Every finding on record at Miami Springs Nursing and Rehabilitation Center

Based on observations, interviews, and records reviewed, it was determined that the facility failed to provide proper supervision for one of three vulnerable residents sampled (Resident #1). On 08/06/2026, Resident #1 left the facility through the main entrance on the first floor without being noticed and was later located by local law enforcement at a shopping center parking lot in a nearby city, 6.5 miles from the facility the following day. The facility and the area where the resident was found has heavy traffic and multiple cross streets, which increased the likelihood of the resident being struck by a vehicle, suffering a fall, or becoming a victim of assault or robbery due to his vulnerability. This lapse in staff supervision and failure to secure the first-floor main entrance also heightened the risk of unauthorized individuals entering the facility undetected, thereby endangering the safety of its occupants. At the time of the survey, 190 residents resided in the facility. The findings included: Review of the facility's Policy and Procedure titled Residents at Risk for Elopement revision dated 09/2024 indicate: The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as elopement risk, institute measures for resident identification at the time of admission, and conduct coordinated resident search in the event of a missing resident. Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. It is the ability of a cognitively impaired resident, who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. Observation during the initial tour and walkthrough on 08/11/ 2026, starting at 7:45 AM, revealed every exit door in the facility had working alarm systems. Additionally, an alarm was being installed on the alternate main entrance door.On 08/11/2026 at 09:40 AM, Resident #1 was observed in the designated smoking area outside the facility. The resident was seated in a wheelchair, engaged in conversation with other residents. Two facility staff members were present. Review of Resident #1's clinical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to cervical disc degeneration, unspecified cervical region, psychotic disorder not due to a substance or known physiological condition, schizophrenia, nicotine dependence, other drug induced dystonia and mood disorder due to known physiological condition.A review of Resident #1's Elopement Risk Evaluations dated 05/06/2026 documented a score of 8, indicating the resident was not at risk for elopement. Subsequent evaluation conducted on 05/19/2026 documented a score of 11 indicating the resident was at risk for elopement.Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] Section for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 10, on a 0-15 scale indicating the resident is moderately impaired cognitively. Section for Behaviors documented no behaviors exhibited. Section for Functional Abilities documented resident is dependent on care, impairment of both sides of upper and lower extremities, uses walker and wheelchair. Section for Bowel and Bladder is always incontinent of bowel and bladder. Section for Medications indicated the resident is taking antipsychotic, Diuretic, Hypoglycemic, Antiplatelet. Record review of an Incident/Progress Notes dated 8/6/2026 timestamped 04:30 AM documented: Rounds completed. Resident observed resting comfortably. No signs or symptoms of acute distress noted. Respirations even and unlabored. Safety measures in place, including bed in lowest positions/call light within reach/appropriate precautions. Resident needs addressed and assistance provided as needed. Will continue to monitor and provided as needed. Will continue to monitor and provided care according to plan of care monitor the situation closely and reconvene as needed until the resident is safely located. Review of Incident/Progress Notes dated 08/6/2026 timestamped 06:30 AM documented: Nursing supervisor reported she was notified by physical therapist that a resident's wheelchair was found unattended outside in gazebo area. Code green was immediately activated. An immediate search of the unit and facility grounds was initiated. Resident was noted to be absent. The nursing supervisor was immediately notified. The missing resident protocol remains in effect. Staff will maintain ongoing communication with all parties involved and document updates regarding resident location and condition. Review of Incident/Progress Notes dated 08/6/2026 timestamped 07:00 AM documented: The Administrator and Director of Nursing, Primary Care Physician (PCP) were notified of missing resident. An expanded outer perimeter including adjacent streets, neighboring properties, and nearby off-site areas within walking distance were thoroughly searched by multiple staff. The resident was not located. The facility missing resident protocol remains active. Staff will continue search efforts, maintain communication with all involve parties and document any updates as they become available. Review of Incident/Progress Notes dated 08/6/2026 timestamped 07:20 AM documented: The Administrator contacted Local law enforcement and provided resident's identifying information, physical description, clothing last seen wearing, medical history, cognitive status and photograph. The attending physician and responsible party were notified of the resident's missing status Review of Incident/Progress Notes dated 08/6/2026 timestamped10:30AM documented: Facility's Medical Director and PCP in facility for an interdisciplinary team meeting regarding missing resident. Ongoing search efforts were reviewed, the team confirmed that facility administration, the attending Physician, responsible party, local law enforcement had been notified in accordance with facility policy. Staff were reminded to remain vigilant, continue following the facility's missing resident protocol. Review of Incident/Progress Notes dated 08/6/2026 timestamped 01:25 PM documented: The facility and the resident's primary care provider (PCP) contacted nearby hospitals regarding the missing resident to determine whether the resident had been admitted or evaluated. At this time, no information confirming resident's whereabouts has been received. Staff will continue to follow facility's missing resident protocol and monitor any updates. Review of Incident/Progress Notes dated 08/6/2026 timestamped 04:23 PM documented: At the beginning of this shift, report was received from the off-going nurse that the resident is still missing and has not been located. Facility staff have been informed of resident's continued absence and will remain alert for any updates regarding the resident whereabouts. Staff will continue to implement the facility's missing resident protocol and follow established procedures until the resident is found or additional direction is provided. Review of Incident/Progress Notes dated 08/7/2026 timestamped 05:45 PM documented: After continued search efforts, the local Police Department notified facility Administrator that the resident was located on a street in the neighboring city. The resident returned to facility with Administrator and Supervisor. Upon return, resident was assessed immediately by nursing staff. Resident was awake, alert, and responsive to verbal stimuli. No visible injuries, bruises, or signs of trauma were noted. Resident did not appear to be in acute distress at the time of assessment. Vital signs were within normal limits. PCP (Primary Care Physician) was made aware and stated that due to the resident being found outside of the facility without supervision and the potential risk for unobserved injury, dehydration, exposure, or other medical complications, new order received to transfer to the local hospital for further medical evaluation and precautionary assessment. Resident's responsible party (brother) was updated regarding location, condition, and order to transfer to the hospital. Interdisciplinary team members, including nursing leadership and administration are aware. Resident placed on one-to-one observation until transportation arrives. Review of Incident/Progress Notes dated 08/7/2026 timestamped 07:00 PM documented: Resident was transferred to the local hospital in stable condition for further evaluation and treatment. During the transfer, the resident remained calm, cooperative, and compliant with staff and transfer personnel. Resident's brother, and PCP were notified of the transfer and pickup. A review of Resident #1's Physician's Orders Sheet for August 2026 showed that the Resident was prescribed Clozapine Oral Tablet 50 mg, to be taken one tablet by mouth twice daily for a psychotic disorder associated with schizophrenia. The orders also included a psychological consultation with the physician, one time only for five days. Additionally, the resident will be observed one-on-one during every shift. Resident #1's Elopement Risk Evaluations dated 08/10/2026 indicated a score of 13,signifying the resident was at risk for elopement. Review of Resident #1's rehabilitation progress notes documedted: On 05/06/2026, the resident walked 30 feet using a two-wheel walker with minimal help. On 07/05/2026, the resident walked 150 feet with standby support and a walker. On 07/19/2026, bed mobility was independent; transfers were made with standby assistance, and walking included 300 feet with occasional use of an assistive device and rest breaks. On 08/04/2026, the abilities remained consistent, covering 300 feet with sporadic device aid, periodic rests, and standby assistance. On 08/11/2026, the resident became fully independent and no longer needed skilled care. Review of Resident #1's Care Plans, with reference date 05/06/2026, indicated the resident is at risk for elopement, having attempted to exit the facility without staff notification. The resident was readmitted on [DATE]. The plan indicate that the resident will remain safe within facility premises until the next review date. Interventions include anticipating and addressing all needs; assisting the resident to and from activities; maintaining an elopement logbook with residents' names and photographs; ensuring staff are aware of the resident's elevated elopement risk; arranging psychiatric follow-up evaluations regarding medication; involving family in the care plan and encouraging frequent visits; ensuring identification bracelet remains on the resident at all times; and continuing fall precautions. Record review of Resident #1's readmission Brief Interview for Mental Status Score (BIMS) dated 08/10/2026 revealed: BIMS 15 on a 0-15 scale indicating the resident is cognitively intact. During an interview on 08/11/2026 at 9:00 AM with the Director of Nursing (DON) and the Administrator (NHA), it was reported that Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident is alert and oriented it was revealed that on 08/6/2026 at 4:30AM Resident #1 was seen by staff during rounds in bed asleep. The resident forced open the alternate main entrance automatic doors with his hands and left the facility. The resident's wheelchair was found under the tiki [NAME] by a staff member arriving at work. The resident was observed around 5:15 AM on a local nearby roadway close to a roundabout on the local city's web camera and the police department showed the video to the facility. On 08/6/2026 at 6:30 AM the nursing supervisor was notified by a rehabilitation staff that an empty wheelchair was seen under the tiki [NAME] outside the facility. A Code [NAME] and missing resident protocol was activated. Staff at facility were alerted to the code green, a head count was completed on each unit which identified a resident was missing; a search was initiated for the resident in all areas of the facility inside and out. The NHA and DON were notified of the missing resident. Police department was notified, and a new search initiated with the police department. The NHA went to the Assisted Living Facility (ALF) where the resident previously resided, family was notified, Doctor (MD) was notified. The NHA, DON and Nursing supervisors drove around the area looking for the resident. The resident was not found anywhere in the neighborhood on 08/06/2026. Resident #1's brother provided multiple addresses and locations where the resident might have went and each address was checked but, the resident was not located. The NHA revealed that on 08/07/2026 at approximately 5:45 PM a call was received from the local police department, stating that they had found the resident in a neighboring city at a shopping center with several stores. The NHA and a nursing supervisor drove to the location and after the local police officers released the resident to the NHA's custody the resident taken back to the facility in the NHA's personal vehicle. The NHA reported that the resident stated: I did not do anything wrong. the resident stated that he stayed overnight next to the local expressway highway, ate food from a fast-food restaurant, had Cuban Coffee at the cafeteria, sodas, water and cigarettes and had 85 dollars on him that he used to make his purchases On arrival at the facility, the resident requested to smoke first, he smoked three cigarette's in the smoking area, was assessed, vital signs were within the resident's normal limits, no visible injuries and the Physician gave orders to send the resident out to the hospital for an evaluation. On 08/10/2026 the resident was readmitted from the hospital, new orders Metformin 1000 MG twice a day. The resident stated that he does not want to be at the facility long term, wants to be independent and is on one-to-one monitoring. The family (brother) wants the resident to stay at the facility long term, but the resident stated that he has enough money to rent an apartment on his own and wants to be independent. A care plan meeting is being scheduled with the family to discuss further plans for the resident's care, and the brother is the proxy. Prior to admission the resident lived at an Assisted Living facility (ALF), was hospitalized and then came to the facility for therapy, recently the resident's family (brother) requested for the resident to stay at the facility long term. The resident completed physical therapy on 08/05/2026 and is walking 300 feet unassisted. The NHA revealed that residents at risk for elopement photos and face sheets are in a white binder with a green sticker located at the four nursing stations. The residents at risk of elopement are in rooms on the second floor of the facility. We have a coded system to use the elevator to go up or down. Staff are not allowed to share the code with visitors or vendors; they can enter the code for visitors or vendors if they need to use the elevator. During an interview on 08/11/2026 at 09:40 AM Resident #1 stated: Last Thursday (08/06/2026) around almost 5:00 in the morning, I left the facility through the front door, I just open it with my hands, I walked from here down the local street, caught the local bus to the mall in a neighboring city, got off the bus at the mall, walked to a store, bought some special cigarettes and started smoking, I ate food, I drank water, sodas and coffee and some alcoholic beverages. I had 85 dollars on me that I used to buy the stuff I needed. I slept under the local expressway highway overnight. I am from around here; I know this city very well. The next day the cops found me by a store, searched me but did not find anything on me. I had an alcohol beverage, but I was not drunk, I went to this place I knew to sleep, I don't want to tell you (surveyor) about the place, I think I want to stay at this facility from now on, I left the facility with a bag with clothes and my hat, I wanted to go and party. When I came back to the facility they took me to the local hospital to get checked out, nothing was wrong with me, and now I am back here at the nursing home. During an interview on 08/11/2026 at 10:20 AM, the Director of Nursing ( DON) stated that residents at risk of elopement, were moved to the second floor, close monitoring-closer to nursing station, one to one as needed. Residents that are smokers is accompanied to the smoking area and always watched. Alert the staff of residents that are at risk for elopement, there are binders at all the nurses' station with the facility map, elopement instructions, pictures and face sheet for residents. Code green is for elopement-when a code green is announced, the staff have been educated to initiate the elopement protocols. The most recent elopement drill was on 08/10/2026 for staff on all shifts. Upon admission all residents are evaluated for the risk of elopement, quarterly and if a situation occurs that warrants an updated elopement risk assessment (Exit seeking behavior, wandering, resident stating they want to leave the facility etc.) A score of 10 or higher indicates a resident is at risk for elopement. If a resident scores 10 or higher on an elopement assessment, we update the resident's care plan, move the resident to the second floor for safety, communicate elopement evaluation results with the family, notify all staff during daily meetings, update the elopement book with resident's photo and identification information, and implement one to one if ordered/needed. During an interview on 08/11/2026 at 11:30 AM the Medical Director stated that Resident #1 was seen for care, resident is cognitive, alert and oriented with fluctuations in cognition during interview sessions at times. Unfortunately, the nature of his condition-he has mental health issues and is on prescribed medications and monitored by psychiatry. I saw the resident at the local hospital yesterday (08/10/26) around 1:30 PM. I had a conversation with the resident, addressed some safety concerns with the resident and spoke with his family. The resident stated he wanted to return to the facility. Currently the resident is alert and oriented and is aware of his surroundings, his capacity to understand complex situations changes daily. I accept my limitations regarding the resident's changing mental ability and I would refer you (the surveyor) to the resident's psychological team. During a telephone interview on 08/11/2026 at 11:50 AM Psychiatric MD stated: The most recent visit with [Resident #1] was today (08/11/26) he was readmitted to the facility yesterday. The resident is oriented to person, place and time, he is delusional with paranoid hallucinations at times, reality testing is impaired, but he is oriented. The resident needs to be supervised by someone in relation to making decisions about his health. I saw the resident today, physically he looks stable, loves to smoke, was on one to one. He is at risk for behaviors that may not be safe for him, he had two cigarettes lit at the same time and was being supervised. Nutrition and hydration need to be monitored; safety needs to be ensured and the resident needs to be supervised closely. During an interview on 08/11/2026 at 12:08 PM the Social Services Director (SSD) stated that on initial admission to the facility in May 2026 the resident's brief interview for Mental Status score (BIMS)was a 10, on the most recent BIMS evaluation conducted on re-admission on [DATE] the resident's BIMS is 15. The resident had a health Care Proxy in place at admission that continues to be honored with his recent re-admission to the facility. During an interview on 08/11/2026 at 12:32 PM the NHA stated that the alternative main entrance that the resident exited through on 08/06/26 is locked around 8:00 PM and it does not open until around 6:30 AM. The door is automatic and is opened/closed with a keypad between the hours of 8:00 PM-6:30 AM. A receptionist is stationed at the door 24 hours a day. The resident reported there was no one at the desk at the time he left out of the facility. After 6:30 AM the sensors open the doors as a person approaches. Today we are installing an alarm that goes off during the lock hours, if someone tries to open the door, the alarm will sound at the 1st floor North Nursing Station. Currently the door cannot be opened when it is locked or forced open, if it is forced open the alarm will go off. Prior to 08/06/2026 the alternative main entrance door did not have an alarm. On 08/11/2026 at 12:03 PM the NHA/Risk Manager stated: On 08/07/2026 I filed a missing person report with the Agency of Healthcare Administration (AHCA), Department of Children and Families (DCF) and the local police department was notified the day before and helped with the search for the resident. I notified the AHCA local office that the resident was found on 08/07/2026. All the details of the investigation were provided in my previous interview. On 08/11/2026 at 1:50 PM the Director of Rehabilitation stated that the resident was initially evaluated on 05/06/2026, resident tolerated walking 30 feet with a two-wheel walker with minimal assistance of one person. On 07/05/2026 the resident walked 150 feet with standby assistance with walker. On 07/19/2026 the resident was independent with bed mobility, transfers with standby, walking 300 feet with occasional assisted device with rest periods with standby. On 08/04/2026 the resident was independent with bed mobility, transfers with standby, walking 300 feet with occasional assistive device with rest periods with standby and on 08/11/2026 the resident was functioning independently and does not warrant skilled intervention. During an interview on 08/11/2026 at 4:18 PM Staff K, Receptionist stated: On 08/06/2026 I worked the 11:00 PM to 7:00 AM shift at the reception desk, I did not see [Resident #1] exit through the door, I was probably in the bathroom which is right next door to my desk, when I came out of the bathroom the entrance door was closed and I did not see any residents outside or inside close by the door, I remained at my post until my shift was over at 7:00 AM when I was relieved by the 7:00 AM to 3:00 PM person. During an interview on 08/11/2026 at 2:47 PM Staff A, Certified Nursing Assistant that worked One North Unit, via Spanish Translator reported that during shifts residents were checked on every 2 hours. If a resident is missing a code green is called, check on residents, start checking rooms, put a green sticker on the rooms that have been already checked, once completed with assigned area go to another area to help. The last elopement drill participated in was today and in-service signed about the drill. During an interview on 08/11/2026 at 2:52 PM, Staff B, Certified Nursing Assistant reported via Spanish Translator that residents are checked every two hours. If a resident is missing, staff retrieve the elopement book at the nurses' station, check rooms, and mark each with a green sticker once inspected. If the resident isn't found indoors, one CNA and one nurse remain on the unit while other staff search outside the facility. The elopement book contains photos and information for all at-risk residents who reside on the second floor. Elopement drills were completed last Thursday and today. During an interview on 08/11/2026 at 3:11 PM, Staff C, Certified Nursing Assistant from the South unit, assisted by a Spanish translator, reported that resident checks are conducted hourly. When notified of a missing resident, staff proceed to the nurses' station for instructions, systematically check rooms, and place a green sticker on each room once it has been searched. If a resident is not found within the facility, one CNA and one nurse remain in the unit while the other staff members search outside the premises. Information and photographs of residents at risk for elopement are in the elopement book at the nurses' station; all elopement risk residents are located on the second floor. Today, an elopement drill was conducted following established protocols, and staff signed for completion of the in-service training. During an interview on 08/11/2026 at 3:15 PM Staff D, Certified Nursing Assistant from the one South unit via Spanish Translator stated that during shift residents are checked every 30 minutes to an hour. If a resident is missing, the nurse is notified, call a code green, check on residents, start checking rooms, put a green sticker on the rooms that have been already checked, once completed with assigned area go to another area to help. The last elopement drill I participated in was on Friday, a code green was announced on the loudspeaker, I started checking all my residents' room, they announced that the resident was found and the drill was over the paper for the in-service on the elopement drill was signed. Residents that are at risk for elopement pictures and information are in the elopement book at the nurses' station and are discussed at shift meetings. During an interview on 08/11/2026 at 3:20 PM, Staff E, Registered Nurse (RN) assigned on South Unit, via a Spanish Translator, explained that during each shift, residents are checked every two hours. Residents may be considered at risk of elopement if observed packing belongings, inquiring about exits, or wandering throughout the facility. An elopement binder is maintained at the nurses' station and updated whenever a new resident identified as an elopement risk is admitted . This binder includes the resident's photograph and face sheet. On Friday, an elopement drill was conducted in which Code [NAME] was initiated. Staff followed the established protocol: a census was taken, and a check mark was placed next to each resident accounted for. If, after checking the entire facility, the resident remains unlocated, staff search outside the building and notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nursing Home Administrator (NHA), family members, and local law enforcement. All personnel participating in the external search are provided with a photograph of the resident. On 08/11/2026 at 3:28 PM, in an interview Staff F, RN, assigned to the North Unit through a Spanish Translator, reported that residents are monitored hourly. If a resident is found to be missing, staff proceed to the nurses' station, retrieve the census, conduct room checks, place a green sticker on each checked room, and mark off observed residents. If the resident is not located within the facility, one CNA and one nurse remain in the unit while the remaining staff search outside the premises. Information and photographs of residents at risk for elopement are maintained in the elopement book at the nurses' station, and all such residents reside on the second floor. An elopement drill was conducted this morning, following established protocols, and participants signed off on the related in-service upon completion. During an interview on 08/11/2026 at 3:43 PM, Staff G, RN, from the North Unit (via Spanish Translator), stated that resident checks are conducted every one to two hours. If a resident is missing, staff go to the nurses' station to obtain the census and systematically check each room, marking rooms with a green sticker once checked and noting observed residents. If the resident is not located within the facility, the search extends outside. Photographs and information about residents at risk of elopement are maintained in the elopement book at the nurses' station; all such residents reside on the second floor. Yesterday, an elopement drill was conducted following protocols, after which participants signed off on a provided in-service. During an interview on 08/11/2026 at 3:50 PM Staff H, Licensed Practical Nurse assigned on two South Unit stated: During my shift I check on my residents every 2 hours. We have an elopement binder at the nurses' station that is updated every time we get a new elopement risk resident. The book contains resident's photo and face sheet. On Friday I completed an elopement drill, a code green was called, we followed the elopement drill protocol-code green is called, nurses have a census, a check mark is placed on each resident seen. Once the entire facility is checked, if the resident is still not found, we look outside the building, notify the DON, ADON, NHA, family and the police department. During an interview on 08/11/2026 at 3:59 PM, Staff I, CNA on the two North Unit, assisted by a Spanish Translator, explained that residents are checked every two hours. When someone reported, a resident missing staff should go to the nurses' station, retrieve the elopement book, and searched rooms, marking each with a green sticker after checking. If the resident is not found inside the building, one CNA and one nurse stayed on the unit while the remaining staff searched outside, photos and details of residents at risk for elopement are in the elopement book at the nurses' station, and elopement risk residents lived on the second floor. Staff I participated in an elopement drill on Sunday, called code green, checked residents according to protocol, and completed in-service training. During an interview on 08/11/2026 at 4:10 PM, Staff J, CNA from the two South Unit, reported via Spanish Translator that if a resident went missing, staff gathered at the nurses' station, notified the nurse, called a code green, checked the rooms, and placed a green sticker on each room once it had been searched. If the resident was not found inside the building, one CNA and one nurse remained in the unit, and the rest of the staff began searching outside the facility. Pictures and information for residents at risk of elopement were kept in the elopement book at the nurses' station. The most recent elopement drill had occurred yesterday, and staff received in-service training on the drill after its completion.

Observation on 07/30/2026 at 10:40 AM, Staff H, a Wound Care Registered Nurse (RN), provided wound care for Resident #201. During the procedure, Staff H removed a sacral dressing that was not dated and disposed of it in a red biohazard bag. When the surveyor asked why the dressing was not dated, Staff H stated that it was changed during the night and the date was accidentally left off. Record review of Resident #201's clinical records revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to Stage 4 Pressure Ulcer (means the damage has gone all the way through the skin and deeper layers, all the way down to bone, tendon, or muscle) of Sacral Region and Stage 4 Pressure Ulcer of Left Hip. Record review of Resident #201's admission Minimum Data Set (MDS), dated [DATE], showed the following: In the Cognitive Status section, the Brief Interview for Mental Status (BIMS) score was 8 out of 15, indicating moderate cognitive impairment. The Functional Status section documented that Resident #201 required full assistance with Activities of Daily Living (ADLs); the Bowel and Bladder section revealed that Resident #201 was consistently incontinent of both bowel and bladder, and the Skin Condition section documented the presence of two unhealed Stage 4 pressure ulcers. Record review of Resident #201's Care Plan initiated on 07/02/2026 and revised 07/19/2026 revealed Resident #201 had two pressure ulcers upon admission [DATE]. Goal included: Open area will have no signs of infection and will decrease in size by next review date, and Interventions included: Wound/skin treatment as ordered and maintain Enhanced Barrier Precautions (EBP) due to wounds. During an interview on 07/30/2026 at 11:01 AM, Staff H, a Wound Care Registered Nurse, explained the facility's protocol for dressing changes. Staff H indicated that staff were required to adhere to physician orders; however, if a dressing became soiled at any time during the shift, they needed to change the dressing and ensure it was dated and signed, without exception. During an interview on 07/30/2026 at 2:06 PM the Infection Preventionist/Assistant Director of Nursing (ADON) explained that anytime a wound dressing is changed, the new dressing should always include the date and initials of the nurse who changed it because that is the facility's protocol.

Based on observations, record reviews and interviews the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals, and preferences for one (Resident#203) out of two sampled residents receiving oxygen as evidenced by multiple observations revealed Resident#203 in bed receiving oxygen at a level above the prescribed rate. There were 17 residents receiving oxygen as needed, at the time of survey. The findings included: On 07/27/2026 at 7:18 AM Resident #203 was observed in bed receiving oxygen via nasal cannula at 4 Liters per minute. No apparent distress noted.Observations on 07/28/2026 at 9:36 AM and at 3:15 PM revealed Resident #203 in bed receiving oxygen via nasal cannula at 3.75 Liters per minute. No apparent distress noted. Record review of Resident # 203's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Respiratory disorders, Emphysema, Acute Respiratory failure with hypoxia. Record review of a July 2026 physician's order sheet revealed Resident #203 had an order dated: 07/25/2026 for oxygen via nasal cannula at two LPM minute as needed for shortness of breath.Record review of a care plan initiated on 07/27/2026 revealed: Resident# 203 was at risk for ineffective breathing pattern related to diagnosis that included: Emphysema, Respiratory Failure with Hypoxia; patient has shortness of breath or trouble breathing when lying flat with interventions that included: administer medication/oxygen as ordered. Record review of the admission Minimum Data Set reference dated: 07/31/2026 revealed the Brief Interview of Mental Status score was undetermined. Record review of the facility's policy and procedure titled, Respiratory Care and Oxygen Administration issued: 3/2020. Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration. During an interview on July 28, 2026, at 3:02 PM, Staff A, Registered Nurse, was asked to verify the current physician's order for Resident #203's oxygen administration. Staff A revealed that the prescribed order was for 2 liters per minute, as needed. The surveyor notified Staff A, RN of the discrepancy and both entered Resident #203's room and observed that oxygen was being administered at 4 liters per minute. When questioned about the protocol for oxygen administration, Staff A, RN stated that the physician's orders are reviewed oxygen flow rates are checked every two hours to ensure accuracy.

Based on observation, interview and record review the facility did not adequately ensure proper disposal and containment of cardboard boxes and trash on its grounds. Cardboard boxes were observed overflowing from the recycling dumpster and trash scattered on the ground outside the kitchen's back door this deficient practice increases the risk for potential pest infestation and safety hazards. The findings included:On 07/27/2026 at 6:55 AM, an observation was conducted with the Kitchen Manager of the area outside the facility's kitchen back door. The recyclable waste dumpster was overflowing with unsecured cardboard boxes; a bed sheet and pieces of wood with nails and were found littering the ground and surrounding areas.On 07/27/2026, at 7:15 AM, the Kitchen Manager stated that cardboard boxes are collected on a daily basis; however, the manager was unable to provide a reason for the excessive overflow and trash on the ground.On 07/30/2026 at 2:00 PM, the Assistant Kitchen Manager stated that the garbage truck comes every day, including weekends. Review of the facility's Policy and Procedure titled Dietary-Disposal of Garbage and Rubbish -dated 03/01/2021 included:Policy: It is the policy of the facility to provide care and services related to the disposal of garbage and rubbish in accordance with the State Requirements.Procedure: 6-Garbage containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. 7-dumpster should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster.

Based on observation, record reviews and interviews, the facility failed to ensure all residents on the facility's Two South unit were always accommodated with working telephones, as evidenced by two observations of several telephones on the Two South Unit not having any dial tones. There were 185 residents residing at the facility at the time of the survey. The findings included: During a family interview via telephone on 05/06/25 at 10:30 A, Resident #5's daughter revealed the telephone in her father's room has not been working for months; and wished she could call and talk to him more. During observation on 05/07/25 at 10:40 AM Resident #5 was observed lying in bed watching television, the telephone was observed on the side of resident. Further inspection of Resident #5's telephone revealed the telephone does not have a dial tone and did not work. Observation and inspection of 10 residents' telephones on the Two South Unit, One South and One North Unit, telephones were sampled. 4 out of the 10 residents whose telephones that were sampled did not work or had no dial tone. The four residents (Resident # 5, Resident #104, Resident #117 and Resident #133) whose telephones did not work were located on the Two South Unit. Review of the medical records for Resident #5 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic obstructive pulmonary disease. Record review of Resident #5 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is 05, on a 0-15 scale indicating the resident is cognitively impaired. Record review of Resident #5's Care Plans revealed the Resident has a self-care deficit and requires staff assistance to perform and complete ADL's secondary to poor safety awareness, impaired mobility, unsteady gait and balance, assistance required with toileting needs. Interview on 05/07/25 at 11:23 AM with Staff I, Registered Nurse (RN) revealed; The resident's telephone does not work but I will put in a maintenance request to fix it. The resident normally has his own cell phone. If a family member or friend calls to speak to a resident, if they press zero it will go to the operator. The operator will then transfer the call to the nursing station. Once the call is at the nursing station, we will transfer the call to the residents' room. There is also a portable phone at the nursing station for residents to use. Interview on 05/08/25 at 01:36 PM, the Director Of Nursing (DON) stated I have been the Director of Nursing at this facility since January this year. Per facility policy, every resident is provided with access to a phone unless they have declined its use. In shared rooms with three or four residents, phone access may be shared among them. To date, there have been no complaints regarding non-functional phones. When an issue is identified, the maintenance department is promptly notified to repair or replace the device as needed. Incoming calls are directed by the facility operator to the appropriate nursing station or nursing staff and then they would direct the call to the resident's room. Each nursing station is equipped with a portable phone accessible to both residents and nursing personnel for communication purposes. At an interview on 05/08/25 at 02:28 PM, the Maintenance Director revealed, I have served as the Director for four years, overseeing monthly operations. We ensure that any resident's telephones are promptly replaced, and if the issue lies with the phone line, we contact the service provider directly. Each floor maintains a dedicated maintenance log. We are actively working to resolve these issues by keeping a daily record of non-functioning phones and tracking the ones we've successfully repaired. Review of the facility policy and procedure regarding resident rights 03/01/21, states the resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard.

Based on observation, interview and record review, the facility failed to 1) store food under sanitary condition as evidence by failure in ensuring the 1 North Station Pantry snack/nourishment freezer on the resident unit contained a thermometer on the inside and 2) failed to ensure the correct wash temperature for washing of the dishes and utensils by not having the correct wash temperature for the operable wash tank temperature gauge on the high temperature dish machine. The missing thermometer has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey and potential to affect 42 out of 44 residents who eat orally residing on the 1 North Wing. The incorrect/improper wash temperature for the operable dish machine has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey. The findings included: 1) Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 1) Refrigerators and Freezers, c) Freezers shall be at or below 0 degrees Fahrenheit (F) and d) Any temperatures recorded outside these ranges will be reported to the supervisor immediately and maintenance will be notified. Observation of the 1 North Station Pantry snack/nourishment freezer on 5/07/25 at 8:30 AM revealed the freezer did not contain a thermometer and was noted empty with condensation. Photographic evidence submitted. Record review of the Resident Refrigerator/Freezer Temperature Log dated May 7, 2025 documented the freezer temperature was -10 degrees F. Photographic evidence submitted. Observation and interview with Staff A, Registered Nurse 1 North Supervisor on 5/07/25 at 8:34 AM. She confirmed there was no thermometer in the 1 North Pantry freezer used for residents and there should have been one there. Record review of the Resident Refrigerator/Freezer Temperature Log dated May 7, 2025 documented the freezer temperature was -10 degrees F. She confirmed how was the temperature taken in the freezer on May 7, 2025, if there is no thermometer in the freezer. 2) Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 2) Dishwasher, a) While the dishwasher is running, with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded for each meal, b) The Wash tank should be 140-160 degrees Fahrenheit (F), or as specified by the manufacturer and d) Any temperatures recorded outside the acceptable levels shall be reported to the supervisor immediately. Maintenance will be notified. Review of the Dish Machine Temperature Log Policy and Procedure (no written date noted); Purpose-To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the wash temperature, which must reach a minimum of 150 degrees F. Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 5/07/25 at 10:04 AM with Staff B, Dietary Aide and the Training Center Account Manager revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff B, Dietary Aide revealed the wash temperature should be at 160 degree F and that she couldn't see the wash dial to read it. Staff B, Dietary Aide continued to place several more trays with dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Training Center Account Manager revealed the wash temperature should be 150-160 degrees F. The Training Center Account Manager stopped the dish machine and called the service tech company to come to the facility and service the dish machine. She instructed the dietary staff to use disposable wear for feeding. Photographic evidence submitted. Review of the Dish Machine Log documented for the month of May 7, 2025 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast. Photographic evidence submitted. Observation and interview on 5/07/25 at 12:17 PM, with the dish machine technician. He was observed servicing the dish machine. He stated, The thermostat was low on the wash tank. That is why it was at 110 degrees F. The temperatures should be 160 degrees F. I reset the temperature. Review of the Dish machine Repair Company Correspondence dated 5/08/25 documented the following: Dish machine was checked and tested . Temperature on wash tank was low. Thermostat needed to be reset. Reason: Electrical activity in building. Wash tank temperature-165 degrees F. Temperature reset.

Based on observations, records reviewed and interviews, the facility failed to demonstrate effective plans of actions implemented to correct identified quality deficiencies in problem areas, as evidenced by repeated deficient practices for F 641- Accuracy of Assessments, F812 Food Procurement Store/Prepare/Serve/Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility. The findings included: Review of the facility's survey history revealed during a recertification survey with exit dated 12/14/2023, F812 was cited-Food Procurement Store/Prepare/Serve/Sanitary; due to the facility's failure to store food under sanitary conditions related improper temperatures in the reach-in cooler and failure to ensure the reach-in cooler was working properly; 2)The facility was Cited F641-Accuracy of Assessments related to the facility's failure to accurately code the Minimum Data Set (MDS) and 3) F867 Quality Assurance and Performance Improvement due to the committee's failure in identifying and preventing potential problems and implementation of QAPI/QAA activities. During this survey with exit dated 05/08/2025 the facility was cited F641-Accuracy of Assessments related to the facility's failure to accurately code the Minimum Data Set (MDS); F812-Food Procurement Store/Prepare/Serve/Sanitary; due to the facility's failure to store food under sanitary conditions related to no thermometer observed inside the One North Station Pantry snack/nourishment freezer on the residents' unit, failed to ensure the proper temperature level for washing the dishes and utensils on the operable high temperature dish machine's tank temperature gauge and F867 Quality Assurance and Performance Improvement due to the committee's failure in identifying and preventing potential problems and implementation of QAPI/QAA activities. Record view of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Policy and Procedure issued 6/10/2021, the policy documented: Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) c. Develop and implement appropriate plans of action to correct identified quality deficiencies. On 05/08/25 at 04:41 PM, during the QAPI/QAA review with the facility's Administrator and the [NAME] President of Clinical Services, it was revealed the QAPI/QAA meetings are conducted on the last Thursday of each month. The committee members include the Administrator, Director of Nursing, Assistant Director of Nursing, Pharmacy Representative Department Heads. The identified problem areas related to F641-Accuracy of Assessment, F812-Food Procurement Store/Prepare/Serve/Sanitary in areas and F867 Quality Assurance and Performance Improvement.

Based on observations, interviews and record review the facility failed to ensure the high temperature dish machine wash cycle was working properly. This has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 2) Dishwasher, a) While the dishwasher is running, with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded for each meal, b) The Wash tank should be 140-160 degrees Fahrenheit (F), or as specified by the manufacturer and d) Any temperatures recorded outside the acceptable levels shall be reported to the supervisor immediately. Maintenance will be notified. Review of the Dish Machine Temperature Log Policy and Procedure (no written date noted); Purpose-To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the wash temperature, which must reach a minimum of 150 degrees F. Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 5/07/25 at 10:04 AM with Staff B, Dietary Aide and the Training Center Account Manager revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff B, Dietary Aide revealed the wash temperature should be at 160 degree F and that she couldn't see the wash dial to read it. Staff B, Dietary Aide continued to place several more trays with dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Training Center Account Manager revealed the wash temperature should be 150-160 degrees F. The Training Center Account Manager stopped the dish machine and called the service tech company to come to the facility and service the dish machine. She instructed the dietary staff to use disposable wear for feeding. Photographic evidence submitted. Review of the Dish Machine Log documented for the month of May 7, 2025 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast. Photographic evidence submitted. Observation and interview on 5/07/25 at 12:17 PM, with the dish machine technician. He was observed servicing the dish machine. He stated, The thermostat was low on the wash tank. That is why it was at 110 degrees F. The temperatures should be 160 degrees F. I reset the temperature. Review of the Dish machine Repair Company Correspondence dated 5/08/25 documented the following: Dish machine was checked and tested . Temperature on wash tank was low. Thermostat needed to be reset. Reason: Electrical activity in building. Wash tank temperature-165 degrees F. Temperature reset.

Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on one (2 North) out of two Nursing Stations on the facility's 2nd floor, as evidenced by observation of an unattended unlocked computer screen with residents' information visible. 2) Failed to provide privacy during medication administration for one (Resident # 152) out of five residents observed during medication administration. There were 185 residents residing in the facility at the time of the survey. The findings included: 1) On 05/05/2025 at 11:49 AM, observation on the 2nd floor of North Nursing Station revealed an unattended unlocked computer screen with visible resident formation. (Photographic evidence). On 05/05/2025 at 11:53 AM, Staff E, Registered Nurse (RN) was notified of the unattended unlocked computer screen. Staff E, RN revealed the supervisor was currently logged in and stated: I will notify the supervisor. On 05/05/2025 at approximately 11:57 AM, Staff G, RN Supervisor was asked about the facility's protocol related to protecting and securing residents' information. Staff G stated: The computer screen should be off when unattended. I left it open by mistake because I was rushing to attend to residents. Review of a Policy titled; HIPAA Security Measures date implemented: 6/2020 revealed Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and or records that are in electronic format. 39177 2) Observation on 05/06/2025 at 10:05 AM of Staff J, Registered Nurse (RN) performing medication administration revealed; Staff J, RN prepared Resident # 152's medications. The door to Resident #152's room was open and from the hallway the resident was seen seated in his room. Staff J, RN entered Resident # 152's room with the prepared medications, did not close the door, identified the resident, did not close the privacy curtain and administered the medications. Interview on 05/06/2025 at 10:32 AM Staff J, RN was asked about professional standards related to privacy during medication administration. Staff J, RN revealed the door, and the privacy curtain should have been closed. Staff J, RN stated: That is one of the most important things. On 05/08/2025 at 03:43 PM, the Assistant Director of Nursing (ADON) was informed of the identified privacy concerns. The ADON revealed staff had made her aware of the identified privacy concerns.

Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident # 184) out of three sampled residents; as evidenced by the resident was discharged to an Assisted Living Facility, and the MDS was coded to indicate that the resident was discharged to a Short-Term General Hospital. The findings included. Review of Resident # 184's clinical records revealed the resident was admitted to the facility on [DATE] from a Short-Term General Hospital (acute hospital). Medical diagnosis includes Traumatic Subdural Hemorrhage without loss of consciousness, subsequent encounter and Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. Review of the Physician's Discharge Summary dated 04/15/2025 documented: The patient will be discharged to [facility name] Assisted Living Facility (ALF) on 4/16/2025. Review of Social Services Note dated 04/17/2025, documented: Resident was discharged to [facility name] ALF. Review of Resident # 184's MDS Discharge assessment - return not anticipated Assessment Reference (ARD) Date/Target Date: 04/16/2025 revealed in the section for cognitive pattern that Resident #184 is cognitively intact. The Discharge Status Section coding indicated the resident was discharged to a Short-Term General Hospital (acute hospital). During an interview on 05/08/2025 at 03:26 PM the Assistant Director of Nursing revealed Resident # 184 was discharged to an ALF as planned on 04/16/2025. During an interview on 04/08/2025 at 3:35 PM, The MDS and Care Plan Coordinator (Staff K) revealed Resident # 184 was admitted from a hospital on 03/18/2025 and was discharged to an ALF on 04/16/2025. Staff K was shown Resident #184's Discharge MDS; Staff K acknowledged the incorrect coded information and stated: I did that one.

Based on observation, record review, and interviews, the facility failed to implement fall risk and seizure care plans for three residents (Resident #106, Resident # 88 and Resident #56) out of three sampled residents; as evidenced by observations of missing padding on one side rail for Resident #106, Resident #88, and Resident # 56. There were 36 residents with orders for padded side rails at the time of this survey. The findings included: Resident # 88: On 05/05/25 at 9:58 AM, Resident #88 was observed in bed the left side rail was in the upward position and padded. The right-side rail was in the down position. Two staff members were in the room tending to other residents. On 05/08/2025 at 12:37 PM Staff E, Registered Nurse (RN) was informed about the padding that was not on side rail. Staff E, RN acknowledge the concern and stated, I received an in-service yesterday about it. Record review of Resident #88's demographic sheet revealed the resident was admitted on [DATE] with diagnosis that included: Epilepsy. Record review of an Annual Minimum Data Set (MDS) reference dated 4/23/25 revealed a Brief Interview of mental Status (BIMS) score of 6 out of 15 meaning Resident # 88 is severely impaired cognitively, has no potential indicators of psychosis, and dependent on transfers. Record review of a care plan initiated on 06/08/2021 and revised on 08/27/2021 revealed Resident #88 has the potential for complications related to seizure disorder with a goal to minimize the risk of injury during seizure through the next review date. The interventions included: Bilateral half side rails while in bed with padding for safety related to diagnosis: Seizures. Record review of a Physician Orders Sheet revealed an order dated 11/18/2024 for bilateral half side rails while in bed with padding for safety related to diagnosis: Seizures for every shift related to and monitor for placement/safety. Resident # 56: On 05/06/25 at 9:45 AM Resident # 56 was observed in bed with both side rails in the upward position and the left side rail was not padded (photo evidence). There were no staff members in the room. During an interview on 05/06/25 at 9:45 AM, (with translation assistance by Staff H, Registered Nurse RN MDS coordinator) Staff C, Certified Nursing Assistant (CNA) was asked if paddings are required on both side rails; Staff C, CNA stated, I know the padding should be on both side rails to prevent injury but I removed it and left the room to get something and forgot to replace it. Record review of Resident #56's demographic face sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that include: Seizures, Muscle Wasting and Atrophy. Record review of a Quarterly MDS reference dated 2/10/25 revealed Resident #56 is moderately impaired cognitively and dependent on transferring. Record review of a care plan initiated 8/31/2023 and revised on 08/192024 revealed Resident # 56 is at risk for falls related to diagnosis that include: Alzheimer's disease and Seizures with a goal to be free of fall related injuries by next review date. The interventions included: Bilateral half side rails with padding while in bed for safety. Record review of Resident # 56's Physician's Order Sheet for May 2025 revealed an order dated 04/20/2025 for bilateral grab bar with padding for safety related to diagnosis Seizures every shift and monitor for placement/safety. Resident # 106: On 05/06/25 at 12:52 PM Resident#106 was observed in bed with bilateral 1/4 side rails in the upward position; the right-side rail padding was observed on the floor. (photographic evidence). On 05/06/25 at 1:53 PM, Staff E, RN picked up the padding and placed it in the laundry and another staff member replaced the padding on side rail. On 05/06/25 at 1:02 PM Staff E, RN stated: The order is for padding to be on the side rails all the time while the resident is in bed. I do frequent rounds to make sure the padding is in place. I don't know why it was on the floor. On 05/06/25 at 1:12 PM, Staff D, CNA stated, I am the CNA for [Resident # 106]' the padding is to always be on the side rails for safety. I round to make sure. Record review of Resident#106's demographic face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include Palliative care, Hemiplegia and Hemiparesis following Cerebral infarction affecting left dominant side. Record review of a Quarterly MDS referenced dated 04/09/2025 revealed Resident#106 is severely impaired cognitively and was dependent for transfers. Record review of Resident#106's Physician Orders Sheet for May 2025 revealed an order dated 11/19/24 for bilateral grab bar with padding to help protect skin integrity while in bed every shift for bed mobility/enabler; Monitor for placement/safety. Record review of a care plan revealed Resident#106 had a risk for falls related to poor safety awareness and diagnosis included: Encounter for Palliative Care, Sequelae of Cerebral infarction, Hemiplegia and Hemiparesis, date Initiated: 12/01/2022 and Revision on: 01/10/2025 with a goal to minimize risk of falls and fall related injury through the next review date. The interventions included: Bilateral half side rails while in bed with padding On 05/08/25 at 12:10 PM, the Restorative RN stated: When I receive an order from the physician for padding of the side rails, I provide the staff with the padding, and I round with the restorative CNAs to monitor padding is put in place. The padding is usually for seizure precautions and protection of skin. The floor nursing staff are responsible for ensuring the paddings are in place. There is no time that the padding should not be on the side rails while the resident is in bed. When staff are providing care, they remove the padding and put the side rail in the down position but must remain next to the resident for safety. On 05/08/25 at 12:21 PM The Director of Nursing (DON) revealed: Staff are expected to do frequent rounds to ensure the padding remains on the side rails according to the physician order. The restorative, floor nurse and the computer tasks inform the CNAs which residents require padded side rails. The padded side rails are typically used for seizure precaution and skin integrity. There is no reason the padding should not be in place without staff present. Record review of a Policy titled, Comprehensive Care Plan date implemented 3/2020, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observations, interviews and record review, the facility failed to 1) store food under sanitary condition by ensuring the proper temperatures in the reach-in cooler and 2) ensure the reach-in cooler was working properly. This has the potential to affect 169 out of 182 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (Issued 9/2018); Policy Statement-The temperatures of the refrigerators and freezers will be recorded twice a day; Procedure-1b) Refrigerators shall be 35-40 degrees Fahrenheit. Observation during the initial kitchen tour on 12/11/23 at 8:16 AM with the Accounts Manager/Food Service Director and the Corporate District Manager revealed, the reach-in cooler temperature was 60 degrees F (Fahrenheit) on the outside and 60 degrees F on the inside. The reach-in cooler contained apple sauce. Observation of the lunch tray line on 12/13/23 at 11:02 AM revealed, food temperatures were being taken and conducted by the Accounts Manager/Food Service Director. The dessert was Gelatin Cubes and the temperature was 52 degrees F. The desserts were contained in a long pan with ice and was removed from the reach-in cooler. Second observation of the reach-in cooler on 12/13/23 at 11:03 AM revealed, 50 degrees F on the outside and 60 degrees F on in the inside. The reach-in cooler contained desserts and juices. On 12/13/23 at 11:04 AM, interview with the Accounts Manager/Food Service Director. He stated, The temperature on the refrigerator should be 41 degrees. Observation of the reach-in cooler on 12/13/23 at 11:05 AM revealed, all desserts and juices were removed from the reach-in cooler by the dietary staff. Record review of the reach-in cooler Temperature Log for December 2023 documented the following: 12/11/23 5:30 AM Temperature was 40 degrees F and on 12/13/23 5:00 AM Temperature was 40 degrees F.

Based on observation, record review, and interviews, the facility failed to ensure dignity during dining for one (resident #173) out of 45 sampled residents as evidenced by one facility staff was standing while feeding resident #173. The findings included: In an observation on 12/11/23 at 11:27 AM, Staff A, C.N.A. (Certified Nursing Assistant) was standing while assisting Resident #173 with eating lunch. Staff A was spoon-feeding resident #173, a pureed diet and assisting him drinking from a plastic cup with a straw. In an observation on 12/11/23 at 11:32 A.M, Staff A, C.N.A. was observed standing while assisting with feeding for Resident #173. In an observation on 12/11/23 at 11:54 AM, Staff A, C.N.A was observed sitting in a chair while assisting with feeding for Resident #179. In an observation on 12/11/23 at 12:14 PM, Staff A, C.N.A. was observed sitting in a chair while assisting with feeding for Resident #500. On 12/11/23 at 12:20 PM, during an interview with Staff A, C.N.A. and Staff B, R.N. (Registered Nurse) for Spanish translation. When asked, What do you do during dining times for residents? What is the assistance required when feeding Resident #173? Staff A, C.N.A. stated, I take care of residents that I'm assigned to on my shift. I bring them their food. I will identify foods on the tray for them. When assisting residents to eat, I take my time with the resident. When the resident is finished. I will record the percentage eaten on the meal ticket and I'll report to the nurse assigned if the resident has eaten or not. For Resident #173, I explained the foods that were on his tray. He eats slowly but he always eats 100% of his meal. When asked, What does the facility teach staff about what to do when assisting residents with eating? Are you to sit or stand while assisting a resident to eat? Staff A, C.N.A stated, Sit down Staff B, R.N. stated, Sit down and sit face to face in front of the resident. When asked, the reason for standing while feeding resident #173, Staff A, C.N.A. stated, There was no chair in the room, and I can bring a chair in the room from the dining room. Staff B, R. N stated, Resident #173 eats in the room. He has floor mats because he tried to get out of bed. It's hard to place a chair in the room because of the floor mats. Residents who are in the dining room do not need eating assistance. On 12/13/23 at 8:05 AM, Staff A, C.N.A. was seen sitting down with a resident for eating assistance during breakfast. On 12/13/23 at 11:27 AM, in an interview with the Director of Nursing, when asked, What is the facility's policy when staff are feeding the residents? Are they able to sit or stand while providing eating assistance? The Director of Nursing stated, Staff are to sit down while feeding the residents. Record review of Resident #173 revealed, medical diagnoses of diagnosis of dysphagia (difficulty in swallowing food or liquids) following cerebrovascular disease (stroke). Record review of Resident #173 revealed, a diet of no added salt, pureed texture, and regular/ thin consistency. Record review of Minimum Data Set, in quarterly dated 12/01/2023 revealed, in Section C: Cognitive Patterns, a brief interview of mental status was a five, which suggests severe cognitive impairment. In Section GG: Functional Limitation in Range of Motion, the Upper extremities has no impairments. In Section K: Swallowing/Nutritional Status, no to swallowing issues. In Section O: Special Treatments, Procedures, and Programs: No to speech therapy. Record review of the task for certified nursing assistants included, activities of daily living, extensive assistance times one for breakfast, lunch, and dinner as needed. Record review of the care plan, with a next review date of 2/29/2024 revealed, Resident #173 is on restorative program assistance with active range of motion to bilateral upper extremities three times a week, bed mobility three times a week, and activities for daily living (grooming hygiene, dressing upper body/ lower body). The interventions included, Assist with Set up/Feeding as needed and as tolerated. The goals included, Resident #173 will maintain the highest functional ability to all extremities and prevent contractures/further contractures. Review of the facility policies and procedures titled Promoting / Maintaining Resident Dignity during mealtimes. Issued 3/2020. The policy statement stated, it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Under the section titled, Policy Explanation and Compliance Guidelines part 5, All staff will be seated, if possible while feeding a resident.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (R # 43) out of one sampled residents reviewed for death. Resident #43 expired in the facility and the MDS Section A for Identification Information, Discharge Status did document the resident was deceased . The findings included: Record review of the clinical records for Resident # 43 revealed the resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. Clinical diagnoses included, but were not limited to, Encounter for Palliative Care; Malignant Neoplasm of Colon, Unspecified; Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Record review of the Significant Change MDS dated [DATE] revealed it was the last MDS completed for resident #43. The MDS Section A for Identification Information, Discharge Status did document the resident was deceased . Record review of Nurses Notes dated [DATE] revealed, the Certified Nursing Assistant called the nurse to resident's room. Upon arrival, the resident was unresponsive to verbal or tactile stimuli. Record review of Nurses Notes dated [DATE] revealed, resident #43 had a (Do Not Resuscitate (DNR) status). Interview with the MDS Coordinator on [DATE] at 10:37 AM revealed, she stated the resident expired in the facility. She stated, she forgot to add the resident was deceased . She stated she will make a correction to the MDS. Interview with MDS Coordinator on [DATE] at 10:45 AM revealed, the MDS Coordinator showed the surveyor the correction with a date of [DATE]. The MDS Section A, Identification Information dated [DATE] was corrected on [DATE] and documented the resident was deceased . Review of Policy and Procedures for Resident Assessments issued ,d+[DATE] revealed Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist to identify health problems for care plan development. Procedure: Completion of the Minimum Data Set: 5-Quarterly assessments are also done for residents every three months, at least every 92 days following a comprehensive assessment. Annual, entry, discharge and re-entry assessments are completed following the guidelines indicated in the Final Rule and the Resident Assessment Instrument (RAI) MDS Version 3.0 guidelines.

Based on record reviews, observations and interviews, the facility failed to provide appropriate Services and care related to foley catheter positioning as per facility policy to prevent a potential Urinary Tract Infection (UTI) for one out (Resident #153) out of 11 residents residing in the facility who had indwelling urinary catheters. The findings included: During observation on 12/13/2023 at 08:40 AM, Certified Nursing Assistant (Staff I), pushed resident #153 in a shower chair in the hallway to his room. Resident #153 was covered with a towel; the catheter tubing was observed to be looped under resident #153 causing the collection bag to be above the level of resident's bladder. Registered Nurse (Staff G) was informed and immediately entered the room with the surveyor. Staff G was obsereved to place the collection bag below the level of the residents bladder into pocket of the shower chair. Staff G explained to Staff I that the collection bag should always be below the level of bladder. On 12/13/23 at 11:15AM, Resident #153 was observed seated in his wheelchair near the designated smoking area with his catheter tubing unkinked, the collection bag was below the level of the bladder was inside a dignity bag, and attached to his wheelchair. Record review revealed, Resident #153 was admitted on [DATE], and readmitted on [DATE] with diagnoses that includes Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Status) Brief Interview for Mental Status score was 11 on a scale of 00-15, indicating no cognitive impairment. Section GG (Functional Abilities and Goals) no information in MDS. Section H (Bladder and Bowel) resident had an indwelling catheter. Section I (Active Diagnosis) Anemia, Heart Failure, Hypertension, Malnutrition, Diabetes, Depression. Section M (Skin conditions) no skin conditions present Review of December 2023 physician orders revealed, suprapubic urinary catheter care every shift and as needed, dated 9/7/2023, always anchor urinary catheter in place to prevent pulling, trauma/dislodgement. dated 11/21/23, maintain dignity bag over urine collection bag for privacy and below the level of the bladder every shift dated 12/7/2023, monitor suprapubic catheter every shift for leakage or blockage notify Medical Doctor (MD) dated 12/7/2023. Review of the Care Plan with the date initiated was December 24, 2022, and date revised December 19, 2023 revealed, A problem of Indwelling catheter and at risk for UTI's. Interventions: Place drainage bag into privacy bag for dignity at all times and below level of the bladder. Attach catheter to leg bag as needed. Attach catheter to bedside drainage and ensure closed drainage system intact. Change catheter, tubing and drainage bag as ordered. Monitor amount, character, color, odor of urine output and notify MD as indicated. Monitor every shift for urinary output, abdominal pain or distention. Observe for blood in urine and notify nurse/MD as indicated. Provide good perineal hygiene. Provide urinary catheter care Every (Q) shift and as needed (PRN). Work with MD for possible discontinue (DC) of catheter. During interview on December 13, 2023, at 10:31 AM, translated by Registered Nurse (Staff H), Staff I reported, when taking care of residents with indwelling catheters, the collection bag should be below level of bladder and not touching the floor. Staff I reported, when a resident with an indwelling catheter is assisted with a shower, the collection bag is to be kept below the level of the bladder by placing it into the pocket on the side of the shower chair. Staff I stated, she did not place foley in the shower chair pocket below the level of the residents bladder because she was nervous. Interview on 12/13/23 at 10:41AM, the DON stated an Inservice regarding indwelling catheters care is in progress. The DON reported the indwelling catheters collection bags are to be kept below the level of the bladder. The DON reported, the Certified Nursing Assistants are educated upon hire about indwelling catheter care. The DON reported, when a resident is being assisted with showering, the indwelling catheters collection bag is to be kept below the level of the bladder by tucking it into the pocket of the shower chair. Review of the facility's Policy and Procedure for Indwelling Catheter Use issued date: 6/2020 Revised: Standard: It is the Policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with State and Federal Regulations and national guidelines. Procedure: Indwelling urinary catheters are to be used when indicated according to national guidelines such as those by the Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines (often referred to as the Centers for Disease Control and Prevention guidelines).

Based on observations, interviews, and record review, the facility failed to follow the physician's orders for changing midline (intravenous catheter or IV line) dressing for one (Resident #485) out of 45 sampled residents as evidenced by a midline dressing dated over five days old. The findings included: In an observation on 12/11/23 at 09:48 AM, Resident #435 was in bed with eyes closed with a nasal cannula at two liters per minute. In an observation on 12/12/23 at 09:12 AM, Resident #435 was resting in bed with eyes closed with a nasal cannula at two liters per minute. In an observation on 12/13/23 at 11:12 AM, Resident #435 was resting in bed with eyes closed. It was observed with Staff C, Registered Nurse (RN) that Resident #435's left arm had a midline IV catheter and the dressing was dated 12/08/2023 with no initials. (See photo evidence) Record review of the treatment administration record for December 2023 revealed, a physician order which stated to change midline catheter site dressing every 72 hours and as needed with transparent Dressing. The treatment recored revealed on 12/08/23 and 12/11/23 the dressing change was initialed as completed and the next midline dressing change due date was on 12/14/2023. On 12/13/23 at 11:17 AM, during an interview with Staff C, R.N. (Registered Nurse). It was asked, Were you Resident #435's nurse on 12/11/23 and was the dressing changed on that day? Staff C, R.N. stated, I was Resident #435 nurse on 12/11/23. I changed her dressing on 12/11/23, but I got the dates confused. I'll change her midline dressing now. On 12/13/23 at 11:31 AM, during an interview with the Director of Nursing. It was discussed that Resident #435's midline dressing was dated 12/08/23. It was charted in the treatment administration record that the midline dressing was changed on 12/08/2023 and 12/11/2023. The Director of Nursing stated, I spoke to Staff C, R.N., and he stated that he changed the dressing. He said he put the wrong date. He was confused with the date. It was a mistake. Record review of Resident #435's medical diagnoses included, subacute osteomyelitis of the left ankle and foot. Record review of physician orders for December 2023 revealed, midline catheter site dressing every 72 hours and as needed with transparent dressing with a start date of 12/5/2023. Ceftriaxone Sodium injection solution of one gram intravenously one time a day for osteomyelitis of left foot for 10 days with a start date of 12/5/2023. Record review of Minimum Data Set revealed, in Medicare five day assessment dated [DATE]. In Section C: Cognitive patterns, a brief interview of mental status was a six suggesting severe cognitive impairment. In Section M: Skin, does this resident have one or more unhealed pressure ulcers/injuries? Yes. Number of these unstageable pressure injuries that were present upon admission/entry or reentry? Two. Section N: Medications, antibiotics as a resident was a yes. Review of Resident #435's care plan revealed, the next review date was 3/3/2024. Resident #435 has a midline (intravenous line or IV line) to the left upper arm and is at risk for complications such as occlusion. Interventions were dressing changes to the site as per facility protocol. The date initiated was on 12/05/2023. The goal was Resident #435 would have no complications from intravenous therapy through the next review date. Review of facility's policy and procedures for Peripheral Inserted Central Catheters. Issue date of 4/1/2022. The policy statement states, It will be the standard of this facility to adhere to IV (intravenous)/PICC line (Peripheral inserted central catheter) administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. In section, procedures, 3. Dressing should be changed as per the physician's orders. In the section titled dressing changes, it stated at least weekly, and dressing changes will be documented in the clinical record.

Based on record reviews, observations and interviews, the facility failed to ensure proper labeling and disposal of medications as evidenced by one eye drop and one insulin pen past expiration dates on one the East medication cart out of five carts reviewed and two bottles of liquid medication past the expiration date printed on the bottle, in the [NAME] Medication room out of four medication rooms reviewed in facility. This affected 4 out of 45 sampled residents (Resident #8, #11, #21, and #146). The findings included: On 12/13/23 at 02:41 PM, observation of the first floor East Medication cart contained one Brimonidine Sol 0.2% eye drop, with an open date of 10/25/2023 written on the bag for Resident#8 and an additional pharmacy label stuck onto the bag with a different resident's name and different medication name. This cart also contained one opened vial of Insulin Glargine sol 100U/mL(10mL) (Units/milliters) with an open date of 11/1/2023 for resident #21. (see photo evidence). On 12/13/23 at 03:00 PM, observation of the first-floor [NAME] Side Medication room contained two bottles in the medication refrigerator past the expiration dates. The first bottle was labeled Omeprazole 2mg/mL (milligrams/milliliters), had a written date of 11/2/23 on the front label, an expiration date of 11/15/2023 printed on the back label, for resident #146. The second bottle was labeled Omeprazole 2mg/mL, had a written date of 11/9/23 on the front label, an expiration date of 11/22/23 printed on the back label for resident #11. (see photo evidence) Review of medical records revealed, Resident#8 was admitted on [DATE] and readmitted on [DATE] with diagnoses to included Primary Open-Angle Glaucoma Bilateral Mild Stage. Further review of the Minimum Data Set (MDS) dated [DATE] Section C for Cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 11 out of a scale of 00-15 indicating moderate impairment. Review of the physician orders revealed, Brimonidine Tartrate Ophthalmic Solution 0.2% Instill 1 drop into both eyes one time a day related to Primary Open-Angle Glaucoma Bilateral Mild Stage dated 10/25/23. Further review of the Electronic Medication Administration Record (EMAR) for 12/2023 revealed the medication is administered daily. Review of the medical records for Resident#21 admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. Review of the quarterly MDS dated [DATE] Section C for Cognitive status revealed a BIMS score of 07 on a scale of 00-15 indicated severe cognitive impairment. Review of the physician orders revealed, Insulin Glargine 100 UNIT/ML Solution Inject 15 units Subcutaneous at bedtime. Further review of the EMAR for 12/2023 revealed, Insulin Glargine medication administered daily. Review of medical records revealed, Resident#146 was admitted on [DATE] with diagnoses that included Gastrostomy. Review of the Quarterly MDS dated [DATE] revealed, Section C for cognitive status revealed a BIMS score of 06 on a scale of 00-15 indicated severe cognitive impairment. Review of the physician orders revealed, Omeprazole Oral Suspension 2 MG/ML (Omeprazole) Give 20 ml via PEG-Tube one time a day related to Gastro-esophageal reflux disease (GERD) dated 1/31/23. Review of the EMAR for 12/2023 revealed, Omeprazole Oral Suspension administered daily. Review of the medical records revealed, Resident#11 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Gastritis. Review of the Quarterly MDS dated [DATE] Section C cognitive status revealed a BIMS score of 06 out 00-15 indicated severe cognitive impairment. Review of the physician orders revealed Omeprazole 2MG/ML solution 10ML (20MG) Give 10 ml by mouth one time a day for GERD dated 11/9/23. EMAR for 12/2023 reviewed Omeprazole administered daily. Interview on 12/13/23 at 02:50 PM with Registered Nurse (Staff D) it was stated, eye drops and insulin once opened are expired after 28 days, then must be discarded. Staff D stated, the Brimonidine eye drop, and Insulin Glargine in the East side medication cart are expired. Staff D stated, she will call the pharmacy and re-order the expired medications. Interview on 12/13/23 at 03:10 PM, Registered Nurse (Staff E) stated, the two liquids bottles of medication in the medication room refrigerator are expired. Staff E stated, when a bottle of medication is received from pharmacy the open date is written on the front of the medication. Staff E stated, the expiration date is located on the back of the bottle and the medication should not be used or stored in the refrigerator after it is expired. Staff E stated, she will reorder the medication and dispose of the expired medication with another nurse. Interview on 12/13/23 at 03:15 PM, the Director of Nurses (DON) stated medications should not be used or stored past the expiration date. The DON stated she will begin in-servicing the nursing staff regarding proper storage of medication. The DON stated, the expired medications will be reordered STAT (immediately) and received within 2 hours from the pharmacy. Interview on 12/14/23 at 11:27 AM, the Assistant Director of Nurses (ADON) stated the medication nurses monitor the medications in the cart daily and dispose of expired medications. The ADON stated, the supervisor follows up daily to ensure accuracy of medication storage. The ADON stated on Fridays each nurse cleans their cart. The ADON stated, that the pharmacy consultant comes in monthly and assesses the medication cart and medication with the nurse. The ADON stated there is a list of medication expiration dates kept in the Narcotic/Log/Resources book on each medication cart. The ADON stated medications cannot be used after the expiration date. The ADON stated nurses should reorder medication a week before medication is due to run out. Interview on 12/14/23 at 11:36 AM, Registered Nurse (Staff F) stated, she is the supervisor for the entire facility on the 7 AM to 7 PM shift. Staff F stated, each day the floor nurses inspect their carts and medication rooms and I check once a week. Staff F stated, if any medication is needed, I call the pharmacy. Staff F stated, when the medication is low or expired, I reorder. Staff F stated, Eye drops and Insulin are good for 30 days after opening. Staff F stated Medications cannot be used after the expiration date. Staff F stated, I reorder medications at least one week before the expiration date. Staff F stated, the pharmacy consultant comes to facility monthly and checks the medications with me and the nurse. Interview on 12/14/23 01:45 PM with a Pharmacy Consultant revealed, a consultant visits the facility monthly. The Pharmancy Consultant stated, if there are deficiencies found on the cart, the nurse is educated at that time. The Pharmancy Consultant stated, the Brimonidine Eye drops bottle is labeled with an expiration date. The Pharmacy Consultant stated, Insulin Glargine expires 28 days once opened. The Pharmacy Consultant stated, Omeprazole suspension expires 30 days after the dispense date. The Pharmancy Consultant stated, it is not advised to administer medications after expiration date. Review of Policy and Procedure entitled, Labeling of Medications Storage of Drugs and Biologicals date implemented: 11/28/2019. Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Purpose: The purpose of this procedure is to ensure the accurate labeling of all medications and biologicals to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. 5. Labels for individual drug containers must include: h. the expiration date when applicable 9. Labels for multi-use vials must include: all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. Review of document entitled, [ Consulting Services], Inc., Last Updated 7/12/2023, Expiration Dates for Open Injectable Diabetes Medication revealed, Insulin Glargine expires 28 days after opening. Review of undated document entitled, [ Consulting Services], Inc. Medications with Shortened Expiration Dates revealed Omeprazole Suspension expires 30 days once opened.

Based on observations, record review and interview, the facility failed to employ a Director of Food and Nutrition Services with required qualifications that includes two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than [DATE]. The findings included: Record review of the Job Description for the Dining Services Director/Account Manager documented: The Dining Services Director/Account Manager manages the dining services program and must hold state and/or federal required credential within no more than three months of placement in Dining Services Director/Account Manager position. Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Essential functions of the job is to: Supervises, coordinates and evaluates work of all dining services employees in preparing and serving food and cleaning facilities and utensils in a production kitchen; Conducts planning and budgeting; Forecasts and plans the purchase of food, supplies and equipment and ensures that established sanitation and safety standards are maintained. The Dining Services Director/Account Manager reports to the Dining Services District Manager. Review of the Job Description for the Registered Dietitian documented: Provides registered dietitian services in according to policies and procedures and federal/state requirements. The registered dietitian has administrative authority, responsibility and accountability necessary to carry out assigned duties. Responsibilities include planning, organizing, developing and directing the nutritional care of the resident in accordance with current federal, state and local standards, guidelines and regulations that govern the facility. Works effectively with others to ensure that quality nutritional services are being provided on a daily basis and acts as a resource to the Director of Dining Services so that the dining services department is maintained in a clean, safe and sanitary manner. Essential functions of the job is to: Completes comprehensive nutrition assessments and care plan development in accordance with federal and state regulatory guidance; Completes comprehensive assessments in accordance with current standards of practice and provides oversight and guidance to the Dining Services Director regarding dining services operations. The Registered Dietitian reports to the Director of Clinical Operations. On [DATE] at 8:03 AM, interview with the Accounts Manager/Food Service Director revealed that he is not a CDM (Certified Dietary Manager) and the RD (Registered Dietitian) does not oversee him or the kitchen. He has only been in the position of Food Service Director for a couple of months. On [DATE] at 8:05 AM, interview with the Corporate District Manager revealed that the Food Service Director is not a CDM and that the Dietitian does not oversee the Food Service Director nor the kitchen. On [DATE] at 8:25 AM, interview with the Registered Dietitian (RD). She stated, I am here in the afternoons. Monday and Fridays in the afternoons. They have me listed as fulltime with 32 hours. I don't oversee the kitchen nor the Food Service Director. On [DATE] at 9:27 AM, interview with the Human Resources Director. She stated, He (Accounts Manager/Food Service Director) was hired on [DATE]. He was a Cook at that time. On [DATE] he became a Dietary Supervisor/Cook. He has a Dietetic Management and Supervision Certificate from [ ] a local technical college dated [DATE]. He had a [ ] sanitation certification dated [DATE] and it expired on [DATE]. He received Food Safety Manager Training on food safety certificate of completion on [DATE]. He is now an employee of the [ ], a contracted company. On [DATE] at 9:32 AM, interview with the Corporate District Manager. He stated, I am his direct supervisor. I manage separate buildings. I try to come in once a week and sometimes twice a week. I'm in the process of trying to see if he qualifies to take the CDM exam. On [DATE] at 8:39 AM, interview with the Administrator. He stated, We signed the contract with [ ], the contracted food services group on [DATE] and we first started with them on October of that year. The Dining Services Director/Account Manager is qualified for the position because he went to school, he has taken the classes. He is pending taking the test. The dietitian is qualified for the position because we have a full time dietitian. She oversees the kitchen. We have two CDMs who are contracted to come in and go in the kitchen. They are not full time, only part time. On [DATE] at 8:43 AM, interview with the RD. She stated, I am here Monday thru Friday doing nutritional assessments and I also go in the kitchen if I am needed. Review of the Dining Service Agreement contract revealed it was completed on [DATE] with the [ ] contracted food services group. Review of the contracted dietary workers and the Account Manager was listed as hire date [DATE]. On [DATE] at 11:14 AM, interview with the contracted CDM. She stated, I come here two times a week and as needed in the kitchen. I am contracted as an LLC (limited liability company) but I am a CDM. I look at the sanitation for the kitchen. I let them know what I find and they deal with their employees. On [DATE] at 11:21 AM, interview with the Human Resources Director. She stated, The dietitian is contracted with [ ] contracted food services group. They have a separate payroll. On [DATE] at 11:23 AM, interview with the Corporate District Manager. He stated, The RD is under our company. Two months of the RD timesheet were requested to verify hours worked. Subsequent interview with the Corporate District Manager on [DATE] at 12:03 PM. He stated, The Dietitian is not designated as the Director of Food Service. On [DATE] at 6:52 AM, interview with the Accounts Manager/Food Service Director. He stated, I see the Dietitian at least four times a week. I do the budget for the kitchen. On [DATE] at 6:54 AM, interview with Staff I, Dietary Aide. She stated, Sometimes the dietitian is here twice a week. On [DATE] at 6:56 AM, interview with Staff J, Dietary Aide. She stated, I see her (the dietitian) everyday. On [DATE] at 6:57 AM, interview with Staff K, Dietary Aide. She stated, I see her (the dietitian) four days in the kitchen. Review of the time sheets dated [DATE] to [DATE] for the RD documented she punched in and out mostly everyday for 6 hours or more. Review of the QAPI (Quality Assurance Performance Improvement) Meeting Minutes for [DATE], [DATE] and [DATE] documented the registered dietitian was not present at the meetings. The diet technician was present at the meetings. Review of the Facility Assessment, updated [DATE], date reviewed with QAPI Committee [DATE] documented: 1) The Dietitian and Food Service Director were involved in completing the facility assessment; 2) Staff Type: Food and Nutrition Services (Director, Support staff, Registered Dietitian); 3) Dietitian or other clinically qualified nutrition professional to serve as the Director of Food and Nutrition Services Range (FTEs)-2 and Food and Nutrition Services Staff Range (FTEs) ,d+[DATE] daily. there were 14 Dietary staff and the Nutrition department provided individualized dietary requirements, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs. The Facility Assessment was received on [DATE]. On [DATE] at 11:30 AM, interview with the RD. She stated, I do not attend the QAPI meetings because I come in the afternoons. I usually come in around 2:30 to 3:00 PM. The Registered Diet Tech attends the QAPI meetings and the care plan meetings. My title is a Clinical Dietitian. I am not designated as the Director of Food Service. Review of the Federal requirements for a qualified Dietitian functioning at a minimum include: Assessing the nutritional needs of residents; Developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents; Developing and implementing person-centered education programs involving food and nutrition services for all facility staff; Overseeing the budget and purchasing of food and supplies, and food preparation, service and storage and participating in the quality assurance program, when food and nutrition services are involved.

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F550 Resident Rights/Exercise of Rights related to the facility failed to ensure that residents had a dignified existence for Resident # 173 of three residents reviewed for dignity and failed to maintain dignity during dining and F812 Food Procurement Store/Prepare/Serve/Sanitary as evidenced by facility failed to 1) store food under sanitary condition by ensuring the proper temperatures in the reach-in cooler and 2) ensure the reach-in cooler was working properly. This deficiency had the potential to affect 182 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated October 12, 2022. F550 Resident Rights/Exercise of Rights was cited related to the facility failed to ensure that residents had a dignified existence for 2 (Resident # 124 and Resident # 21) of 4 residents reviewed for dignity and failed to maintain dignity during dining for 1 (Resident #15) of 4 residents reviewed for dignity and F812 Food Procurement Store/Prepare/Serve/Sanitary as evidenced that the facility failed to store, prepare, serve food in accordance with professional standards for food service safety. The issues included: failure to protect food from contamination, failure to maintain sanitizing chemical solutions, failure to maintain refrigeration and ice machines, and proper cleaning and maintenance of food preparation equipment. Interview with Administrator and Director of Nursing on 12/14/23 at 12:57 PM. They stated that the QAPI (Quality Assurance and Performance Improvement) meeting is held on the third or fourth week of every month. They stated QAPI Committee included the Administrator, Director of Nursing, Medical Director, Social Services Director, Dietary Director, Infection Preventions, Medical Records Director, Nurse supervisors, the Maintenance Director, Environmental Director, Minimum Data Set (MDS) Coordinator and a Certified Nursing Assistant is invited. They stated they have morning meetings; staff reveal the issues from the prior day. They stated if the issue is high risk for residents, it is addressed immediately. The administrator stated last month's meetings were discussed and they were working to prevent falls and it worked, the resident's fall incidents decreased in comparison to last year. The Director of Nursing stated that the Quality Assessment and Assurance (QAA) committee knows when an issue arises because every department brings its own reports and discusses each area. She stated the CASPER report and trends are used to know what is occurring in the facility. The Administrator stated staff received in-service education to prevent abuse/neglect, how to prevent falls, how to prevent pressure injuries for the residents with risk for injuries, and etc.

Based on observations, interviews and record review, the facility failed to ensure the reach-in cooler was working properly. This has the potential to affect 169 out of 182 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (Issued 9/2018); Policy Statement-The temperatures of the refrigerators and freezers will be recorded twice a day; Procedure-1b) Refrigerators shall be 35-40 degrees Fahrenheit. Observation during the initial kitchen tour on 12/11/23 at 8:16 AM with the Accounts Manager/Food Service Director and the Corporate District Manager revealed, the reach-in cooler temperature was 60 degrees F (Fahrenheit) on the outside and 60 degrees F on the inside. The reach-in cooler contained apple sauce. Observation of the lunch tray line on 12/13/23 at 11:02 AM revealed, food temperatures were being taken and conducted by the Accounts Manager/Food Service Director. The dessert was Gelatin Cubes and the temperature was 52 degrees F. The desserts were contained in a long pan with ice and was removed from the reach-in cooler. Second observation of the reach-in cooler on 12/13/23 at 11:03 AM revealed, 50 degrees F on the outside and 60 degrees F on in the inside. The reach-in cooler contained desserts and juices. On 12/13/23 at 11:04 AM, interview with the Accounts Manager/Food Service Director. He stated, The temperature on the refrigerator should be 41 degrees. Observation of the reach-in cooler on 12/13/23 at 11:05 AM revealed, all desserts and juices were removed from the reach-in cooler. Record review of the reach-in cooler Temperature Log for December 2023 documented the following: 12/11/23 5:30 AM Temperature was 40 degrees F and on 12/13/23 5:00 AM Temperature was 40 degrees F.

Based on observations, interviews and record review, the facility failed to prevent neglect by not providing the quality of care necessary to prevent further harm to the residents. The facility failed to immediately isolate eleven residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, & #11) who were roommates of other residents that tested positive for COVID-19/Coronavirus. Furthermore, they cohorted the eleven residents with fifteen other residents (Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) that tested negative and who were not previously exposed to the Coronavirus. The facility failed to place the eleven residents on droplet precaution and contact precautions. They did not follow the Center for Disease Control and Prevention (CDC) guidelines and their own policy for COVID-19 for isolating the eleven residents. The deficient practice affected 26 out of 109 sampled residents. Based on these concerns, it was determined that the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. On May 7, 2020 at 7:45 p.m. the facility's administration were notified of ongoing Widespread Immediate Jeopardy that started on 4/27/2020. Cross Reference: F835-Administration F880- Infection Control & Prevention F921- Safe/Functional/Sanitary/Comfortable Environment The findings included: Review of the facility's policy titled, Coronavirus prevention last revised on 03/18/20, documented that any residents suspected or exposed to COVID-19 infection will be removed from other residents and placed in separate rooms. They will further be in isolation and monitored for 14 days. It further showed that the facility will follow Standard, Contact, and Droplets precautions that are recommended for the management of residents suspected of an Coronavirus infection by the CDC. Review of the CDC guidelines under the title, Responding to Coronavirus in Nursing Homes revealed, roommates of residents with COVID-19 should be considered exposed and potentially infected and should not share a room with other residents. It further showed that they need to remain asymptomatic and test negative for COVID-19, 14 days after their last exposure. In an observation conducted on 05/06/20 at 9:30 AM, it was noted that 61 residents (#47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107), who were positive for COVID-19 were placed on a droplet/contact isolation unit on the 2nd floor of the facility. The remaining residents were placed on the 1st floor, in various rooms. Further observation showed that 13 residents (#34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, and #46) were placed on droplet/contact isolation for various reasons on the 1st floor. Record review of the facility's census dated 05/06/20 showed 190 in house residents. Further record review showed that the 11 exposed residents who had roommates that were positive for COVID-19 were placed in rooms with the 15 other residents who tested negative for COVID-19 and had not been previously exposed to COVID 19. According to the CDC guidelines titled, People Who Are at Higher Risk for Severe Illness, documents adults over the age of 65 and who have serious underlying medical conditions might be at a higher risk for serious severe illness from COVID-19. These medical conditions may include [MEDICAL CONDITION], heart conditions, obesity, diabetes and liver disease. Review of the clinical records for the 11 exposed residents who had roommates who tested positive for COVID-19 showed the following: Resident #1, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #3, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #4, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #5, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #6, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #7, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #8, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #9, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #10, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #11, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Record review of the (15) residents who were located in the same room with the (11) exposed residents revealed the following: Resident #12, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #13, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #14, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #15, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #16, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #17, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #18, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #19, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #20, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #21, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #22, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #23, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #24, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #25, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #26, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. On 05/06/20 at 10:30 AM, the Director of Nursing, (DON) stated, currently they have 93 residents that tested positive for the COVID-19. The DON reported, 32 of the residents that tested positive for COVID-19 were admitted to the hospital. The DON explained, the 11 roommates who were exposed to the positive COVID-19 residents remained in the facility and were not placed on isolation. The DON further reported, they had full in-house testing for COVID-19 which was provided by a private laboratory on 04/25/20 and on 04/27/20 they received the results for all the residents. However, two residents (Resident #46 and #120) did not receive their results until 04/29/20. According to the DON, they immediately isolated all positive residents for COVID-19 on the 2nd floor on 04/27/20. On 05/06/20 at 12:30 PM, the facility's Vice President of Operations, was asked why they did not place the 11 residents who were exposed to residents positive for COVID-19 on droplet/contact isolation and why they cohorted those 11 residents with the other 15 residents who tested negative and were not previously exposed. The Vice President of Operations reported, if they had to isolate the 11 residents who were exposed, they would run out of Personal Protective Equipment in one week. The Vice President of Operations further stated, they also had 32 staff members who tested positive for COVID-19, and if they had to isolate all residents who were exposed to them it would be the entire facility. In an interview conducted on 05/06/20 at 3:00 PM, the facility's Vice President of Clinical Services reported, the 11 residents who had positive COVID-19 roommates, were not placed on isolation because they did not show any symptoms of COVID-19. The Vice President of Clinical Services further stated, all residents in the facility are being monitored every shift for any signs and symptoms of COVID-19. During an observation conducted on 05/06/20 at 5:00 PM, the 11 residents who were exposed to positive COVID-19 residents were not on any type of contact isolation/droplet precautions and were not separated from the 15 residents who tested negative that were not previously exposed to COVID-19. Review of the facility's two weeks staffing documentation of the combined nurses and Certified Nurse Assistant (CNA) ratio, showed for nurses and CNAs was above 3.5. The nursing ratio was above 1.0 and the CNAs was above 2.5 indicating no issues with the facility's staffing or lack of staffing for the last two weeks in the facility. In an observation conducted on 05/07/20 at 10:00 AM, of the facility's multiple supply rooms, showed boxes of Personal Protective Equipment's. The boxes were a combination of gowns, masks, face shields, and gloves. In this observation, the Vice President of Operations reported, the facility has plenty of supplies, and they always made sure that they have two weeks of supplies on hand. No concerns or issues were reported during this observation and interview related to purchasing supplies or shortage of supplies.

Based on observations, interviews and record reviews, the facility's administration failed to ensure that their policies and the Center for Disease Control and Prevention (CDC) guidelines related to infection control and COVID-19 were implemented. The facility's administration failure to place eleven roommates of sixty-one residents that tested positive for COVID-19 on isolation. The facility placed the eleven residents in resident rooms with fifteen residents that were not exposed to COVID-19. The placement of the eleven residents exposed the fifteen residents to COVID-19. This deficient practice affected twenty-six (residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) out of the 109 sampled residents. It was determined that the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. The facility's administration was notified that Ongoing Immediate Jeopardy existed on May 7, 2020 at 7:45 p.m. Refer to: F600 -Free From Abuse and Neglect F880- Infection Control & Prevention F921- Safe/Functional/Sanitary/Comfortable Environment The findings included: Review of the facility's Plan of Action titled, COVID-19- Breakout Improvement Plan/ Plan of action, dated 04/27/2020 revealed, the objective & goals of this Plan of Action was to minimize the spread of the COVID-19 infection in the facility, implementing facility Infection Control measures to minimize risk. In the Action Steps, it was documented that suspected or exposed residents needed to be on isolation and the facility would follow the outbreak policy. Review of the facility's policy titled, Policies and Procedures: Coronavirus Prevention last reviewed on 03/18/2020 revealed, any residents suspected or exposed to COVID-19 infection would be removed from other residents and placed in a separate room. They would be in isolation and monitored for 14 days. The facility would follow Standard, Contact, Droplets and Airborne precautions that were recommended for the management of residents suspected with the Coronavirus infection by the CDC. Review of the CDC guidelines under the title, Responding to Coronavirus in Nursing Homes revealed, roommates of residents with COVID-19 should be considered exposed and potentially infected and should not share a room with other residents. It further showed that they need to remain asymptomatic and test negative for COVID-19, 14 days after their last exposure. Review of the Job Description for the Nursing Home Administrator revealed, the Administrator is responsible for the direct day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all the times. Review of the Job Description for the Director of Nursing revealed, the Director of Nursing responsibilities included planning, organizing, developing and directing the overall operation of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Review of the Job Description for the Risk Manager revealed, the Risk Manager is responsible for planning, organizing, budgeting, coordinating, evaluating and developing policy for the facility's risk management systems in accordance with current federal, state, and local standards, guidelines, and regulations to protect residents, staff, and the facility from loss. Review of the Job Description for the Assistant Director of Nursing (ADON) Services revealed, the Assistant Director of Nursing Services is responsible for assisting the Director of Nursing Services in planning, organizing, developing, and directing the day-to-day functions of the Nursing Service Department in accordance with federal, state and local standards, guidelines, and regulations that govern facility, and as may be directed by the Administrator, the Medical Director, and/or the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all the times. Review of the Job Description for the Infection Preventionist revealed, the Infection Preventionist or designee is responsible for reporting to the State Department of Health Infectious Disease Division, within one working day of knowledge of a case, suspected case, carrier, or death from any of the diseases such as [DIAGNOSES REDACTED], Anthrax, etc. In addition, the Infection Preventionist or designee shall monitor the effectiveness of the facility's infection prevention and control work practices and protective equipment, that included, but were not limited to, the surveillance of the workplace to ensure that established infection prevention and control practices are observed, and protective clothing and equipment are provided and properly used; investigation of known or suspected transmission of healthcare-associated infections; improvement in training, work practices, or protective equipment to prevent recurrence of occupational exposures and/or healthcare-associated infections; effective implementation of hand-hygiene practices by all departments to prevent spread of infections. On 05/06/20 at 10:23 AM, in an attempt by the surveyor to get information related to concerns, the Nursing Home Administrator (NHA) was unable to respond or give answers to questions asked by the surveyor. The NHA reported that she cannot give the correct information because she was not sure and told the surveyor to ask the Vice President (VP) of Clinical Services or the Director of Nursing (DON). During an environmental tour of the COVID 19 Unit on 05/06/20 at 10:40 AM with Assistant Director of Nursing (ADON), the ADON was asked how the facility is managing the trash and laundry on the COVID Unit, which is located on the second floor of the facility. The ADON stated that they have a laundry shoot and a trash shoot at the end of the hallways. At 11:19 AM the ADON showed the surveyor the locked door with a sign on the door LINEN CHUTE. Also, on the door were paper signs in English and Spanish that read DO NOT THROW GARBAGE IN THIS BIN (photographic evidence obtained). The ADON opened the locked door and stated, Wait a minute this is the garbage chute. The ADON explained that one chute was being used for laundry and one chute was being used for trash. The ADON was asked about the conflicting signage on the door, the ADON stated that he could not speak to the signage. The ADON was asked how staff would know that this chute was not to be used for linen, the ADON stated that he was not sure how that information was given to the staff. On 05/06/20 at approximately 12:00 PM an unlabeled spray bottle was observed in the Personal Protective Equipment (PPE) doffing area of the COVID Unit. Doffing is the practice of employees removing work-related Personal Protective Equipment (PPE). The ADON stated that in order to conserve PPE staff was washing the protective face shields then spraying the face shield with the unlabeled spray bottle. The ADON was asked what was in the unlabeled spray bottle, the ADON stated that he did not know. The ADON was asked what the contact time for the unknown unlabeled product is, the ADON stated, I think it is ten minutes. The ADON was asked what staff did with the face shield after disinfecting them, the ADON stated they take them home, so they don't lose them. The ADON was asked to clarify that facility staff working in the COVID Unit are instructed to take used PPE home, the ADON stated, yes, because we do not have a lot of them. The ADON was asked if it is the facilities expectation that all staff exiting the COVID Unit doff all PPE and cleanse their face shield and stand in the COVID Unit with no PPE on for the 10 minutes to disinfect the face shield, the ADON stated that the staff can put the masks in a plastic bag. It was observed at this time that there were no plastic bags in the COVID Unit doffing area. The ADON stated that there should be plastic bags in the soiled utility room. The soiled utility room is located approximately 30 feet away from the doffing area. On 05/07/20 at approximately 5:00 PM, the Risk Management COVID 19 Breakout Improvement Plan Dated 04/27/20 was reviewed with the Director of Nursing (DON) who is also the Risk Manager. The DON revealed, the area of focus was the multiple residents that tested positive when the mass testing was done. Review of the Action Steps revealed, suspected or exposed residents need to be on isolation. Staff are to wear appropriate Personal Protective Equipment (PPE) for Droplet precautions. The DON stated, we discussed how we were managing the relocation of the residents. We were focused on getting the positives onto the COVID Unit. We were thinking a negative can cohort with another negative, and we are surveilling everyone. The residents with exposure should have been isolated and on droplet precautions. We have placed everyone on precautions.

Based on observation, record review, staff interviews, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines to practice Standard and transmission-based precautions to prevent the spread of a known infection, Coronavirus Disease 2019 (COVID 19). The facility failed to immediately isolate eleven residents whose roommates tested positive for COVID-19. The facility cohorted the eleven residents with fifteen residents that tested negative and did not have known direct exposure to COVID 19 positive residents. The facility failed to place the eleven residents on Droplet precautions (actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions). They did not follow the Center for Disease Control and Prevention (CDC) guidelines and their own policy for COVID-19 for isolating eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, & #11). The facility exposed fifteen other residents by cohorting the 11 residents with known exposure to the 15 residents to include (Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, & #26). The facility failed to maintain droplet precautions on the COVID Unit. The facility failed to maintain resident equipment in a sanitary manner on the COVID Unit, a mechanical lift. The facility failed to maintain side rail bumpers in a sanitary manner for 1 resident on the COVID Unit (Resident # 51). The facility's deficient practice affected 27 out of 109 sampled residents. It was determined the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. On May 7, 2020 at 7:45 p.m. the facility's administration was notified that ongoing Immediate Jeopardy existed. Cross reference: F600- Free from Abuse and Neglect F835-Administration F921- Safe/Functional/Sanitary/Comfortable Environment The findings included: 1. In an observation conducted on 05/06/20 at 9:30 AM, it was noted that 61 residents (#47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107), who were positive for COVID-19 were placed on a droplet/contact isolation unit on the 2nd floor of the facility (COVID Unit). The remaining residents were placed on the 1st floor, in various rooms. On 05/06/20 at approximately 10:00 AM the Administrator and the Director of Nursing were asked to identify the roommates of the 61 COVID-19 positive residents at the time of the testing. The Administrator provided a list of 11 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). Review of the facility's census on 05/06/20 showed that the 11 exposed residents who had roommates that were positive for COVID-19 were placed in rooms with 15 other residents who tested negative for COVID-19 and did not have known direct exposure to COVID-19. The residents included, Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26. Observation of these residents revealed, none of the identified resident were on droplet precautions. Review of the facility's policy titled, Coronavirus Prevention last revised on 03/18/20, documented that residents suspected or exposed to COVID-19 are to be in isolation and monitored for 14 days. The policy documents that staff are to wear appropriate personal protective equipment (PPE) such as masks, gowns, gloves, shoe covers, etc. It further showed that the facility will follow Standard, Contact, Droplets precautions that are recommended for the management of residents suspected with COVID 19 by the CDC. Review of the facility's COVID 19 Breakout Improvement Plan/Plan of action, dated 04/27/20 revealed, suspected or exposed residents need to be on isolation and staff are to wear appropriate PPEs for droplet precautions. The document revealed that the Assistant Director of Nursing and the Staff Developer are responsible for these action items as part of the COVID 19 Breakout Improvement Plan/Plan of action. Review of the CDC guidelines under the title, Responding to Coronavirus in Nursing Homes revealed, roommates of residents with COVID-19 should be considered exposed and potentially infected and should not share a room with other residents. It further showed that they need to remain asymptomatic and test negative for COVID-19, 14 days after their last exposure. Review of the clinical records for the 11 exposed residents who had roommates who tested positive for COVID-19 showed the following: Resident #1, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #3, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #4, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #5, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #6, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #7, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #8, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #9, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #10, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Resident #11, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a known exposure to a positive COVID-19 resident on 04/27/20. Record review of the (15) residents who were located in the same room with the (11) exposed residents revealed the following: Resident #12, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #13, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #14, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #15, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #16, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #17, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #18, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #19, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #20, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #21, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #22, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #23, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #24, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #25, [AGE] years old, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. Resident #26, [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Was exposed to COVID-19 on 4/27/20 by a roommate who had a previous roommate that tested positive for COVID-19. In an interview conducted on 05/06/20 at 10:30 AM, the Director of Nursing, (DON) stated that the 11 roommates who were exposed to positive COVID-19 residents remained in the facility and were not placed on isolation. The DON further reported that they had a full in-house testing for COVID-19 which was provided by a private laboratory on 04/25/20 and on 04/27/20 they received the results for all the residents. However, two residents (Resident #46 and #120) did not receive their results until 04/29/20. According to the DON, they immediately isolated all positive residents for COVID-19 on the 2nd floor on 04/27/20. In an interview on 05/07/20 at approximately 5:00 PM the DON, who is also the facility Risk Manager, stated that the area of focus was the multiple residents that tested positive when we did the mass testing. The DON stated, the Risk Management COVID 19 Breakout Improvement Plan Dated 04/27/20 was the tool the facility had developed to manage the COVID 19 virus outbreak. The DON was asked to address the COVID 19 Breakout Improvement Plan Action Steps for suspected or exposed residents needing to be on isolation and staff are to wear appropriated PPEs for Droplet precautions. The DON stated, we discussed how we were managing the relocation of the residents. We were focused on getting the positives onto the COVID Unit. We were thinking a negative could cohort with another negative, and we are surveilling everyone. The residents with exposure should have been isolated and on droplet precautions. We have placed everyone on precautions. In an interview conducted on 05/06/20 at 12:30 PM, with the facility's Vice President of Operations, he was asked why they did not place the 11 residents who were exposed to positive COVID-19 on droplet/contact isolation. Furthermore, why they cohorted those 11 residents with the other 15 residents who tested negative and were not previously exposed. The Vice President of Operations reported, if they had to isolate the 11 residents who were exposed, they would run out of Personal Protective Equipment in one week. He further stated that they also had 32 staff members who tested positive for COVID-19, and if they had to isolate all residents who were exposed to them it will be the entire facility. 2. On 05/06/20 at 10:50 AM, observation revealed, Staff T, an activities aide, on the COVID -19 unit doffing her gown in front of the surveyor. Observation revealed Staff T with bare hands, pinched the gown on the dirty side of her left sleeve, pulled the gown off and place it on the biohazard trash can. On 05/06/20 at 10:51 AM, Staff T was asked if she was supposed to touch the outside of the gown, Staff T stated that she removed her gloves and took the gown off. Staff T stated, that she is not supposed to touch the outside of the gown. On 05/06/20 at approximately 11:20 AM, an observational tour of the facility's first floor north unit revealed, Staff C, a Licensed Practical Nurse (LPN) in front of a medication cart. Observation revealed Resident #141 sitting in a wheelchair out in the hallway wearing a mask, they were observed to be approximately three (3) feet apart, not the recommended six (6) feet, as per CDC guidelines. Continued observation revealed, Resident #142 and Resident #143 were sitting in a wheelchair next to each other out in the hallway next to their room door and were approximately three (3) feet distanced from Resident #142 and approximately two (2) feet distanced from Staff C. Further, observations revealed no evidence of Staff C attempting to separate the residents or to provide education regarding social distancing. On 05/06/20 at 11:25 AM, an interview was conducted with Resident #142. Resident #142 stated that he is supposed to be six (6) feet apart from them and confirmed that he was not distanced. Resident # 143 was asleep and not interviewable. On 05/06/20, at 11:30 AM, an interview was conducted with Staff C. Staff C stated that she is supposed to keep her residents six (6) apart. At 11:35 AM on 5/6/20, observations revealed Staff C left the medication cart with medications in her hand and entered a random resident's room. Staff C did not move Resident #142 and Resident #143 six (6) apart from each other after the interview. Review of Resident #141 Minimum Data Set (MDS) quarterly assessment dated [DATE] documents resident's BIMS (brief interview for mental status) score was 14 of 15, indicative of little to no cognitive impairment. Review of Resident #142 Minimum Data Set (MDS) quarterly assessment dated [DATE] documents the resident's BIMS (brief interview for mental status) score was 14 of 15, indicative of little to no cognitive impairment. Review of Resident #143 Minimum Data Set (MDS) quarterly assessment dated [DATE] documents resident's BIMS (brief interview for mental status) score was 12 of 15, indicative of little to no cognitive impairment. On 05/06/20 at 11:50 AM, during the continued observational tour of the first-floor north unit revealed Resident #144 and Resident #145 sitting in wheelchairs outside their room in the hallway distanced approximately three (3) feet, and not six (6) feet as recommended by the CDC guidelines. Observation revealed Resident #145 was wearing her mask underneath her chin and talking to the people walking in front of her. Continued observation revealed, the unit secretary walked in front of Resident #144 and Resident #145 and did not acknowledge that the residents were not six feet apart and did not attempt to place Resident #145's mask on properly. On 05/06/20 at 11:52 AM, an attempt was made to interview Resident #144 and Resident #145 and revealed they were not able to follow the questions asked. On 05/06/20 at 12:01pm, an interview was conducted with Staff D, a Registered Nurse. Staff D was asked to observe and tell the surveyor what was wrong between Resident #144 and Resident #145. Staff D kept looking at both residents and was not able to state what was wrong. Staff D was asked about social distancing and stated that they are to keep residents six feet apart. Staff D was asked to demonstrate how she measured the six feet and proceeded to go to the front of both residents and counted from wheelchair leg rest to wheelchair leg rest. Staff D was asked to count how many feet were between the residents' side by side and she counted four (4) feet. Staff D confirmed that Resident #144 and Resident #145 were not six feet apart as per CDC guidelines and proceeded to distance Resident #144. Staff D moved away from Resident #145 and did not attempt to place or to ask her to place her mask properly. Staff D was asked about the resident wearing the mask on her chin. Staff D stated that she had educated the resident about keeping her mask in place, but that she takes it off. Staff D failed to offer or ask Resident #145 to place the mask on her face despite the concern brought to her attention by the surveyor that the resident was not wearing her mask properly. Review of Resident #144 Minimum Data Set (MDS) quarterly assessment date 02/12/20 documents the resident's BIMS (brief interview for mental status) score was 6 of 15, indicative of severe cognitive impairment. Review of Resident #145 Minimum Data Set (MDS) quarterly assessment date 02/11/20 documents the resident's BIMS (brief interview for mental status) score was 8 of 15, indicative of moderate cognitive impairment. On 05/06/20 at 5:50 PM, observation revealed Staff U, a receptionist at the facility's entry point blowing her nose, placing the tissue into the trash can without hand sanitation, went to the screening desk, retrieved a surgical mask from a box located at the desk, placed the mask on her face and then answered the phone. On 05/06/20 at 5:59 PM, an interview was conducted with Staff U and she confirmed that she blew her nose and did not do hand sanitation. Staff U stated, she should have wash her hand after blowing her nose and added that she will do now. Review of the CDC guidelines, [MEDICAL CONDITION] Disease 2019 (COVID-19) How to protect yourself or others, last reviewed on 04/24/20 documents, everyone should wash hands .after blowing your nose Review of the facility policy titled, [MEDICAL CONDITION] Prevention revised on 03/18/20 documents wash your hands often .especially after .blowing your nose . On 05/06/20 at 6:02 PM, an observational tour to the facility's Kellogg unit was conducted. Observation revealed Staff A, a Certified Nursing Assistant (CNA) and Staff B, a Certified Nursing Assistant in the lunchroom. On 05/06/20 at 6:05 PM, an interview was conducted with Staff A. Staff A stated that she usually worked the day shift but was asked to work the evening shift. On 05/06/20 at 6:08 PM, Staff A was asked about her assigned residents and she proceeded to their rooms one by one. Staff A entered a random resident in room [ROOM NUMBER], donned one glove without hand sanitation, re-arrange the resident's cover sheet, removed the glove without hand sanitation proceeded to room [ROOM NUMBER], donned one glove, pulled the window curtain to close it, then removed the glove and without hand sanitation, entered room [ROOM NUMBER], donned gloves, removed the resident food tray, removed her gloves and performed hand sanitation. During an interview, Staff A stated that she did hand sanitation. Review of the facility's policy titled, Hand washing/hand hygiene revised on 08/2015 documents use an alcohol-based hand rub .or alternatively, soap and water for the following situations .before donning gloves .after removing gloves . On 05/06/20 at 6:19 PM, during an interview, Staff A was asked about her face shield care and stated that she uses a face shield during work and before she goes home, she cleans the face shield with soap and water, then wiped it with alcohol pads, placed it in a plastic bag and leaves it in her car for her to use the next day. On 05/06/20 at 6:20 PM, an interview was conducted with Staff B, a Certified Nursing Assistant. Staff B stated that she uses a face shield during work and before she goes home, she cleans the face shield with soap and water, then wiped it with alcohol pads, placed in a plastic bag and leaves it in her car for her to use the next day. Review of the Center for Disease Control and Prevention (CDC) guidelines titled, Strategies for Optimizing the Supply of Eye Protection last reviewed on 03/17/20 documents under Options for Reprocessing Eye Protection While wearing gloves, carefully wipe the inside, followed by the outside of the face shield .using a clean cloth saturated with neutral detergent solution or cleaner wipe. Carefully wipe the outside of the face shield .using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution. Wipe the outside of face shield .with clean water or alcohol to remove residue. On 05/07/20, at 9:50 AM, observation revealed two (2) random residents smoking outside and a cigarette ash tray container between them. Observation revealed the residents were approximately three feet apart, not six feet apart as per CDC guidelines. Further observation revealed the facility's Director of Nursing (DON) walked outside facing the two residents and did not attempt to separate them or educate them or the aide regarding social distancing. On 05/07/20 at 9:55 AM, an interview was conducted with Staff E, a Restorative Aide, and stated that she is watching the two residents smoking because they can't be alone. Staff E was asked how many feet apart the residents must be and she stated six feet. Staff E was asked if the two random residents were six feet apart and she stated, no, they are not and added that she keeps telling them, but they do not listen. Staff E was informed that the surveyor has been standing behind the residents inside the facility observing them and her and that she did not attempt to separate them until surveyor asked her. Staff E acknowledged the findings. On 05/07/20 at 4:35 PM, an interview was conducted with the DON and she stated that they educated the residents on keeping the social distancing and they don't listen. The DON was apprised that Staff E did not attempt to separate them during the observations and did it after an interview with the surveyor. On 05/07/20 at 1:35 PM, observation revealed five (5) staff members (Staff G, Staff H, Staff I, Staff J and Staff K, all Certified Nursing Assistants) sitting in a 10 x 10 lunchroom table located on the facility's first floor north unit lunchroom without keeping social distancing, they were observed almost elbow to elbow. The surveyor walked by the room three times, the staff looked at the surveyor and they continued to eat and stay in the small room. On 05/07/20 at 1:39 PM, Staff F, the unit supervisor was called to observe the five staff members in the lunchroom. Staff F stated that they are not six feet apart and that they know that only two staff members at a time are allowed in the room. Staff F added that Staff J was doing documentation and was not supposed to be there. On 05/07/20 at 1:40 PM, Staff G stated that she was finished and was ready to leave the room. Staff G stated that she is aware of the social distancing and confirmed that she was not six feet apart. On 05/07/20 at 1:42 PM, in an interview Staff H stated, we got the education, but I did it wrong today. Staff H confirmed that she was not six feet apart from Staff G during lunch. On 05/07/20 at 1:44 PM, Staff I stated that she is aware of the social distancing and confirmed that she was not six feet apart from Staff J. On 05/07/20 at 1:44 PM, in an interview Staff J stated, that she is aware of the social distancing and confirmed that she was in between Staff G and Staff I, less that one foot apart from Staff G and Staff I. Staff J confirmed that she was in the lunchroom documenting and it was not her time to be in the room. On 05/07/20 at 1:46 PM, surveyor asked for Staff K to conduct an interview and was informed that she left the unit. Staff K was not available for an interview. On 05/07/20 at 1:50 PM, an interview was conducted with Staff G, a Certified Nursing Assistant revealed, she had 11 residents in three rooms with room capacity of 3 to 4 residents per room that were on droplet precautions assigned to her. Observation revealed all the assigned rooms for droplet precautions had room doors wide open. Staff G was asked if those room doors were supposed to be open and she stated that she kept them open because she likes to see her residents. Staff G was not aware that the doors were supposed to be closed due to the droplet precautions.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment that is free of hazards to ensure the health and safety of the 190 residents residing in the facility. The facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for infection control, to practice Standard and transmission-based precautions to prevent the spread of a known infection, Coronavirus Disease 2019 (COVID 19). This systemic failure and the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. The facility's administration was notified that Immediate Jeopardy existed on May 7, 2020 at 7:45 p.m. Refer to: 483.12: F600 -Free From Abuse and Neglect 483.70: F835-Administration 483.80: F880- Infection Control & Prevention The findings included: Review of the facility's policy titled, [MEDICAL CONDITION] Prevention last revised on 03/18/20, documented that residents suspected or exposed to COVID-19 are to be in isolation and monitored for 14 days. The policy documents that staff are to wear appropriate personal protective equipment (PPE) such as masks, gowns, gloves, shoe covers, etc. It further showed that the facility will follow Standard, Contact, Droplets precautions that are recommended for management of residents suspected with COVID 19 by the CDC. Review of the facility's COVID 19 Breakout Improvement Plan/Plan of action, dated 04/27/20, revealed suspected or exposed residents need to be on isolation and staff are to wear appropriate PPEs for droplet precautions. During an environmental tour of the COVID 19 Unit on 05/06/20 at 10:40 AM with Assistant Director of Nursing (ADON), the ADON was asked how the facility is managing the trash and laundry on the COVID-19 Unit, which is located on the second floor of the facility. The ADON stated, they have a laundry chute and a trash chute at the end of the hallways. At 11:19 AM, the ADON presented the locked door in the East Wing with a sign on the door LINEN CHUTE. Also, on the door were paper signs in English and Spanish that read DO NOT THROW GARBAGE IN THIS BIN (photographic evidence obtained). The ADON opened the locked door and stated, Wait a minute this is the garbage chute. The ADON explained that one chute was being used for laundry and one chute was being used for trash. The ADON was asked about the conflicting signage on the door, the ADON stated that he could not speak to the signage. The ADON was asked how staff would know that this chute was not to be used for linen, the ADON stated that he was not sure how that information was given to the staff. At 11:23 AM on 05/06/20 the ADON presented the locked linen chute on the West Wing hall. The ADON was unable to unlock the door and called Staff W, a housekeeper to unlock the door. Staff W was wearing a white full body suit PPE. Staff W unzipped the full body suit and reached inside and took out a key chain with an approximate 24-inch nylon lanyard attached. Staff W opened the stainless-steel door to the chute, on the inside of the door was a copious amount of a raised dried brown organic substance (photographic evidence obtained). The stainless-steel door jamb of the linen chute was observed to have compacted dried brown organic substance (photographic evidence obtained). Staff W's PPE remained unzipped while opening the linen chute, Staff W then removed the key chain with the 24-inch nylon lanyard and placed it back inside the full body suit PPE. During the environmental tour of the COVID-19 Unit on 05/06/20 at 10:52 AM, Resident #51 was observed in bed with full side rails and full padded bumpers. The bumpers were torn open exposing the foam padding over approximately 50% of the length of the bumper. The exposed padding was observed to be pitted and stained (photographic evidence obtained). The ADON was asked how staff were cleaning and disinfecting the exposed pitted foam, the ADON stated, I don't know, those need to be replaced immediately. During the environmental tour of the COVID-19 Unit on 05/06/20 and observation was made at 10:59 AM of a mechanical lift in the shower room with brown dried material on both handles (photographic evidence obtained). On 05/06/20 at approximately 12:00 PM an unlabeled clear spray bottle was observed in the doffing area of the COVID-19 Unit. Doffing is the practice of employees removing work-related Personal Protective Equipment (PPE). The ADON stated, that in order to conserve PPE staff was washing the protective face shields then spraying the face shield with the liquid in the unlabeled spray bottle. The ADON was asked what was in the unlabeled spray bottle, the ADON stated that he did not know. The ADON was asked what the contact time for the unknown liquid product in the unlabeled spray bottle, the ADON stated, I think it is ten minutes. The ADON was asked what staff did with the face shield after disinfecting them, the ADON stated, they take them home, so they don't lose them. The ADON was asked to clarify that facility staff working in the COVID-19 Unit are instructed to take used PPE home, the ADON stated, yes the face shields because we do not have a lot of them. The ADON was asked if it is the facilities expectation that all staff exiting the COVID-19 Unit doff all PPE and cleanse their face shield and stand in the COVID-19 Unit with no PPE on for the 10 minutes to disinfect the face shield, the ADON stated that the staff can put the masks in a plastic bag. It was observed at this time that there were no plastic bags in the COVID-19 Unit doffing area. The ADON stated that there should be plastic bags in the soiled utility room. The soiled utility room is located approximately 30 feet away from the doffing area. The ADON was asked what education had been provided to the staff when the facility opened the COVID-19 Unit or when new protocols are introduced. The ADON stated that the Staff Developer, a Registered Nurse, had done a tremendous amount of training and in-servicing related to the COVID Unit. On 05/07/20 at approximately 1:20 PM Staff W was observed placing soiled laundry in the linen chute on the COVID-19 Unit without a face shield. On 05/07/20 at approximately 04:30 PM, the Infection Control Nurse/Staff Developer was asked what education had been provided to the staff that related to the opening of and/or the daily staffing rolls and responsibilities of the COVID-19 Unit, the Infection Control Nurse/Staff Developer stated, none.

Based on record review and interview, the facility failed to honor a resident's right to refuse treatment by failure to honor the advance directive as evidenced by initiation of cardio-pulmonary resuscitation (CPR) on a resident with a do not resuscitate (DNR) order for one (resident #3) of nine residents reviewed. This has the potential to affect 121 residents residing in the facility with DNR orders. There were 264 residents residing in the facility at the time of the survey. Cross reference: F600, F678 and F835 On (MONTH) 20, 2019, it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 20, 2019. The immediate jeopardy was identified on [DATE], beginning on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The findings included: Review of the facility policy titled, Advanced Directives revised (MONTH) (YEAR) revealed information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treatment against his or her wishes. Review of the facility policy statement titled Resident Rights (undated) revealed Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's rights to self-determination, participate in decision making regarding care and participate in his or her care planning and treatment. Record review revealed resident #3 was admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident was sent to a local hospital due to shortness of breath. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident had short of breath (SOB), the oxygen saturation was 83% with oxygen on the resident at 2 liters/minute, the respiratory rate was 16 breaths/minute, the bood glucose fingerstick was 240, blood pressure was ,[DATE], the breathing was labored and the resident skin was clammy. The resident was sent to a local hospital by 911/rescue. Resident #3 was readmitted to the facility on [DATE] and she expired in the facility on [DATE]. Record review revealed resident #3 had multiple [DIAGNOSES REDACTED]. Record review revealed a Do Not Resuscitate order dated [DATE] and signed by two physicians and resident #3's health care proxy. The State of Florida Do Not Resuscitate (DNR) order form was on file in the resident #3's clinical record. Review of the physicians order sheet for the admissions of [DATE] through [DATE] and [DATE] through [DATE] revealed a code status checked for: Do Not Resuscitate. Review of the facility's demographic face sheet for the admission of [DATE] revealed code status documented as: Full Code. Record review revealed resident #3 last readmission to the facility was on [DATE] with [DIAGNOSES REDACTED]. Physician's orders included the use of a [MEDICAL CONDITION] (bilevel positive airway pressure) machine at HS (hour of sleep) and prn (as needed. A [MEDICAL CONDITION] machine is a type of non-invasive mechanical ventilator that can help push air into the lungs. There was also an order for [REDACTED]. Review of the daily skilled nursing notes dated [DATE] revealed: 12:40 AM Resident received in bed with HOB (head of bed) elevated. Awake, alert. [MEDICAL CONDITION] and O2 @ 4 L/NC in use. Respirations unlabored. Call bell in reach. No signs or symptoms (s/s) of hypo/hyperglycemic episode. No s/s of distress or discomfort. Vitals assessed. Pleasant demeanor. 1:15 AM Resident noted unresponsive, eyes open. [MEDICAL CONDITION] in use with 4 L/NC. Skin warm and dry. No response to name called. Unable to detect vital signs, CPR (Cardiopulmonary Resuscitation) in progress. 1:20 am Called placed to rescue 911, report reported. 1:25 AM Rescue arrived at 1:15 @ bedside, brother aware. 1:30 AM Resident declared expired by rescue. Doctor made aware. 1:35 AM Brother at bedside with other family members. Interview with the Licensed Practical Nurse (staff I) via telephone on [DATE] at 1:38 PM the following was reported, resident # 3 was a resident who was at the facility for a very long time. She was dependent on staff for all care. She was not verbal, but she was able to gesture her needs. She had just returned from the hospital the afternoon before she expired. She was using a Bi-PAP machine and she used continuous oxygen. When I went to check on her and she was not responding. She was sitting upright in the bed. She had the Bi-PAP machine and the oxygen on. When I entered the room I saw her with her eyes open, but she was not looking at me. I called her name and she did not respond. Normally, she would always look at you. I had just recently checked on her and she was alert. She was happy to be back at the facility. I immediately called the supervisor who was present on the floor. He immediately checked on her and he started to do CPR on her. While he was doing the CPR, the other nurse called 911 and the crash cart was brought into the room. CPR was continued until 911 arrived and they took over from there. I was not in the room at this time because I was gathering the paperwork for them. If a resident has a DNR we would check the chart to get that information. The chart and the MAR have the yellow copy of the DNR. If a resident is found unresponsive we have to go quickly to check the chart or the MAR (medication administration record) to see if the resident has a DNR. I do not remember if Resident # 3 had a DNR order. During a follow up interview with the Licensed Practical Nurse (staff I) on [DATE] at 11:44 AM the following was reported, when I found resident # 3 unresponsive, I alerted the supervisor immediately. The room is close to the supervisor's office. The other nurse on the unit called 911. The crash cart was taken into the room and the supervisor started CPR. This was my patient and I should have checked to see if she had a DNR. In the process of all this running around we immediately reacted in the moment and started CPR. This patient was a young women. After the CPR was started, the other nurse called 911 and gathered the papers. She showed the supervisor the DNR and he stopped the CPR. I do not know if he reported this to the DON (Director of Nursing). Interview with the Assistant Director of Nursing (ADON)/Risk Manager on [DATE] at 8:26 AM the following was reported, resident # 3 was a long term resident who was here since 2009. She had End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT], [MEDICAL CONDITIONS], Diabetes, cardiac issues and [MEDICAL CONDITION]. She had been stable, but towards the end, she had exacerbation of her [MEDICAL CONDITION] and fluid overload. Her brother was her POA (power of attorney) and he was very involved. She was in and out of the hospital from the end of (MONTH) through the time she expired. She was readmitted on [DATE] with a [DIAGNOSES REDACTED]. She was readmitted just before 5 PM on [DATE] and she expired later that day on the morning of [DATE] about 1:30 AM. Her code status at the time of this admission was DNR. She had a DNR ordered while she was in the hospital on [DATE]. Her brother stated they tried to intubate her at the hospital, but the brother did not want this. She came back to us with a Bi-PAP machine on [DATE]. He opted to sign the DNR rather than have her intubated. The Risk Manager reviewed the nurses notes for [DATE] and stated she could not explain why CPR was implemented for a resident with a DNR. She stated, during all of her other admissions resident #3 was a full code. Normally, if we find a resident unresponsive we will check for vitals. The supervisor is called right away and the chart is checked for DNR status. CPR is started or not depending on the code status. The yellow DNR's are filed in the front of the MAR and in the front of the chart binder. I thought they checked and resident # 3's status and called 911. I was not aware the staff did CPR. This is the first I knew they did CPR. This was a nurse who was very familiar with this resident and she had been a full code until [DATE]. The protocol is simple, you check the vitals, check the chart and start CPR if they are a full code. If they have a DNR they are supposed to call non-emergency and not do CPR. The only thing I can think of is, she had been full code for so long. Interview with the ADON/Risk Manager on [DATE] at 8:45 AM revealed the following was reported, if I became aware of a resident who did not receive CPR and was not DNR status or a resident who received CPR and had a DNR, we would do an investigation and report the situation as an adverse incident. I have never had this situation before. I did not report this incident or do an investigation because I was not aware resident #3 received CPR. She reported, part of the staff orientation included training on CPR and the DNR process. The nurses receive a three to four day orientation and this training is done by either the nurse on the floor or the supervisor. The DNR/CPR training is not done annually, it is part of the orientation. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM revealed the following was reported, she was not made aware that CPR had been provided for resident # 3. I was never made aware of this incident until today. The information that I have gotten so far is that resident # 3 had been very sick for the past few months. She had been in and out of the hospital. Her brother is very involved with her care and prior to this last admission she had always been a full code. During her last hospitalization he made her a DNR. The DNR was in her record. What I found out so far is that she was found unresponsive, the supervisor was checking her vital signs. He started CPR. The nurse came in and said she was a DNR and he stopped. They called 911 and they arrived and she was pronounced. I do not know how this happened. The nurses know they have to check the chart first before starting CPR. If the chart is not there, we even have a copy of the DNR in the MAR so time would not be lost determining someone's code status. If they see that something like this happened and they made an error, they have to report to me as the DON, the Risk Manager/ADON and then I would report it to the administrator. I would have started an investigation, notified the family and started to re-educate the staff. We have now started the investigation. Of course, I will notify her primary doctor today. Her primary doctor is also our Medical Director. Interview with the Nursing Home Administrator (NHA) on [DATE] at 12:06 PM revealed she reported, she had no idea that CPR was initiated on a resident with a DNR in place. I just found out today that this occurred when the DON and ADON found out. When an incident like this occurs, we have to do an investigation, an adverse report, notify the family and in-service all of our nurses and CNA's (Certified Nursing Assistant) and everyone involved in the care of residents to make sure this does not happen again. That I am aware of, we do not have a policy to address the steps taken in the event of this type of situation. We keep the DNR's in the chart and the MAR, but we do not have a written step by step policy and procedure to address CPR or DNR status. After this incident that happened, I will have to sit down with the DON to establish a step by step procedure for the staff to follow. They do know where the DNR's are located. I do not think the supervisor had the DNR, so this is why he started CPR. I would expect the staff to contact either the DON or the ADON/Risk Manager to report that this occurred and then to notify me so an investigation could be started. I am very upset that this incident was never reported to anyone. The staff is supposed to immediately report an incident such as this to the DON immediately. If she could not be reached the ADON should have been called. Interview with the Licensed Practical Nurse Supervisor (staff L) via telephone on [DATE] at 12:41 PM revealed, he was the supervisor the night resident # 3 expired. Staff L reported, I was told she was not breathing. I went to her room immediately to check her airway. She had a Bi-PAP on. I checked her pulse and I checked her chest to see if she was breathing or not. She did not have a pulse. I was in the room and the other nurse was checking her papers. This happened in one or two minutes when I did the assessment. One of the nurses brought me the paper that she was a DNR. We brought the crash cart to the room in case we had to start CPR. I called all of the nurses to help out. I did not start CPR when they brought me the paper. I told the CNA to clean her up and call her brother. The other nurse was on the phone with rescue and the police. Interview with the Certified Nursing Assistant (staff N) conducted by a Spanish speaking surveyor via telephone on [DATE] at 2:26 PM revealed the following was reported, she is familiar with the resident who passed away not too long ago. The nurse was the one that found her. The nurse (staff I) entered the room and I imagine that she saw her and she notified us and the supervisor (staff L). We went there with the crash cart, the nurses from the North and South and the other staff were involved in what was happening with the resident. I myself was in charge of bringing the crash cart and the supervisor had started at that moment. He had his hands on her chest. It was a matter of a couple of minutes. In one to two minutes, the nurse came with the yellow paper and everything was stopped. It was a very short time that had passed. We prepared her, cleaned and changed her so her brother could see her presentable. Interview with resident #3's primary care physician (PCP) who is the facility's Medical Director via telephone on [DATE] at 1:26 PM revealed the following was reported, he was the primary care physician for this resident. She was in the facility for a very long time and she was not a DNR until her last hospital stay. The DNR was signed at the hospital and I signed a DNR when she was readmitted . The DNR was in the chart, so I do not know why they started CPR. For the last two months of her life she only spent five days in the nursing home and the rest of the time in the hospital. She was very sick and her brother opted for the DNR. The DNR form was in her chart and they should not have started CPR. As her primary care physician and the Medical Director for the facility, I should have been told that this error occurred. When they called me to tell me she had expired, the CPR was never mentioned and I should have been told and the family should have been told. The facility's Immediate Jeopardy Removal Plan included: -CPR was immediately withdrawn for resident #3 in question, once Do Not Resuscitate (DNR) status was determined. Resident expired and was pronounced by Fire Rescue; therefore, no corrective action can be taken for the resident. -The Charge Nurse and Nursing Supervisor were both suspended pending outcome of the investigation. In addition, the nurse who performed CPR has been removed from the supervisory position. -The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Risk Manager, Medical Director, Primary Care Physician, Quality Assurance and Performance Improvement (QAPI) Committee and Resident's Proxy were notified on (MONTH) 20, 2019 that CPR had been initiated and immediately withdrawn once DNR status was confirmed. -Facility reported the incident of resident #3 in question to state agencies on (MONTH) 20, 2019 for neglect in the failure to honor a DNR. -Facility would report the license of the nurse involved in the incident to the state agency for failure to honor the resident's DNR on (MONTH) 11, 2019. -An investigation was initiated on (MONTH) 20, 2019 by the Administrator; the Director of Nursing (DON); and Assistant Director of Nursing (ADON)/Risk Manager to determine circumstances surrounding the events. Employees are being interviewed and statements collected related to the incident. -Any resident with a DNR has the potential to be affected by the same deficient practice. As such, the facility Administrative Nursing staff completed a 100% audit of residents' medical records to determine their code status and to ensure that the status was clearly identifiable. All residents identified to have a DNR were reviewed to ensure that all DNR documents were appropriately placed. -A new written protocol was developed and implemented on (MONTH) 20, 2019 which provides staff step by step instructions to follow in the event a resident is observed without pulse or respirations. All staff are being educated on the new protocol beginning on (MONTH) 20, 2019 by Nursing Administrative Staff. -On (MONTH) 20, 2019, the facility enforced use of their current CPR policy to ensure proper understanding on importance to check a residents Advanced Directives prior to initiating CPR. Nursing staff is being in-serviced on the current policy on (MONTH) 20, 2019 by Nursing Administration. -On (MONTH) 20, 2019, the facility initiated a directive requiring all nursing supervisors to immediately inform Administrative staff regarding any event requiring initiation of CPR and for all supervisory staff to notify Administration of any other systemic failure. All supervisors would be in-serviced on the new policy prior to reporting to duty effective (MONTH) 20, 2019 by the Administrator, DON and ADON/Risk Manager. -On (MONTH) 20, 2019, the facility's abuse policy and procedure were revised to include the failure to implement Advanced Directives as an example of neglect. -On (MONTH) 20, 2019, the DNR protocol was revised to require a supervisor to respond to all emergencies to ensure that appropriate protocols are followed. Nursing supervisors were in-serviced on the new policy on (MONTH) 20, 2019 by the Administrator; the DON; the ADON/Risk Manager. -Effective (MONTH) 20, 2019, all staff are currently being in-serviced by the Nursing Administration on the resident's right to formulate Advanced Directives, the facility's requirement to honor and implement those Advanced Directives, how to identify a resident's code status and Advanced Directives, and identification and reporting of abuse/neglect. -Employee must be able to answer all questions on proficiency audit correctly, otherwise they would not be able to work until proficiency is achieved. -Inservice education is being completed prior to the employee being able to work. Employees may not work until inservice education is completed. -197 employees in-serviced (75%) and continuous inservice education and proficiency audits until all employees were educated. Expectation of completing training of all employees by end of the last shift on (MONTH) 24, 2019. -The effectiveness of education would be audited via direct observation of implementation of the new policies and facility systems. If performance gaps or lack of understanding was identified, immediate remedial education would be provided. Documentation of education would be compiled by the facility. -The DON, ADON and/or the Risk Manager would audit the record of all residents who expire in the facility to ensure proper protocol was followed related to the implementation of Advanced Directives. The DON/designee would summarize audit findings and report results to the Quality Assurance Performance Improvement Committee Monthly. -A special QAPI Committee Meeting would be held on (MONTH) 21, 2019 to discuss the newly revised and developed policies. The committee would review possible areas of improvement in staff reporting of systemic failures, educational opportunities related to Advanced Directives and ways to improve identification of quality of care and life deficiencies. On [DATE], the information in the facility's removal plan was verified as completed. Thirteen facility staff members were interviewed to confirm the implementation of the facility's removal plan to include (1) Nurse Supervisor, (1) Unit Manager, (1) Restorative Nurse, (1) Registered Dietitian, (2) CNAs and (7) Nurses. The facility's immediate jeopardy was removed on [DATE] at 6:07 P.M.

Based on record review and interview, the facility failed to ensure residents were free from neglect by failing to provide medical services in accordance with the residents advance directive as evidenced by initiation of cardio-pulmonary resuscitation (CPR) on a resident with a do not resuscitate (DNR) order for one (resident #3) of nine residents reviewed. This has the potential to affect 121 residents residing in the facility with DNR orders. There were 264 residents residing in the facility at the time of the survey. Cross reference: F578, F678 and F835 On (MONTH) 20, 2019, it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 20, 2019. The immediate jeopardy was identified on [DATE], beginning on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The findings included: Review of the facility policy titled Abuse Policy and Procedure updated [DATE] revealed neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or in the deterioration of a resident's physical or mental condition. Failure to honor a resident's advance directive is an example of neglect. Record review revealed resident #3 was admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident was sent to a local hospital due to shortness of breath. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident had short of breath (SOB), the oxygen saturation was 83% with oxygen on the resident at 2 liters/minute, the respiratory rate was 16 breaths/minute, the bood glucose fingerstick was 240, blood pressure was ,[DATE], the breathing was labored and the resident skin was clammy. The resident was sent to a local hospital by 911/rescue. Resident #3 was readmitted to the facility on [DATE] and she expired in the facility on [DATE]. Record review revealed resident #3 had multiple [DIAGNOSES REDACTED]. Record review revealed a Do Not Resuscitate order dated [DATE] and signed by two physicians and resident #3's health care proxy. The State of Florida Do Not Resuscitate (DNR) order form was on file in the resident #3's clinical record. Review of the physicians order sheet for the admissions of [DATE] through [DATE] and [DATE] through [DATE] revealed a code status checked for: Do Not Resuscitate. Review of the facility's demographic face sheet for the admission of [DATE] revealed code status documented as: Full Code. Record review revealed resident #3 last readmission to the facility was on [DATE] with [DIAGNOSES REDACTED]. Physician's orders included the use of a [MEDICAL CONDITION] (bilevel positive airway pressure) machine at HS (hour of sleep) and prn (as needed. A [MEDICAL CONDITION] machine is a type of non-invasive mechanical ventilator that can help push air into the lungs. There was also an order for [REDACTED]. Review of the daily skilled nursing notes dated [DATE] revealed: 12:40 AM Resident received in bed with HOB (head of bed) elevated. Awake, alert. [MEDICAL CONDITION] and O2 @ 4 L/NC in use. Respirations unlabored. Call bell in reach. No signs or symptoms (s/s) of hypo/hyperglycemic episode. No s/s of distress or discomfort. Vitals assessed. Pleasant demeanor. 1:15 AM Resident noted unresponsive, eyes open. [MEDICAL CONDITION] in use with 4 L/NC. Skin warm and dry. No response to name called. Unable to detect vital signs, CPR (Cardiopulmonary Resuscitation) in progress. 1:20 am Called placed to rescue 911, report reported. 1:25 AM Rescue arrived at 1:15 @ bedside, brother aware. 1:30 AM Resident declared expired by rescue. Doctor made aware. 1:35 AM Brother at bedside with other family members. Interview with the Licensed Practical Nurse (staff I) via telephone on [DATE] at 1:38 PM the following was reported, resident # 3 was a resident who was at the facility for a very long time. She was dependent on staff for all care. She was not verbal, but she was able to gesture her needs. She had just returned from the hospital the afternoon before she expired. She was using a Bi-PAP machine and she used continuous oxygen. When I went to check on her and she was not responding. She was sitting upright in the bed. She had the Bi-PAP machine and the oxygen on. When I entered the room I saw her with her eyes open, but she was not looking at me. I called her name and she did not respond. Normally, she would always look at you. I had just recently checked on her and she was alert. She was happy to be back at the facility. I immediately called the supervisor who was present on the floor. He immediately checked on her and he started to do CPR on her. While he was doing the CPR, the other nurse called 911 and the crash cart was brought into the room. CPR was continued until 911 arrived and they took over from there. I was not in the room at this time because I was gathering the paperwork for them. If a resident has a DNR we would check the chart to get that information. The chart and the MAR have the yellow copy of the DNR. If a resident is found unresponsive we have to go quickly to check the chart or the MAR (medication administration record) to see if the resident has a DNR. I do not remember if Resident # 3 had a DNR order. During a follow up interview with the Licensed Practical Nurse (staff I) on [DATE] at 11:44 AM the following was reported, when I found resident # 3 unresponsive, I alerted the supervisor immediately. The room is close to the supervisor's office. The other nurse on the unit called 911. The crash cart was taken into the room and the supervisor started CPR. This was my patient and I should have checked to see if she had a DNR. In the process of all this running around we immediately reacted in the moment and started CPR. This patient was a young women. After the CPR was started, the other nurse called 911 and gathered the papers. She showed the supervisor the DNR and he stopped the CPR. I do not know if he reported this to the DON (Director of Nursing). Interview with the Assistant Director of Nursing (ADON)/Risk Manager on [DATE] at 8:26 AM the following was reported, resident # 3 was a long term resident who was here since 2009. She had End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT], [MEDICAL CONDITIONS], Diabetes, cardiac issues and [MEDICAL CONDITION]. She had been stable, but towards the end, she had exacerbation of her [MEDICAL CONDITION] and fluid overload. Her brother was her POA (power of attorney) and he was very involved. She was in and out of the hospital from the end of (MONTH) through the time she expired. She was readmitted on [DATE] with a [DIAGNOSES REDACTED]. She was readmitted just before 5 PM on [DATE] and she expired later that day on the morning of [DATE] about 1:30 AM. Her code status at the time of this admission was DNR. She had a DNR ordered while she was in the hospital on [DATE]. Her brother stated they tried to intubate her at the hospital, but the brother did not want this. She came back to us with a Bi-PAP machine on [DATE]. He opted to sign the DNR rather than have her intubated. The Risk Manager reviewed the nurses notes for [DATE] and stated she could not explain why CPR was implemented for a resident with a DNR. She stated, during all of her other admissions resident #3 was a full code. Normally, if we find a resident unresponsive we will check for vitals. The supervisor is called right away and the chart is checked for DNR status. CPR is started or not depending on the code status. The yellow DNR's are filed in the front of the MAR and in the front of the chart binder. I thought they checked and resident # 3's status and called 911. I was not aware the staff did CPR. This is the first I knew they did CPR. This was a nurse who was very familiar with this resident and she had been a full code until [DATE]. The protocol is simple, you check the vitals, check the chart and start CPR if they are a full code. If they have a DNR they are supposed to call non-emergency and not do CPR. The only thing I can think of is, she had been full code for so long. Interview with the ADON/Risk Manager on [DATE] at 8:45 AM revealed the following was reported, if I became aware of a resident who did not receive CPR and was not DNR status or a resident who received CPR and had a DNR, we would do an investigation and report the situation as an adverse incident. I have never had this situation before. I did not report this incident or do an investigation because I was not aware resident #3 received CPR. She reported, part of the staff orientation included training on CPR and the DNR process. The nurses receive a three to four day orientation and this training is done by either the nurse on the floor or the supervisor. The DNR/CPR training is not done annually, it is part of the orientation. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM revealed the following was reported, she was not made aware that CPR had been provided for resident # 3. I was never made aware of this incident until today. The information that I have gotten so far is that resident # 3 had been very sick for the past few months. She had been in and out of the hospital. Her brother is very involved with her care and prior to this last admission she had always been a full code. During her last hospitalization he made her a DNR. The DNR was in her record. What I found out so far is that she was found unresponsive, the supervisor was checking her vital signs. He started CPR. The nurse came in and said she was a DNR and he stopped. They called 911 and they arrived and she was pronounced. I do not know how this happened. The nurses know they have to check the chart first before starting CPR. If the chart is not there, we even have a copy of the DNR in the MAR so time would not be lost determining someone's code status. If they see that something like this happened and they made an error, they have to report to me as the DON, the Risk Manager/ADON and then I would report it to the administrator. I would have started an investigation, notified the family and started to re-educate the staff. We have now started the investigation. Of course, I will notify her primary doctor today. Her primary doctor is also our Medical Director. Interview with the Nursing Home Administrator (NHA) on [DATE] at 12:06 PM revealed she reported, she had no idea that CPR was initiated on a resident with a DNR in place. I just found out today that this occurred when the DON and ADON found out. When an incident like this occurs, we have to do an investigation, an adverse report, notify the family and in-service all of our nurses and CNA's (Certified Nursing Assistant) and everyone involved in the care of residents to make sure this does not happen again. That I am aware of, we do not have a policy to address the steps taken in the event of this type of situation. We keep the DNR's in the chart and the MAR, but we do not have a written step by step policy and procedure to address CPR or DNR status. After this incident that happened, I will have to sit down with the DON to establish a step by step procedure for the staff to follow. They do know where the DNR's are located. I do not think the supervisor had the DNR, so this is why he started CPR. I would expect the staff to contact either the DON or the ADON/Risk Manager to report that this occurred and then to notify me so an investigation could be started. I am very upset that this incident was never reported to anyone. The staff is supposed to immediately report an incident such as this to the DON immediately. If she could not be reached the ADON should have been called. Interview with the Licensed Practical Nurse Supervisor (staff L) via telephone on [DATE] at 12:41 PM revealed, he was the supervisor the night resident # 3 expired. Staff L reported, I was told she was not breathing. I went to her room immediately to check her airway. She had a Bi-PAP on. I checked her pulse and I checked her chest to see if she was breathing or not. She did not have a pulse. I was in the room and the other nurse was checking her papers. This happened in one or two minutes when I did the assessment. One of the nurses brought me the paper that she was a DNR. We brought the crash cart to the room in case we had to start CPR. I called all of the nurses to help out. I did not start CPR when they brought me the paper. I told the CNA to clean her up and call her brother. The other nurse was on the phone with rescue and the police. Interview with the Certified Nursing Assistant (staff N) conducted by a Spanish speaking surveyor via telephone on [DATE] at 2:26 PM revealed the following was reported, she is familiar with the resident who passed away not too long ago. The nurse was the one that found her. The nurse (staff I) entered the room and I imagine that she saw her and she notified us and the supervisor (staff L). We went there with the crash cart, the nurses from the North and South and the other staff were involved in what was happening with the resident. I myself was in charge of bringing the crash cart and the supervisor had started at that moment. He had his hands on her chest. It was a matter of a couple of minutes. In one to two minutes, the nurse came with the yellow paper and everything was stopped. It was a very short time that had passed. We prepared her, cleaned and changed her so her brother could see her presentable. Interview with resident #3's primary care physician (PCP) who is the facility's Medical Director via telephone on [DATE] at 1:26 PM revealed the following was reported, he was the primary care physician for this resident. She was in the facility for a very long time and she was not a DNR until her last hospital stay. The DNR was signed at the hospital and I signed a DNR when she was readmitted . The DNR was in the chart, so I do not know why they started CPR. For the last two months of her life she only spent five days in the nursing home and the rest of the time in the hospital. She was very sick and her brother opted for the DNR. The DNR form was in her chart and they should not have started CPR. As her primary care physician and the Medical Director for the facility, I should have been told that this error occurred. When they called me to tell me she had expired, the CPR was never mentioned and I should have been told and the family should have been told. The facility's Immediate Jeopardy Removal Plan included: -CPR was immediately withdrawn for resident #3 in question, once Do Not Resuscitate (DNR) status was determined. Resident expired and was pronounced by Fire Rescue; therefore, no corrective action can be taken for the resident. -The Charge Nurse and Nursing Supervisor were both suspended pending outcome of the investigation. In addition, the nurse who performed CPR has been removed from the supervisory position. -The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Risk Manager, Medical Director, Primary Care Physician, Quality Assurance and Performance Improvement (QAPI) Committee and Resident's Proxy were notified on (MONTH) 20, 2019 that CPR had been initiated and immediately withdrawn once DNR status was confirmed. -Facility reported the incident of resident #3 in question to state agencies on (MONTH) 20, 2019 for neglect in the failure to honor a DNR. -Facility would report the license of the nurse involved in the incident to the state agency for failure to honor the resident's DNR on (MONTH) 11, 2019. -An investigation was initiated on (MONTH) 20, 2019 by the Administrator; the Director of Nursing (DON); and Assistant Director of Nursing (ADON)/Risk Manager to determine circumstances surrounding the events. Employees are being interviewed and statements collected related to the incident. -Any resident with a DNR has the potential to be affected by the same deficient practice. As such, the facility Administrative Nursing staff completed a 100% audit of residents' medical records to determine their code status and to ensure that the status was clearly identifiable. All residents identified to have a DNR were reviewed to ensure that all DNR documents were appropriately placed. -A new written protocol was developed and implemented on (MONTH) 20, 2019 which provides staff step by step instructions to follow in the event a resident is observed without pulse or respirations. All staff are being educated on the new protocol beginning on (MONTH) 20, 2019 by Nursing Administrative Staff. -On (MONTH) 20, 2019, the facility enforced use of their current CPR policy to ensure proper understanding on importance to check a residents Advanced Directives prior to initiating CPR. Nursing staff is being in-serviced on the current policy on (MONTH) 20, 2019 by Nursing Administration. -On (MONTH) 20, 2019, the facility initiated a directive requiring all nursing supervisors to immediately inform Administrative staff regarding any event requiring initiation of CPR and for all supervisory staff to notify Administration of any other systemic failure. All supervisors would be in-serviced on the new policy prior to reporting to duty effective (MONTH) 20, 2019 by the Administrator, DON and ADON/Risk Manager. -On (MONTH) 20, 2019, the facility's abuse policy and procedure were revised to include the failure to implement Advanced Directives as an example of neglect. -On (MONTH) 20, 2019, the DNR protocol was revised to require a supervisor to respond to all emergencies to ensure that appropriate protocols are followed. Nursing supervisors were in-serviced on the new policy on (MONTH) 20, 2019 by the Administrator; the DON; the ADON/Risk Manager. -Effective (MONTH) 20, 2019, all staff are currently being in-serviced by the Nursing Administration on the resident's right to formulate Advanced Directives, the facility's requirement to honor and implement those Advanced Directives, how to identify a resident's code status and Advanced Directives, and identification and reporting of abuse/neglect. -Employee must be able to answer all questions on proficiency audit correctly, otherwise they would not be able to work until proficiency is achieved. -Inservice education is being completed prior to the employee being able to work. Employees may not work until inservice education is completed. -197 employees in-serviced (75%) and continuous inservice education and proficiency audits until all employees were educated. Expectation of completing training of all employees by end of the last shift on (MONTH) 24, 2019. -The effectiveness of education would be audited via direct observation of implementation of the new policies and facility systems. If performance gaps or lack of understanding was identified, immediate remedial education would be provided. Documentation of education would be compiled by the facility. -The DON, ADON and/or the Risk Manager would audit the record of all residents who expire in the facility to ensure proper protocol was followed related to the implementation of Advanced Directives. The DON/designee would summarize audit findings and report results to the Quality Assurance Performance Improvement Committee Monthly. -A special QAPI Committee Meeting would be held on (MONTH) 21, 2019 to discuss the newly revised and developed policies. The committee would review possible areas of improvement in staff reporting of systemic failures, educational opportunities related to Advanced Directives and ways to improve identification of quality of care and life deficiencies. On [DATE], the information in the facility's removal plan was verified as completed. Thirteen facility staff members were interviewed to confirm the implementation of the facility's removal plan to include (1) Nurse Supervisor, (1) Unit Manager, (1) Restorative Nurse, (1) Registered Dietitian, (2) CNAs and (7) Nurses. The facility's immediate jeopardy was removed on [DATE] at 6:07 P.M.

Based in record review and interview, the facility failed to ensure necessary medical care and services were provided in accordance with the resident's advance directives and physician's orders [REDACTED].#3) of nine residents reviewed. This has the potential to affect 121 residents residing in the facility with a DNR orders. There were 264 residents residing in the facility at the time of the survey. Cross reference: F578, F600, F835 On (MONTH) 20, 2019, it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 20, 2019. The immediate jeopardy was identified on [DATE], beginning on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The findings included: Review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation dated [DATE] Procedure revealed the following: 1. Determine unresponsiveness by tapping or gently shaking resident and shouting Are you okay? 2. Call out for help. 3. Delegate specific individual to check residents care plan for CPR or no CPR order, have individual call paramedics, attending physician and administrative personnel per facility policy and report back to you as soon as possible. General Documentation Guidelines: 1. Date and exact time condition change was observed. 2. VS or absence of vital signs 3. Exact time CPR was started. 4. Exact time paramedics were notified 5. Exact time paramedics arrived 6. Exact time physician was called and exact time reached. 7. physician's orders [REDACTED].>8. Exact time resident was transferred. Review of the policy statement titled Do Not Resuscitate Order revised (MONTH) (YEAR) revealed: Our facility will not use cardio-pulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate order in effect. A DNR order must be completed and signed by the attending physician and the resident or legal surrogate as permitted by State law and scanned into the resident's medical record. Use only State approved DNR forms. DNR orders will remain in effect until the resident or legal representative provides the facility with a signed and dated request to end the DNR order. Record review revealed resident #3 was admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident was sent to a local hospital due to shortness of breath. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident had short of breath (SOB), the oxygen saturation was 83% with oxygen on the resident at 2 liters/minute, the respiratory rate was 16 breaths/minute, the bood glucose fingerstick was 240, blood pressure was ,[DATE], the breathing was labored and the resident skin was clammy. The resident was sent to a local hospital by 911/rescue. Resident #3 was readmitted to the facility on [DATE] and she expired in the facility on [DATE]. Record review revealed resident #3 had multiple [DIAGNOSES REDACTED]. Record review revealed a Do Not Resuscitate order dated [DATE] and signed by two physicians and resident #3's health care proxy. The State of Florida Do Not Resuscitate (DNR) order form was on file in the resident #3's clinical record. Review of the physicians order sheet for the admissions of [DATE] through [DATE] and [DATE] through [DATE] revealed a code status checked for: Do Not Resuscitate. Review of the facility's demographic face sheet for the admission of [DATE] revealed code status documented as: Full Code. Record review revealed resident #3 last readmission to the facility was on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A [MEDICAL CONDITION] machine is a type of non-invasive mechanical ventilator that can help push air into the lungs. There was also an order [REDACTED]. Review of the daily skilled nursing notes dated [DATE] revealed: 12:40 AM Resident received in bed with HOB (head of bed) elevated. Awake, alert. [MEDICAL CONDITION] and O2 @ 4 L/NC in use. Respirations unlabored. Call bell in reach. No signs or symptoms (s/s) of hypo/hyperglycemic episode. No s/s of distress or discomfort. Vitals assessed. Pleasant demeanor. 1:15 AM Resident noted unresponsive, eyes open. [MEDICAL CONDITION] in use with 4 L/NC. Skin warm and dry. No response to name called. Unable to detect vital signs, CPR (Cardiopulmonary Resuscitation) in progress. 1:20 am Called placed to rescue 911, report reported. 1:25 AM Rescue arrived at 1:15 @ bedside, brother aware. 1:30 AM Resident declared expired by rescue. Doctor made aware. 1:35 AM Brother at bedside with other family members. Interview with the Licensed Practical Nurse (staff I) via telephone on [DATE] at 1:38 PM the following was reported, resident # 3 was a resident who was at the facility for a very long time. She was dependent on staff for all care. She was not verbal, but she was able to gesture her needs. She had just returned from the hospital the afternoon before she expired. She was using a Bi-PAP machine and she used continuous oxygen. When I went to check on her and she was not responding. She was sitting upright in the bed. She had the Bi-PAP machine and the oxygen on. When I entered the room I saw her with her eyes open, but she was not looking at me. I called her name and she did not respond. Normally, she would always look at you. I had just recently checked on her and she was alert. She was happy to be back at the facility. I immediately called the supervisor who was present on the floor. He immediately checked on her and he started to do CPR on her. While he was doing the CPR, the other nurse called 911 and the crash cart was brought into the room. CPR was continued until 911 arrived and they took over from there. I was not in the room at this time because I was gathering the paperwork for them. If a resident has a DNR we would check the chart to get that information. The chart and the MAR have the yellow copy of the DNR. If a resident is found unresponsive we have to go quickly to check the chart or the MAR (medication administration record) to see if the resident has a DNR. I do not remember if Resident # 3 had a DNR order. During a follow up interview with the Licensed Practical Nurse (staff I) on [DATE] at 11:44 AM the following was reported, when I found resident # 3 unresponsive, I alerted the supervisor immediately. The room is close to the supervisor's office. The other nurse on the unit called 911. The crash cart was taken into the room and the supervisor started CPR. This was my patient and I should have checked to see if she had a DNR. In the process of all this running around we immediately reacted in the moment and started CPR. This patient was a young women. After the CPR was started, the other nurse called 911 and gathered the papers. She showed the supervisor the DNR and he stopped the CPR. I do not know if he reported this to the DON (Director of Nursing). Interview with the Assistant Director of Nursing (ADON)/Risk Manager on [DATE] at 8:26 AM the following was reported, resident # 3 was a long term resident who was here since 2009. She had End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT], [MEDICAL CONDITIONS], Diabetes, cardiac issues and [MEDICAL CONDITION]. She had been stable, but towards the end, she had exacerbation of her [MEDICAL CONDITION] and fluid overload. Her brother was her POA (power of attorney) and he was very involved. She was in and out of the hospital from the end of (MONTH) through the time she expired. She was readmitted on [DATE] with a [DIAGNOSES REDACTED]. She was readmitted just before 5 PM on [DATE] and she expired later that day on the morning of [DATE] about 1:30 AM. Her code status at the time of this admission was DNR. She had a DNR ordered while she was in the hospital on [DATE]. Her brother stated they tried to intubate her at the hospital, but the brother did not want this. She came back to us with a Bi-PAP machine on [DATE]. He opted to sign the DNR rather than have her intubated. The Risk Manager reviewed the nurses notes for [DATE] and stated she could not explain why CPR was implemented for a resident with a DNR. She stated, during all of her other admissions resident #3 was a full code. Normally, if we find a resident unresponsive we will check for vitals. The supervisor is called right away and the chart is checked for DNR status. CPR is started or not depending on the code status. The yellow DNR's are filed in the front of the MAR and in the front of the chart binder. I thought they checked and resident # 3's status and called 911. I was not aware the staff did CPR. This is the first I knew they did CPR. This was a nurse who was very familiar with this resident and she had been a full code until [DATE]. The protocol is simple, you check the vitals, check the chart and start CPR if they are a full code. If they have a DNR they are supposed to call non-emergency and not do CPR. The only thing I can think of is, she had been full code for so long. Interview with the ADON/Risk Manager on [DATE] at 8:45 AM revealed the following was reported, if I became aware of a resident who did not receive CPR and was not DNR status or a resident who received CPR and had a DNR, we would do an investigation and report the situation as an adverse incident. I have never had this situation before. I did not report this incident or do an investigation because I was not aware resident #3 received CPR. She reported, part of the staff orientation included training on CPR and the DNR process. The nurses receive a three to four day orientation and this training is done by either the nurse on the floor or the supervisor. The DNR/CPR training is not done annually, it is part of the orientation. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM revealed the following was reported, she was not made aware that CPR had been provided for resident # 3. I was never made aware of this incident until today. The information that I have gotten so far is that resident # 3 had been very sick for the past few months. She had been in and out of the hospital. Her brother is very involved with her care and prior to this last admission she had always been a full code. During her last hospitalization he made her a DNR. The DNR was in her record. What I found out so far is that she was found unresponsive, the supervisor was checking her vital signs. He started CPR. The nurse came in and said she was a DNR and he stopped. They called 911 and they arrived and she was pronounced. I do not know how this happened. The nurses know they have to check the chart first before starting CPR. If the chart is not there, we even have a copy of the DNR in the MAR so time would not be lost determining someone's code status. If they see that something like this happened and they made an error, they have to report to me as the DON, the Risk Manager/ADON and then I would report it to the administrator. I would have started an investigation, notified the family and started to re-educate the staff. We have now started the investigation. Of course, I will notify her primary doctor today. Her primary doctor is also our Medical Director. Interview with the Nursing Home Administrator (NHA) on [DATE] at 12:06 PM revealed she reported, she had no idea that CPR was initiated on a resident with a DNR in place. I just found out today that this occurred when the DON and ADON found out. When an incident like this occurs, we have to do an investigation, an adverse report, notify the family and in-service all of our nurses and CNA's (Certified Nursing Assistant) and everyone involved in the care of residents to make sure this does not happen again. That I am aware of, we do not have a policy to address the steps taken in the event of this type of situation. We keep the DNR's in the chart and the MAR, but we do not have a written step by step policy and procedure to address CPR or DNR status. After this incident that happened, I will have to sit down with the DON to establish a step by step procedure for the staff to follow. They do know where the DNR's are located. I do not think the supervisor had the DNR, so this is why he started CPR. I would expect the staff to contact either the DON or the ADON/Risk Manager to report that this occurred and then to notify me so an investigation could be started. I am very upset that this incident was never reported to anyone. The staff is supposed to immediately report an incident such as this to the DON immediately. If she could not be reached the ADON should have been called. Interview with the Licensed Practical Nurse Supervisor (staff L) via telephone on [DATE] at 12:41 PM revealed, he was the supervisor the night resident # 3 expired. Staff L reported, I was told she was not breathing. I went to her room immediately to check her airway. She had a Bi-PAP on. I checked her pulse and I checked her chest to see if she was breathing or not. She did not have a pulse. I was in the room and the other nurse was checking her papers. This happened in one or two minutes when I did the assessment. One of the nurses brought me the paper that she was a DNR. We brought the crash cart to the room in case we had to start CPR. I called all of the nurses to help out. I did not start CPR when they brought me the paper. I told the CNA to clean her up and call her brother. The other nurse was on the phone with rescue and the police. Interview with the Certified Nursing Assistant (staff N) conducted by a Spanish speaking surveyor via telephone on [DATE] at 2:26 PM revealed the following was reported, she is familiar with the resident who passed away not too long ago. The nurse was the one that found her. The nurse (staff I) entered the room and I imagine that she saw her and she notified us and the supervisor (staff L). We went there with the crash cart, the nurses from the North and South and the other staff were involved in what was happening with the resident. I myself was in charge of bringing the crash cart and the supervisor had started at that moment. He had his hands on her chest. It was a matter of a couple of minutes. In one to two minutes, the nurse came with the yellow paper and everything was stopped. It was a very short time that had passed. We prepared her, cleaned and changed her so her brother could see her presentable. Interview with resident #3's primary care physician (PCP) who is the facility's Medical Director via telephone on [DATE] at 1:26 PM revealed the following was reported, he was the primary care physician for this resident. She was in the facility for a very long time and she was not a DNR until her last hospital stay. The DNR was signed at the hospital and I signed a DNR when she was readmitted . The DNR was in the chart, so I do not know why they started CPR. For the last two months of her life she only spent five days in the nursing home and the rest of the time in the hospital. She was very sick and her brother opted for the DNR. The DNR form was in her chart and they should not have started CPR. As her primary care physician and the Medical Director for the facility, I should have been told that this error occurred. When they called me to tell me she had expired, the CPR was never mentioned and I should have been told and the family should have been told. The facility's Immediate Jeopardy Removal Plan included: -CPR was immediately withdrawn for resident #3 in question, once Do Not Resuscitate (DNR) status was determined. Resident expired and was pronounced by Fire Rescue; therefore, no corrective action can be taken for the resident. -The Charge Nurse and Nursing Supervisor were both suspended pending outcome of the investigation. In addition, the nurse who performed CPR has been removed from the supervisory position. -The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Risk Manager, Medical Director, Primary Care Physician, Quality Assurance and Performance Improvement (QAPI) Committee and Resident's Proxy were notified on (MONTH) 20, 2019 that CPR had been initiated and immediately withdrawn once DNR status was confirmed. -Facility reported the incident of resident #3 in question to state agencies on (MONTH) 20, 2019 for neglect in the failure to honor a DNR. -Facility would report the license of the nurse involved in the incident to the state agency for failure to honor the resident's DNR on (MONTH) 11, 2019. -An investigation was initiated on (MONTH) 20, 2019 by the Administrator; the Director of Nursing (DON); and Assistant Director of Nursing (ADON)/Risk Manager to determine circumstances surrounding the events. Employees are being interviewed and statements collected related to the incident. -Any resident with a DNR has the potential to be affected by the same deficient practice. As such, the facility Administrative Nursing staff completed a 100% audit of residents' medical records to determine their code status and to ensure that the status was clearly identifiable. All residents identified to have a DNR were reviewed to ensure that all DNR documents were appropriately placed. -A new written protocol was developed and implemented on (MONTH) 20, 2019 which provides staff step by step instructions to follow in the event a resident is observed without pulse or respirations. All staff are being educated on the new protocol beginning on (MONTH) 20, 2019 by Nursing Administrative Staff. -On (MONTH) 20, 2019, the facility enforced use of their current CPR policy to ensure proper understanding on importance to check a residents Advanced Directives prior to initiating CPR. Nursing staff is being in-serviced on the current policy on (MONTH) 20, 2019 by Nursing Administration. -On (MONTH) 20, 2019, the facility initiated a directive requiring all nursing supervisors to immediately inform Administrative staff regarding any event requiring initiation of CPR and for all supervisory staff to notify Administration of any other systemic failure. All supervisors would be in-serviced on the new policy prior to reporting to duty effective (MONTH) 20, 2019 by the Administrator, DON and ADON/Risk Manager. -On (MONTH) 20, 2019, the facility's abuse policy and procedure were revised to include the failure to implement Advanced Directives as an example of neglect. -On (MONTH) 20, 2019, the DNR protocol was revised to require a supervisor to respond to all emergencies to ensure that appropriate protocols are followed. Nursing supervisors were in-serviced on the new policy on (MONTH) 20, 2019 by the Administrator; the DON; the ADON/Risk Manager. -Effective (MONTH) 20, 2019, all staff are currently being in-serviced by the Nursing Administration on the resident's right to formulate Advanced Directives, the facility's requirement to honor and implement those Advanced Directives, how to identify a resident's code status and Advanced Directives, and identification and reporting of abuse/neglect. -Employee must be able to answer all questions on proficiency audit correctly, otherwise they would not be able to work until proficiency is achieved. -Inservice education is being completed prior to the employee being able to work. Employees may not work until inservice education is completed. -197 employees in-serviced (75%) and continuous inservice education and proficiency audits until all employees were educated. Expectation of completing training of all employees by end of the last shift on (MONTH) 24, 2019. -The effectiveness of education would be audited via direct observation of implementation of the new policies and facility systems. If performance gaps or lack of understanding was identified, immediate remedial education would be provided. Documentation of education would be compiled by the facility. -The DON, ADON and/or the Risk Manager would audit the record of all residents who expire in the facility to ensure proper protocol was followed related to the implementation of Advanced Directives. The DON/designee would summarize audit findings and report results to the Quality Assurance Performance Improvement Committee Monthly. -A special QAPI Committee Meeting would be held on (MONTH) 21, 2019 to discuss the newly revised and developed policies. The committee would review possible areas of improvement in staff reporting of systemic failures, educational opportunities related to Advanced Directives and ways to improve identification of quality of care and life deficiencies. On [DATE], the information in the facility's removal plan was verified as completed. Thirteen facility staff members were interviewed to confirm the implementation of the facility's removal plan to include (1) Nurse Supervisor, (1) Unit Manager, (1) Restorative Nurse, (1) Registered Dietitian, (2) CNAs and (7) Nurses. The facility's immediate jeopardy was removed on [DATE] at 6:07 P.M.

Based on record review and interview, the facility failed to ensure effective administration as evidenced by a failure to ensure resident's rights were honored related to advanced directives, failure to ensure residents were free from neglect, failure to oversee care and ensure the facility's policy addressing advanced directives w followed as evidenced by initiation of cardio-pulmonary resuscitation (CPR) on a resident with a do not resuscitate (DNR) order. This has the potential to affect 121 residents residing in the facility with DNR orders. There were 264 residents residing in the facility at the time of the survey. Cross reference: F578, F600 and F678 On (MONTH) 20, 2019, it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 20, 2019. The immediate jeopardy was identified on [DATE], beginning on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The findings included: Review of the job description for the Administrator dated 2003 revealed, the primary purpose of your job position is to direct the day to day functions of the facility in accordance with current state, federal and local standard, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Duties and responsibilities include: -Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. -Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. -Ensure that all employees follow the facility's established policies and procedures. -Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility. -Ensure that the resident's rights to fair and equitable treatment, self determination, and individuality are well established and maintained at all times. Review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation dated [DATE] Procedure revealed the following: 1. Determine unresponsiveness by tapping or gently shaking resident and shouting Are you okay? 2. Call out for help. 3. Delegate specific individual to check residents care plan for CPR or no CPR order, have individual call paramedics, attending physician and administrative personnel per facility policy and report back to you as soon as possible. General Documentation Guidelines: 1. Date and exact time condition change was observed. 2. VS or absence of vital signs 3. Exact time CPR was started. 4. Exact time paramedics were notified 5. Exact time paramedics arrived 6. Exact time physician was called and exact time reached. 7. physician's orders [REDACTED].>8. Exact time resident was transferred. Review of the policy statement titled Do Not Resuscitate Order revised (MONTH) (YEAR) revealed: Our facility will not use cardio-pulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate order in effect. A DNR order must be completed and signed by the attending physician and the resident or legal surrogate as permitted by State law and scanned into the resident's medical record. Use only State approved DNR forms. DNR orders will remain in effect until the resident or legal representative provides the facility with a signed and dated request to end the DNR order. Record review revealed resident #3 was admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident was sent to a local hospital due to shortness of breath. Resident #3 was readmitted to the facility on [DATE] through [DATE]. On [DATE], the resident had short of breath (SOB), the oxygen saturation was 83% with oxygen on the resident at 2 liters/minute, the respiratory rate was 16 breaths/minute, the bood glucose fingerstick was 240, blood pressure was ,[DATE], the breathing was labored and the resident skin was clammy. The resident was sent to a local hospital by 911/rescue. Resident #3 was readmitted to the facility on [DATE] and she expired in the facility on [DATE]. Record review revealed resident #3 had multiple [DIAGNOSES REDACTED]. Record review revealed a Do Not Resuscitate order dated [DATE] and signed by two physicians and resident #3's health care proxy. The State of Florida Do Not Resuscitate (DNR) order form was on file in the resident #3's clinical record. Review of the physicians order sheet for the admissions of [DATE] through [DATE] and [DATE] through [DATE] revealed a code status checked for: Do Not Resuscitate. Review of the facility's demographic face sheet for the admission of [DATE] revealed code status documented as: Full Code. Record review revealed resident #3 last readmission to the facility was on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A [MEDICAL CONDITION] machine is a type of non-invasive mechanical ventilator that can help push air into the lungs. There was also an order [REDACTED]. Review of the daily skilled nursing notes dated [DATE] revealed: 12:40 AM Resident received in bed with HOB (head of bed) elevated. Awake, alert. [MEDICAL CONDITION] and O2 @ 4 L/NC in use. Respirations unlabored. Call bell in reach. No signs or symptoms (s/s) of hypo/hyperglycemic episode. No s/s of distress or discomfort. Vitals assessed. Pleasant demeanor. 1:15 AM Resident noted unresponsive, eyes open. [MEDICAL CONDITION] in use with 4 L/NC. Skin warm and dry. No response to name called. Unable to detect vital signs, CPR (Cardiopulmonary Resuscitation) in progress. 1:20 am Called placed to rescue 911, report reported. 1:25 AM Rescue arrived at 1:15 @ bedside, brother aware. 1:30 AM Resident declared expired by rescue. Doctor made aware. 1:35 AM Brother at bedside with other family members. Interview with the Licensed Practical Nurse (staff I) via telephone on [DATE] at 1:38 PM the following was reported, resident # 3 was a resident who was at the facility for a very long time. She was dependent on staff for all care. She was not verbal, but she was able to gesture her needs. She had just returned from the hospital the afternoon before she expired. She was using a Bi-PAP machine and she used continuous oxygen. When I went to check on her and she was not responding. She was sitting upright in the bed. She had the Bi-PAP machine and the oxygen on. When I entered the room I saw her with her eyes open, but she was not looking at me. I called her name and she did not respond. Normally, she would always look at you. I had just recently checked on her and she was alert. She was happy to be back at the facility. I immediately called the supervisor who was present on the floor. He immediately checked on her and he started to do CPR on her. While he was doing the CPR, the other nurse called 911 and the crash cart was brought into the room. CPR was continued until 911 arrived and they took over from there. I was not in the room at this time because I was gathering the paperwork for them. If a resident has a DNR we would check the chart to get that information. The chart and the MAR have the yellow copy of the DNR. If a resident is found unresponsive we have to go quickly to check the chart or the MAR (medication administration record) to see if the resident has a DNR. I do not remember if Resident # 3 had a DNR order. During a follow up interview with the Licensed Practical Nurse (staff I) on [DATE] at 11:44 AM the following was reported, when I found resident # 3 unresponsive, I alerted the supervisor immediately. The room is close to the supervisor's office. The other nurse on the unit called 911. The crash cart was taken into the room and the supervisor started CPR. This was my patient and I should have checked to see if she had a DNR. In the process of all this running around we immediately reacted in the moment and started CPR. This patient was a young women. After the CPR was started, the other nurse called 911 and gathered the papers. She showed the supervisor the DNR and he stopped the CPR. I do not know if he reported this to the DON (Director of Nursing). Interview with the Assistant Director of Nursing (ADON)/Risk Manager on [DATE] at 8:26 AM the following was reported, resident # 3 was a long term resident who was here since 2009. She had End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT], [MEDICAL CONDITIONS], Diabetes, cardiac issues and [MEDICAL CONDITION]. She had been stable, but towards the end, she had exacerbation of her [MEDICAL CONDITION] and fluid overload. Her brother was her POA (power of attorney) and he was very involved. She was in and out of the hospital from the end of (MONTH) through the time she expired. She was readmitted on [DATE] with a [DIAGNOSES REDACTED]. She was readmitted just before 5 PM on [DATE] and she expired later that day on the morning of [DATE] about 1:30 AM. Her code status at the time of this admission was DNR. She had a DNR ordered while she was in the hospital on [DATE]. Her brother stated they tried to intubate her at the hospital, but the brother did not want this. She came back to us with a Bi-PAP machine on [DATE]. He opted to sign the DNR rather than have her intubated. The Risk Manager reviewed the nurses notes for [DATE] and stated she could not explain why CPR was implemented for a resident with a DNR. She stated, during all of her other admissions resident #3 was a full code. Normally, if we find a resident unresponsive we will check for vitals. The supervisor is called right away and the chart is checked for DNR status. CPR is started or not depending on the code status. The yellow DNR's are filed in the front of the MAR and in the front of the chart binder. I thought they checked and resident # 3's status and called 911. I was not aware the staff did CPR. This is the first I knew they did CPR. This was a nurse who was very familiar with this resident and she had been a full code until [DATE]. The protocol is simple, you check the vitals, check the chart and start CPR if they are a full code. If they have a DNR they are supposed to call non-emergency and not do CPR. The only thing I can think of is, she had been full code for so long. Interview with the ADON/Risk Manager on [DATE] at 8:45 AM revealed the following was reported, if I became aware of a resident who did not receive CPR and was not DNR status or a resident who received CPR and had a DNR, we would do an investigation and report the situation as an adverse incident. I have never had this situation before. I did not report this incident or do an investigation because I was not aware resident #3 received CPR. She reported, part of the staff orientation included training on CPR and the DNR process. The nurses receive a three to four day orientation and this training is done by either the nurse on the floor or the supervisor. The DNR/CPR training is not done annually, it is part of the orientation. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM revealed the following was reported, she was not made aware that CPR had been provided for resident # 3. I was never made aware of this incident until today. The information that I have gotten so far is that resident # 3 had been very sick for the past few months. She had been in and out of the hospital. Her brother is very involved with her care and prior to this last admission she had always been a full code. During her last hospitalization he made her a DNR. The DNR was in her record. What I found out so far is that she was found unresponsive, the supervisor was checking her vital signs. He started CPR. The nurse came in and said she was a DNR and he stopped. They called 911 and they arrived and she was pronounced. I do not know how this happened. The nurses know they have to check the chart first before starting CPR. If the chart is not there, we even have a copy of the DNR in the MAR so time would not be lost determining someone's code status. If they see that something like this happened and they made an error, they have to report to me as the DON, the Risk Manager/ADON and then I would report it to the administrator. I would have started an investigation, notified the family and started to re-educate the staff. We have now started the investigation. Of course, I will notify her primary doctor today. Her primary doctor is also our Medical Director. Interview with the Nursing Home Administrator (NHA) on [DATE] at 12:06 PM revealed she reported, she had no idea that CPR was initiated on a resident with a DNR in place. I just found out today that this occurred when the DON and ADON found out. When an incident like this occurs, we have to do an investigation, an adverse report, notify the family and in-service all of our nurses and CNA's (Certified Nursing Assistant) and everyone involved in the care of residents to make sure this does not happen again. That I am aware of, we do not have a policy to address the steps taken in the event of this type of situation. We keep the DNR's in the chart and the MAR, but we do not have a written step by step policy and procedure to address CPR or DNR status. After this incident that happened, I will have to sit down with the DON to establish a step by step procedure for the staff to follow. They do know where the DNR's are located. I do not think the supervisor had the DNR, so this is why he started CPR. I would expect the staff to contact either the DON or the ADON/Risk Manager to report that this occurred and then to notify me so an investigation could be started. I am very upset that this incident was never reported to anyone. The staff is supposed to immediately report an incident such as this to the DON immediately. If she could not be reached the ADON should have been called. Interview with the Licensed Practical Nurse Supervisor (staff L) via telephone on [DATE] at 12:41 PM revealed, he was the supervisor the night resident # 3 expired. Staff L reported, I was told she was not breathing. I went to her room immediately to check her airway. She had a Bi-PAP on. I checked her pulse and I checked her chest to see if she was breathing or not. She did not have a pulse. I was in the room and the other nurse was checking her papers. This happened in one or two minutes when I did the assessment. One of the nurses brought me the paper that she was a DNR. We brought the crash cart to the room in case we had to start CPR. I called all of the nurses to help out. I did not start CPR when they brought me the paper. I told the CNA to clean her up and call her brother. The other nurse was on the phone with rescue and the police. Interview with the Certified Nursing Assistant (staff N) conducted by a Spanish speaking surveyor via telephone on [DATE] at 2:26 PM revealed the following was reported, she is familiar with the resident who passed away not too long ago. The nurse was the one that found her. The nurse (staff I) entered the room and I imagine that she saw her and she notified us and the supervisor (staff L). We went there with the crash cart, the nurses from the North and South and the other staff were involved in what was happening with the resident. I myself was in charge of bringing the crash cart and the supervisor had started at that moment. He had his hands on her chest. It was a matter of a couple of minutes. In one to two minutes, the nurse came with the yellow paper and everything was stopped. It was a very short time that had passed. We prepared her, cleaned and changed her so her brother could see her presentable. Interview with resident #3's primary care physician (PCP) who is the facility's Medical Director via telephone on [DATE] at 1:26 PM revealed the following was reported, he was the primary care physician for this resident. She was in the facility for a very long time and she was not a DNR until her last hospital stay. The DNR was signed at the hospital and I signed a DNR when she was readmitted . The DNR was in the chart, so I do not know why they started CPR. For the last two months of her life she only spent five days in the nursing home and the rest of the time in the hospital. She was very sick and her brother opted for the DNR. The DNR form was in her chart and they should not have started CPR. As her primary care physician and the Medical Director for the facility, I should have been told that this error occurred. When they called me to tell me she had expired, the CPR was never mentioned and I should have been told and the family should have been told. The facility's Immediate Jeopardy Removal Plan included: -CPR was immediately withdrawn for resident #3 in question, once Do Not Resuscitate (DNR) status was determined. Resident expired and was pronounced by Fire Rescue; therefore, no corrective action can be taken for the resident. -The Charge Nurse and Nursing Supervisor were both suspended pending outcome of the investigation. In addition, the nurse who performed CPR has been removed from the supervisory position. -The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Risk Manager, Medical Director, Primary Care Physician, Quality Assurance and Performance Improvement (QAPI) Committee and Resident's Proxy were notified on (MONTH) 20, 2019 that CPR had been initiated and immediately withdrawn once DNR status was confirmed. -Facility reported the incident of resident #3 in question to state agencies on (MONTH) 20, 2019 for neglect in the failure to honor a DNR. -Facility would report the license of the nurse involved in the incident to the state agency for failure to honor the resident's DNR on (MONTH) 11, 2019. -An investigation was initiated on (MONTH) 20, 2019 by the Administrator; the Director of Nursing (DON); and Assistant Director of Nursing (ADON)/Risk Manager to determine circumstances surrounding the events. Employees are being interviewed and statements collected related to the incident. -Any resident with a DNR has the potential to be affected by the same deficient practice. As such, the facility Administrative Nursing staff completed a 100% audit of residents' medical records to determine their code status and to ensure that the status was clearly identifiable. All residents identified to have a DNR were reviewed to ensure that all DNR documents were appropriately placed. -A new written protocol was developed and implemented on (MONTH) 20, 2019 which provides staff step by step instructions to follow in the event a resident is observed without pulse or respirations. All staff are being educated on the new protocol beginning on (MONTH) 20, 2019 by Nursing Administrative Staff. -On (MONTH) 20, 2019, the facility enforced use of their current CPR policy to ensure proper understanding on importance to check a residents Advanced Directives prior to initiating CPR. Nursing staff is being in-serviced on the current policy on (MONTH) 20, 2019 by Nursing Administration. -On (MONTH) 20, 2019, the facility initiated a directive requiring all nursing supervisors to immediately inform Administrative staff regarding any event requiring initiation of CPR and for all supervisory staff to notify Administration of any other systemic failure. All supervisors would be in-serviced on the new policy prior to reporting to duty effective (MONTH) 20, 2019 by the Administrator, DON and ADON/Risk Manager. -On (MONTH) 20, 2019, the facility's abuse policy and procedure were revised to include the failure to implement Advanced Directives as an example of neglect. -On (MONTH) 20, 2019, the DNR protocol was revised to require a supervisor to respond to all emergencies to ensure that appropriate protocols are followed. Nursing supervisors were in-serviced on the new policy on (MONTH) 20, 2019 by the Administrator; the DON; the ADON/Risk Manager. -Effective (MONTH) 20, 2019, all staff are currently being in-serviced by the Nursing Administration on the resident's right to formulate Advanced Directives, the facility's requirement to honor and implement those Advanced Directives, how to identify a resident's code status and Advanced Directives, and identification and reporting of abuse/neglect. -Employee must be able to answer all questions on proficiency audit correctly, otherwise they would not be able to work until proficiency is achieved. -Inservice education is being completed prior to the employee being able to work. Employees may not work until inservice education is completed. -197 employees in-serviced (75%) and continuous inservice education and proficiency audits until all employees were educated. Expectation of completing training of all employees by end of the last shift on (MONTH) 24, 2019. -The effectiveness of education would be audited via direct observation of implementation of the new policies and facility systems. If performance gaps or lack of understanding was identified, immediate remedial education would be provided. Documentation of education would be compiled by the facility. -The DON, ADON and/or the Risk Manager would audit the record of all residents who expire in the facility to ensure proper protocol was followed related to the implementation of Advanced Directives. The DON/designee would summarize audit findings and report results to the Quality Assurance Performance Improvement Committee Monthly. -A special QAPI Committee Meeting would be held on (MONTH) 21, 2019 to discuss the newly revised and developed policies. The committee would review possible areas of improvement in staff reporting of systemic failures, educational opportunities related to Advanced Directives and ways to improve identification of quality of care and life deficiencies. On [DATE], the information in the facility's removal plan was verified as completed. Thirteen facility staff members were interviewed to confirm the implementation of the facility's removal plan to include (1) Nurse Supervisor, (1) Unit Manager, (1) Restorative Nurse, (1) Registered Dietitian, (2) CNAs and (7) Nurses. The facility's immediate jeopardy was removed on [DATE] at 6:07 P.M.