergency room at the hospital) with lower extremity swelling, [MEDICAL CONDITION], and chronic diabetic ulcers. Also underwent [MEDICAL CONDITION], Para pneumonic effusion, pneumonia, and underwent thoracentesis. He also had [MEDICAL CONDITION] with rapid ventricular rate and acute kidney failure. The patient was intubated and then extubated respiratory. He went through a pretty complex hospital course with difficult management of his diabetes, [MEDICAL CONDITION], which was thought to be secondary to [MEDICATION NAME]. Patient was very weak and debilitated as a result of all this. He had difficulty with self-care ADLs and ambulation. At this point, the patient was medically stabilized and cleared to participate in acute inpatient rehabilitation. Resident #1 was discharged from acute inpatient rehabilitation at the hospital and transferred to the skilled nursing facility 0n [DATE]. Review of the Physician ' s Order Sheet (POS), dated and signed by the physician on [DATE], revealed the resident had multiple [DIAGNOSES REDACTED]. The advanced directive section indicated: Code Status: Full (handwritten). Resident #1 had a Living Will, dated [DATE], and signed by the resident. The resident indicated he did not want life prolonging procedures in the following conditions: mentally or physically incapacitated, terminal condition, end-stage condition, persistent vegetative state, and if the attending or treating physician and another consulting physician determine that there is no reasonable medical probability of recovery from such condition. A Designation of Health Care Surrogate was signed by the resident on [DATE] and designated the resident ' s spouse as his health care surrogate in the event the resident became incapacitated and unable provide informed consent for medical treatment and surgical and diagnostic procedures. Review of Resident #1 ' s Admission Evaluation , dated [DATE], revealed under Section B (Resident Status) the following information: Alert with no problems related to cognition/emotional or behavioral factors, no obvious neurological, respiratory, or cardiovascular problems, no obvious problem with oral status, nutrition, gastrointestinal, urinary, or bowel problems, independent with eating, personal hygiene, and bed mobility. He was dependent for transfers and needed assistance with ambulation, dressing, toileting, and bathing, continent of bowel and bladder, and, skin breakdown on his left posterior thigh and sacrum. A review of Resident #1 ' s Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] under the Cognitive Patterns section revealed a Brief Interview of Mental Status (BIMS) score was 15. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) MDS Manual: The BIMS total score is highly correlated with the Mini-Mental Exam (MMSE; Foldtein, Folstein, & McHuh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: Cognitively intact ,[DATE]: Moderately impaired ,[DATE]: Severe Impairment. Per the nurses notes dated [DATE] at 5:00 p.m. the resident was transported to the facility via ambulance. Alert and oriented x3, wife at bedside, breathing even and unlabored, lungs clear bilaterally. Bowel sounds present x 4 quadrants. Pedal pulse palpable. Resident denies pain at this time, sitting up in bed with pillow under one side to keep pressure off back. MD confirmed patient and meds. Call light within reach. Per nurses notes dated [DATE], at 2:30 a.m., CNA came up to me and said I think the patient is deceased around 1:50 a.m. Upon entering the room the patient was hunched over sitting up in bed, not breathing, no vital signs, no pulse. Patient cold, pale, and rigid unable to move without difficulty. Blood was already pooled to backside. The other nurse was present and also confirmed patient as deceased . Family notified. MD notified of patient deceased . An interview was conducted on [DATE], at approximately 10:00 a.m. with the Certified Nurse ' s Assistant (CNA), (Staff C) who initially found the resident unresponsive at approximately 1:50 a.m. on [DATE]. She said she went into Resident #1 ' s room at approximately 11:00 p.m.; he was sleeping. She went back to his room at approximately 12:00 a.m. to take his vital signs. He was asleep so she did not wake him. She said she knew he was sleeping because she could hear him breathing. She said, at approximately 2:00 a.m. while making rounds, she went back in his room. She stated, He did not look right; I put my hand on his hand and called his name. I went out and got the nurse (Staff A), and she came down and listened to his heart and said, ' Oh, he is dead. ' The nurse left the room. Per the CNA (Staff C) she went back up the hall and asked the nurse (Staff A) what she wanted the CNA to do. The nurse told the CNA to clean the resident. The CNA asked the nurse if the resident was a Do Not Resuscitate (DNR). The nurse said No. The CNA then went to the supervisor to inform her that the resident did not receive CPR. The supervisor (Staff F) approached the nurse and asked why CPR was not initiated on Resident #1. The nurse said He was stone cold dead; I am not doing CPR on a stone cold dead person. The CNA said when she and another CNA performed the post mortem care the resident had warmth to his skin. His limbs and neck were limber and the two CNAs were able to roll the resident from side to side without difficulty. On [DATE] at 9:07 a.m., an interview was conducted with the CNA (Staff I) who assisted with post mortem care for resident #1. He said the resident was cold on the finger tips and warm on the rest of the body. There was no rigor or blood pooling. An interview was conducted on [DATE] at 9:32 a.m. with the 11:00 p.m.-7:00 a.m. Registered Nurse (RN) (Staff F), supervisor on duty on [DATE]. She said on [DATE] (unable to recall time) as she was walking by station 6, going back to station 7, the Licensed Practical Nurse (LPN) (Staff A) was on the phone, covered the mouthpiece, and said a resident had passed away and she was on the phone with the family member. The supervisor said, I just went about my business. About twenty minutes later Resident #1 ' s CNA came to the supervisor and informed her that the resident who expired was a Full Code. The supervisor went to the LPN (Staff A) to verify that the resident was in fact a Full Code. The supervisor stated, I said to her (Staff A): You know in this facility when they are full code, we do CPR. She (Staff A) said, he was stone cold. I said, I do not care, you should have done CPR. I told her you are going to have to call the Director of Nurses (DON). She (the LPN) said: I will. An interview was conducted on [DATE] at 10:01 a.m. with the Director of Nurses (DON); who stated that the LPN (Staff A) was no longer employed at the facility. The DON said she was called early in the morning of [DATE] by the LPN (Staff A) and was informed of Resident #1 ' s death. The DON asked the LPN (staff A) if the resident was a full code, and Staff A said Yes . The DON asked if she initiated CPR and Staff A said No. The DON asked the LPN why she did not initiate CPR. The LPN (Staff A) said that she did not code him because there was pooling of blood on the back side and she observed rigor mortis. The DON stated, I informed her that we had several meetings in regards to performing CPR; which included if a patient presents with rigor mortis; we would still perform CPR; that we must honor the resident ' s wishes in regards to advance directives. The LPN (Staff A) stated, Well I didn ' t do it. An interview was conducted on [DATE] at 12:05 p.m. with the Registered Nurse (RN) (Staff D) who was on orientation with Staff A at the time of the incident. She stated, I had recently started, I was orienting with the Staff Member A, and I had been orienting for a few days before that. I do not exactly remember the time when the CNA (Staff C) came and asked Staff member A to come down to (Resident #1 ' s) room and I followed her down. Staff member A entered the room. The patient was sitting up in bed; gray in color. Staff A went over, she kind of touched him, used a stethoscope; she did not hear anything. At that point she came out of the room and went to the nurses ' station. She called the family member; told the family that the patient was deceased and asked them what their wishes were. I was in shock. The RN said she (herself) did not touch the resident or listen for a pulse. She said she left the room with Staff A. On [DATE] at 12:30 p.m., an interview was conducted with the Medical Director. He said he participated in the Quality Assurance meeting on [DATE]. The only item on the agenda for that day was the incident that occurred on [DATE] when the resident did not receive CPR as per his wishes. The Medical Director said the team discussed the details, cause of the incident and the course of action to prevent this from happening again. He said his expectation of a nurse is that if a resident is found unresponsive and is a Full code he expects CPR to be initiated. When asked if the nurse found a resident unresponsive and had no idea how long the resident had been unresponsive what would his expectation be as far as CPR? He said, I expect them to always follow protocol. An interview was conducted with the resident ' s primary care physician on [DATE] at 3:18 p.m. He said he was notified of the event early in the morning on [DATE]. He was told the resident had expired and that CPR was not done. He said he told the nurse that it needed to be reported because the resident was a Full Code. The Physician said he spoke with the Resident ' s wife that morning but did not elaborate on the discussion. He said his expectation for the nurse when a resident is found unresponsive is to initiate CPR if the resident is a Full Code. When he was asked what his expectations were if a nurse found a resident unresponsive for an undetermined length of time he said, I would expect the nurse to follow protocol. An interview was conducted via telephone with Resident #1 ' s wife on [DATE] at 4:13 p.m. She verified that her husband had expressed his wishes to receive CPR in the event of [MEDICAL CONDITION]. She also said the Director of Nurses at the facility called her the morning of the resident ' s death and informed her that CPR was not initiated as per the resident ' s wishes. The spouse did not have any additional comments regarding the omission of CPR for her husband. An interview was conducted on [DATE] at 10:01 a.m. with the DON revealed the following information: When asked if initiating CPR was considered a service that the facility offers, the DON said Yes. When asked if the nurse (Staff A) failed to provide the service of initiating CPR the DON said, Yes. An interview was conducted on [DATE] at 10:00 a.m. with the Director of Nurses. She said, immediately after the event the facility implemented education which included review of the policy and procedures for advanced directives and CPR. In addition mock code drills were done on ,[DATE], ,[DATE], and ,[DATE] with a total of 12 out of 32 nurses present. At the time of the incident the facility had a total of 32 nurses on staff. At the time of the complaint investigation there was no evidence that the facility had continued conducting mock code drills since [DATE]. The facility began conducting mock surveys on [DATE] to ensure the staff was knowledgeable about CPR process and their roles. The following measures were taken by the facility to remove the Immediate Jeopardy: On [DATE] at 10:34 a.m. the Nursing Home Administrator and the Director of Nurses presented seventeen signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: CPR-Emergency Procedure: CPR Roles and Responsibilities and Code Blue. In addition a master list of all active employees was presented with the dates that indicated when the employees attended the in-service training. The contents of the in-service were attached to the signature sheets and were as follows: Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure and Code Blue Roles and Responsibilities. Per the Administrator the Policy and procedure for Emergency procedure, CPR was reviewed and updated as of [DATE]. The document entitled Code Blue Roles and responsibilities was developed to clarify the roles all staff in a code blue situation. Effective [DATE], staff education was provided to all employees regarding a Code Blue occurrence and the facility ' s policy and procedure. This was completed by the DON, ADON, Unit Managers and Department Heads. Employees were provided with handouts containing the CPR policy, Code Blue Roles and responsibilities, mock code blue guidelines and Mock code blue checklist. The Administrator (NHA) and Director of Nurses (DON) verified that all employees with the exception of four employees from the nursing department that were on vacation and eleven therapy department employees, that only worked on an as needed basis, had received the in-service training. The NHA and DON presented a document with the names of the employees that had not received the training. (The signatures of the staffing coordinator and the Director of the therapy department were on the document next to the names of the employees that were responsible for scheduling staff to work.) The DON and NHA verified that these employees will not return to work until they have received the in-service training. In addition, the NHA and DON presented five signature sheets for in-service training dated ,[DATE], ,[DATE], and [DATE] titled: Mock Code Blue. The NHA and DON verified that the drills were started on [DATE] and were ongoing with a plan as follows: One mock drill per shift per week for at least four weeks. The DON said We have completed four and we are doing one more today. Attached to the signature sheets was a Mock Code Checklist. The NHA said the check list was used to monitor the drill and give feed back to the staff after each drill. In addition a Data Collection Form (Copy form ,[DATE]) was presented to the survey team. The NHA said the form was completed by the administrator to monitor the progress of the mock code drills. The Administrator provided a Performance Improvement Plan tool for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director. The tool revealed: Issues: Provision of Emergency Care for Cardiopulmonary Arrest. Actions: 1. Staff education regarding provision of emergency CPR for residents found in arrest without a DNR status. 2. Process for identifying if a resident is a DNR status. 3. Clarification of roles and responsibilities of all employees regarding implementation of CPR. 4. Mock Code Blue drills. 5. System for monitoring drills and frequency of drills. 6. Continued QAPI monitoring drills of Emergency CPR process. 7. All new hires will be educated prior to first working shift. 8. Annual review at annual re-orientation. 9. All staff who has not received education will not be placed on active duty until education has been provided to them. A review of all documents that were provided to the survey team was reviewed. A comparison was made between the in-service signatures sheets and the master list of all employees to verify the completion of the in services. The comparison verified that all employees were in-serviced with the exception of four nursing staff who were on vacation and eleven therapy employees who work only on an as needed basis. Random staff interviews from all shifts (30 total) were conducted to ensure they had received the in-services as reported by the NHA and DON. All employees interviewed verified they had received the in-services related to CPR and roles and responsibilities. A review of CPR certifications for all licensed staff (Nurses and CNAs) was conducted. One hundred percent of all certified staff were verified with up-to-date- hands on training. Based on this information the immediate jeopardy was found to be removed on [DATE] and the scope and severity was reduced to a D.