Every finding on record at North Healthcare and Rehabilitation Center

Based on record review and interviews, the facility failed to have eight consecutive Registered Nurse (RN) hours seven days a week for seventeen of ninety-one days in the third quarter of Fiscal Year (FY) 2025.Findings included: Review of Payroll Based Journal (PBJ) Data (FY) Quarter 3 2025 (April 1-June 30) revealed no RN Hours were Triggered on 10/05/2024; 10/12/2024; 10/13/2024; 4/5/2025; 4/6/2025; 4/12/2025; 4/13/2025; 4/19/2025; 4/20/2025; 4/26/2025; 4/27/2025; 5/11/2025; 5/25/2025; 5/26/2025; 5/31/2025; 6/1/2025 and 6/21/2025.During an interview on 9/4/25 at 09:50 a.m., with Staff H, Staffing Coordinator, employed for one year, stated, It is my responsible to staff the building and when I staff the building, I make sure that I have enough Licensed Practical Nurses (LPN) and RNs to meet the needs of the residents. For instance, if I have 38 residents, .when it comes to nurses, I try to always have two to three RN's and LPN's, which we're required to have an RN on staff eight hours a day. If I do not have an RN working on the floor for med [medication] pass, I use the Assistant Director of Nursing [ADON] or the Director of Nursing [DON] as substitutes for RNs on the floor during med pass. The ADON or DON will fill in and no temp [contracted staff] services are used in the facility. Not having temps has not caused us an issue. We have not run into an instance where we weren't able to cover RN hours. Looking at the scheduling, it appears we didn't have RN's assigned during 10/05/2024; 10/12/2024; 10/13/2024; 4/5/2025; 4/6/2025; 4/12/2025; 4/13/2025; 4/19/2025; 4/20/2025; 4/26/2025; 4/27/2025; 5/11/2025; 5/25/2025; 5/26/2025; 5/31/2025; 6/1/2025 and 6/21/2025. My order for acquiring an RN for staff is to call the current staff, then go to the ADON, then the DON. The staff that is on call that weekend is given a company phone to answer to come to staff that weekend. While reviewing the dates with no RN hours reported, the Staffing Coordinator stated, The days you're referring to, we did not have RN's available to fill in per my schedule.During an interview on 9/4/25 at 10:39 with the NHA and DON. The DON stated, we generally always have a minimum of two LPN'S and RN'S on staff 24/7 [twenty-four hours a day, seven days a week]. Just to ensure if someone calls out an emergency to cover them, we use a master schedule if someone calls out, then we have a call in policy. We ensure there is coverage, either from the DON or the ADON makes the call and provides coverage. We have a work phone for the call down list to ensure that someone answers. The DON and ADON will be called in to staff if we can't get anyone else to staff the floor, specifically Registered Nurse's. We alternate weekends with the DON/ADON for on-call staff. The NHA said, the data was sent was miscoded by the contracted human resources department to the payroll-based journal reporting system. The companies that we used to report to payroll data and to the Centers for Medicaid Services (CMS) were contracted and unfortunately, based on past payroll policy we don't have data to show RN hours for the covered periods identified. Due to a policy with the old payroll and reporting company who reported the hours, I learned I miscoded the data and will get help with staffing and coding going forward to fix the reporting issue. Review of facility's staffing coordinator job description dated January 2015. The primary purpose of your position is to ensure adequate and appropriate staffing of the facility's nursing department to meet the needs of the residents based on budget, census and as may be directed by Facility administration.Delegation of AuthorityAs Staffing Coordinator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.Work with Human Resource Delegate and DON when scheduling modified work duty employees, in accordance with work restrictions and Facility policy.Complete monthly nursing schedule coordinating requests to ensure appropriate coverage of units.Consult with nursing department staff and supervisors concerning the staffing and scheduling needs: to assist in elimination and correction of problem areas, and/or improvement of services. Review of the facility's policy Staffing revised on October 2017 revealed, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care and services.4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter.

Based on observations and interviews, the facility did not ensure infection control practices were followed related to: 1) food handling; 2) a non-cleanable surface and storage of a respiratory mask in two out of two resident rooms. Findings included: 1. On 9/3/25 at 10:31 a.m., an observation of Resident #2 revealed he was sitting in the wheelchair using a yellow gait belt to maneuver between the bed and the window. He lifted up the mattress and revealed a flattened cardboard box on top of the bed frame. He said facility staff put the cardboard box there because the bar in the middle of the bed was hurting his back. Further observations of the top of the cardboard box revealed particles of food and other small debris. A review of Resident #2’s admission record revealed an initial admission date of 11/7/22 and a re-admission date of 3/29/23. Further review of the admission record revealed diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), other muscle spasm, and other lower back pain. On 9/4/25 at 10:29 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She said Resident #2 has told her his mattress is not comfortable and the bar presses into his back. She said that is why the cardboard box is under the mattress. Staff D, LPN said the mattress had been switched a few times, but the resident continued to say it is not comfortable. On 9/4/25 at 4:32 p.m., an interview was conducted with the Housekeeping Supervisor. She said she was not aware Resident #2 had cardboard under the mattress and between the bed frame. The Housekeeping Supervisor said it could be nursing or maintenance staff who put it there. An observation of the flattened cardboard box with the Housekeeping Supervisor, and Resident #2 present, revealed it was put there to prevent the mattress from slipping. The Housekeeping Supervisor said the cardboard box is cleanable. She said it could be sprayed with chemicals and wiped down. Observations of the cardboard box revealed it had the same food particles and debris seen on 9/3/25. On 9/4/25 at 4:47 p.m., a follow-up interview was conducted with the Housekeeping Supervisor. She said the previous Director of Maintenance (DOM) put the cardboard box under Resident #2’s mattress because he expressed his back was hurting. She said this information was provided to her from the resident. On 9/4/25 at 4:49 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated Resident #2’s, “Mattress has always been an issue.” She said the previous DOM put the cardboard box under the mattress. The NHA stated, “The resident asked for it because there’s a pole there.” She stated staff sprayed liquid on the cardboard and, “Sounds like they are letting the liquid sit.” The NHA said she didn’t consider that it was not a cleanable surface. 2. On 9/4/25 at 11:17 a.m., an observation of Staff E, dietary staff revealed he was handling food with gloved hands, walked away to cough, and came back to resume the task without changing gloves/performing hand hygiene. Staff E, dietary staff wiped his face on his sleeve multiple times during the observation with the same gloves and did not perform hand hygiene. He was observed touching his pants and shirt while wearing gloves and handling food. At 11:24 a.m., the Kitchen Manager removed the gloves he had on while completing tasks and put those gloves on a meal tray that was to be used by a resident. On 9/4/25 at 2:58 p.m., an interview was conducted with the Kitchen Manager. He said staff should be completing hand hygiene when they are in the middle of a task, then leave the area to complete another task, and come back. The Kitchen Manager stated when staff, “Move away from tasks,” they should wash their hands. He stated, “You should take your gloves off, wash your hands, put gloves on again, then do the next task.” The Kitchen Manager said if staff touched their clothes while handling food, they should take their gloves off and wash their hands. He said he's responsible for educating the dietary staff on hand hygiene. He said the last education the dietary staff received on hand hygiene was about two weeks ago. 3. An observation was conducted on 9/3/25 at 10:50 a.m. of a nebulizer mask sitting on the bedside table with stuffed animals, unbagged in room [ROOM NUMBER]. The nebulizer machine was sitting on a carboard box on the floor beside the table. An observation was made on 9/5/25 at 10:00 a.m. of the respiratory mask was again observed to be unbagged in room [ROOM NUMBER] and hanging off the side of the table behind a balloon. An interview was conducted on 9/5/25 at 10:10 a.m. with Staff D, Licensed Practical Nurse (LPN). Staff D said respiratory masks in resident rooms should be in a bag at the bedside. An interview was conducted on 9/5/25 10:45 a.m. with the facility’s Infection Preventionist (IP). The IP said carboard is not a cleanable surface. She said she was not aware of the carboard on the bed in room [ROOM NUMBER] until 9/4/25. The IP said the carboard should not have been on the bed and a new bed had been ordered for the room. As for infection control practices of the kitchen staff, she said the CDM would have educated them. The IP said the kitchen staff did participate in “all staff” trainings that are held and they did participate the skills fair in the spring that include infection control. The IP said she had not done infection control audits of kitchen staff but she would expect them to do hand hygiene after coughing and between touching other items such as clothes or hair then touching food items. Regarding respiratory masks, the IP said the masks in resident rooms should be in plastic bags at the bedside when they are not in use. The IP said she saw the respiratory mask in room [ROOM NUMBER] unbagged on 9/4/25 and she went and got a bag for it. She said the nebulizer must have been administered and then not put back in a bag. The IP said she also saw the nebulizer machine sitting on the cardboard box on the floor and staff had done that to keep the machine off the floor. The IP said the machine needs to be on the table. Review of a facility policy titled “Infection Prevention and Control Program,” revised October 2018, showed: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of a facility policy titled “Handwashing/Hand Hygiene,” revised August 2019, showed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The facility did not have a policy related to nebulizer mask storage.

Based on observations, interviews, and record reviews the facility did not ensure chemicals were secured and the smoking policy was followed for two residents (#32 and #50) out of seven residents that smoke. Finding included: An observation was conducted on 9/3/25 at 9:29 a.m. of Residents #32 and #50. Both residents were on the smoking patio with no staff present or in sight of the residents and no smoking aprons on or available. It was also observed that a shed on the patio was unlocked. The shed had a CAUTION HAZARDOUS CHEMICALS. AUTHORIZED PERSONNEL ONLY sign on the door and inside the shed were multiple bottles of chemicals observed.An observation was conducted on 9/3/25 at 1:18 p.m. of Resident #32 on the smoking patio with no staff present or within sight and no smoking apron on or available. Resident #32 was sitting in his/her wheelchair slumped over asleep. The resident woke up when his/her name was called. Upon waking up it was observed Resident #32 had a lit cigarette in their right hand. The shed containing chemicals remained unlocked.An observation was conducted on 9/4/25 at 1:20 p.m. of Resident #32 along with three other residents on the smoking patio. Staff C, Certified nursing Assistant (CNA) was present. Resident #32 did not have a smoking apron in place. The shed containing chemicals remained unlocked. Review of admission Records showed Resident #32 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), polyneuropathy, muscle weakness, and tobacco use. Review of Resident #32's Brief Interview for Mental Status (BIMS), dated 7/28/25, showed a score of 15 out of 15, indicating intact cognition. Review of Resident #32's care plan, revised on 9/3/25, showed a focus area of a desire to smoke. Resident #32 has been assessed as able to smoke with a smoking apron. Interventions included, accompany resident to designated smoking area as needed and provide supervision while smoking in resident-designated smoking area, monitoring for signs of unsafe smoking practices, apply/remove smoking apron. Prior to the 9/3/25 smoking care plan revision Resident #32 was care planned from 4/25/24 through 9/3/25 to be assessed as able to smoke independently. Review of Resident #32's progress notes showed a nurse's note dated 8/31/25, Nursing attempted to give resident am [morning] medications. He is currently sitting on the patio asleep. He has burned a hole in his pants, and the cigarette is on the ground still lit with fire. Resident states he wasn't asleep.Review of Resident #32's Nursing Smoking Evaluation, dated 9/2/25 revealed Resident #32 does not remain alert during the course of smoking. The resident safely lights a cigarette, safely holds a cigarette, disposes ashes and butts properly, the resident is free of visible upper extremity tremors, is free from upper extremity contractures, is free from loss of mobility, reduced movement, weakness, or paralysis of the dominant upper extremity. And the resident is free from visual issues that impair their ability to smoke. the total score of the smoking assessment was a 1 if the total number is 1 or more, they are considered and unsafe smoker and must use a smoking apron until a screening is completed by occupational therapy. The resident/resident representative/resident family have been informed of the smoking policy/procedures. can plan has been reviewed and updated. On 9/3/25 the Occupation Therapist documented on the smoking assessment During observation by this therapist several time[sic] during the day, patient demonstrated good safety while lighting, holding, smoking and extinguishing cigarette. Patient shows good fine motor coordination and dexterity needed to smoke a cigarette. Review of Resident #50's admission Records showed Resident #50 was admitted on [DATE] with diagnoses of acute kidney failure, fall on same level, and tobacco use. Review of Resident #50's BIMS score, dated 8/29/25, showed a score of 14 out of 15, indicating intact cognition. Review of Resident #50's care plan, dated 9/4/25, showed a focus area of Resident desires to smoke. Resident has been assessed as able to smoke with supervision. Interventions included, accompany resident to designated smoking area as needed and provide supervision while smoking in resident-designated smoking are, monitor for signs of unsafe smoking practices, and accompany resident to designated smoking area to provide supervision. An observation and interview were conducted on 9/4/25 at 1:30 p.m. with the Nursing Home Administrator (NHA). The NHA was observed walking on to the smoking patio and going to the shed containing chemicals. The NHA confirmed the shed was unlocked and it contained chemicals from the housekeeping department. The NHA said the shed should always be locked and agreed it was a potential hazard to residents. The NHA confirmed residents are able to come and go from the courtyard. An interview was conducted on 9/4/25 at 2:48 p.m. with Staff C, CNA. Staff C confirmed he was the staff member on the smoking patio on 9/4/25 at 1:20 p.m. He said Resident #32 did not have a smoking apron on while smoking. A follow up interview was conducted on 9/4/25 at 2:35 p.m. with the NHA. The NHA said there is not a set staff member to be the smoking aid, it rotates. She said a staff member should be present in sight of the residents smoking on the patio during the smoking times. The NHA said she had spoken to Resident #32 about needing to wear an apron while smoking but did not think it had been put in place yet. The NHA was surprised to hear staff were not present while residents were smoking on the patio. Review of a facility policy titled Storage Areas, Environmental Services, revised December 2009, showed:Policy StatementHousekeeping and laundry department storage areas shall be maintained in a clean and safe manner. Review of a facility policy titled Hazardous Areas, Devices and Equipment, revised July 2017, showed:Policy StatementAll hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.Policy Interpretation and Implementation1. As part of the facilities overall safety and accident prevention program, hazardous areas and objects in the resonant environment will be identified and addressed by the safety committee.Identification of Hazards1. A hazard is defined as anything in the environment that has the potential to cause injury of illness. Examples of environmental hazards include, but are not limited to the following:.d. Open areas or items that should be locked when not in use Review of a facility policy titled Smoking Policy, undated, showed:Purpose: Resident, employee and visitor safety.Smoking Area: Garden Patio4. Residents will be evaluated to ensure safe smoking.5. Residents evaluated as requiring supervision or assistance may only do so with assistance of staff or a responsible party as determined by the facility and may have specific smoking times assigned.

Based on observations, interviews, and record reviews the facility did not ensure one resident (#7) was assisted out of bed daily and splints were placed for one resident (#27) out of thirteen sampled residents.Findings included: An observation was conducted on 9/3/25 at 9:25 a.m. of Resident #7. The resident was observed to be lying in bed flat on his/her back with a neck support pillow. The resident remained in this position throughout the day. An observation was conducted on 9/4/25 at 10:09 a.m. and 12:00 p.m. of Resident #7 lying flat in the bed with a neck support pillow in place. Review of Resident #7’s “admission Record” showed Resident #7 was admitted on [DATE] with diagnoses of unspecified fall, dementia, cerebral infarction, muscle weakness, difficulty in walking, and need for assistance with personal care. Review of Resident #7’s quarterly Minimum Data Set (MDS), dated , 6/8/25, Section C, cognitive patterns, showed a score of 99, indicating the resident was unable to complete the interview. Review of Resident #7’s care plan, dated 8/21/24, showed a focus area of extensive assistance to total care for most activities of daily living (ADL) completion due to weakness, cognitive condition and poor safety awareness. Interventions included extensive assistance needed to get in and out of bed to a chair/wheelchair and returning to bed. An interview was conducted on 9/3/25 at 1:08 p.m. with Resident #7’s Resident Representative (RR). The RR said they don’t understand why the resident is never out of bed. The RR said Resident #7 is only out of bed when they request staff to get him/her up. The RR said they wanted the resident to have a good quality of life for what life he/she had left and did not want the resident to sit in bed all the time. The RR said they want Resident #7 up and in the common areas and being able to see other people. An interview was conducted on 9/4/25 at 1:25 p.m. with Staff A, Certified Nursing Assistant (CNA). Staff A said Resident #7 was typically out of bed on Tuesdays when the RR visited. Staff A said there was a staff member that got the resident up on Mondays. Staff A said he/she got the resident up on the weekends they worked. When asked about Resident #7 being out of bed the other days of the week, Staff A only responded by saying “I will probably get [Resident #7] up this weekend.” Staff A confirmed Resident #7 had not been out of bed on 9/3/25 or 9/4/25. An interview was conducted on 9/4/25 at 3:22 p.m. with Staff B, Licensed Practical Nurse (LPN). Staff B said Resident #7 used to be out of bed more and didn’t know why the resident didn’t get out of bed now. Staff A said maybe it was the family’s request, but they didn’t know. An interview was conducted on 9/4/25 at 4:51 p.m. with the Director of Nursing (DON). The DON said Resident #7 did get out of bed and they wanted him up at least three days a week. She did say that it is not written anywhere or documented. The DON said Resident #7’s RR had spoken to her not long ago about getting the resident out of bed more. The DON said she told the RR she would work on it but honestly hadn’t done much to make sure it happened and had not put anything in the medical record. The DON agreed it was not ok for Resident #7 to lay in bed all day and not be up. She said the resident even had a new wheelchair. Review of a facility policy titled “Activities of Daily Living (ADLs), Supporting, undated, showed: Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. mobility (transfer and ambulation, including walking) 2. An observation was conducted on 9/3/25 at 11:00 a.m. of Resident #27. The resident was observed lying in bed, and the resident’s right hand was visible. Resident #27’s right hand appeared contracted (fingers bent into the palm of the hand). Resident #27 stated he/she had a splint for the right hand, but staff don’t offer to put the splint on. The resident’s right hand remained in this position throughout the day without a splint on. During an interview on 9/4/25 at 9:49 a.m. Resident #27 stated the splint is dirty and needs to be cleaned, the staff do not offer to wash it. Resident #27 stated the staff did not offer to put the splint on today. Review of Resident #27’s admission Records showed Resident #27 was admitted on [DATE] with diagnoses of Parkinson’s Disease, epilepsy, cerebral infarction, and other co-morbidities. Review of Resident #27’s quarterly MDS dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. The quarterly MDS also revealed Resident #27 had range of motion (ROM) impairment on one side of Resident #27’s upper and lower extremities. Review of Resident #27’s care plan with a revision date of 10/25/21 showed Resident #27 had a self-care deficit with dressing, grooming, bathing related to: generalized weakness and Parkinson’s Disease. The goal revealed Resident #27 will continue to improve toward previous baseline ADL functioning throughout this review period. The interventions showed: resting hand splint to right hand seven times week. Apply following a.m. care, remove prior to p.m. care. Monitor skin integrity when applying and removing. Review of Resident #27’s “Visual/Bedside Kardex [a care document showing a specific resident’s care needs]” dated as of 9/3/25 showed ADLs: put on palm pillow to right hand in a.m. (morning) up to 8 hours… to prevent further contractures. May remove for ADL care; put on palm pillow to right hand seven times week. Apply following a.m. care, remove prior to p.m. (evening) care. Monitor skin integrity when applying and removing; and resting hand splint to right hand seven times week. Apply following a.m. care, remove prior to p.m. care. Monitor skin integrity when applying and removing. Review of Resident #27’s physician order summary revealed an order dated 8/20/24 occupational therapy clarification: DON (put on) palm pillow to right hand in a.m. and doff (take off) in p.m. as tolerated. Remove every shift to ensure skin integrity. May remove PRN (as needed) for ADL care. During an interview on 9/4/25 at 10:06 a.m. Staff N, CNA stated the Kardex is how we know what each resident is cared for. Staff N, CNA stated being familiar with Resident #27 and not sure if Resident #27 needs hand splints. During an interview on 9/4/25 at 10:10 a.m. Staff B, LPN stated CNAs are responsible for putting on residents’ splints or other personal care items if residents have them. Staff B, LPN stated being responsible for Resident #27 and not being sure if hand splints are required. During an interview on 9/4/25 at 10:24 a.m. the Director of Nursing (DON) stated splints should be donned and doffed according to the physician orders. The CNAs usually don and doff the splints, although any member of the nursing or therapy team are able. The DON stated not being aware the staff have not been placing Resident #27’s hand splint on and off. Review of the facility’s policy and procedure titled Splints, not dated, revealed: Policy: When a patient is on rehab for contracture management and splinting, the Therapy Department will monitor the splints and the wearing schedule. In preparation for discharge from therapy, Nursing, and Nursing Assistants will be trained in proper donning/doffing of equipment and proper skin evaluation. Procedure: 1. The therapist will write a T.O. (telephone order) with the proper instructions. The therapist will implement tasks on Kardex and MDS will follow up with placing in Care plan. 2. The resident's splint will be placed in the dresser or in the closet. The splint will have the resident's name on it. 3. CNA/nursing will be responsible for the proper donning/doffing of splints at the appropriate times. 4. Therapy will conduct random audits to determine if the splints are being properly donned/doffed. 5. Upon removing a splint and prior to donning, the resident should receive proper range of motion as tolerated and the skin should be checked for any reddened areas. Skin should be clean, dry, but moisturized (not wet) upon donning a splint. 6. Splints may be removed for ADLS, and prn (as needed) per patient tolerance. 7. Any areas that are reddened indicate areas of pressure. Pale or blanched areas may indicate severe pressure. In both cases, nursing is to be notified immediately, and the splint shall be returned to the DON who will then communicate with therapy. 8. Splints should be returned to therapy for proper cleaning.

Based on record review and interviews, the facility failed to honor the right of a resident or his/her legal representative to receive medical records timely, within two working days, for three (#1, #7, and #8) of three sampled residents reviewed for medical record request. Findings included: On 02/12/2025 at 9:55 a.m., a phone interview was conducted with Resident #1's representative. When asked if she was involved in the admission process for (Resident #1), she stated, yes. When asked if she signed a contract during the admission process, she stated, No contract, I just signed a consent to treat. When asked if she had requested medical records, she stated, I asked for a copy of the medical cost responsibilities. An interview conducted on 02/12/2025 at 2:09 p.m. with the Nursing Home Administrator, when asked if the resident/representative had requested medical records for Resident #1, she stated no, the only thing she asked for was a copy of the insurance conversion letter, which I supplied her with. No documentation was provided as to the date of the request or the fulfillment of the request. A review of the medical record request log for 12/2023 through the date of survey reflected no listing for medical record request for Resident #1. Further review of the log reflected the following entries for 12/2024 listed: Resident #8 requested medical records on 12/19/2024, by attorney office. Record fulfillment was documented to be 02/27/2024. Resident #7 requested medical records on 12/16/2024, by (representative). Record fulfillment was documented to be January 17, 2025. An interview was conducted on 02/12/2025 at 4:11 p.m. with the Medical Records Coordinator. For Resident #8, she said she had made an error on the fulfillment date, it should have been 01/27/2025. She stated the date received column was when she received the request, then she would forward the request to the facility's attorney and wait for a response. She stated she had 30 days to fulfill a medical records request. A review of the facility's policy and procedure for Access to Personal and Medical Records, revised 05/2017, documented the policy statement: Each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. The policy interpretation and implementation included: A resident may submit his/her request either orally or in writing for access to personal or medical information pertaining to him/her. The resident may obtain a copy of his or her personal or medical record within two business days of an oral or written request. The resident, or his/her legal representative, may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information is to be released.

Based on observation, record review, and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility did not label, date and/or cover food items stored in the refrigerator or freezer. Findings included: An observation, on 09/05/23 at 9:20 a.m., showed a reach-in refrigerator in the kitchen area that contained: - Three (3) sandwiches not labeled or dated. - A big bag of lettuce not labeled or dated. - 1 package of lunch meat smoked ham not dated. - An open package of orange square cheese slices with package ripped and left uncovered. (photographic evidence obtained) During an interview on 09/05/23 at 9:20 a.m., Staff A Dietary Manager (DM) stated food items stored in the refrigerator should be labeled and dated. Staff A stated the cheese should have been covered and stored appropriately. An observation, on 09/05/23 at 9:30 a.m., showed a reach-in freezer in the kitchen that contained: - Two whole frozen chicken breasts not labeled or dated. - Six frozen bags of broccoli (2 pounds and 8 ounces) each not labeled or dated. - Four frozen sugar peas (2 pound) bags each not labeled or dated. - One catalina blend (3 pound) bag not labeled or dated. - 12 bags of frozen peas/carrots mix (2 pound and 8 ounces) bags each not labeled or dated. (photographic evidence obtained) During an interview on 09/05/23 at 9:30 a.m., Dietary Manager (DM) stated that food in the freezer should be labeled and dated. DM stated the food truck came while he was not in the facility however, he would expect the dietary staff to label and date the food items before storing in the freezer. A review of the facility's policy titled, Food Receiving and Storage revised date October 2017. stated, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observation, interview, and record review, the facility failed to ensure a clean homelike environment on two out of two units and failed to ensure medical equipment was in good repair for two (Residents #11 and #26) of 21 sampled residents related to two out of six shower chairs and one out of two [brand name] positioning chairs not being in good condition. Findings included: An observation was made on 9/5/23 at 7:20 a.m. on the resident smoking patio of flower beds being overgrown with grass and weeds and trash around the area, including a medical glove in the middle of the patio on the ground. On 9/6/23 at 1:35 p.m. the patio remained in the same condition. An observation was made on 9/5/23 at 12:35 p.m. of the linen closet on a box on the floor that appeared to have a water stain on it. The box had yellow gowns spilling out on the floor with black marks on the sleeves. The linen closest also contained three pillows in a plastic bag stored on the floor. An observation was made on 9/5/23 at 12:37 p.m. of an approximate 4 by 2 area of a white dryed substance on the handrail in the hall outside of room [ROOM NUMBER]. This remained there throughout the survey on 9/6 and 9/7/23. An observation was made on 9/7/23 at 4:28 p.m. in room [ROOM NUMBER] of walls that were patched and not painted, wall board anchors in the wall where something used to hang, scratched up doors, and a dirty towel on the room floor. In the bathroom there were pieces of plastic pipe or pipe covers on the floor under the sink. There is also a missing tile in front of the toilet. An observation was made on 9/7/23 at 4:30 p.m. in room [ROOM NUMBER] of walls scratched down to the dry wall, dry wall anchors in the wall where something used to hang, dirty floor, and a used towel on the bathroom floor. An observation was made on 9/7/23 at 4:32 p.m. in room [ROOM NUMBER] of walls with what appeared to be dried liquid drips, walls that had been patched and not painted, and doors and wall scratched down to the wood. There was also a broken tile at the bathroom entrance. An observation was made on 9/7/23 at 4:36 p.m. in room [ROOM NUMBER] of two holes in the wall, baseboards peeling off, and a black stain on the ceiling. An observation was made on 9/7/23 at 5:08 p.m. in room [ROOM NUMBER] of dirty floors, chipped and scratched walls and doors. An observation was made on 9/7/23 at 5:10 p.m. in room [ROOM NUMBER] of dirty floors, paint peeling off the wall and the bathroom door scratched down to the wood. An observation was made on 9/7/23 at 5:12 p.m. in room [ROOM NUMBER] of a dirty towel on the floor behind the door. There was also a drywall patch on the wall that had not been sanded or painted and had a baseboard missing. The bathroom door and frame were observed to be scratched down to the wood. An observation was made on 9/7/23 at 5:13 p.m. in room [ROOM NUMBER] of marked up walls and dry wall anchors in the wall were items used to be hung. An observation was made on 9/7/23 at 5:15 p.m. in room [ROOM NUMBER] of the bedroom door chipped with missing paint. The door frame had gouges and black marks at the top. The floors in the room were also observed to be marked up and dirty. An observation was made on 9/7/23 at 5:16 p.m. in room [ROOM NUMBER] of drip stains on the wall under the window as well as marks along the wall. The floors in the room were also observed to be dirty. An observation was made on 9/7/23 at 5:18 p.m. of the bathroom door and bedroom door in room [ROOM NUMBER] being scratched up and missing paint. The floors were dirty. An observation was made on 9/7/23 at 5:20 p.m. of the wallpaper pealing and an unfinished patch on the wall above the double doors in the front hall near the nurses' station. An observation was made on 9/7/23 at 5:22 p.m. in room [ROOM NUMBER] of dirty floors and baseboards peeling off the wall. An observation was made on 9/7/23 at 6:56 p.m. of a used washcloth on the floor in room [ROOM NUMBER]. No staff were present, and no residents were moving around the room. An observation was made on 9/6 and 9/7/23 of the recreational room having boxes stacked in the corner and by the cabinets. This is an area residents use throughout the day. An observation was made on 9/7/23 at 4:38 p.m. in room [ROOM NUMBER] of paint chipping off the walls, walls having black marks on them, dry wall anchors in the wall where something use to be hung, walls had what appeared to be dried liquid drips, scratched up doors, and black marks on the floor in front of the cabinets. An interview was conducted on 9/7/23 at 7:01 p.m. with Staff J, Certified Nursing Assistant (CNA) Staff J, CNA said for maintenance items, he did not enter them in the computer tracking system, but let a nurse know so they could enter them. He said he regularly had residents complain to him about how long it took to get maintenance items done. He said one room had a broken sink and it took months to fix. Staff J, CNA also said a lot of residents did not have chairs in their rooms for residents or guests to sit. He said if a family member needed a chair, staff went to get one from the dining room. An interview was conducted on 9/7/23 at 4:05 p.m. with Staff B, Licensed Practical Nurse (LPN), She said for maintenance issues staff entered items into a computer tracking system. Staff B, LPN said there is a chance it will get fixed. She added the facility did have angel rounds, but maintenance did not check the rooms for issues. An interview was conducted on 9/7/23 at 5:25 p.m. with the Maintenance Director. He said the facility did angel rounds and all the managers were assigned rooms to check. He said he had rooms [ROOM NUMBERS]. He said he checked everything in the room and bathroom such as toilets, lights, call lights, remote controls, oxygen signs. The Maintenance Director said most of the staff used the computer tracing system for maintenance issues, but some were not educated on it. He said if staff put things in the system, it would allow him to prioritize work orders. He said when he walked down the hall, ten people would tell him things, so he insisted on using the computer tracking system. He said if a resident asked for something to be fixed, he tried to get his tools and do it right away. He said he was the only maintenance person in the building and must do everything from air conditioners to water temperatures. He said the building was reconditioned about [AGE] years ago and had not been maintained since. The Maintenance Director said he had been in the facility for about 4 months and was trying to catch up. He said he understood the doors were chipped and things needed to be painted, but he had life safety things that need to be prioritized, like air conditioning and hot water. He said the cosmetic things had to wait until after the structural. As far as floors being dirty, he said housekeeping did the floors, and he did recently fix their floor buffer. An interview was conducted on 9/7/23 at 5:38 p.m. with the Housekeeping Director. She said there was no floor tech in the facility. She said they tried to pick two to three rooms to buff everyday and 3-5 rooms a week to strip and wax. She said she was the one currently doing floors, but it had to be done consistently. As for cleaning resident rooms, she said housekeeping should be cleaning high to low and doing the entire room. She said the spot on the ceiling in room [ROOM NUMBER], they had attempted to clean, and it would not come off so she let maintenance know so they could fix it. She looked at the black marks on the floor in room [ROOM NUMBER] and said it would not come up. She said they had tried, but the tiles needed replacing. An interview was conducted on 9/7/23 at 6:24 p.m. with the Director of Nursing (DON.) The DON stated she had noticed the issues with maintenance. She said she as well as her staff enter maintenance items into the computer tracking system. Regarding used towels and washcloths being left in residents' rooms and bathrooms, she said that should not happen and she would address it. An interview was conducted on 9/7/23 at 5:48 p.m. with the Nursing Home Administrator (NHA.) The NHA said they do angel rounds in the facility where managers look for odors, cleanliness, rooms that have concerns, holes in the wall, curtains, paint, walls, etc. The NHA said managers are assigned to certain rooms and they bring their findings to him in stand down and they review it. He said he had been in the facility a little over a month and he bought paint supplies so they could have a paint party. Discussing the condition of resident rooms in relation to the dirty floor, scratched up doors and walls he said no I don't consider it satisfactory. 46498 On 9/5/2023 at 12:20 p.m., Resident #11 was seen sitting upright in a [brand name] positioning chair, fully dressed, and well-groomed. Resident #11's ankles were seen resting against the metal leg bars of the chair, which was damaged and missing the footrest cushion support. On 9/5/2023 at 3:00 pm., On 9/5/2023 at 3:00 pm, Resident #11 was seen sitting erect in a [brand name] positioning Chair with his feet resting against the footrest's outer edge of the chair. A review of Resident # 11 Admission Record showed, he was admitted to the facility on [DATE], with diagnoses to include but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Unspecified, Cognitive Communication Deficit, and Recurrent, Unspecified, Extrapyramidal and Movement Disorder. A review of the quarterly MDS dated [DATE], Section C, Cognitive Patterns, C0600, revealed Resident #11 was unable to complete the Brief Interview for Mental Status. Further review of the quarterly MDS, Section G, Functional Status, showed Resident #11 transferred with total staff dependence with two-person physical assistance. An interview was conducted with Resident #11 On 9/5/2023 at 3:00 pm., Resident # 11 said he had had the [brand name] positioning Chair for a year, and the chair had not had a cushion on the footrest. He said his ankle hurt sometimes when he was up in the chair. An interview was conducted with the Director of Nurses, DON, on 9/7/2023 at 6:47 pm. The DON said she was not aware of the broken footrest on Resident #11's [brand name] positioning chair. The DON said she expected staff to quickly report any damaged medical equipment so that a work order could be filed to get the chair fixed. On 9/5/2023 at 9:20 am., Resident # 26 was observed laying down in bed, fully dressed, well-groomed with his call light in reach with no signs of distress. Resident #26's bathroom was observed with a broken shower chair left in shower stall. On 9/5/2023 at 3:00 pm., Resident #26 was observed laying down in his bed with his call light within reach, with no signs of distress. The resident's bathroom was observed with a broken shower chair in the shower stall. Review of Resident #26 Admission Record showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to HB-SS Disease with Cerebral Vascular Involvement, and Recurrent, Unspecified, Lower Back Pain. Review of the annual Minimum Data Set, dated dated dated [DATE], showed Section C, Cognitive Patterns, Brief Interview for Mental Status, BIMS score of 15, which indicated Resident # 26 was cognitively intact. An interview was conducted on 9/5/2023 at 9:20 am., and at 3:00 pm., with Resident # 26. Resident #26 said he almost fell in the shower today because his shower chair was broken and it had been that way for about a week. He said he spoke with the Maintenance Director this morning about his chair and was told his chair would be fixed today. Another interview was conducted on 9/5/2023 at 3:00 pm., with Resident #26. Resident # 26 said no one had come to his room to fix his shower chair, so he would hold off taking a shower until his chair is fixed. An interview was conducted on 9/7/2023 at 5:40 pm., with the Nursing Home Administrator (NHA). The NHA said he expected when a resident reported a concern to a member of his staff, such as a broken shower, it should be resolved right away for the resident's safety. The NHA said he would take the shower chair out of Resident # 26's room for repair. Review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, revised on August 2019, showed 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis, when spills occur, and when surfaces are visible soiled. 11. walls, blinds, and windows curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Review of the facility policy titled, Standard and Guidelines: Training - Floor care, dated 12- 2018 showed, Housekeeping in-service Floor Care, One of the ways infections is spread in a facility is through air-borne particles settle on the floors, Sanitizing the floors is the key to a good infection Control Program. Occasional care: The area 1/4 along baseboards collect dust and debris left by the buffer and mop. it is necessary to scrub and scrape these areas to ensure a clean appearance. Daily care: All ceramic tile should be swept and mopped daily, this helps control odor and retains floor appearance. Further facility policy review showed the facility did not have a policy for broken equipment.

Based on observation, interview, and record review, the facility failed to ensure advanced care planning with a legal appointed designated health care proxy or power of attorney (POA) was completed for one (Resident #9) out of the sampled twenty-one residents. Findings included: On 09/05/23 at 12:12 p.m. Resident #9 was observed lying in bed. Resident #9 was not able to respond to questions in an attempted interview. A review of the Admission Record for Resident #9 did not reflect the resident had a health care proxy or a POA. Resident #9 was admitted on [DATE] with diagnoses to include anxiety disorder and cognitive communication deficit. A review of the Admission Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score was not obtained and showed the resident was rarely/never understood. A review of Resident #9's annual MDS, dated [DATE], Section C - Cognitive Patterns revealed a BIMS score was not obtained and showed the resident was rarely/ never understood. The MDS also showed the resident had memory problems and cognitive skills were severely impaired. A review of the active care plan for Resident #9, initiated 08/23/22 and revised 08/08/23, revealed the resident had expressed wishes as Full Code with interventions to include: - discuss Advanced Directives with resident and/or appointed health care representative, - contact appointed health care representative for health care decisions. A review of Resident #9's active care plan, initiated 08/29/22 and revised 08/08/23, revealed alteration in communication due to primary language [not English]. A review of Resident #9's consents, revealed the following consents were signed by family members. - Authorization for treatment while residing at healthcare center, signed 08/22/22 by Family Member #1, - Psychotropic Medication Informed Consent, signed 08/22/22 by Family Member #1, -Informed Consent for Influenza Vaccine, signed 08/22/22 by Family Member #1, - Informed Consent for Pneumococcal Vaccine, signed 08/22/22 by Family Member #1, - Authorization for treatment while residing at healthcare center, signed 08/26/22 by Family Member #1, - Psychotropic Medication Informed Consent, signed 11/08/22 by Family Member #1, -Patient Consent Form, verbal consent 12/06/22 by Family Member #2, - Psychotropic Medication Informed Consent, signed 12/06/22 by Family Member #3. On 09/07/23 at 1:37 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN), who stated Resident #9 primarily used gestures to communicate and was unable to make decisions. Staff B contacted [Family Member #1] for healthcare decisions. On 09/05/23 at 3:08 p.m., a review of the medical record for Resident #9 revealed the record was silent of documentation of/for Advanced Directive and/or Healthcare Proxy documentation. On 09/06/23 at 12:57 p.m., Resident #9 was observed in her room repeating words [not English], gesturing to move her wheelchair away from bedside. She was not able to respond to questions in an attempted interview. On 09/06/23 at 1:11 p.m., an interview was conducted with the Social Services Director (SSD), who confirmed Advanced Directive and healthcare proxy documentation was not available for Resident #9. The SSD verified interventions related to advance care planning listed in Resident #9's care plan were not completed. The SSD confirmed [Family Member #1] signed consents for the resident. The SSD confirmed [Family Member #1] was not considered a legal representative. The SSD stated he has a notation to look at this (documentation of a healthcare proxy) but has not. He stated the next step was to get a health care proxy consent or complete a POA/ Advanced Directive from Resident #9's family member. On 09/07/23 at 2:20 p.m. in an interview, the Director of Nursing (DON) stated staff had responsibilities to ensure the legal health care proxy or POA was identified. Review of the facility's policy titled, Advance Directives, revised on 12/2016, showed: Policy Interpretation and Implementation -3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's representative. -6. Prior to admission of a resident, the Social Services Director or designee will inquire of his/her family members and /or his or her legal representative, about the existence of an advanced directive.

Based on observations, record review, and interview, the facility failed to ensure the physician was informed about refusal of medications and dialysis services for one (Resident #194) of six sampled residents. Findings Includes: On 9/5/2023 at 11:45 a.m., Resident #194 was observed in her room sitting up in her wheelchair with her call light within reach. The resident was well groomed. The room was clean and well lit. A review of the Admission Record showed Resident # 194 was admitted to the facility on [DATE] with diagnoses to include but not limited to Epilepsy, Cognitive Communication, Conversion Disorder with Seizures or Convulsions, End Stage Renal Disease, and Dependence on Renal Dialysis. A review of Admission Minimum Data Set, dated dated dated [DATE], Section C, Cognitive Patterns, C0600, Titled, Should the Staff Assessment for Mental Status be conducted, Code entered showed 0, indicating No. The resident was able to complete a Brief Interview for Mental Status. A review of the Order Summary Report dated 9/7/2023, showed an active verbal order to Send to emergency room for Evaluation, one time only for 1 day. Additional review of the order summary showed an active order dated 8/25/2023, for Hemodialysis M-W-F at [name of dialysis center]. Pick up 05:00 am Chair time 6:00 a.m. An active written order dated 8/24/2023, for Lacosamide Oral Table 200 MG, give 1 tablet by month two times a day for Conversion Disorder with Seizures or Convulsions. An active verbal order for LevEtiracetam Solution 100 MG/, give 10 mL by month two times a day for seizure. An active written order dated 8/24/2023 for NIDEdipine ER Oral Tablet Extended Release 24 Hour 60 MG (Nifedipine), give 1 tablet by month one time a day for Cardiac related to Hypotension, Unspecified. A review of the Electronic Medication Administration Record (eMAR) dated 9/4/2023 at 21:34 (9:34 p.m.) showed an incomplete progress note referencing the resident refused medication. The progress note did not show the resident's physician was notified about refusal. A review of daily skilled note dated 9/4/2023 at 16:54 (4:54 p.m.), showed Resident # 194 refused all medication this shift, stating I only take daytime medications. Additional review of the daily skilled note showed the resident's physician was not notified about the resident's refusal of medications. A review of the eMAR, dated 9/3/2023 at 20:59 (8:59 p.m.), showed Resident # 194 refused all medications. Additional review of the eMAR showed Resident #194 physician was not notified about the refusal of medication. A review of the eMAR dated 9/2/2023 at 20:39 (8:39 p.m.) showed Resident #194 refused medication again after repeated education. Additional review of the eMAR showed Resident #194's physician was not notified about the refusal of medication. A review of the eMAR, dated 8/31/2023 at 9:48 a.m., showed Resident #194 refused. Additional eMAR review showed the resident's physician was not notified. A review of the eMAR dated 8/30/2023 at 22:46 (10:46 p.m.), showed Resident #194 refused medication. Additional review of the eMAR showed Resident #194's physician was not notified about the refusal of medication. A review of narrative nurses note dated 8/30/2023 at 20:55 (10:55 p.m.), showed Resident #194 refused medications, it was noted the resident was explained the importance and adverse effects of not taking seizure, cholesterol, and blood pressure medications. Resident #194's, blood pressure was 180/72. The review showed resident stated, I Don't care. Additional review showed Resident #194's physician was not notified about the refusal of medications and blood pressure. During an interview on 9/6/2023 at 4:27 p.m. with the Medical Director, Resident #194's primary care physician, he said he was not notified about Resident #194's condition because he was on vacation when she was admitted to the facility and another provider covered for him during that time. The facility would have used his on-call service on the weekend if they needed to report to an physician. During an interview on 9/6/2023 at 4:48 p.m. with Staff I, the covering physician for Resident #194's primary physician, he said he was covering for Resident #194's primary physician on 8/24/2023 through 9/4/2023, however, he was never present at the facility during those times, and he was not made aware of the Resident #194's refusal to receive dialysis or her medicine. He stated, Maybe the facility notified the ARNP during those times when [Resident #194] refused her medication. During an interview on 9/6/2023 at 5:06 p.m. with the Advanced Registered Nurse Practitioner (ARNP), he said he was not notified when Resident #194 was sent out to the hospital, refused dialysis or her medications. The ARNP said he was on the phone with the Director of Nursing, and she never told him about Resident #194's refusals of medication or being sent out to the hospital. During an interview on 9/7/2023 at 11:31 a.m. with Staff G an On Call physician, she confirmed she was on call for the facility on Friday, 8/25/2023 from 5:00 p.m. to 7:00 p.m. and she did not remember receiving any calls from the facility about any residents at the facility. During an interview on 9/7/2023 at 11:46 a.m. with Staff H, a second On Call physician he said he worked on call from Sunday 8/27/2023, 7:00 p.m. to Monday 8/28/2023 7: 00 a.m. and he did not recall getting a call from the facility about Resident #194 refusing her medication or dialysis services. The on- call physician said if he received a call about the resident refusing dialysis or her medication, he would have instructed the facility to send the resident to the emergency room . During an interview on 9/7/2023 at 3:30 p.m. with Staff E, License Practical Nurse (LPN), she said she notified the ARNP on 9/5/2023 when Resident #194 was sent out to the hospital, but she did not notify the provider of the ARNP about the resident refusing dialysis or her medication. Staff E said when Resident #194 refused dialysis she notified a nurse at the dialysis center to let them know the resident refused dialysis. During an interview on 09/07/23 at 3:20 p.m. with the Director of Nursing, she said she was not made aware the resident was refusing. She stated, I was made aware [Resident #194] was refusing meds probably Tues, Wed (5th and the 6th). She was taking her meds on 7:00 p.m.-7:00 a.m. on 08/25/23. I was not made aware that the resident refused dialysis until after the fact. I don't see anywhere where the doctor was notified. They [the nurses] may document in the EMAR, or a progress note, they can document either place. I would expect them to document doctor notification after any missed medication. I looked everywhere in the EMAR and progress note and did not see any notification to the doctors. All entries under EMAR show blank with nothing about doctor being notified. I would expect my nurses to let me know when a resident stop taking meds. I would then ensure they contact the doctor. There are some meds that we asked to get liquid form but [Resident #194] not taking any meds were not brought to my attention and I would expect to see it care planned for refusal of medications. If it had been brought to my attention earlier that she had not taken her meds, I probably would have recommended that [mental health services] see her. The DON said the Resident was currently refusing all her medications at the hospital right now. She refused dialysis for the night nurse, and I got report. I talked to her, and she refused. The resident said she got a note from transportation stating that they weren't picking her up. The resident refused to go to dialysis they said it was too late to see her that day. I let the night nurse know she was refusing meds and dialysis. The resident was aware of the decision she was making and how serious it was. Her daughter would come visit her and I told her daughter about her refusing meds and she responded, 'I know how she is'. When the ARNP came in on Friday we made him aware when he was in the building. Review of the facility policy titled, Change in a Resident's Condition or Status, Revised date February 2021. Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/ or status ( e.g., changes in level of care, billing/ payments, resident rights, etc. ) Policy Interpretation and Implementation 1. The nurse will notify the resident; s attending physician or physician on call when there has been a( an) d. : significant change in the resident's physical/ emotional/mental condition. F refusal of treatment or medications two (2) or more consecutive times);

Based on observations, interviews, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner during two of two visits conducted on 10/04/21 at 9:37 a.m. and on 10/05/21 at 11:20 a.m., related to proper food storage, equipment and surface cleanliness, and storage of personal items in food prep and food storage areas. Findings included: An initial tour of the kitchen was conducted on 10/04/21 at 09:37 a.m. facilitated by the Certified Dietary Manager (CDM). An observation was made of Staff B, Dietary Aide standing in front of the food prep counter. Staff B was noted without a face mask. Staff B proceeded to grab her mask that was resting on the food prepping counter and held it on her right hand. A blue drinking cup with a straw and a cell phone were resting on the food prep counter. Next to the cell phone was a package of an opened snack and a small bag that was not opened. Also, on the counter were food service items including condiments in sachets and napkins. An interview was conducted on 10/04/21 at 9:38 a.m. with Staff B. Staff B stated that the items were her personal items. Staff B did not answer when asked if the items should be stored on the food prep counter. Staff B put on her face mask and walked away. The CDM stated that the items should not be on the food prep counter. On 10/04/21 at 9:38 a.m., an observation was made of dirt and a grimy substance on the floor by the dishwashing station. Food residue and papers were observed on the floor under the drying racks. On 10/04/21 at 9:38 a.m., a large piece of ham was noted thawing on the counter by the microwave. The CDM stated that he was just getting ready to cut it up for lunch. The CDM stated that he placed the meat on the counter when he arrived this morning. On 10/04/21 at 9:39 a.m., the stove was observed with oil and grease build up on the surface. The CDM stated that he usually cleaned the kitchen at the end of his shift. On 10/04/21 at 9:39 a.m. dirt, rust, and grimy matter was noted under the handwashing sink. Food substances were observed on the floor beside the ice machine. On 10/04/21 at 9:41 a.m., an observation was made of the ice machine noted with bio- growth on the inside of the door and inside the ice machine. The bio-growth was noted on surfaces touching the ice cubes. The CDM stated that he was not going to serve the ice to the residents. The CDM reported that he had stopped by the grocery store on his way to work and brought in some ice. The CDM said this was not the first time and that he bought the ice with his own money because he did not want to serve contaminated ice to the residents. The CDM stated that the administration did not know the ice machine had bio growth. The CDM said they were planning on cleaning the ice machine today, 10/04/21. The outside of the ice machine and the floor around it were noted with dark grimy substances, dirt, and debris. On 10/04/21 at 9:43 a.m., the bottom of the freezer was observed with a dried, frozen, red substance where the meat was resting. The freezer door was noted with icicles on the door frame and bio-growth and water dripping on food boxes. On 10/04/21 at 9:44 a.m., an unlabeled and undated disposable cup was observed on the shelf inside the freezer. The CDM stated that it was a shake that he had just made this morning. The CDM said, it should be dated and labeled. The floor of the second freezer was also noted with a red substance smeared on the bottom surface, next to a bag of french fries. On 10/04/21 at 9:47 a.m., a grocery store plastic bag was observed on the top shelf of the refrigerator next to yogurt cups. The bag was not labeled or dated. The CDM stated it was an employee's meal. The CDM stated that staff should not store their food in that refrigerator. On 10/04/21 at 9:48 a.m., a green filter in the beverage dispensing unit was noted blanketed with dirt and dust. The CDM stated that maintenance staff cleaned the beverage machine. The CDM could not remember the last time the filter was cleaned or changed. On 10/04/21 at 9:49 a.m., a blue drinking cup with a straw, a bag of opened snack, and a blue lunch bag were observed on the shelf below the food prep counter. These items were stored on food service items including tea bags, condiments, cup lids and exposed silverware and serving utensils. On 10/04/21 at 9:49 a.m., an interview was conducted with Staff B. Staff B stated that this was her cup and her personal items. Staff B stated she had removed them from the top of the prepping counter and stored them on the shelf below. Staff B said the items should not be stored on a food prep station. On 10/04/21 at 9:50 a.m., a green bucket was observed under the hand washing sink collecting water. The floors were noted with dirt and food remains. On 10/04/21 at 9:51 a.m., the floor underneath the stove was noted with dust, dirt, papers, and food stuff. An observation was made of two large flour containers stored on a lower shelf underneath the microwave counter, noted with dirt and grease. Dates and labels were not legible from wear and dust. On 10/04/21 at 9:56 a.m., a tour of the dry food storage area was conducted. An unlabeled and undated container with a yellow - flour looking substance was noted. Another undated, unlabeled container with a white - flour looking substance was noted below it. The CDM stated that this was fish fry mix. The CDM said, I know it should be labeled and dated. The floors in the dry good storage area were noted with papers, dirt, and dust. 10/04/21 10:00 a.m., an interview was conducted the CDM. The CDM stated they had a cleaning checklist and that they were just about to clean the kitchen after breakfast service. The CDM stated that the expectation was to keep the kitchen clean and sanitary. The CDM stated that employees' personal items should not be stored in the food prep areas and the resident's food storage units. On 10/05/21 at 11:20 a.m., a tour of the kitchen was conducted. The CDM stated that they had cleaned the ice -machine. A note was observed on the machine stating, Ice machine has been cleaned and sanitized. The CDM stated that they will make sure the ice machine was cleaned regularly to prevent bio-growth. On 10/05/21 at 11:21 a.m., an observation was made of bio growth on the freezer and refrigerator doors. Bio growth was observed on the corners of the freezer next to a bag of french fries. The CDM said, I missed that. On 10/05/21 at 11:25 a.m., a second observation of the dish washer drainage compartment was noted with dirty, murky water, and food residue. The CDM stated that he would clean it after lunch dishes. On 10/05/21 at 11:32 a.m., an observation was made of a shelf with clean baking trays noted with grimy dirt, food particles, and dust. The CDM stated that this shelf was for storing clean items. The kitchen floor corners and walls were noted with food stains and grimy black matter. (Photographic evidence was obtained.) In an interview conducted on 10/05/21 at 11:32 a.m., the CDM said, We cleaned a lot. The building is old. They need to replace the floors. An interview was conducted on 10/05/21 at 4:32 p.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON). They were notified of concerns in the kitchen related to housekeeping and unsanitary surfaces. The NHA stated he would make it his priority to address the concerns. The DON stated that they would follow-up. Review of a facility policy titled, Next level hospitality services with a heading, environment dated October 2019, states that it is the center policy that all food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition. Action steps (1.) The dining service director will ensure that the physical plant is maintained in clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. (4.) The dining service director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and services. A policy titled, Equipment dated October 2019 states that it is the center policy that all food service equipment is clean, sanitary, and in proper working order.

Based on observations, interviews, and record review, the facility did not honor a resident's preference to receive therapy services for one (Resident #33) of twenty residents. Findings included: During a facility tour on 10/04/21 at 10: 45 AM, Resident #33 stated that she had been at this facility since June 2021 and had not received any therapy. Resident # 33 said, I have been asking for over 2 months. Resident #33 said, Please look into it. I want to be able to take care of myself. I need therapy. I don't want to be a dependent for the rest of my life. Resident #33 stated that she had spoken to the Social Services Director (SSD) and the Director of Rehabilitation (DOR) about receiving restorative services. A review of Resident #33's electronic medical record (EMR) showed a resident information sheet revealing that Resident #33 was [AGE] years old and was admitted to the facility on [DATE]. Resident #33 was her own responsible party and was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) dated 08/31/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G- functional abilities showed that Resident #33 required extensive assistance with one person assist for activities of daily living (ADLs) including, bed mobility, dressing, eating, toilet use and personal hygiene. Resident #33 was totally dependent on 2 persons plus for transfers, locomotion on and off unit and bathing. A Care plan dated 06/03/21 showed that Resident #33 had a self-care deficit with dressing, grooming, bathing related to generalized weakness and chronic pain. Resident participated with ADLs with cues from staff. Interventions to include therapy to screen as indicated. A functional limitation screening conducted on 06/03/21, revealed that Resident #33 had severe range of motion (ROM) limitations on her upper and lower extremities. Resident #33 had 0 -25% functional ROM. The screening conducted by the director of rehab (DOR) indicated that an evaluation should be conducted. Review of the active physician orders for Resident #33 dated 10/06/21, showed no active orders for treatment or evaluation for OT (Occupational Therapy), PT (Physical Therapy), or ST Speech Therapy). The physician orders further revealed an order dated 06/03/21 stating may participate in restorative program as needed and as tolerated. Review of the restorative binder showed that Resident #33 was not receiving restorative services. An interview was conducted on 10/06/21 at 9: 04 AM with the SSD. She stated that Resident #33 came from a sister facility and was admitted for long term care. The SSD confirmed that Resident #33 had been asking for therapy or restorative services, most recent request was in the last three weeks. SSD stated that authorization paperwork for therapy services was sent to Resident #33's doctor upon admission in June, but her doctor had not responded. SSD stated that DOR sent the paperwork. On 10/06/21 at 09:08 AM, an interview was conducted with the DOR. She confirmed that Resident #33 had been asking for therapy since she moved in. The DOR stated that she had re-faxed the paperwork to request therapy about 2-3 weeks ago and had been waiting for the doctor to approve the script. When asked why Resident #33 had not be evaluated for therapy per her request, the DOR said, The initial screening was conducted on 06/14/21 when the resident was admitted , but I did not conduct further assessment because the doctor's office did not respond. The DOR explained that the initial fax was sent on 06/07/21 and a second request was faxed on 06/24/21. A third request was faxed on 09/15/21 following the resident's verbalized request for therapy. The DOR stated that she had not heard from the doctor's office. She stated that a resident who needed total staff assist and was using adaptive equipment should be evaluated. The DOR stated that the facility expectation was for all new residents to receive screening, evaluation, and a comprehensive care plan upon admission. An interview was conducted on 10/06/21 at 9:30 AM with the DOR, Director of Nursing (DON), Regional Clinical Nurse, and the Nursing Home Administrator (NHA). The DON stated that there was a problem getting in touch with the doctor because the medical director contracted services out. The DON stated that a new doctor started last Friday and had reviewed all residents. The DON said, I don't know if they have reviewed [Resident #33's] file. The Regional nurse said she would look at the facility policy to see if an in- house evaluation should have been initiated to determine resident's plan of care as they wait for the authorization. She said, Maybe we could have initiated restorative to help her maintain physical abilities. The DON stated that even though the resident had not been assessed, she had not lost her abilities. The DON agreed that a 4- month wait was not acceptable. The DON confirmed that Resident #33, who was fully dependent on staff, wore a splint, and used specialized feeding equipment, should have received some assessment to give staff direction on plan of care. Review of an undated facility assessment page 9 revealed that services are provided based on resident's need. The facility provides specific care or practices in transfers, ambulation, restorative nursing, contracture prevention / care, supporting resident independence in doing as much of these activities by himself / herself. The facility assessment stated that the facility provided PT, OT, ST. Review of the facility policy titled, dignity revised February 2021, #2 showed the facility culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.

Based on observations, interviews, and record review, the facility did not ensure meals were served in a dignified manner related to staff standing when assisting a resident with meals during two of two observations for Resident #33. Findings included: During a facility tour on 10/04/21 at 12:40 PM, an observation was made of Staff B, CNA (Certified Nursing Assistant) assisting Resident #33 with the lunch meal while standing. Staff B was observed standing to the left of Resident #33's bed, spooning food into her mouth. An interview was conducted with Resident #33 on 10/04/21 at 12:55 PM. Resident #33 stated that staff were always standing by her bed during mealtime. Resident #33 said, Every once in while a CNA will bring a chair, but not [Staff B]. On 10/05/21 at 12:51 PM, an observation was made of Staff C, CNA assisting Resident #33 with her meal while standing. A follow -up interview was conducted with Staff C on 10/05/21 at 1:03 PM. Staff C said, I stand when assisting residents. I don't sit. No one ever said anything to me. A resident information sheet revealed that Resident #33 was [AGE] years old and was admitted to the facility on [DATE]. Resident #33 was her own responsible party. Resident #33 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) dated 08/31/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G- functional abilities showed that Resident #33 required extensive assistance with one person assist for activities of daily living including eating. A Care plan dated 06/03/21, showed that Resident #33 was at risk for an alteration in nutrition and/or hydration related to receiving a therapeutic diet and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to encourage meal intake, provide cues or encouragement during meals and to provide hands on assist with eating at meals and as needed. An interview was conducted on 10/05/21 at 1:06 PM with Staff D, CNA. Staff D stated that they [CNA's] have all been trained. Staff D said, We are supposed to sit at bed level and sit the resident at 45 degrees. An interview was conducted on 10/05/21 at 4:28 PM with the Regional Nurse (RN) and Assistant director of nursing (ADON). The RN stated that CNAs should be sitting when assisting residents with meals. The RN said, If there is no chair in the room, they should grab a folding chair. Staff should never stand over a resident during meal assistance. The ADON stated that she would start in-services. The ADON said, it is about dignity. The ADON provided in-service training material on dining and dignity indicating, Patient's who need assist with dining must have their dignity maintained at all times. Employees must sit while feeding residents and only feed one resident at a time. A follow-up interview was conducted on 10/06/21 11:15 AM with the DON. The DON stated that staff should be seated at bed level. The DON stated that they started education last night, 10/05/21, and have made foldable chairs available. Review of the facility's policy titled, assistance with meals Revised July 2017, statement showed, residents shall receive assistance with meals in a manner that meets the individual needs of each resident. #2 Facility staff will serve resident trays and will help residents who require assistance with eating. #3 Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: (a) Not standing over residents while assisting with meals. Review of the facility's policy titled, Dignity revised February 2021, states that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: (e.) Provided with a dignified dining experience.

Based on observation, interview, and policy review, the facility failed to ensure that one (Resident #21) of four residents reviewed was notified prior to a room change. Resident #21 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 21's most recent Minimum Data Set (MDS), dated [DATE],Section C: Cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 10/04/21 at 2:45 p.m. an interview was conducted with Resident #21. He stated that he was moved from his prior room a few days ago. Resident #21 stated that he was not notified of the room change ahead of time. The staff did not give him a chance to get out of bed, while still in bed, he was rolled across the hall to the new room. On 10/06/21 11:15 a.m. an interview was conducted with the Social Services Director. She stated that she did not initiate room changes, the Business Office was responsible for doing so. The process was to notify the resident of the room change, if they were not their own person (responsible party), they, the business office, would notify the family. They show the resident or family member the room and introduce them to their potential roommate. The room that Resident #21 was moved from was used for isolation and was the only private room in the facility. They needed the room for another resident that was being readmitted to the facility. The Social Services Director checked the progress note to see if there was any documentation related to the room change and could not find any. She stated that she was not in the facility the day that the move occurred but was notified via email by the Business office. She believed that the Business Office Manager might have provided verbal notification to Resident #21. On 10/06/21 at 1:15 p.m. an interview with the Director of Nursing was conducted. She stated that the notification might not have been done. She would not make any excuses, if the resident stated he had not been notified than we must take his word for it. She received a text on the weekend notifying her of the room change for the resident. A review of the facility policy titled Room Change/Roommate Assignment, revised in March 2021 revealed, Policy Statement: changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Policy Interpretation and Implementation: 1. Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 4. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given at least a (space left blank) hour/day advance written notice of such change. A. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. B. If a resident's roommate passes away, the resident will be allowed time to adjust before another roommate is moved into the room. 7. Documentation of a room change is recorded in the resident's medical record.

Based on observation, record review and interview, the facility failed to ensure it developed a comprehensive person-centered care plan to include protective and supportive health care services for an elopement risk for two residents (#1 and #2) identified as high risk for elopement of a total of 16 sampled residents. Findings included: 1. On 03/11/21 at 10:29 a.m., an observation was conducted of Resident #2. He was sitting in his wheelchair inside his room, shuffling and using his hands to move his wheelchair about his room, coloring books on his bed. During an attempt to interview the resident, he stated that he was on his way to Gainesville (city in Florida). A review of Resident #2's medical record, documented an admission date of [DATE]. The medical [DIAGNOSES REDACTED]. A review of Resident #2's medical record revealed, a Risk Screen Form, signed as completed by the Director of Nursing (DON) on 01/23/21. Section B. Elopement Risk on the Risk Screen Form scored the resident at a 7. It was documented on the form that A score of 5 or greater = HIGH RISK for Wandering /Elopement Potential. Based on the answers in the Elopement Risk section completed for the resident, a health status note dated 1/23/21 at 10:40 a.m. documented that Resident #2, scored a 7 as an elopement risk . On 03/11/21, a review of Resident #2's current and active care plan, reflected no focus area for Resident #2 being at risk for elopement or services to be provided to minimize or prevent elopement. On 03/11/21 at 3:51 p.m., the DON confirmed that Resident #2 was not present in the elopement book and that he had no Elopement Care Plan focus area at the time of review. 2. A review of Resident #1's medical record, documented an admission date of [DATE]. Resident #1's medical [DIAGNOSES REDACTED]. A review of Resident #1's Admission/Re-Admission Nursing Note, dated 01/05/21, documented an Elopement Screen, which scored the resident at a 5. The screening form documented, A score of 5 or greater= HIGH RISK for Wandering/Elopement Potential. A review of the Risk Management Tracking Log for January 2021 documented one event on 1/22/21 of an unsubstantiated elopement for Resident #1. On 03/11/21, Resident #1's current and active care plan was reviewed. The care plan reflected no focus area for the resident being an Elopement Risk, nor did it have any interventions listed for elopement prevention. On 03/11/21, at 11:45 a.m. Resident #1 was observed sitting in a wheelchair in the hall at the main entrance area, dressed in seasonally appropriate clothing with an elopement device on the resident's left leg. During an interview with the Director of Clinical Reimbursement at 12:24 p.m. she reviewed the care plan for Resident #1 and confirmed there was not an elopement risk care plan in place. She stated the care plan should have an elopement plan and that it would be added today (3/11/21). On 03/11/21 at 12:45 p.m. an interview with the Director of Nursing (DON) was conducted. She stated that she was the risk manager and the abuse coordinator. She confirmed that the front door had an elopement device system. If a resident that has an elopement device on and approaches the front door, the doors will lock and the alarm will sound. She confirmed that Resident #1 was found outside of the building on 01/22/21. On 03/11/21 at 1:30 p.m., an interview was conducted with Resident #1. He confirmed that he recalled the day that he walked out of the front of the building. When asked if he opened the door. He stated that at the time he went out the front door, he did not have the wheelchair. He stated that he just depressed the bar and walked out; not that he was going anywhere; he just did not know that he was not supposed to. He confirmed the facility has educated him and stated that he knows better now. He stated that he is trying to get better in order that he can go home to his wife. On 03/11/21 at 3:15 p.m., the DON was interviewed, she confirmed that the resident scored a 5 (elopement screen) at the time of admission, and that would mean that the resident was at risk for elopement and that a care plan should have been created with interventions. She stated that he was in the wheelchair when he was out front. He did not walk out of the building. She confirmed that he did go out with no one seeing him exit the building. A review of the policy titled, Resident Elopement Risk Management Guidelines, (Risk Management Incident Guideline Manual Version 2.0 (February 2021), documented the purpose as: The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. Definition: Elopement-an elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Resident Guidelines. 1. Upon admission each resident will be evaluated for risk of elopement by nursing. If found to be at risk, nursing will proceed to the Elopement Identification Form. 2. A care plan will be developed, as appropriate, for all residents identified as at risk for elopement. 3. A Resident Identification Form which includes a photo of the resident will be completed for all residents identified as at risk for elopement. It is recommended that photos be updated annually. These forms should be maintained in a binder and kept accessible to staff in a specific location. 4. All residents will be evaluated no less than quarterly to ensure an appropriate plan of care is in place. 5. If wandering behavior is identified for any current resident who previously has not exhibited this behavior, change of condition documentation should be charted in the resident medical record and a care plan implemented A review of the policy titled, Standards and Guidelines: SG Comprehensive Assessments and Care Plans, revised 10/18/19, revealed for Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity .6. The facility will maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review and revise the resident's comprehensive care plan.

Based on observation, record review and interviews, the facility failed to ensure that an accurate assessment for Elopement Risk was completed after the resident exited the facility unwitnessed for one resident (#1) of 16 sampled residents. Findings included: A review of the Risk Management Tracking Log for January 2021 documented one event on 1/22/21 of an unsubstantiated elopement for Resident #1. On 03/11/21, at 11:45 a.m. Resident #1 was observed sitting in a wheelchair in the hall at the main entrance area, dressed in seasonally appropriate clothing with an elopement device on the resident's left leg. On 03/11/21 at 12:45 p.m. an interview with the Director of Nursing (DON) was conducted. She stated that she was the risk manager and the abuse coordinator. She confirmed that the front door had an elopement device system. If a resident that has an elopement device on and approaches the front door, the doors will lock and the alarm will sound. She confirmed that Resident #1 was found outside of the building on 01/22/21. On 03/11/21 at 1:30 p.m., an interview was conducted with Resident #1. He confirmed that he recalled the day that he walked out of the front of the building. When asked if he opened the door. He stated that at the time he went out the front door, he did not have the wheelchair. He stated that he just depressed the bar and walked out; not that he was going anywhere; he just did not know that he was not supposed to. He confirmed the facility has educated him and stated that he knows better now. He stated that he is trying to get better in order that he can go home to his wife. A review of Resident #1's medical record, documented an admission date of [DATE]. Resident #1's medical [DIAGNOSES REDACTED]. A review of Resident #1's Admission/Re-Admission Nursing Note, dated 01/05/21, documented an Elopement Screen, which scored the resident at a 5. The screening form documented, A score of 5 or greater= HIGH RISK for Wandering/Elopement Potential. On 03/11/21, Resident #1's current and active care plan was reviewed. The care plan reflected no focus area for the resident being an Elopement Risk, nor did it have any interventions listed for elopement prevention. A review of a Risk Screen Form, effective date of 01/22/21, at 14:00 (2:00 p.m.), documented in Section B. Elopement Screen, that Resident #1 scored at a 3. In addition, on the form, Question #6: Based on admission information and/or responsible party information, has the resident ever eloped before or does the resident have a habit of wandering or pacing? This question was answered No. For the field of Additional Comments, signed by the DON on 01/23/21, showed: Resident fairly new to this environment. His function and mobility has improved as he continues to work with therapy. He is cooperative with assistance provided with his ADL (Activity of Daily Living) needs. He improved to the point being able to maneuver about in his w/c (wheelchair). No exit seeking behavior or tendencies noted. 03/11/21, at 3:02 p.m., an interview with the DON and the Regional MDS (Minimum Data Set) Coordinator was conducted. In review of the Risk Screen Form dated 1/22/21 for the answer of No, for Question #6 in Section B. Elopement Screen, that was completed two hours following the incident of Resident #1 leaving the building unsupervised, the DON stated, The question asks if the resident, based on admission information ever eloped. She stated that based on admission information, the resident had not eloped. She stated that she used the information that was provided at the time of admission. It was noted during the interview that Resident #1 had scored a 5 on the elopement risk screening that was conducted at the time of admission (1/5/21), which indicated he was a high risk for elopement. A review of the policy titled, Resident Elopement Risk Management Guidelines, (Risk Management Incident Guideline Manual Version 2.0 (February 2021), documented the purpose as: The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. Definition: Elopement-an elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Resident Guidelines. 1. Upon admission each resident will be evaluated for risk of elopement by nursing. If found to be at risk, nursing will proceed to the Elopement Identification Form. 2. A care plan will be developed, as appropriate, for all residents identified as at risk for elopement. 3. A Resident Identification Form which includes a photo of the resident will be completed for all residents identified as at risk for elopement. It is recommended that photos be updated annually. These forms should be maintained in a binder and kept accessible to staff in a specific location. 4. All residents will be evaluated no less than quarterly to ensure an appropriate plan of care is in place. 5. If wandering behavior is identified for any current resident who previously has not exhibited this behavior, change of condition documentation should be charted in the resident medical record and a care plan implemented A review of the policy titled, Standards and Guidelines: SG Comprehensive Assessments and Care Plans, revised 10/18/19, revealed for Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity .6. The facility will maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review and revise the resident's comprehensive care plan.

Based on observation, record review and interviews, the facility failed to ensure that a baseline care plan was developed to include instructions to provide effective and person-centered care for minimizing elopement for a resident that was identified as high risk for elopement for one resident (#1) of 16 sampled residents. Findings included: A review of Resident #1's medical record, documented an admission date of [DATE]. Resident #1's medical [DIAGNOSES REDACTED]. A review of Resident #1's Admission/Re-Admission Nursing Note, dated 01/05/21, documented an Elopement Screen, which scored the resident at a 5. The screening form documented, A score of 5 or greater= HIGH RISK for Wandering/Elopement Potential. A review of the Risk Management Tracking Log for January 2021 documented one event on 1/22/21 of an unsubstantiated elopement for Resident #1. On 03/11/21, at 11:45 a.m. Resident #1 was observed sitting in a wheelchair in the hall at the main entrance area, dressed in seasonally appropriate clothing with an elopement device on the resident's left leg. On 03/11/21 at 12:45 p.m. an interview with the Director of Nursing (DON) was conducted. She stated that she was the risk manager and the abuse coordinator. She confirmed that the front door had an elopement device system. If a resident that has an elopement device on and approaches the front door, the doors will lock and the alarm will sound. She confirmed that Resident #1 was found outside of the building on 01/22/21. On 03/11/21 at 1:30 p.m., an interview was conducted with Resident #1. He confirmed that he recalled the day that he walked out of the front of the building. When asked if he opened the door. He stated that at the time he went out the front door, he did not have the wheelchair. He stated that he just depressed the bar and walked out; not that he was going anywhere; he just did not know that he was not supposed to. He confirmed the facility has educated him and stated that he knows better now. He stated that he is trying to get better in order that he can go home to his wife. On 03/11/21 at 3:15 p.m., the DON was interviewed, she confirmed that the resident scored a 5 (elopement screen) at the time of admission, and that would mean that the resident was at risk for elopement and that a care plan should have been created with interventions. She stated that he was in the wheelchair when he was out front. He did not walk out of the building. She confirmed that he did go out with no one seeing him exit the building. On 03/11/21, Resident #1's current and active care plan was reviewed. The care plan reflected no focus area for the resident being an Elopement Risk, nor did it have any interventions listed for elopement prevention. A review of the policy titled, Standards and Guidelines: SG Comprehensive Assessments and Care Plans, revised 10/18/19, revealed for Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity .6. The facility will maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review and revise the resident's comprehensive care plan. A review of the policy titled, Resident Elopement Risk Management Guidelines, (Risk Management Incident Guideline Manual Version 2.0 (February 2021), documented the purpose as: The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. Definition: Elopement-an elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Resident Guidelines. 1. Upon admission each resident will be evaluated for risk of elopement by nursing. If found to be at risk, nursing will proceed to the Elopement Identification Form. 2. A care plan will be developed, as appropriate, for all residents identified as at risk for elopement. 3. A Resident Identification Form which includes a photo of the resident will be completed for all residents identified as at risk for elopement. It is recommended that photos be updated annually. These forms should be maintained in a binder and kept accessible to staff in a specific location. 4. All residents will be evaluated no less than quarterly to ensure an appropriate plan of care is in place. 5. If wandering behavior is identified for any current resident who previously has not exhibited this behavior, change of condition documentation should be charted in the resident medical record and a care plan implemented

Based on interview and closed record review, the facility failed to ensure that discharge summaries for planned discharges to the community included the required components to ensure continuous, coordinated, person-centered care for two (Resident #1 and Resident #2) out of four sampled residents. Findings included: 1. A closed record review was completed for discharged Resident #1. The record reflected that the resident had been admitted to the facility on [DATE] and discharged home on[DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Inventory of Mental Status (BIMS) score of 5 which meant that the resident had severe cognitive impairment. Section Q of the MDS revealed that the resident's discharge goal was to be discharged to the community. A review of the care plan revealed, The resident/responsible party wishes to return/be discharged to community/prior living arrangements, and interventions that included the following: Prepare and give the resident, family member, care giver contact numbers for all community referrals as indicated .Make arrangements with required community resources to support independence post discharge HHC (Home Health Care), MD (Medical Doctor). The discharge summary and post discharge plan document for Resident #1 titled, FGS Discharge Home, with effective date of 12/08/2019, was reviewed and revealed the following missing elements: the recapitulation of the resident's stay did not include diagnoses, course of illness treatment, or course of therapy treatment; the post discharge plan did not reflect interdisciplinary input and only Staff A, Registered Nurse (RN) was entered as the author for all sections; No was entered on the form in response to the question, Did the resident/resident representative initiate the discharge either verbally or in writing, which was incorrect compared with the care plan documentation in the medical record which reflected that the discharge was resident/family initiated; no contact information was entered for community resources and service planning; no details were entered regarding scheduled appointments; the field Final Discharge Note simply read, pt to dc home per md order; no documented evidence of discharge medication list, though it was documented that a discharged medication list was printed out for the resident; the Important Names and Phone Numbers section with fields to document physician names and contact information and facility name and contact information was blank; the document was not signed by the resident. 2. A closed record review was completed for discharged Resident #2. The record reflected that the resident had been initially admitted to the facility on [DATE] and discharged home on[DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of 15, which meant that the resident did not have cognitive impairment. Section Q revealed that the resident's discharge goal was to be discharged to the community. A review of the care plan revealed, The resident/responsible party wishes to return/be discharged to community/prior living arrangements, and interventions that included the following: Prepare and give the resident, family member, care giver contact numbers for all community referrals as indicated .Make arrangements with required community resources to support independence post discharge HHC (Home Health Care), MD (Medical Doctor). The discharge summary and post discharge plan document for Resident #2 titled, FGS Discharge Home with effective date of 11/09/2019 was reviewed and revealed the following missing elements: the recapitulation of the resident's stay did not include diagnoses, course of illness treatment, or course of therapy treatment; the post discharge plan did not reflect interdisciplinary input and the only Staff A was entered as author for all sections; Yes was entered on the form in response to the question, Did the resident/resident representative initiate the discharge either verbally or in writing with the description, md order to dc after therapy and no details referencing the resident's involvement; the Community resources and service planning section was documented with (provider name) home health in the Home Health Care Agency and phone number field and (hospital name and location) was documented in the Name of contact person field with no additional contact information or details on services to be provided; The entire section B. Scheduled Appointments was blank; the fields for lab and/or diagnostic test results within the Final Summary of Resident Condition section were blank; the Final Discharge Note was entered with, transferring home per md order; the Recreation Services and Rehabilitation Services sections were signed and dated by Staff A but no information was entered in the information fields; the Important Names and Phone Numbers section with fields to document physician names and contact information and facility name and contact information was blank; the resident/caregiver signature field revealed the resident's name typed in but no physical signature. 3. Staff A, RN was interviewed on 12/17/2019 at 1:42 PM about his role as an RN in the discharge process and documentation. Staff A revealed the discharge summaries in the Electronic Health Record (EHR) for Resident #1 and Resident #2 and confirmed that he had completed both. He stated that his role was to follow the physician's orders [REDACTED].when the day comes follow the order. Staff A stated that the documentation required was to complete the discharge summary form, give a discharge medication list, follow the physician orders [REDACTED]. Staff A added that details of any appointments were provided to the discharging resident and that a copy of the discharge summary got printed and sent with the resident. Staff A stated that he had only discharged a few residents since working in the facility. On 12/17/2019 at 2:07 PM an interview was conducted with the Staff B, the current Admissions and Social Services Director, the facility Administrator, the facility Director of Nursing (DON), and the Corporate Director of Regulatory Compliance (CDRC). The Administrator confirmed that Staff B was new to the facility and in training. Staff B confirmed that she had not been involved in discharging a resident yet since working at the facility. When asked about documentation required at discharge, Staff B was unsure of her response and the Administrator and CDRC assisted in answering, confirming that for planned discharges to the community a discharge summary document must be completed, reviewed with the resident, and a copy sent with the resident. They reported that the summary should include a recapitulation of the stay and should be initiated by the facility Social Services Director and completed as applicable by multiple disciplines including nursing, dietary, activities, and rehabilitation. The Administrator and CDRC stated that the facility expectation was that the discharge summary form be interdisciplinary and completed by multiple disciplines. The Administrator suggested that the former Admissions and Social Services Director, Staff C, be contacted by telephone to provide additional information about the discharge documentation process, since she had just recently transferred to another facility in the corporation. Staff C was reached and confirmed that the discharge summary form was initiated by the Admissions and Social Services Director and completed by multiple disciplines. The interview closed with the CDRC confirming that the only paperwork sent home with the resident was the completed discharge summary form and anything checked off on the form as given additionally. No additional discharge documentation sent with Resident #1 and Resident #2 was revealed. The facility policy titled, Standards and Guidelines: Discharge Planning Process, with issue date of 12/2017, revealed: When the facility anticipates discharge, a resident will have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative . (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care will indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and nonmedical services.

Based on observation, interview, and record review the facility failed to ensure the kitchen was kept in a clean and sanitary manner. The facility failed to ensure the floors were cleaned in accordance with their cleaning schedule to prevent buildup and possible cross contamination. Finding included: During the initial brief kitchen tour on 05/28/2019 at 10:40 am observations of the kitchen revealed possible concerns with soiled and debris covered areas underneath the kitchen appliances, counters, and shelves. The dietary staff was in the process of cleaning the kitchen and dishes from the morning's breakfast meal. A follow-up visit on 5/30/2019 at 11:20 am revealed the accumulation of a dark brownish-black colored debris was still present underneath the range. The tile on the wall where it meets the floor was also soiled with the same dark brownish-black colored debris. Adjacent to the range was a counter with wheels that held the steam oven and food processor. Underneath that counter was more of the debris and it was also covering the wheels and legs (photo evidence obtained). A window directly behind and above that wheeled counter was observed with reddish colored debris splashed on the window glass as well as the window sill. Observation of the dishwasher area revealed more of the dark brownish-black colored debris. The debris was also spread over the items stored underneath the dishwasher and a wheeled shelf sitting adjacent to the dishwasher that held a mixer and other bulk kitchen items (photo evidence obtained). The debris was also covering the wheel and leg of that shelf. An additional observation was conducted on 5/31/2019 at 10:40 am, and the Certified Dietary Manager (CDM) and a dietary aide were present and prepping for the lunch meal service. Observation of the areas under the major appliances that included the refrigerators and freezers, the range, and dishwasher, revealed the same brownish-black debris with some larger particles was still present located underneath the appliances and counters and shelving throughout the kitchen to include the reddish colored debris on the window and window sill. The Regional CDM and Registered Dietician entered the kitchen at 10:43 am and were advised of the observed concerns. The Regional CDM confirmed the presence of the debris and stated that they may need to add a deep cleaning once monthly, as this was done at her other facilities. Review of the Food and Nutrition Cleaning List, provided by the facility on 5/30/2019, for the past two months did not indicate which month either document represented. The document did, however, indicate the floor was to be swept and mopped after breakfast and supper. The list was checked off on most days, indicating that this was done. Review of the facility's policy Cleaning and Sanitizing of Food and Non Food Contact Surfaces, with an effective date of 4/17/2019, revealed: Standard- Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment.

Based on observation and interviews the facility did not ensure that the Controlled Substance Emergency Drug Kit, which contained Schedule II drugs such as [MEDICATION NAME], was locked and stored in a permanently affixed compartment in one of one medication storage room. Findings included: On 05/30/19 at 9:36 a.m., during the performance of the medication storage and labeling task, the locked medication room was accessed by the Director of Nursing (DON). In an upper-level unlocked cabinet a large black plastic box measuring approximately 14 inches long, 10 inches wide, and 1.5 inches thick was retrieved, the box was closed and secured with plastic tie wraps at either end of the handle, there was no lock on the box. The label on the box identified it as the Controlled Substance Emergency Drug Kit (EDK), it described the contents as 25 forms of Schedule II controlled substance medications, 1 form of Schedule III controlled substance medication, 14 forms of Schedule IV controlled substance medications and 2 forms of Schedule V controlled substance medications. At the time of the observation, the DON was asked if this was the usual place that the EDK was stored. She replied that it was. She stated that this was where they always kept the EDK and that the Nurses were the only staff members who had the keys to the medication room. A telephone interview with the Pharmacist Consultant on 5/31/19 at 1:30 p.m. revealed that his expectations would be that the controlled substances would be in permanently affixed containers. He did not recall if the EDK was kept in such a container at this facility. He did suggest that he could provide some guidance to the DON about suppliers who have such compartments for sale. He also suggested that an in-house solution could also be devised with the help of the maintenance department of the facility.

Based on interview and record review the facility failed to ensure that care plan interventions related to aggressive sun-downing behaviors were implemented for one (#492) out of 23 residents sampled. Findings included A review of Resident #492's admission record revealed an initial admitted in (YEAR) and the most recent readmission date of [DATE] for a [DIAGNOSES REDACTED]. In a 5-day minimum data set ((MDS) dated [DATE] the resident was assessed to have a brief interview for mental status (BIMS) of 15 (cognitively intact). In an admission MDS given to the surveyor by the facility dated 5/28/19 and noted to be in progress, the resident was assessed to have a BIMS of 10 (moderately impaired). The resident was assessed to have negative behaviors including physical behaviors that were directed towards others that significantly interfered with the resident's Activities of Daily Living (ADL) care, and other residents' environment and ADLs. The resident was assessed to have felt down or depressed 2-6 days during the assessment period. A review of physician orders [REDACTED].>Hospice Services dated 5/20/19 Resident on Hospice Services for severe protein/calorie malnutrition dated 5/20/19 A review of the care plan in the electronic medical record on 5/29/19 at 3:33 p.m. revealed the resident had a behavior problem related to (r/t) sun downing behaviors. Resident behaviors included arguing with roommate, accusing people of killing her dog, and looking for her mother. The goal for this area was for the resident to not harm herself or others related to her behaviors. There were no interventions for this focus area (photographic evidence obtained). When attempting to leave the care plan area of the resident's record, a warning box popped up that said This care plan contains an incomplete care plan item. Every focus must have at least one goal and at least one intervention selected before it is considered complete. (Photographic evidence obtained.) On 05/31/19 at 10:32 AM, an interview was conducted with the Assistant Director of Nursing (ADON), Staff A/Regional Director of Clinical Services, and the Nursing Home Administrator (NHA). The ADON (who was serving as the temporary MDS/care plan coordinator) said that she doesn't know how that was even possible to have a care plan without interventions. The NHA said that Resident #492 had only been in the facility for a couple of days,so she did not need to have a comprehensive care plan yet. Staff A asked if maybe it was showing an old resolved baseline care plan. The ADON pulled up the resident's care plan on her computer and began looking through it. The ADON said that she did see the area with no interventions, and that she was checking the rest of the care plan to see if any other focus areas had no interventions. When she got back to the first page of the care plan where the focus area in questions was, there were new interventions available. The surveyor went and got the facility provided computer and pulled up the information in front of the ADON, NHA, and Staff A. The interventions were also now available for the surveyor to see. The date of implementation for the interventions were noted to be 5/31/19. These interventions were created by a staff member identified by the ADON as her corporate clinical MDS support person. The date of the focus area was originally created on 5/23/19 by the ADON with a revision date of the focus area being 5/30/19 by the same person. The goal for this intervention was dated 5/23/19. No explanation was given about how this could have happened. All three staff members in the meeting verbalized again that they didn't know that this was even a possibility. The ADON said that there are other behavior focus areas in the care plan. The surveyor acknowledged that there were in fact other behavior focus areas, but this was the only focus that specifically addressed the resident and her sun-downing behaviors. Review of the job description for the MDS coordinator, under essential job functions B. Plan of Care under duties: coordinates and leads the development of a comprehensive resident assessment and care plan for each resident. Review of the facility's policy titled Standards and Guidelines Comprehensive Assessments and Care Plans, issued 11/1/16, revealed under standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals The assessment must include at least the following: (vi) Mood and behavior patterns. Under guidelines: The facility must develop and implement a baseline care plan for each resident that includes the instructions (interventions) needed to provide effective and person-centered care There was no mention of the need for this in the resident's non-baseline comprehensive person-centered care plan.

Based on interviews, and clinical and facility record review, the facility failed to provide the necessary care and services required to properly identify constipation and provide the timely, physician ordered interventions to treat constipation for five (Residents #1, #8, #17, #18 and #19) of twelve residents sampled that required assistance with toileting. Resident #1, #8 and #17 had physician's orders (identified as the bowel protocol) to provide laxatives for no bowel movement (BM) after three days, but did not receive this treatment or any symptom management for constipation. Resident #1 was receiving pain medication with a known side effect of constipation. The facility did not develop a care plan or interventions to address the symptom management of constipation, but did have a care plan that addressed bowel conscious behaviors, which was inaccurate. In addition, the facility failed to administer their standard physician ordered bowel protocol when the resident was absent of bowel movements. Resident #1 was sent to the hospital with altered mental status on [DATE]. The physician's Death Summary indicated the resident was severely constipated and this resulted in Resident #1's bowel perforation and subsequent death two days later. This failure created a situation that resulted in the serious injury and death of Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 5:15 p.m. Findings included: 1. A review of Resident #1's hospital records indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on [DATE]. A Death Summary for a date of death of [DATE] documented, Final Diagnosis-1. Bowel Perforation, 2. Acute [MEDICAL CONDITION], and 5. Fecal impaction. Under Hospital Course, the summary stated this is a [AGE] year-old woman who was brought from the facility to the hospital emergency room (ER) with complaint of abdominal discomfort. Patient had no bowel movement x 3 weeks .She was placed on suppository as well as an enema but was not having a bowel movement so [MEDICATION NAME] was consulted .She was placed on IV fluids for gentle hydration .[MEDICATION NAME] ordered a medicine called [MEDICATION NAME] due to what is believed to be opiate induced constipation. KUB showed large amount of stool and possible pneumonitis with possible [MEDICATION NAME] gas and free air. CT was recommended. The patient had a CT of the abdomen and pelvis, which showed evidence of bowel perforation likely of the sigmoid colon as the colon was distended and demonstrated extensive pneumatosis. There was a large amount of [MEDICATION NAME] fecal material seen adjunct to the sigmoid colon. Surgery was consulted. On the way back, patient became hypotensive, unresponsive, and became hypoxic, so patient ended up on a ventilator . The patient was initially DNR (do not resuscitate) but due to her condition her family requested all treatments .Patient was doing poorly and she passed away on [DATE] at 2:51 a.m. A review of the hospital History and Physical (H&P) dated [DATE] revealed the history of present illness was documented as a [AGE] year old woman presented to the ER via EMS from the skilled nursing facility with complaint of abdominal discomfort for 3 weeks .Patient also has been very weak for past 5 days with confusion on and off .Currently, she complains of rectal pain due to constipation .She is unsure if she is passing gas. A review of the Abdominal/Pelvis CT scan performed on [DATE] due to abdominal pain and constipation had findings of rectum markedly distended with solid fecal material. The rectal lumen measured 11 cm in AP dimension by 10 cm in [MEDICATION NAME] dimension. There is mild associated presacral [MEDICAL CONDITION]. There is abundant fecal material present throughout the colon. There are multiple diverticuli in the descending colon. There are a few diverticuli in the ascending colon. There is no evidence of extralumenal air. There is no free fluid or fluid collections. Resident #1's clinical record included a face sheet that indicated an admission date of [DATE], and medical [DIAGNOSES REDACTED]. Resident #1's clinical record included an admission MDS (Minimum Data Set) dated [DATE] that showed under Section C a BIMS (Brief Interview for Mental Status) score of 14 that indicated Resident #1's cognition was intact and she was able to make her needs known. Section G showed that she required extensive assistance of one person for toileting. Section H included that she was always incontinent of bowel and bladder. A review of the facility's Bowel Documentation included three categories: continent or incontinent, size and consistency. On [DATE] at 1:55 p.m., the Director of Nursing (DON) confirmed all three criteria must be entered by the Certified Nursing Assistants (CNAs) in order to record a BM in the facility's electronic medical record system. The DON said if there is no BM in 3 days, the system sends an alert to the licensed nurse's electronic dashboard, and the constipation was treated per the standing physician's orders, known as a bowel protocol. Resident #1's bowel documentation for the two weeks prior to her transfer to the hospital included the following: · [DATE] was marked as continent at 12:42, which included medium under question #2 size, and formed for consistency. · [DATE] was marked incontinent at 13:22 but size or consistency were both marked as not-applicable. · [DATE] was marked continent at 11:02 and medium and formed were marked for size and consistency. · [DATE] was marked incontinent at 1:06 but size and consistency were marked as none and not-applicable. · [DATE] was marked incontinent at 12:33 but size and consistency were marked as not-applicable. · [DATE] was marked as incontinent as at 2:07 and 11:24 but size was marked as none and not-applicable, and consistency were marked as not applicable. · [DATE] was marked as incontinent at 11:05 and 18:12, but not applicable was marked for size and consistency. · [DATE] was marked as continent at 13:59 and size was marked as small and consistency, formed. · [DATE] was marked as incontinent at 21:33 but size was marked as none and consistency not applicable. · [DATE] was marked as continent at 11:23 but size and consistency were marked as not applicable. · [DATE] was marked as continent at 19:58 and size and consistency were marked as medium and formed. On [DATE] at 1:30 p.m., the Bowel Documentation for Resident #1 was reviewed with the DON. She confirmed that bowel movements should be monitored and accurately documented, and this was a standard of nursing care. She confirmed several entries indicated Resident #1's continence or incontinence, but had no proper follow- through that included size and consistency of the BM. She stated the partial or incomplete documentation can cause the alert not to appear on the nurse's dashboard and the nurse would not be notified of the resident's lack of BM's. In this event, the nurse would not know that the physician ordered bowel protocol needed to be implemented. She confirmed for seven days between the dates of ,[DATE] and ,[DATE], there were no entries that included a description of size and consistency but instead included, none and not applicable. The DON acknowledged that if the alert had appeared and the licensed nurse had taken the appropriate action, then the first step of the bowel protocol, Milk of Magnesia, should have been administered ,[DATE]-[DATE], but it was not. She confirmed that she herself documented a small BM on [DATE] and then another five days went by without another BM documented that included a description, and the bowel protocol was not implemented at that time either. A review of the Medication Administration Record (MAR) revealed the resident was receiving the pain medication [MEDICATION NAME]/[MEDICATION NAME] tablets ,[DATE] mg for chronic generalized pain, which began on [DATE]. The resident received 29 doses between [DATE] and [DATE], the same period of time that incomplete documentation of bowel movements was identified. The physician's orders did not include a scheduled laxative or stool softener, but did include: Milk of Magnesia suspension 400 mg/5 ml, give 30 ml by mouth as needed for constipation at bedtime of no BM in 3 days; [MEDICATION NAME] suppository 10 mg insert one rectally as needed for constipation daily if no results for Milk of Magnesia; and a Fleet enema insert one dose rectally as needed for constipation if no results 1 day after suppository. The physician's orders also included [MEDICATION NAME] Ointment insert one application rectally every 8 hours as needed for mild pain related to other hemorrhoids. A review of the side effects of [MEDICATION NAME]/[MEDICATION NAME] included a known side effect of constipation. (www.ncbi.nlm.gov). The Journal of the American Board of Family Medicine stated in the article, Chronic Constipation: An Evidence-Based Review: .medical personnel define constipation as less than 3 bowel movements per week . and also included under Complications of Chronic Constipation: Hemorrhoids .and Bowel Perforation (www.jabfm.org) A comparison of the MAR and the documentation of Resident #1's bowel movements showed that although Resident #1 should have received Milk of Magnesia on [DATE], when she had not had a bowel movement recorded since [DATE]. She did not receive this first step of the bowel protocol to alleviate constipation. Further review showed that she did receive a [MEDICATION NAME] suppository on [DATE] and this was repeated on [DATE]. The nursing notes included, effective as a result after the [MEDICATION NAME] suppository was administered on [DATE], but there was no documentation to explain why the resident required another suppository the following day, [DATE], and there were no documented results for this second dose. Additionally, it was documented only once on [DATE] at 0601 that Resident #1 received the Hemorrhoid Ointment. The Progress Notes were silent regarding Resident #1's absence of bowel movements between [DATE] and [DATE]. A therapy entry dated [DATE] indicated Resident #1 was planning to be discharged to home and declined a home evaluation saying that she would be fine. A late entry dated [DATE] by the facility's wound care nurse included that when the coccyx wound dressing was changed, the resident requested treatment for [REDACTED]. An entry dated [DATE] indicated the resident was offered a laxative with morning medications and she accepted. An entry dated [DATE] stated, .has anxiety at times along with generalized pain and [MEDICATION NAME] pain-see MAR. Reluctant to participate in therapy and eventually does so after some negotiations and manipulations. Psych has been consulted. Entries dated ,[DATE] at 8:00 a.m. indicated Resident has altered mental status. She is sleepy but arousable . and at 11:49 a.m., Resident has altered mental status and is more sleepy than usual . and at 12:00 p.m. the emergency medical services was notified and Resident #1 was transported to the hospital. The last nursing documentation was an SBAR (Situation-background-assessment-recommendation) form dated [DATE] that indicated Resident #1 was sent out to an acute care hospital via emergency transportation for a change in mental status; the section for Abdominal/Gastrointestinal Evaluation was checked, Not clinically applicable to the change in condition being reported. On [DATE] at 2:44 p.m., an interview was conducted with the wound care nurse. She said that she recalled Resident #1, and stated that she was seeing the resident regularly because she was admitted with a Stage I pressure ulcer to the coccyx. The wound care nurse recalled telling the resident's assigned nurse on [DATE] that the resident was constipated. On [DATE] at 5:30 p.m., a telephone interview was conducted with Employee B, a licensed practical nurse that confirmed she was assigned to Resident #1 when she was transferred out to the hospital on [DATE]. She said that she did not know what was wrong with Resident #1 on [DATE]. She stated, We couldn't pin point it. She was asked about her gastrointestinal status, and she stated that she thinks she remembers the resident had received some laxatives earlier, but was not sure about this. She stated she heard the resident had died . On [DATE] at 3:12 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that she usually spoke with her mother every day while she was in the facility. She said that her mother had been admitted to the facility for therapy to get stronger. She stated that her mother had complained of constipation to her frequently, and she had spoken with the nursing staff and relayed the concerns, but nothing was done to alleviate her mother's constipation and discomfort. Resident #1's daughter said that her mother became so severely constipated while in the facility, that her bowel had ruptured, and that was why she was so lethargic and in pain when she was sent out to the hospital on [DATE]. On [DATE] at 1:04 p.m., an interview was conducted with Resident #1's caregiver. He stated that he had cared for the resident for a number of years at home. He stated that he knew Resident #1 was getting older and had some medical problems, but it was unacceptable that she had to go to the hospital for severe constipation and then died , because that could have been prevented. He stated that she took opioid medication that caused constipation, and at home she was on a regular laxative every day to counteract the constipation, but had not received this while in the facility. A review of Resident #1's care plans did not include a focus of potential constipation, or to monitor for constipation related to opioid medications. However, there was a care plan titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. Interventions included, Administer medications as ordered. Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Reinforce positive behaviors. On [DATE] at 2:00 p.m., the clinical record was reviewed with the MDS/Care Plan Coordinator. She confirmed that there was no care plan that addressed constipation, and Resident #1, who was assessed to be incontinent of stool and required assistance with toileting, was at risk for constipation. She confirmed that there was a care plan titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. The MDS Coordinator was asked if severe constipation could cause a person to be bowel conscious and she said that it could. She stated that she had heard the nursing staff talking about Resident #1's repeated requests for hemorrhoid ointment and complaints of rectal discomfort. She confirmed that complaints of hemorrhoid pain could be a sign of constipation. She stated that she did not review the documentation of bowel movements or ensure that there were any other medical causes for Resident #1 to be bowel conscious before she implemented this care plan that centered on behaviors. She confirmed that there were no behaviors monitored or tracked related to the resident's bowels, and the only intervention that was documented was a one- time application of the hemorrhoid cream. On [DATE] at 10:28 a.m., an interview was conducted with Employee D, a licensed practical nurse, who recalled caring for Resident #1, She stated that if a resident had not had a bowel movement (BM) in 3 days, an electronic alert appeared on the nurse's electronic dashboard. The licensed nurse will then administer a laxative as per the physician's bowel protocol standing orders. She stated the Certified Nursing Assistants (CNAs) enter bowel movements on their electronic kiosk and this information was stored and calculated. If 3 days go by without a bowel movement, then an electronic alert was triggered on the nurse's electronic dashboard, and the bowel protocol physician orders were implemented. She described the bowel protocol and stated the first step was to give Milk of Magnesia. If a BM within 24 hours had not been produced, then a [MEDICATION NAME] suppository was administered, and if that didn't work in 24 hours then a Fleet enema was given, then Magnesium [MEDICATION NAME]. On [DATE] at 12:04 p.m., an interview was conducted with the facility's Clinical Educator. She stated that the Bowel Documentation that the CNAs in-put into their electronic kiosks was required to be completed by answering three initial questions, which included whether the resident was continent or incontinent of stool, what the size of the BM was, and the consistency. Additionally, there were options that included: no bowel movement, resident not available, not applicable, or resident refused. She stated that through the survey process, it came to the attention of the facility's management that the electronic alerts were not triggered for the nurse to implement the bowel protocol because the CNAs were not entering all required information. She stated all direct care staff that included licensed nurses and CNAs were educated one on one at the kiosk with return demonstrations on how to document bowel movements. A review of Resident #1's physician's progress notes dated [DATE] and [DATE] included nothing about constipation, hemorrhoids or bowel conscious behaviors, but did indicate Resident #1 was planning to go home upon discharge. A review of the Psychiatric Evaluation dated [DATE] indicated the resident was pleasant and psychiatric [DIAGNOSES REDACTED]. Under Review of Systems included, No psychotic symptoms noted or reported. There was nothing documented regarding bowel conscious behaviors. The psychiatrist wrote under Care Plan: Patient has remained stable since her admission to the SNF [DATE]. Continue current medications as prescribed. No acute need to intervene at this time. The psychiatrist indicated that they would follow the resident's medications monthly. On [DATE] at 10:46 a.m., an interview was conducted with the Medical Director. He confirmed that it was a nursing responsibility to effectively monitor and track bowel movements, and he would expect a phone call from nursing if the resident hadn't had a bowel movement in 36 hours. He also stated that the bowel protocol standing orders should be implemented if no BM after 3 days. He said that debilitated patients may present differently with constipation than other patients. He confirmed that residents may still have a soft abdomen and positive bowel sounds yet still be constipated or impacted. He stated that Resident #1 was receiving high dose long- term steroids for end stage [MEDICAL CONDITION], which could mask symptoms of constipation, and also contribute to bowel perforation. He confirmed that if this were the case, then it would be extremely important to ensure the resident was having regular bowel movements. He stated that everyone was trying to learn from this now and do a better job, and additional training was under way. He confirmed that size of bowel movement would be important to include, as a resident may have leakage of stool or increased incontinence if they are severely constipated or impacted with stool. He confirmed that opioid medications may contribute to constipation but it was on an individual basis whether or not a scheduled laxative was required. The Medical Director stated that he was unaware that Resident #1 was care planned for bowel conscious behaviors on [DATE] after several days of no bowel movement. He stated they should have called the physician first (and prior to care planning for behaviors) to rule out serious things first, such as severe constipation or impaction. He confirmed that if the direct care staff thought that she was bowel conscious then they may not pay the proper amount of attention to the resident's complaints of constipation. 2. A review of Resident #8's clinical record included a face sheet that indicated he had a readmission date of [DATE] and was originally admitted [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders for May, (YEAR) included: Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #8 included contradictory Bowel Documentation between Question #1, which documented continence or incontinence, Question #2, which indicated size of BM, and Question #3, which indicated the consistency of the bowel movement. A review of the bowel documentation for Resident #8 for the dates of [DATE] -[DATE] included the following bowel movement documentation: · [DATE] was marked as continent at 13:23, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as incontinent at 03:54 for Question #1 but none was marked for the size of bowel movement for Question #2 and not applicable was marked for consistency. · [DATE] was marked as incontinent at 05:54, continent at 13:59 and no bowel movement at 21:54 for Question 1, but Question #2 indicated none at 05:54, and not applicable at 13:59. · [DATE] was marked as incontinent at 03:22, but Question #2 included none. · [DATE] was marked as continent at 13:59, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as continent at 13:43. Question #2 was marked not applicable for 13:43. Question #3 at 13:43 was also marked not applicable. The third shift did not document if Resident #8 had a bowel movement. · [DATE] was marked as incontinent at 21:59. Question #2 was marked large for 21:59. Question #3 at 21:59 was marked formed. · [DATE] was marked as incontinent at 05:02 and continent at 11:25. For Question #2, none was documented for both shifts and Question #3 was also marked not applicable. The bowel movement documentation for Question #2 and #3 (size and consistency of BM) from [DATE] - [DATE] indicated no bowel movements occurred for those four days. A review of the May, (YEAR) Medication Administration Record revealed no documentation that the bowel protocol physician's orders were initiated for the lack of a BM in 3 days for Resident #8. On [DATE] at 4:25 p.m. an interview with Staff E (LPN), who reviewed the Bowel Documentation and the MAR for Resident #8, confirmed the bowel protocol should have been initiated by [DATE] and there were no notes indicating why the bowel protocol was not administered according to physician orders for Resident #8. A review of Resident #8's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was severely impaired for decision making. An attempt was made to interview the resident during the course of the survey but he was unable to answer simple questions when asked. 3. A clinical record review of Resident #17 included a face sheet that indicated Resident #17 had a readmission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the care plan for Resident #17 revealed a focus for actual or potential for constipation and/or loose stools related to the use and side effects of medication initiated on [DATE]. Interventions included but were not limited to, monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed of any problems and follow facility bowel protocol for bowel management. A review of the current physician's orders for (MONTH) (YEAR) included the bowel protocol as follows: Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #17 included contradictory bowel movement documentation completed by the CNAs. A comparison of the discrepancies within the bowel movement documentation for Resident #17 revealed: · [DATE] was marked as incontinent at 10:40,and 23:33, but Question #2 regarding size had none checked for 10:40 and 23:33. Question #3 related to consistency, showed not applicable was marked for 10:40 and 23:33. · [DATE] was marked as incontinent at 21:21, Question #2 regarding size had large checked for 21:21. Question #3 related to consistency, showed putty was marked for 21:21. · [DATE] was marked as incontinent at 21:23, but response not required was documented at the same time for Question#2/size of BM, and not applicable was marked as the third question related to consistency of BM. · [DATE] was marked as incontinent at 13:12 and 21:59, but Question #2/size was marked as none and non-applicable, respectively. · [DATE] was marked as incontinent at 1:16, 08:42, and 23:43, but Question #2/size was marked as none for all three entries. · [DATE] was marked as incontinent at 11:16 and 23:45 but Question #2/size was marked as none for both entries. · [DATE] was marked as incontinent at 10:52, Question #2 regarding size had large checked for 10:52. Question #3 related to consistency, showed formed was marked for 10:52. · [DATE] was marked as incontinent at 23:39 but Question #2/size was marked as none at 23:39, and Question #3/consistency was marked as not applicable. · [DATE] was marked as incontinent at 10:48 but Questions #2/size and Question #3/consistency were marked as none and non-applicable respectively. · [DATE] was marked as incontinent at 12:31 and 19:21 but Question #2/size was marked as none for both entries, and Question #3 was marked as not applicable. · [DATE] was marked as incontinent at 13:52, but Question #2/size showed none. · [DATE] was marked as incontinent at 00:24, but Question #2/size, was marked as none, and Question #3/consistency was marked as not applicable. The bowel movement documentation for Question #2 and #3 revealed no documented bowel movement from [DATE] - [DATE]. A review of the (MONTH) (YEAR) Medication Administration Record included no documentation that the bowel protocol physician's orders were initiated. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was moderately impaired for decision making. An attempt was made to interview the resident during the course of the survey but she was unable to answer simple questions when asked. On [DATE] at 4:56 p.m., an interview with Staff D, LPN confirmed the bowel protocol should have been initiated for Resident #17. She confirmed she never received an alert within the electronic system or from the CNAs. She said, Never been alerted that she hasn't gone at all. She said, All doctors agree with the protocol, and after three days we will start it. She reviewed the bowel movement documentation for Resident #17 and confirmed the bowel protocol should have been initiated on [DATE] or [DATE]. She said, The third or fourth day should have started the bowel protocol. She verified the bowel protocol was not followed according to physician orders. 4. A review of Resident #18's clinical record included a face sheet that indicated a readmission date of [DATE], and an original admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the care plan for Resident #18 revealed a focus for actual or potential for constipation and/or loose stools related to the use and side effects of medication initiated on [DATE]. Interventions included but were not limited to, monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed of any problems and follow facility bowel protocol for bowel management. Further review of the clinical record for Resident #18 included the following incomplete bowel movement documentation completed by the CNAs: · [DATE] was documented as continent at 00:45, but non-applicable was documented for size and consistency. · [DATE] was documented as continent at 02:58, but none and non-applicable were documented for size and consistency respectively. · [DATE] was documented as continent at 12:02, but none and non-applicable were documented for size and consistency respectively. 5. A review of Resident #19's clinical record included a face sheet that indicated an admission to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A review of Resident #19's current care plans included a focus of potential for constipation and/or loose stools . Interventions included monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed by reporting changes in bowel status. Further review of the bowel documentation for Resident #19 included the following incomplete documentation: · [DATE] was marked as incontinent at 21:48 but Question #2 and #3 was marked as not applicable. · [DATE] was marked as incontinent at 3:31 but Question #2 and #3 was marked as not applicable. · [DATE] was marked as continent at 13:59 but none and non-applicable was marked for Question #2 and #3 respectively. · [DATE] was marked as continent at 13:59, but not applicable was marked for size and consistency. 6. A review of the Job Description for the Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) revealed the following: RN/LPN: General Description: Delivery and administration of nursing care as directed by physician orders, regulations and standards of practice to meet the needs of the residents. Continually evaluate nursing care in the daily delivery of care to assure optimal results. Resident Assessment: Duties: Adhere to the state and federal regulations concerning delivery of care and assure that effective quality nursing care is delivered through utilization of standards of nursing practice.

Based on interviews, and clinical and facility record review, the facility failed to provide the care and services required to identify and treat constipation for five (Resident #1, #8, #17, #18, and #19) of twelve residents that required assistance with bowel incontinence. The facility staff inaccurately and incompletely documented bowel movements which caused Resident #1 not to receive timely treatment for constipation. Residents #8, #17, #18 and #19 had incomplete and inaccurate bowel movement documentation, which placed them at risk for constipation and lack of treatment and symptom manage. In addition, the facility failed to administer their standard physician ordered bowel protocol when the resident was absent of bowel movements. Resident #1 was sent to the hospital with altered mental status on [DATE]. The physician's Death Summary indicated the resident was severely constipated and this resulted in Resident #1's bowel perforation and subsequent death two days later. This failure created a situation that resulted in the serious injury and death of Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 5:15 p.m. Findings included: 1. On [DATE] at 10:28 a.m., an interview was conducted with Employee D, a licensed practical nurse, who recalled caring for Resident #1. She stated that if a resident had not had a bowel movement (BM) in 3 days, an electronic alert appeared on the nurse's electronic dashboard. The licensed nurse will then administer a laxative as per the physician's bowel protocol standing orders. She stated the Certified Nursing Assistants (CNAs) enter bowel movements on their electronic kiosk and this information was stored and calculated. If 3 days go by without a bowel movement, then an electronic alert was triggered on the nurse's electronic dashboard, and the bowel protocol physician orders [REDACTED]. If a BM within 24 hours had not been produced, then a [MEDICATION NAME] suppository was administered, and if that didn't work in 24 hours then a Fleet enema was given, then Magnesium [MEDICATION NAME]. On [DATE] at 12:04 p.m., an interview was conducted with the facility's Clinical Educator. She stated the Bowel Documentation that the CNAs in-put into their electronic kiosks was required to be completed by answering three initial questions, which included whether the resident was continent or incontinent of stool, what the size of the BM was, and the consistency. She stated that through the survey process, it came to the attention of the facility's management that the electronic alerts were not triggered for the nurse to implement the bowel protocol because the CNAs were not entering all required information. Resident #1's clinical record included a face sheet that indicated an admission date of [DATE], and medical [DIAGNOSES REDACTED]. Resident #1's clinical record included an admission MDS (Minimum Data Set) dated [DATE] that showed under Section C a BIMS score of 14 that indicated Resident #1's cognition was intact and she was able to make her needs known. Section G showed that she required extensive assistance of one person for toileting. Section H included that she was always incontinent of bowel and bladder. A review of Resident #1's hospital records indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on [DATE]. A Death Summary for a date of death of [DATE] documented, Final Diagnosis-1. Bowel Perforation, 2. Acute [MEDICAL CONDITION], and 5. Fecal impaction. Under Hospital Course, the summary stated this is a [AGE] year-old woman who was brought from the facility to the hospital emergency room (ER) with complaint of abdominal discomfort. Patient had no bowel movement x 3 weeks .She was placed on suppository as well as an enema but was not having a bowel movement so [MEDICATION NAME] was consulted .She was placed on IV fluids for gentle hydration .[MEDICATION NAME] ordered a medicine called [MEDICATION NAME] due to what is believed to be opiate induced constipation. KUB showed large amount of stool and possible pneumonitis with possible [MEDICATION NAME] gas and free air. CT was recommended. The patient had a CT of the abdomen and pelvis, which showed evidence of bowel perforation likely of the sigmoid colon as the colon was distended and demonstrated extensive pneumatosis. There was a large amount of [MEDICATION NAME] fecal material seen adjunct to the sigmoid colon. Surgery was consulted. On the way back, patient became hypotensive, unresponsive, and became hypoxic, so patient ended up on a ventilator . The patient was initially DNR (do not resuscitate) but due to her condition her family requested all treatments .Patient was doing poorly and she passed away on [DATE] at 2:51 a.m. A review of the hospital History and Physical (H&P) dated [DATE] revealed the history of present illness was documented as a [AGE] year old woman presented to the ER via EMS from the skilled nursing facility with complaint of abdominal discomfort for 3 weeks .Patient also has been very weak for past 5 days with confusion on and off .Currently, she complains of rectal pain due to constipation .She is unsure if she is passing gas. A review of the Abdominal/Pelvis CT scan performed on [DATE] due to abdominal pain and constipation had findings of rectum markedly distended with solid fecal material. The rectal lumen measured 11 cm in AP dimension by 10 cm in [MEDICATION NAME] dimension. There is mild associated presacral [MEDICAL CONDITION]. There is abundant fecal material present throughout the colon. There are multiple diverticuli in the descending colon. There are a few diverticuli in the ascending colon. There is no evidence of extralumenal air. There is no free fluid or fluid collections. Resident #1's bowel documentation for the two weeks prior to her transfer to the hospital included the following: · [DATE] was marked as continent at 12:42, which included medium under question #2 size, and formed for consistency. · [DATE] was marked incontinent at 13:22 but size or consistency were both marked as not-applicable. · [DATE] was marked continent at 11:02 and medium and formed were marked for size and consistency. · [DATE] was marked incontinent at 1:06 but size and consistency were marked as none and not-applicable. · [DATE] was marked incontinent at 12:33 but size and consistency were marked as not-applicable. · [DATE] was marked as incontinent as at 2:07 and 11:24 but size was marked as none and not-applicable, and consistency were marked as not applicable. · [DATE] was marked as incontinent at 11:05 and 18:12, but not applicable was marked for size and consistency. · [DATE] was marked as continent at 13:59 and size was marked as small and consistency, formed. · [DATE] was marked as incontinent at 21:33 but size was marked as none and consistency not applicable. · [DATE] was marked as continent at 11:23 but size and consistency were marked as not applicable. · [DATE] was marked as continent at 19:58 and size and consistency were marked as medium and formed. A review of the Medication Administration Record (MAR) included physician's orders [REDACTED]. A comparison of the MAR and the documentation of Resident #1's bowel movements showed that although Resident #1 should have received Milk of Magnesia on [DATE], when she had not had a bowel movement recorded since [DATE], she did not receive this first step of the bowel protocol to alleviate constipation. Further review showed that she did receive a [MEDICATION NAME] suppository on [DATE] and this was repeated on [DATE]. The nursing notes included, effective as a result after the [MEDICATION NAME] suppository that was administered on [DATE], but there was no documentation to explain why the resident required another suppository the following day, [DATE], and there were no documented results for this second dose. The Journal of the American Board of Family Medicine stated in the article, Chronic Constipation: An Evidence-Based Review: .medical personnel define constipation as less than 3 bowel movements per week . and also included under Complications of Chronic Constipation: Hemorrhoids .and Bowel Perforation . (www.jabfm.org) On [DATE] at 1:30 p.m., the Bowel Documentation for Resident #1 was reviewed with the DON. She confirmed that bowel movements should be monitored and accurately documented, and this was a standard of nursing care. She confirmed several entries indicated Resident #1's continence or incontinence, but had no proper follow- through that included size and consistency of the BM. She stated the partial or incomplete documentation can cause the alert not to appear on the nurse's dashboard and the nurse would not be notified of the resident's lack of BM's. In this event, the nurse would not know that the physician ordered bowel protocol needed to be implemented. She confirmed for seven days, between the dates of ,[DATE] and ,[DATE], there were no entries that included a description of size and consistency but, instead, included, none and not applicable. The DON acknowledged that if the alert had appeared and the licensed nurse had taken the appropriate action, then the first step of the bowel protocol, Milk of Magnesia, should have been administered ,[DATE]-[DATE], but it was not. She confirmed that she herself documented a small BM on [DATE] and then another five days went by without another BM documented that included a description, and the bowel protocol was not implemented at that time either. The Progress Notes were silent regarding Resident #1's absence of bowel movements between [DATE] and [DATE]. A therapy entry, dated [DATE], indicated Resident #1 was planning to be discharged to home and declined a home evaluation saying that she would be fine. A late entry, dated [DATE], by the facility's wound care nurse included that when the coccyx wound dressing was changed, the resident requested treatment for hemorrhoids, and soft stool was noted to the rectal opening. An entry, dated [DATE], indicated the resident was offered a laxative with morning medications and she accepted. An entry dated [DATE] stated, .has anxiety at times along with generalized pain and [MEDICATION NAME] pain-see MAR. Reluctant to participate in therapy and eventually does so after some negotiations and manipulations. Psych has been consulted. Entries dated ,[DATE] at 8:00 a.m., indicated Resident has altered mental status. She is sleepy but arousable . and at 11:49 a.m., Resident has altered mental status and is more sleepy than usual . and at 12:00 p.m. the emergency medical services was notified and Resident #1 was transported to the hospital. The last nursing documentation was an SBAR (Situation-background-assessment-recommendation) form, dated [DATE], which indicated Resident #1 was sent out to an acute care hospital via emergency transportation for a change in mental status; the section for Abdominal/Gastrointestinal Evaluation was checked, Not clinically applicable to the change in condition being reported. On [DATE] at 5:30 p.m., a telephone interview was conducted with Employee B, a licensed practical nurse that confirmed she was assigned to Resident #1 when she was transferred out to the hospital on [DATE]. She said that she did not know what was wrong with Resident #1 on [DATE]. She stated, We couldn't pin point it. She was asked about her gastrointestinal status, and she stated that she thinks she remembers the resident had received some laxatives earlier, but was not sure about this. She stated she heard the resident had died . On [DATE] at 3:12 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that she usually spoke with her mother every day while she was in the facility. She said that her mother had been admitted to the facility for therapy to get stronger. She stated that her mother had complained of constipation to her frequently, and she had spoken with the nursing staff and relayed the concerns, but nothing was done to alleviate her mother's constipation and discomfort. Resident #1's daughter said that her mother became so severely constipated while in the facility, that her bowel had ruptured, and that was why she was so lethargic and in pain when she was sent out to the hospital on [DATE]. On [DATE] at 1:04 p.m., an interview was conducted with Resident #1's caregiver. He stated that he had cared for the resident for a number of years at home. He stated that he knew Resident #1 was getting older and had some medical problems, but it was unacceptable that she had to go to the hospital for severe constipation and then died , because that could have been prevented. He stated that she took opioid medication that caused constipation, and at home she was on a regular laxative every day to counteract the constipation, but had not received this while in the facility. A review of Resident #1's physician's progress notes, dated [DATE] and [DATE], included nothing about constipation, but did indicate Resident #1 was planning to go home upon discharge. A review of the Evaluation, dated [DATE], indicated the resident was pleasant and psychiatric [DIAGNOSES REDACTED]. Under Review of Systems included, No psychotic symptoms noted or reported. The consulting physician wrote under Care Plan: Patient has remained stable since her admission to the SNF [DATE]. Continue current medications as prescribed. No acute need to intervene at this time. The physician indicated that they would follow the resident's medications monthly. On [DATE] at 10:46 a.m., an interview was conducted with the Medical Director. He confirmed that it was a nursing responsibility to effectively monitor and track bowel movements, and he would expect a phone call from nursing if the resident hadn't had a bowel movement in 36 hours. He also stated that the bowel protocol standing orders should be implemented if no BM after 3 days. 2. A review of Resident #8's clinical record included a face sheet that indicated he had a readmission date of [DATE] and was originally admitted [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #8 included contradictory Bowel Documentation between Question #1, which documented continence or incontinence, Question #2, which indicated size of BM, and Question #3, which indicated the consistency of the bowel movement. A review of the bowel documentation for Resident #8 for the dates of [DATE] -[DATE] included the following bowel movement documentation: · [DATE] was marked as continent at 13:23, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as incontinent at 03:54 for Question #1 but none was marked for the size of bowel movement for Question #2 and not applicable was marked for consistency. · [DATE] was marked as incontinent at 05:54, continent at 13:59 and no bowel movement at 21:54 for Question 1, but Question #2 indicated none at 05:54, and not applicable at 13:59. · [DATE] was marked as incontinent at 03:22, but Question #2 included none. · [DATE] was marked as continent at 13:59, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as continent at 13:43. Question #2 was marked not applicable for 13:43. Question #3 at 13:43 was also marked not applicable. The third shift did not document if Resident #8 had a bowel movement. · [DATE] was marked as incontinent at 21:59. Question #2 was marked large for 21:59. Question #3 at 21:59 was marked formed. · [DATE] was marked as incontinent at 05:02 and continent at 11:25. For Question #2, none was documented for both shifts and Question #3 was also marked not applicable. The bowel movement documentation for Question #2 and #3 (size and consistency of BM) from [DATE] - [DATE] indicated no bowel movements occurred for those four days. A review of the May, (YEAR) Medication Administration Record revealed no documentation that the bowel protocol physician's orders [REDACTED].#8. On [DATE] at 4:25 p.m. an interview with Staff E (LPN), who reviewed the Bowel Documentation and the MAR for Resident #8, confirmed the bowel protocol should have been initiated by [DATE] and there were no notes indicating why the bowel protocol was not administered according to physician orders [REDACTED]. A review of Resident #8's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was severely impaired for decision making. An attempt was made to interview the resident during the course of the survey but he was unable to answer simple questions when asked. 3. A clinical record review of Resident #17 included a face sheet that indicated Resident #17 had a readmission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the care plan for Resident #17 revealed a focus for actual or potential for constipation and/or loose stools related to the use and side effects of medication initiated on [DATE]. Interventions included but were not limited to, monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed of any problems and follow facility bowel protocol for bowel management. A review of the current physician's orders [REDACTED]. Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #17 included contradictory bowel movement documentation completed by the CNAs. A comparison of the discrepancies within the bowel movement documentation for Resident #17 revealed: · [DATE] was marked as incontinent at 10:40, and 23:33, but Question #2 regarding size had none checked for 10:40 and 23:33. Question #3 related to consistency, showed not applicable was marked for 10:40 and 23:33. · [DATE] was marked as incontinent at 21:21, Question #2 regarding size had large checked for 21:21. Question #3 related to consistency, showed putty was marked for 21:21. · [DATE] was marked as incontinent at 21:23, but response not required was documented at the same time for Question#2/size of BM, and not applicable was marked as the third question related to consistency of BM. · [DATE] was marked as incontinent at 13:12 and 21:59, but Question #2/size was marked as none and non-applicable, respectively. · [DATE] was marked as incontinent at 1:16, 08:42, and 23:43, but Question #2/size was marked as none for all three entries. · [DATE] was marked as incontinent at 11:16 and 23:45 but Question #2/size was marked as none for both entries. · [DATE] was marked as incontinent at 10:52, Question #2 regarding size had large checked for 10:52. Question #3 related to consistency, showed formed was marked for 10:52. · [DATE] was marked as incontinent at 23:39 but Question #2/size was marked as none at 23:39, and Question #3/consistency was marked as not applicable. · [DATE] was marked as incontinent at 10:48 but Questions #2/size and Question #3/consistency were marked as none and non-applicable respectively. · [DATE] was marked as incontinent at 12:31 and 19:21 but Question #2/size was marked as none for both entries, and Question #3 was marked as not applicable. · [DATE] was marked as incontinent at 13:52, but Question #2/size showed none. · [DATE] was marked as incontinent at 00:24, but Question #2/size, was marked as none, and Question #3/consistency was marked as not applicable. The bowel movement documentation for Question #2 and #3 from revealed no documented bowel movement from [DATE] - [DATE]. A review of the (MONTH) (YEAR) Medication Administration Record included no documentation that the bowel protocol physician's orders [REDACTED]. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed she was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was moderately impaired for decision making. An attempt was made to interview the resident during the course of the survey but she was unable to answer simple questions when asked. On [DATE] at 4:56 p.m., an interview with Staff D, LPN confirmed the bowel protocol should have been initiated for Resident #17. She confirmed she never received an alert within the electronic system or from the CNAs. She said, Never been alerted that she hasn't gone at all. She said, All doctors agree with the protocol, and after three days we will start it. She reviewed the bowel movement documentation for Resident #17 and confirmed the bowel protocol should have been initiated on [DATE] or [DATE]. She said, The third or fourth day should have started the bowel protocol. She verified the bowel protocol was not followed according to physician orders. 4. A review of Resident #18's clinical record included a face sheet that indicated a readmission date of [DATE], and an original admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the care plan for Resident #18 revealed a focus for actual or potential for constipation and/or loose stools related to the use and side effects of medication initiated on [DATE]. Interventions included but were not limited to, monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed of any problems and follow facility bowel protocol for bowel management. Further review of the clinical record for Resident #18 included the following incomplete bowel movement documentation completed by the CNAs: · [DATE] was documented as continent at 00:45, but non-applicable was documented for size and consistency. · [DATE] was documented as continent at 02:58, but none and non-applicable were documented for size and consistency respectively. · [DATE] was documented as continent at 12:02, but none and non-applicable were documented for size and consistency respectively. 5. A review of Resident #19's clinical record included a face sheet that indicated an admission to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A review of Resident #19's current care plans included a focus of potential for constipation and/or loose stools . Interventions included monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed by reporting changes in bowel status. Further review of the bowel documentation for Resident #19 included the following incomplete documentation: · [DATE] was marked as incontinent at 21:48 but Question #2 and #3 was marked as not applicable. · [DATE] was marked as incontinent at 3:31 but Question #2 and #3 was marked as not applicable. [DATE] was marked as continent at 13:59 but none and non-applicable was marked for Question #2 and #3 respectively. · [DATE] was marked as continent at 13:59, but not applicable was marked for size and consistency. 6. The facility's policy titled, Perineal/Incontinence Care, Policy Number 12.07.04.11 revised [DATE], included under Guidelines: 7. For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. The facility's policy titled, Charting and Documentation, Policy Number 12.05.094, revised [DATE], included under Guidelines: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 2. Incidents, accidents or changes in the resident's condition should be recorded in the clinical record 7. On [DATE] at 3:08 p.m., an interview with the Director of Nursing (DON) and the Clinical Educator confirmed the inaccurate and incomplete bowel movement documentation for Residents #1, #8, #17, #18 and #19. The DON confirmed that the licensed staff would not have been able to discern when or if a resident had a bowel movement, the size of the bowel movement and the consistency of the bowel movement. The DON verified that this would place the residents at risk for constipation and complications from constipation. The Clinical Educator said, We have discussed this with our (corporate) education (department). She stated that if a resident has a BM, then the size and consistency must be documented, and it was not acceptable to include non-applicable. The Clinical Educator stated that all direct care staff were first in-serviced on [DATE] when it came to their attention that there were inaccuracies and incomplete documentation of bowel movements. She stated that audits were started on all resident's bowel documentation after the education was provided. The DON stated that further one- on- one in-services were started on [DATE] with CNA's and training was given at the electronic kiosks with return demonstrations given, and 100% of direct care staff were educated and re-educated through [DATE]. She stated that new processes were put into place that included licensed staff over-sight of all CNA bowel documentation entered. After each shift, all BMs were documented and reviewed each day in the morning meeting. A review of the facility's list of direct care CNAs included a total of 24 employees. A review of the facility's list of direct care licensed nurses included a total of 13 employees. A review of the in-service sign in sheets dated [DATE] titled Daily Documentation of Bowel Movements documented 100% of the CNAs attended the training, and the sign in sheet dated [DATE] titled, Bowel Protocol, included 100% of the LPNs/RNs attended. Further review of educational in-services included a [DATE] one to one training at the electronic kiosk on how to document bowel movements and monitor to ensure the documentation was complete and accurate. A review of the documentation revealed 100% of the CNAs and licensed nurses received this one to one training with return demonstration. The facility also instituted a BM audit to include whether or not the resident had a BM within the past 3 days, if the bowel protocol was initiated as applicable, the effectiveness of the protocol, and a description of the results. On [DATE] at 3:00 p.m. Employees F, G, H, I, J, K, L, M, N, and O, all CNAs were interviewed and asked to provide a demonstration of how a bowel movement was documented on the kiosk. All provided full and accurate demonstrations. On [DATE], random interviews were conducted with licensed nurses across both 12-hour shifts. The nurses were able to articulate the new system that was put into place. They indicated that they now verify at the end of each shift CNA documentation of bowel movements to ensure accurate and complete documentation and the need to implement the bowel protocol as applicable. Immediate Jeopardy was determined removed on [DATE] at 5:15 p.m. and the scope and severity was reduced to an E.

Based on interviews with the facility's staff, physician, a family member, and reviews of clinical and facility records, it was determined that administration failed to provide the proper training and oversight to ensure care and services were provided related to bowel care for five (Resident #1, #8, #17, #18 and #19) of twelve residents sampled that required assistance with toileting. Administration did not ensure the direct functions and operations of the facility, which included monitoring bowel movements and implementing the appropriate treatment for [REDACTED]. Residents #8, #17, #18 and #19 had inaccurate documentation of bowel movements and physician's orders were not followed to treat potential constipation. Resident #1 was receiving pain medication with a known side effect of constipation. The facility did not develop a care plan or interventions to address the symptom management of constipation, but did have a care plan that addressed bowel conscious behaviors, which was inaccurate. In addition, the facility failed to administer their standard physician ordered bowel protocol when the resident was absent of bowel movements. Resident #1 was sent to the hospital with altered mental status on [DATE]. The physician's Death Summary indicated the resident was severely constipated and this resulted in Resident #1's bowel perforation and subsequent death two days later. This failure to assess and monitor constipation resulted in the serious injury and death of Resident #1 and resulted in the determination of immediate jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 5:15 p.m. Findings included: 1. A review of the job description for the Administrator, which was undated and signed by the Administrator, revealed the following relevant information: General Purpose included, Manage, lead and direct the overall operations of the facility in accordance with customer needs, regulations and company policies. With focus on maintaining excellent care for the residents/patients, support and encouragement of employees and achieving the facility's business objectives. Under B. Facility Management Duties: Responsible for recruitment, interviewing and selection of the facility managers . Oversees regular rounds to monitor delivery of nursing care, operation of support departments .and ensures resident needs are being addressed. Provide leadership to maintain interdepartmental teamwork. Ensures consultants and other support resources are appropriately utilized. Under C. Compliance Management Duties: Develops and maintain written policies and procedures that govern efficient day to day operation of the facility. Maintain a working knowledge of and ensure compliance with all governmental regulations including risk management function. The Administrator performs the role of the facility risk manager. A review of the job description for the Director of Nursing (DON), which was signed by the DON on [DATE], revealed the following relevant information: General Description included, The Director of Nursing Services is responsible for maintaining consistent, safe and effective nursing practices and the management of the overall operation of the Nursing Department in accordance with policies, standards of nursing practices and regulatory requirements. Establish processes that are outcome focused as to maintain the highest possible level of care and services of reach resident, while achieving the facility business objectives. Under A. Facility Management Duties: Develop and maintain nursing care objectives and standards of nursing care practices for facility. Under B. Nursing Care and Documentation Function Duties: Develop and maintain nursing standards and service objectives that govern efficient day to day operations of the nursing department .Review documentation, the delivery of nursing care according to the physician's orders, care plans, and established standards and facility policy. 2. A review of Resident #1's hospital records indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on [DATE]. A Death Summary dated [DATE] documented, Final Diagnosis-1. Bowel Perforation. Under Hospital Course, the summary indicated that Resident #1 was admitted with abdominal discomfort, and a [MEDICATION NAME] consultation indicated opiate induced constipation. An x-ray showed a large amount of stool, and a CT (computerized tomography) scan showed evidence of a bowel perforation and distention of the sigmoid colon. Resident #1's clinical record included a face sheet that indicated an admission date of [DATE], and medical [DIAGNOSES REDACTED]. Resident #1's clinical record included an admission MDS (Minimum Data Set) dated [DATE] that showed under Section C a BIMS score of 14 that indicated Resident #1's cognition was intact and she was able to make her needs known. Section G showed that she required extensive assistance of one person for toileting. Section H included that she was always incontinent of bowel and bladder. A review of the facility's Bowel Documentation included three categories: continent or incontinent, size and consistency. On [DATE] at 1:55 p.m., the Director of Nursing (DON) confirmed all three criteria must be entered by the Certified Nursing Assistants (CNAs) in order to record a BM in the facility's electronic medical record system. The DON said, If there is no BM in 3 days, the system sends an alert to the licensed nurse's electronic dashboard. The constipation was treated per the standing physician's orders, known as a bowel protocol. Resident #1's bowel documentation for the two weeks prior to her transfer to the hospital included the following: · [DATE] was marked as continent at 12:42, which included medium under question #2 size, and formed for consistency. · [DATE] was marked incontinent at 13:22 but size or consistency were both marked as not-applicable. · [DATE] was marked continent at 11:02 and medium and formed were marked for size and consistency. · [DATE] was marked incontinent at 1:06 but size and consistency were marked as none and not-applicable. · [DATE] was marked incontinent at 12:33 but size and consistency were marked as not-applicable. · [DATE] was marked as incontinent as at 2:07 and 11:24 but size was marked as none and not-applicable, and consistency were marked as not applicable. · [DATE] was marked as incontinent at 11:05 and 18:12, but not applicable was marked for size and consistency. · [DATE] was marked as continent at 13:59 and size was marked as small and consistency, formed. · [DATE] was marked as incontinent at 21:33 but size was marked as none and consistency not applicable. · [DATE] was marked as continent at 11:23 but size and consistency were marked as not applicable. · [DATE] was marked as continent at 19:58 and size and consistency were marked as medium and formed. A review of the Medication Administration Record (MAR) revealed the resident was receiving the pain medication [MEDICATION NAME]/[MEDICATION NAME] tablets ,[DATE] mg for chronic generalized pain, which began on [DATE]. The resident received 29 doses between [DATE] and [DATE], the same period of time that incomplete documentation of bowel movements was identified. The physician's orders did not include a scheduled laxative or stool softener, but did include the bowel protocol: Milk of Magnesia suspension 400 mg/5 ml, give 30 ml by mouth as needed for constipation at bedtime of no BM in 3 days; [MEDICATION NAME] suppository 10 mg insert one rectally as needed for constipation daily if no results for Milk of Magnesia; and a Fleet enema insert one dose rectally as needed for constipation if no results 1 day after suppository. The physician's orders also included [MEDICATION NAME] Ointment insert one application rectally every 8 hours as needed for mild pain related to other hemorrhoids. A review of the side effects of [MEDICATION NAME]/[MEDICATION NAME] included a known side effect of constipation. (www.ncbi.nlm.gov). The Journal of the American Board of Family Medicine stated in the article, Chronic Constipation: An Evidence-Based Review: .medical personnel define constipation as less than 3 bowel movements per week . and also included under Complications of Chronic Constipation: Hemorrhoids .and Bowel Perforation (www.jabfm.org) A comparison of the MAR and the documentation of Resident #1's bowel movements showed that Resident #1 should have received Milk of Magnesia on [DATE], when she had not had a bowel movement recorded since [DATE]. She did not receive this first step of the bowel protocol to alleviate constipation. Further review showed that she did receive a [MEDICATION NAME] suppository on [DATE] and this was repeated on [DATE]. The nursing notes included, effective as a result after the [MEDICATION NAME] suppository was administered on [DATE], but there was no documentation to explain why the resident required another suppository the following day, [DATE], and there were no documented results for this second dose. Additionally, it was documented only once on [DATE] at 0601 that Resident #1 received the Hemorrhoid Ointment. On [DATE] at 1:30 p.m., the Bowel Documentation for Resident #1 was reviewed with the DON. She confirmed that bowel movements should be monitored and accurately documented, and this was a standard of nursing care. She confirmed several entries indicated Resident #1's continence or incontinence, but had no proper follow- through that included size and consistency of the BM. She stated the partial or incomplete documentation can cause the alert not to appear on the nurse's dashboard and the nurse would not be notified of the resident's lack of BM's. In this event, the nurse would not know that the physician ordered bowel protocol needed to be implemented. She confirmed for seven days between the dates of ,[DATE] and ,[DATE], there were no entries that included a description of size and consistency but instead included, none and not applicable. The DON acknowledged that if the alert had appeared and the licensed nurse had taken the appropriate action, then the first step of the bowel protocol, Milk of Magnesia, should have been administered ,[DATE]-[DATE], but it was not. She confirmed that she herself documented a small BM on [DATE] and then another five days went by without another BM documented that included a description, and the bowel protocol was not implemented at that time either. The Progress Notes were silent regarding Resident #1's absence of bowel movements between [DATE] and [DATE]. A therapy entry dated [DATE] indicated Resident #1 was planning to be discharged to home and declined a home evaluation saying that she would be fine. A late entry dated [DATE] by the facility's wound care nurse included that when the coccyx wound dressing was changed, the resident requested treatment for [REDACTED]. An entry dated [DATE] indicated the resident was offered a laxative with morning medications and she accepted. An entry dated [DATE] stated, .has anxiety at times along with generalized pain and [MEDICATION NAME] pain-see MAR. Reluctant to participate in therapy and eventually does so after some negotiations and manipulations. Psych has been consulted. Entries dated ,[DATE] at 8:00 a.m. indicated Resident has altered mental status. She is sleepy but arousable . and at 11:49 a.m., Resident has altered mental status and is more sleepy than usual . and at 12:00 p.m. the emergency medical services was notified and Resident #1 was transported to the hospital. The last nursing documentation was an SBAR (Situation-background-assessment-recommendation) form dated [DATE] that indicated Resident #1 was sent out to an acute care hospital via emergency transportation for a change in mental status; the section for Abdominal/Gastrointestinal Evaluation was checked, Not clinically applicable to the change in condition being reported. 3. A closer review of the hospital records for Resident #1 indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on [DATE]. A Death Summary for a date of death of [DATE] documented, Final Diagnosis-1. Bowel Perforation, 2. Acute [MEDICAL CONDITION], and 5. Fecal impaction. Under Hospital Course, the summary stated this is a [AGE] year-old woman who was brought from the facility to the hospital emergency room (ER) with complaint of abdominal discomfort. Patient had no bowel movement x 3 weeks .She was placed on suppository as well as an enema but was not having a bowel movement so [MEDICATION NAME] was consulted .She was placed on IV fluids for gentle hydration .[MEDICATION NAME] ordered a medicine called [MEDICATION NAME] due to what is believed to be opiate induced constipation. KUB showed large amount of stool and possible pneumonitis with possible [MEDICATION NAME] gas and free air. CT was recommended. The patient had a CT of the abdomen and pelvis, which showed evidence of bowel perforation likely of the sigmoid colon as the colon was distended and demonstrated extensive pneumatosis. There was a large amount of [MEDICATION NAME] fecal material seen adjunct to the sigmoid colon. Surgery was consulted. On the way back, patient became hypotensive, unresponsive, and became hypoxic, so patient ended up on a ventilator . The patient was initially DNR (do not resuscitate) but due to her condition her family requested all treatments .Patient was doing poorly and she passed away on [DATE] at 2:51 a.m. A review of the hospital History and Physical (H&P) dated [DATE] revealed the history of present illness was documented as a [AGE] year old woman presented to the ER via EMS from the skilled nursing facility with complaint of abdominal discomfort for 3 weeks .Patient also has been very weak for past 5 days with confusion on and off .Currently, she complains of rectal pain due to constipation .She is unsure if she is passing gas. A review of the Abdominal/Pelvis CT scan performed on [DATE] due to abdominal pain and constipation had findings of rectum markedly distended with solid fecal material. The rectal lumen measured 11 cm in AP dimension by 10 cm in [MEDICATION NAME] dimension. There is mild associated presacral [MEDICAL CONDITION]. There is abundant fecal material present throughout the colon. There are multiple diverticuli in the descending colon. There are a few diverticuli in the ascending colon. There is no evidence of extralumenal air. There is no free fluid or fluid collections. On [DATE] at 2:44 p.m., an interview was conducted with the wound care nurse. She said that she recalled Resident #1, and stated that she was seeing the resident regularly because she was admitted with a Stage I pressure ulcer to the coccyx. The wound care nurse recalled telling the resident's assigned nurse on [DATE] that the resident was constipated. On [DATE] at 5:30 p.m., a telephone interview was conducted with Employee B, a licensed practical nurse that confirmed she was assigned to Resident #1 when she was transferred out to the hospital on [DATE]. She said that she did not know what was wrong with Resident #1 on [DATE]. She stated, We couldn't pin point it. She was asked about her gastrointestinal status, and she stated that she thinks she remembers the resident had received some laxatives earlier, but was not sure about this. She stated she heard the resident had died . On [DATE] at 3:12 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that she usually spoke with her mother every day while she was in the facility. She said that her mother had been admitted to the facility for therapy to get stronger. She stated that her mother had complained of constipation to her frequently, and she had spoken with the nursing staff and relayed the concerns, but nothing was done to alleviate her mother's constipation and discomfort. Resident #1's daughter said that her mother became so severely constipated while in the facility, that her bowel had ruptured, and that was why she was so lethargic and in pain when she was sent out to the hospital on [DATE]. On [DATE] at 1:04 p.m., an interview was conducted with Resident #1's caregiver. He stated that he had cared for the resident for a number of years at home. He stated that he knew Resident #1 was getting older and had some medical problems, but it was unacceptable that she had to go to the hospital for severe constipation and then died , because that could have been prevented. He stated that she took opioid medication that caused constipation, and at home she was on a regular laxative every day to counteract the constipation, but had not received this while in the facility. A review of Resident #1's care plans did not include a focus of potential constipation, or to monitor for constipation related to opioid medications. However, there was a care plan titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. Interventions included, Administer medications as ordered. Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Reinforce positive behaviors. On [DATE] at 2:00 p.m., the clinical record was reviewed with the MDS/Care Plan Coordinator. She confirmed that there was no care plan that addressed constipation, and Resident #1, who was assessed to be incontinent of stool and required assistance with toileting, was at risk for constipation. She confirmed that there was a care plan titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. The MDS Coordinator was asked if severe constipation could cause a person to be bowel conscious and she said that it could. She stated that she had heard the nursing staff talking about Resident #1's repeated requests for hemorrhoid ointment and complaints of rectal discomfort. She confirmed that complaints of hemorrhoid pain could be a sign of constipation. She stated that she did not review the documentation of bowel movements or ensure that there were any other medical causes for Resident #1 to be bowel conscious before she implemented this care plan that centered on behaviors. She confirmed that there were no behaviors monitored or tracked related to the resident's bowels, and the only intervention that was documented was a one- time application of the hemorrhoid cream. On [DATE] at 10:28 a.m., an interview was conducted with Employee D, a licensed practical nurse, who recalled caring for Resident #1. She stated that if a resident had not had a bowel movement (BM) in 3 days, an electronic alert appeared on the nurse's electronic dashboard. The licensed nurse will then administer a laxative as per the physician's bowel protocol standing orders. She stated the Certified Nursing Assistants (CNAs) enter bowel movements on their electronic kiosk and this information was stored and calculated. If 3 days go by without a bowel movement, then an electronic alert was triggered on the nurse's electronic dashboard, and the bowel protocol physician orders were implemented. She described the bowel protocol and stated the first step was to give Milk of Magnesia. If a BM within 24 hours had not been produced, then a [MEDICATION NAME] suppository was administered, and if that didn't work in 24 hours then a Fleet enema was given, then Magnesium [MEDICATION NAME]. On [DATE] at 12:04 p.m., an interview was conducted with the facility's Clinical Educator. She stated that the Bowel Documentation that the CNAs in-put into their electronic kiosks was required to be completed by answering three initial questions, which included whether the resident was continent or incontinent of stool, what the size of the BM was, and the consistency. Additionally, there were options that included: no bowel movement, resident not available, not applicable, or resident refused. She stated that through the survey process, it came to the attention of the facility's management that the electronic alerts were not triggered for the nurse to implement the bowel protocol because the CNAs were not entering all required information. She stated all direct care staff that included licensed nurses and CNAs were educated one on one at the kiosk with return demonstrations on how to document bowel movements. A review of Resident #1's physician's progress notes dated [DATE] and [DATE] included nothing about constipation, hemorrhoids or bowel conscious behaviors, but did indicate Resident #1 was planning to go home upon discharge. A review of an evaluation, dated [DATE], indicated the resident was pleasant and psychiatric [DIAGNOSES REDACTED]. Under Review of Systems included, No psychotic symptoms noted or reported. There was nothing documented regarding bowel conscious behaviors. The physician wrote under Care Plan: Patient has remained stable since her admission to the SNF [DATE]. Continue current medications as prescribed. No acute need to intervene at this time. The physician indicated that they would follow the resident's medications monthly. On [DATE] at 10:46 a.m., an interview was conducted with the Medical Director. He confirmed that it was a nursing responsibility to effectively monitor and track bowel movements, and he would expect a phone call from nursing if the resident hadn't had a bowel movement in 36 hours. He also stated that the bowel protocol standing orders should be implemented if no BM after 3 days. He said that debilitated patients may present differently with constipation than other patients. He confirmed that residents may still have a soft abdomen and positive bowel sounds yet still be constipated or impacted. He stated that Resident #1 was receiving high dose long- term steroids for end stage [MEDICAL CONDITION], which could mask symptoms of constipation, and also contribute to bowel perforation. He confirmed that if this were the case, then it would be extremely important to ensure the resident was having regular bowel movements. He stated that everyone was trying to learn from this now and do a better job, and additional training was under way. He confirmed that size of bowel movement would be important to include, as a resident may have leakage of stool or increased incontinence if they are severely constipated or impacted with stool. He confirmed that opioid medications may contribute to constipation but it was on an individual basis whether or not a scheduled laxative was required. The Medical Director stated that he was unaware that Resident #1 was care planned for bowel conscious behaviors on [DATE] after several days of no bowel movement. He stated they should have called the physician first (and prior to care planning for behaviors) to rule out serious things first, such as severe constipation or impaction. He confirmed that if the direct care staff thought that she was bowel conscious then they may not pay the proper amount of attention to the resident's complaints of constipation. 4. A review of Resident #8's clinical record included a face sheet that indicated he had a readmission date of [DATE] and was originally admitted [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders for May, (YEAR) included: Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #8 included contradictory Bowel Documentation between Question #1, which documented continence or incontinence, Question #2, which indicated size of BM, and Question #3, which indicated the consistency of the bowel movement. A review of the bowel documentation for Resident #8 for the dates of [DATE] -[DATE] included the following bowel movement documentation: · [DATE] was marked as continent at 13:23, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as incontinent at 03:54 for Question #1 but none was marked for the size of bowel movement for Question #2 and not applicable was marked for consistency. · [DATE] was marked as incontinent at 05:54, continent at 13:59 and no bowel movement at 21:54 for Question 1, but Question #2 indicated none at 05:54, and not applicable at 13:59. · [DATE] was marked as incontinent at 03:22, but Question #2 included none. · [DATE] was marked as continent at 13:59, but Question #2 and #3 were marked as not applicable. · [DATE] was marked as continent at 13:43. Question #2 was marked not applicable for 13:43. Question #3 at 13:43 was also marked not applicable. The third shift did not document if Resident #8 had a bowel movement. · [DATE] was marked as incontinent at 21:59. Question #2 was marked large for 21:59. Question #3 at 21:59 was marked formed. · [DATE] was marked as incontinent at 05:02 and continent at 11:25. For Question #2, none was documented for both shifts and Question #3 was also marked not applicable. The bowel movement documentation for Question #2 and #3 (size and consistency of BM) from [DATE] - [DATE] indicated no bowel movements occurred for those four days. A review of the May, (YEAR) Medication Administration Record revealed no documentation that the bowel protocol physician's orders were initiated for the lack of a BM in 3 days for Resident #8. On [DATE] at 4:25 p.m. an interview with Staff E (LPN), who reviewed the Bowel Documentation and the MAR for Resident #8, confirmed the bowel protocol should have been initiated by [DATE] and there were no notes indicating why the bowel protocol was not administered according to physician orders for Resident #8. A review of Resident #8's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was severely impaired for decision making. An attempt was made to interview the resident during the course of the survey but he was unable to answer simple questions when asked. 5. A clinical record review of Resident #17 included a face sheet that indicated Resident #17 had a readmission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the care plan for Resident #17 revealed a focus for actual or potential for constipation and/or loose stools related to the use and side effects of medication initiated on [DATE]. Interventions included but were not limited to, monitoring bowel movement status and notify nurse of signs and symptoms of constipation, monitor medications for side effects of constipation and keep physician informed of any problems and follow facility bowel protocol for bowel management. A review of the current physician's orders for (MONTH) (YEAR) included the bowel protocol as follows: Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for no BM in 3 days at bedtime; Ducolax Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally as needed for constipation in AM if no results 1 day after MOM; Enema Disposable Enema (Sodium [MEDICATION NAME]) Insert 1 unit rectally as needed for constipation if no results 1 day after suppository; Citroma Solution 1.745 GM/30ML (Magnesium [MEDICATION NAME]) - give 296 ml by mouth as needed for constipation In AM if no results after enema. If no results within 1 hour of completion of bowel protocol contact MD (medical doctor) immediately for further orders. Further review of the clinical record for Resident #17 included contradictory bowel movement documentation completed by the CNAs. A comparison of the discrepancies within the bowel movement documentation for Resident #17 revealed: · [DATE] was marked as incontinent at 10:40,and 23:33, but Question #2 regarding size had none checked for 10:40 and 23:33. Question #3 related to consistency, showed not applicable was marked for 10:40 and 23:33. · [DATE] was marked as incontinent at 21:21, Question #2 regarding size had large checked for 21:21. Question #3 related to consistency, showed putty was marked for 21:21. · [DATE] was marked as incontinent at 21:23, but response not required was documented at the same time for Question#2/size of BM, and not applicable was marked as the third question related to consistency of BM. · [DATE] was marked as incontinent at 13:12 and 21:59, but Question #2/size was marked as none and non-applicable, respectively. · [DATE] was marked as incontinent at 1:16, 08:42, and 23:43, but Question #2/size was marked as none for all three entries. · [DATE] was marked as incontinent at 11:16 and 23:45 but Question #2/size was marked as none for both entries. · [DATE] was marked as incontinent at 10:52, Question #2 regarding size had large checked for 10:52. Question #3 related to consistency, showed formed was marked for 10:52. · [DATE] was marked as incontinent at 23:39 but Question #2/size was marked as none at 23:39, and Question #3/consistency was marked as not applicable. · [DATE] was marked as incontinent at 10:48 but Questions #2/size and Question #3/consistency were marked as none and non-applicable respectively. · [DATE] was marked as incontinent at 12:31 and 19:21 but Question #2/size was marked as none for both entries, and Question #3 was marked as not applicable. · [DATE] was marked as incontinent at 13:52, but Question #2/size showed none. · [DATE] was marked as incontinent at 00:24, but Question #2/size, was marked as none, and Question #3/consistency was marked as not applicable. The bowel movement documentation for Question #2 and #3 revealed no documented bowel movement from [DATE] - [DATE]. A review of the May, (YEAR) Medication Administration Record included no documentation that the bowel protocol physician's orders were initiated. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was not an interviewable candidate for the Brief Interview for Mental Status (BIMS) and was recorded to have long/short term memory problems and was moderately impaired for decision making. An attempt was made to interview the resident during the course of the survey but she was unable to answer simple questions when asked. On [DATE] at 4:56 p.m., an interview with Staff D, LPN confirmed the bowel protocol should have been initiated for Resident #17. She confirmed she never received an alert within the electronic system or from the CNAs. She said, Never been alerted that she hasn't gone at all. She said, All doctors agree with the protocol, and after three days we will start it. She reviewed the bowel movement documentation for Resident #17 and confirmed the bowel protocol should have been initiated on [DATE] or [DATE]. She said, The third or fourth day should have started the bowel protocol. She verified th (TRUNCATED)

Based on clinical and facility record reviews and interviews, the facility failed to develop a care plan that addressed potential constipation for one (Resident #1) of twelve residents sampled who required assistance with toileting. Resident #1 was at risk for constipation due to opioid medications that have a known side effect of constipation, a history of hemorrhoids, and muscle weakness, but was not care planned with interventions to identify and relieve constipation. Resident #1 was sent to the hospital on [DATE] and the physician's Death Summary, dated [DATE], indicated that Resident #1 was severely constipated and had perforated her bowel. This failure created a situation that resulted in the serious injury and death of Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 5:15 p.m. Findings included: 1. A review of Resident # 1's physician's orders [REDACTED]. Continued review of Resident #1's physician's orders [REDACTED]. However, a standing order, which was present on all resident's records was in place for the following routine bowel protocol: Milk of Magnesia (MOM) suspension 400 mg/5 ml, give 30 ml by mouth, as needed, for constipation at bedtime if no BM in 3 days; [MEDICATION NAME] suppository 10 mg insert one rectally, as needed, for constipation daily if no results for Milk of Magnesia; and a Fleet enema insert one dose rectally, as needed, for constipation if no results 1 day after suppository. Additionally, the physician's orders [REDACTED]. A review of the side effects of [MEDICATION NAME]/[MEDICATION NAME] included a known side effect of constipation. (www.ncbi.nlm.gov). A review of Resident #1's care plans did not include a focus of potential constipation, or to monitor for constipation related to opioid medications. However, there was a care plan titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. Interventions included, Administer medications as ordered. Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Reinforce positive behaviors. The Journal of the American Board of Family Medicine stated in the article, Chronic Constipation: An Evidence-Based Review: .medical personnel define constipation as less than 3 bowel movements per week . and also included under Complications of Chronic Constipation: Hemorrhoids .and Bowel Perforation . (www.jabfm.org). Resident #1's clinical record included a face sheet that indicated an admission date of [DATE], and medical [DIAGNOSES REDACTED]. Further review found Resident #1 was admitted for short term rehab therapy and a physician's note, dated [DATE], indicated that she had a recent respiratory infection and had significantly improved. Resident #1's clinical record included an admission MDS (Minimum Data Set), dated [DATE], that showed under Section C, a BIMS score of 14 that indicated Resident #1's cognition was intact and she was able to make her needs known. Section G showed that she required extensive assistance of one person for toileting. Section H included that she was always incontinent of bowel and bladder. On [DATE] at 2:00 p.m., the clinical record was reviewed with the MDS/Care Plan Coordinator. She confirmed that there was no care plan for Resident #1 that addressed constipation. The Care Plan Coordinator also confirmed that she was familiar with Resident #1, who was assessed to be incontinent of stool, required assistance with toileting and had impaired mobility and muscle weakness, and received opiate medications with a known side effect of constipation. She confirmed that there was a care plan for Resident #1 that addressed behavioral issues related to bowel conscious behaviors. Resident #1's bowel documentation for the two weeks prior to her transfer to the hospital included the following: · [DATE] was marked as continent at 12:42, which included medium under question #2 size, and formed for consistency. · [DATE] was marked incontinent at 13:22 but size or consistency were both marked as not-applicable. · [DATE] was marked continent at 11:02 and medium and formed were marked for size and consistency. · [DATE] was marked incontinent at 1:06 but size and consistency were marked as none and not-applicable. · [DATE] was marked incontinent at 12:33 but size and consistency were marked as not-applicable. · [DATE] was marked as incontinent as at 2:07 and 11:24 but size was marked as none and not-applicable, and consistency were marked as not applicable. · [DATE] was marked as incontinent at 11:05 and 18:12, but not applicable was marked for size and consistency. · [DATE] was marked as continent at 13:59 and size was marked as small and consistency, formed. · [DATE] was marked as incontinent at 21:33 but size was marked as none and consistency not applicable. · [DATE] was marked as continent at 11:23 but size and consistency were marked as not applicable. · [DATE] was marked as continent at 19:58 and size and consistency were marked as medium and formed. No bowel movements or description of bowel movements was present for [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The resident received 29 doses of this pain medication between [DATE] and [DATE]. Continued review of the MAR for the time period of [DATE] - [DATE] revealed no evidence of administration of MOM or Fleet enema. The resident was documented to receive the [MEDICATION NAME] suppository on [DATE] and [DATE]. A review of the resident's nurses notes found the [DATE] dose was effective (however, no BM was documented for that day) and no effectiveness of the [DATE] dose was noted, nor was there any documentation of why the second dose was required. On [DATE] at 1:30 p.m., the Bowel Documentation for Resident #1 was reviewed with the DON. She confirmed that bowel movements should be monitored and accurately documented, and this was a standard of nursing care. She confirmed several entries that indicated Resident #1's continence or incontinence, but had no proper follow- through that included size and consistency of the BM. She confirmed for seven days, between the dates of ,[DATE] and ,[DATE], there were no entries that included a description of size and consistency but, instead, included, none and not applicable. The DON confirmed that, if the licensed nurse had taken the first step of the bowel protocol, Milk of Magnesia should have been administered ,[DATE]-[DATE], but it was not. She confirmed that she, herself, documented a small BM on [DATE] and, then, another five days went by without another BM documented that included a description, and the bowel protocol was not implemented at that time either. The Progress Notes were silent regarding Resident #1's absence of bowel movements between [DATE] and [DATE]. A late entry, dated [DATE], by the facility's wound care nurse noted that when the coccyx wound dressing was changed, the resident requested treatment for [REDACTED]. An entry, dated [DATE], indicated the resident was offered a laxative with morning medications and she accepted. An entry, dated [DATE], found, .has anxiety at times along with generalized pain and [MEDICATION NAME] pain-see MAR. Reluctant to participate in therapy and eventually does so after some negotiations and manipulations. Psych has been consulted. Entries, dated ,[DATE] at 8:00 a.m., indicated, Resident has altered mental status. She is sleepy but arousable . and at 11:49 a.m., Resident has altered mental status and is more sleepy than usual . and, at 12:00 p.m., the emergency medical services was notified and Resident #1 was transported to the hospital. The last nursing documentation was an SBAR (Situation-background-assessment-recommendation) form, dated [DATE], which indicated Resident #1 was sent out to an acute care hospital via emergency transportation for a change in mental status; the section for Abdominal/Gastrointestinal Evaluation was checked, Not clinically applicable to the change in condition being reported. 2. A review of Resident #1's hospital records indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on [DATE]. A Death Summary for a date of death of [DATE] documented, Final Diagnosis-1. Bowel Perforation, 2. Acute [MEDICAL CONDITION], and 5. Fecal impaction. Under Hospital Course, the summary stated this is a [AGE] year-old woman who was brought from the facility to the hospital emergency room (ER) with complaint of abdominal discomfort. Patient had no bowel movement x 3 weeks .She was placed on suppository as well as an enema but was not having a bowel movement so [MEDICATION NAME] was consulted .She was placed on IV fluids for gentle hydration .[MEDICATION NAME] ordered a medicine called [MEDICATION NAME] due to what is believed to be opiate induced constipation. KUB showed large amount of stool and possible pneumonitis with possible [MEDICATION NAME] gas and free air. CT was recommended. The patient had a CT of the abdomen and pelvis, which showed evidence of bowel perforation likely of the sigmoid colon as the colon was distended and demonstrated extensive pneumatosis. There was a large amount of [MEDICATION NAME] fecal material seen adjunct to the sigmoid colon. Surgery was consulted. On the way back, patient became hypotensive, unresponsive, and became hypoxic, so patient ended up on a ventilator . The patient was initially DNR (do not resuscitate) but due to her condition her family requested all treatments .Patient was doing poorly and she passed away on [DATE] at 2:51 a.m. A review of the hospital History and Physical (H&P), dated [DATE], found the history of present illness was documented as a [AGE] year old woman presented to the ER via EMS from the skilled nursing facility with complaint of abdominal discomfort for 3 weeks .Patient also has been very weak for past 5 days with confusion on and off .Currently, she complains of rectal pain due to constipation .She is unsure if she is passing gas. A review of the Abdominal/Pelvis CT scan, performed on [DATE] due to abdominal pain and constipation, had findings of rectum markedly distended with solid fecal material. The rectal lumen measured 11 cm in AP dimension by 10 cm in [MEDICATION NAME] dimension. There is mild associated presacral [MEDICAL CONDITION]. There is abundant fecal material present throughout the colon. There are multiple diverticuli in the descending colon. There are a few diverticuli in the ascending colon. There is no evidence of extralumenal air. There is no free fluid or fluid collections. On [DATE] at 5:30 p.m., a telephone interview was conducted with Employee B, a licensed practical nurse, who confirmed she was assigned to Resident #1 when she was transferred out to the hospital on [DATE]. She said that she did not know what was wrong with Resident #1 on [DATE]. She stated, We couldn't pin point it. She was asked about her gastrointestinal status, and she stated that she thinks she remembers the resident had received some laxatives earlier, but was not sure about this. She stated she heard the resident had died . On [DATE] at 3:12 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that she usually spoke with her mother every day while she was in the facility. She said that her mother had been admitted to the facility for therapy to get stronger. She stated that her mother had complained of constipation to her frequently, and she had spoken with the nursing staff and relayed the concerns, but nothing was done to alleviate her mother's constipation and discomfort. Resident #1's daughter said that her mother became so severely constipated while in the facility, that her bowel had ruptured, and that was why she was so lethargic and in pain when she was sent out to the hospital on [DATE]. On [DATE] at 1:04 p.m., an interview was conducted with Resident #1's caregiver. He stated that he had cared for the resident for a number of years at home. He stated that he knew Resident #1 was getting older and had some medical problems, but it was unacceptable that she had to go to the hospital for severe constipation and then died , because that could have been prevented. He stated that she took opioid medication that caused constipation, and at home she was on a regular laxative every day to counteract the constipation, but had not received this while in the facility. 3. On [DATE] at 10:46 a.m., an interview was conducted with the Medical Director who stated that he was unaware that Resident #1 was care planned for bowel conscious behaviors on [DATE] after several days of no bowel movement. He stated they should have called the physician first (and prior to care planning for behaviors) to rule out serious things first, such as severe constipation or impaction. He stated that opioid medications traditionally constipate people. He confirmed that by care planning Resident #1 inappropriately for bowel focused behaviors and not constipation could create further rejection of the resident's complaints and result in the absence of appropriate interventions. On [DATE] at 4:40 p.m., an additional interview was conducted with the Care Plan Coordinator. She confirmed that Resident #1 should have been care planned for constipation given the opiate medications, impaired mobility, history of hemorrhoids, and repeated complaints from Resident #1 concerning discomfort in her rectal area. She stated that Resident #1 was the first and only resident that she had ever care planned for bowel conscious behaviors. She stated that Resident #1 did not want to talk about anything else except her bowels and she was very focused on treatment for [REDACTED]. The Care Plan Coordinator stated that this care plan was created after a request was made to her in the morning meeting due to comments made by the staff nurses. She was asked if she had consulted Resident #1's physician and/or psychiatrist prior to care planning for bowel conscious behaviors and she said no. She was asked if she had reviewed Resident #1's bowel documentation and she said no. She confirmed that there was no documentation of bowel focused behavior that was being monitored and documented regularly in the clinical record. The MDS Coordinator was asked if severe constipation could cause a person to be bowel conscious and she said yes. She stated that going forward, she would look at bowel movement documentation and get input from the interdisciplinary team. On [DATE] at 1:30 p.m. an interview was conducted with the DON and the Clinical Educator. They confirmed that Resident #1 had been inappropriately and incompletely care planned when she did not have a plan for constipation, but did for bowel conscious behaviors. The DON stated that all residents were re-assessed and care planned when there was a potential for constipation. She stated that with the correction of the bowel movement documentation, this issue will not happen again because it will be clear when the resident last had a BM and constipation will be easier to identify. She stated that there would be no further behavior care plans without contributions from the entire team, including physicians and psychiatry when necessary. 4. The facility's policy titled, Perineal/Incontinence Care, Policy Number 12.07.04.11 revised [DATE], included under Guidelines: 7. For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. The facility's policy titled, Charting and Documentation, Policy Number 12.05.094, revised [DATE], included under Guidelines: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 2. Incidents, accidents or changes in the resident's condition should be recorded in the clinical record. 5. On [DATE] at 3:08 p.m., an interview with the Director of Nursing (DON) and the Clinical Educator confirmed the inaccurate and incomplete bowel movement documentation for Resident #1. The DON confirmed that the licensed staff would not have been able to discern when or if a resident had a bowel movement, the size of the bowel movement and the consistency of the bowel movement. The DON verified that this would place the resident at risk for constipation and complications from constipation. The Clinical Educator said, We have discussed this with our (corporate) education (department). She stated that if a resident has a BM, then the size and consistency must be documented, and it was not acceptable to include non-applicable. The Clinical Educator stated that all direct care staff were first in-serviced on [DATE] when it came to their attention that there were inaccuracies and incomplete documentation of bowel movements. She stated that audits were started on all resident's bowel documentation after the education was provided. The DON stated that further one- on- one in-services were started on [DATE] with CNA's and training was given at the electronic kiosks with return demonstrations given, and 100% of direct care staff were educated and re-educated through [DATE]. She stated that new processes were put into place that included licensed staff over-sight of all CNA bowel documentation entered. After each shift, all BMs were documented and reviewed each day in the morning meeting. A review of the facility's list of direct care CNAs included a total of 24 employees. A review of the facility's list of direct care licensed nurses included a total of 13 employees. A review of the in-service sign in sheets, dated [DATE], titled Daily Documentation of Bowel Movements documented 100% of the CNAs attended the training, and the sign in sheet, dated [DATE], titled, Bowel Protocol, included 100% of the LPNs/RNs attended. Further review of educational in-services included a [DATE] one to one training at the electronic kiosk on how to document bowel movements and monitor to ensure the documentation was complete and accurate. A review of the documentation revealed 100% of the CNAs and licensed nurses received this one to one training with return demonstration. The facility also instituted a BM audit to include whether or not the resident had a BM within the past 3 days, if the bowel protocol was initiated as applicable, the effectiveness of the protocol, and a description of the results. On [DATE] at 3:00 p.m. Employees F, G, H, I, J, K, L, M, N, and O, all CNAs were interviewed and asked to provide a demonstration of how a bowel movement was documented on the kiosk. All provided full and accurate demonstrations. On [DATE], random interviews were conducted with licensed nurses across both 12-hour shifts. The nurses were able to articulate the new system that was put into place. They indicated that they now verify at the end of each shift CNA documentation of bowel movements to ensure accurate and complete documentation and the need to implement the bowel protocol as applicable. Immediate Jeopardy was determined removed on [DATE] at 5:15 p.m. and the scope and severity was reduced to an D.

Based on clinical and facility record reviews and interviews, the facility developed a care plan without the appropriate contribution from members of the interdisciplinary team for one (Resident #1) of twelve residents sampled that required assistance with toileting. Resident #1 was care-planned for bowel conscious behaviors but there was no indication that the attending physician or psychiatric provider contributed any information to indicate that Resident #1 had inappropriate or bowel conscious behaviors. By developing a care plan that that focused on behavior, the facility failed to properly monitor, identify, and treat constipation or any symptom management for constipation. Resident #1 was receiving pain medication with a known side effect of constipation. The facility did not develop a care plan or interventions to address the symptom management of constipation, but, instead, did have a care plan that addressed bowel conscious behaviors. In addition, the facility failed to administer their standard physician ordered bowel protocol when the resident was absent of bowel movements. Resident #1 was sent to the hospital with altered mental status on 2/26/18. The physician's Death Summary indicated the resident was severely constipated and this resulted in Resident #1's bowel perforation and subsequent death two days later. This failure created a situation that resulted in the serious injury and death of Resident #1 and resulted in the determination of Immediate Jeopardy on 5/16/18. The findings of Immediate Jeopardy were determined to be removed on 5/16/18 at 5:15 p.m. Findings included: 1. A review of Resident #1's care plans included a care plan dated 2/22/18 that was titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. Interventions included, Administer medications as ordered. Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Reinforce positive behaviors. Resident #1's clinical record included a face sheet that indicated an admission date of [DATE], and medical [DIAGNOSES REDACTED]. Resident #1's clinical record included an admission MDS (Minimum Data Set), dated 2/2/18, that showed under Section C a BIMS score of 14 that indicated Resident #1's cognition was intact and she was able to make her needs known. Section G showed that she required extensive assistance of one person for toileting. Section H included that she was always incontinent of bowel and bladder. A review of the facility's Bowel Documentation included three categories: continent or incontinent, size and consistency. On 5/2/18 at 1:55 p.m., the Director of Nursing (DON) confirmed all three criteria must be entered by the Certified Nursing Assistants (CNAs) in order to record a BM in the facility's electronic medical record system. The DON said, If there is no BM in 3 days, the system sends an alert to the licensed nurse's electronic dashboard. The constipation was treated per the standing physician's orders [REDACTED]. Resident #1's bowel documentation for the two weeks prior to her transfer to the hospital included the following: · 2/10/18 was marked as continent at 12:42, which included medium under question #2 size, and formed for consistency. · 2/11/18 was marked incontinent at 13:22 but size or consistency were both marked as not-applicable. · 2/13/18 was marked continent at 11:02 and medium and formed were marked for size and consistency. · 2/14/18 was marked incontinent at 1:06 but size and consistency were marked as none and not-applicable. · 2/15/18 was marked incontinent at 12:33 but size and consistency were marked as not-applicable. · 2/16/18 was marked as incontinent as at 2:07 and 11:24 but size was marked as none and not-applicable, and consistency were marked as not applicable. · 2/19/18 was marked as incontinent at 11:05 and 18:12, but not applicable was marked for size and consistency. · 2/20/18 was marked as continent at 13:59 and size was marked as small and consistency, formed. · 2/21/18 was marked as incontinent at 21:33 but size was marked as none and consistency not applicable. · 2/24/18 was marked as continent at 11:23 but size and consistency were marked as not applicable. · 2/25/18 was marked as continent at 19:58 and size and consistency were marked as medium and formed. On 5/16/18 at 1:30 p.m., the Bowel Documentation for Resident #1 was reviewed with the DON. She confirmed that bowel movements should be monitored and accurately documented, and this was a standard of nursing care. The DON reviewed the documentation and confirmed that continent or incontinent should not be followed up with none or not applicable. She confirmed that there was no documentation of the size and consistency of a BM for seven days between 2/13/18 and 2/20/17. She confirmed the first step of the bowel protocol, Milk of Magnesia, should have been administered 2/16-2/17/18, but it was not. She confirmed that she herself documented a small BM on 2/20/18 and then another five days went by without another BM documented that included a description, and the bowel protocol was not implemented at that time either. 2. A review of Resident #1's hospital records indicated she was transferred from the skilled nursing facility to an acute care hospital emergency department on 2/26/18. A Death Summary for a date of death of [DATE] documented, Final Diagnosis-1. Bowel Perforation, 2. Acute [MEDICAL CONDITION], and 5. Fecal impaction. Under Hospital Course, the summary stated this is a [AGE] year-old woman who was brought from the facility to the hospital emergency room (ER) with complaint of abdominal discomfort. Patient had no bowel movement x 3 weeks .She was placed on suppository as well as an enema but was not having a bowel movement so [MEDICATION NAME] was consulted .She was placed on IV fluids for gentle hydration .[MEDICATION NAME] ordered a medicine called [MEDICATION NAME] due to what is believed to be opiate induced constipation. KUB showed large amount of stool and possible pneumonitis with possible [MEDICATION NAME] gas and free air. CT was recommended. The patient had a CT of the abdomen and pelvis, which showed evidence of bowel perforation likely of the sigmoid colon as the colon was distended and demonstrated extensive pneumatosis. There was a large amount of [MEDICATION NAME] fecal material seen adjunct to the sigmoid colon. Surgery was consulted. On the way back, patient became hypotensive, unresponsive, and became hypoxic, so patient ended up on a ventilator . The patient was initially DNR (do not resuscitate) but due to her condition her family requested all treatments .Patient was doing poorly and she passed away on 2/28/18 at 2:51 a.m. A review of the hospital History and Physical (H&P) dated 2/26/18 revealed the history of present illness was documented as a [AGE] year old woman presented to the ER via EMS from the skilled nursing facility with complaint of abdominal discomfort for 3 weeks .Patient also has been very weak for past 5 days with confusion on and off .Currently, she complains of rectal pain due to constipation .She is unsure if she is passing gas. A review of the Abdominal/Pelvis CT scan performed on 2/26/18 due to abdominal pain and constipation had findings of rectum markedly distended with solid fecal material. The rectal lumen measured 11 cm in AP dimension by 10 cm in [MEDICATION NAME] dimension. There is mild associated presacral [MEDICAL CONDITION]. There is abundant fecal material present throughout the colon. There are multiple diverticuli in the descending colon. There are a few diverticuli in the ascending colon. There is no evidence of extralumenal air. There is no free fluid or fluid collections. The Journal of the American Board of Family Medicine stated in the article, Chronic Constipation: An Evidence-Based Review: .medical personnel define constipation as less than 3 bowel movements per week . and also included under Complications of Chronic Constipation: Hemorrhoids .and Bowel Perforation (www.jabfm.org) A comparison of the MAR and the documentation of Resident #1's bowel movements showed that Resident #1 should have received Milk of Magnesia on 2/17/18, when she had not had a bowel movement recorded since 2/13/18. She did not receive this first step of the bowel protocol to alleviate constipation. Further review showed that she did receive a [MEDICATION NAME] suppository on 2/22/18 and this was repeated on 2/23/18. The nursing notes included, effective as a result after the [MEDICATION NAME] suppository was administered on 2/22/18, but there was no documentation to explain why the resident required another suppository the following day, 2/23/18, and there were no documented results for this second dose. Additionally, it was documented only once on 2/7/18 at 0601 that Resident #1 received the Hemorrhoid Ointment. A review of the progress notes included a late entry dated 2/21/18 by the facility's wound care nurse. She documented that when the coccyx wound dressing was changed, the resident requested treatment for [REDACTED]. An entry dated 2/22/18 indicated the resident was offered a laxative with morning medications and she accepted. An entry dated 2/23/18 stated, .has anxiety at times along with generalized pain and [MEDICATION NAME] pain-see MAR. Reluctant to participate in therapy and eventually does so after some negotiations and manipulations. Psych has been consulted. Entries dated 2/26 at 8:00 a.m. indicated Resident has altered mental status. She is sleepy but arousable . and at 11:49 a.m., Resident has altered mental status and is more sleepy than usual . and at 12:00 p.m. the emergency medical services was notified and Resident #1 was transported to the hospital. The last nursing documentation was an SBAR (Situation-background-assessment-recommendation) form dated 2/26/18 that indicated Resident #1 was sent out to an acute care hospital via emergency transportation for a change in mental status; the section for Abdominal/Gastrointestinal Evaluation was checked, Not clinically applicable to the change in condition being reported. 3. On 5/16/18 at 10:46 a.m., an interview was conducted with the Medical Director who stated that he was unaware that Resident #1 was care planned for bowel conscious behaviors on 2/22/18 after several days of no bowel movement. He stated they should have called the physician first (and prior to care planning for behaviors) to rule out serious things first, such as severe constipation or impaction. He confirmed that a severely constipated or impacted person may have stool or leakage at the rectal opening. He confirmed that an inappropriate care plan that focused on bowel focused behaviors could create further rejection of the resident's complaints. This could have resulted in the absence of appropriate interventions to monitor bowel movements and provide treatment. A review of the Evaluation, dated 2/6/18, indicated the resident was pleasant and psychiatric [DIAGNOSES REDACTED]. Under Review of Systems included, No psychotic symptoms noted or reported. There was nothing documented regarding bowel conscious behaviors. The physician wrote under Care Plan: Patient has remained stable since her admission to the SNF 1/26/18. Continue current medications as prescribed. No acute need to intervene at this time. The physician indicated that they would follow the resident's medications monthly. On 5/2/18 at 2:00 p.m., Resident #1's care plan was reviewed with the Care Plan Coordinator. She confirmed that she developed the care plan for Resident #1 that was titled, The resident has a behavior problem related to bowel conscious behaviors because of history of hemorrhoids. Goals included, Resident will not harm themselves or others related to behavior. The MDS Coordinator was asked if severe constipation could cause a person to be bowel conscious and she said that it could. On 5/15/18 at 4:40 p.m., Resident #1's care plan and the clinical record were reviewed, again, with the Care Plan Coordinator. She stated that Resident #1 did not want to talk about anything else except her bowel and she was very focused on treatment for [REDACTED]. She stated that she was asked to develop a care plan with a focus on behaviors for Resident #1 because the nursing staff were talking about Resident #1's repeated requests for hemorrhoid ointment and complaints of rectal discomfort. She confirmed that complaints of hemorrhoid pain could be a sign of constipation. She stated that she did not review the documentation of bowel movements or check for medical causes for Resident #1 to be bowel conscious before she implemented this care plan that centered on behaviors. She stated that she had not elicited in-put from the resident's physicians prior to developing a care plan that focused on behaviors. On 5/16/18 at 1:30 p.m. an interview was conducted with the DON and the Clinical Educator. They confirmed that Resident #1 had been inappropriately care planned for bowel conscious behaviors. She stated she had discussed this with the Care Plan Coordinator. She stated care plans that target behaviors will include contributions from the entire team including physicians and psychiatry when necessary. 4. The facility's policy titled, Perineal/Incontinence Care, Policy Number 12.07.04.11 revised 9/1/17, included under Guidelines: 7. For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. The facility's policy titled, Charting and Documentation, Policy Number 12.05.094, revised 11/1/2016, included under Guidelines: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 2. Incidents, accidents or changes in the resident's condition should be recorded in the clinical record 5. On 5/16/18 at 3:08 p.m., an interview with the Director of Nursing (DON) and the Clinical Educator confirmed the inaccurate and incomplete bowel movement documentation for Resident #1. The DON confirmed that the licensed staff would not have been able to discern when or if a resident had a bowel movement, the size of the bowel movement and the consistency of the bowel movement. The DON verified that this would place the residents at risk for constipation and complications from constipation. The Clinical Educator said, We have discussed this with our (corporate) education (department). She stated that if a resident has a BM, then the size and consistency must be documented, and it was not acceptable to include non-applicable. The Clinical Educator stated that all direct care staff were first in-serviced on 5/2/18 when it came to their attention that there were inaccuracies and incomplete documentation of bowel movements. She stated that audits were started on all resident's bowel documentation after the education was provided. The DON stated that further one- on- one in-services were started on 5/14/18 with CNA's and training was given at the electronic kiosks with return demonstrations given, and 100% of direct care staff were educated and re-educated through 5/16/18. She stated that new processes were put into place that included licensed staff over-sight of all CNA bowel documentation entered. After each shift, all BMs were documented and reviewed each day in the morning meeting. A review of the facility's list of direct care CNAs included a total of 24 employees. A review of the facility's list of direct care licensed nurses included a total of 13 employees. A review of the in-service sign in sheets dated 5/2/18 titled, Daily Documentation of Bowel Movements, documented 100% of the CNAs attended the training, and the sign in sheet dated 5/2/18 titled, Bowel Protocol, included 100% of the LPNs/RNs attended. Further review of educational in-services included a 5/15/18 one to one training at the electronic kiosk on how to document bowel movements and monitor to ensure the documentation was complete and accurate. A review of the documentation revealed 100% of the CNAs and licensed nurses received this one to one training with return demonstration. The facility also instituted a BM audit to include whether or not the resident had a BM within the past 3 days, if the bowel protocol was initiated as applicable, the effectiveness of the protocol, and a description of the results. On 5/16/18 at 3:00 p.m. Employees F, G, H, I, J, K, L, M, N, and O, all CNAs, were interviewed and asked to provide a demonstration of how a bowel movement was documented on the kiosk. All provided full and accurate demonstrations. On 5/16/18, random interviews were conducted with licensed nurses across both 12-hour shifts. The nurses were able to articulate the new system that was put into place. They indicated that they now verify at the end of each shift CNA documentation of bowel movements to ensure accurate and complete documentation and the need to implement the bowel protocol as applicable. Immediate Jeopardy was determined removed on 5/16/18 at 5:15 p.m. and the scope and severity was reduced to an D.

Based on resident record review, review of hospital records, observation, staff interview, family interview and review of policies and procedures, it was determined that the facility failed to implement written policies ,[DATE]and procedures to prevent neglect by failing to ensure that structures and processes were in place to provide needed care and services to one of fifteen residents reviewed (#1). The facility failed to honor Resident # 1's signed Do Not Resuscitate order. The facility failed to honor Resident # 1's express and written wishes to have cardiopulmonary resuscitation withheld in the event his heart failed. Resident #1 was [AGE] years old and in failing health. The Facility lost Resident # 1's hospital paperwork, including the DNR order and a palliative care consult, which clearly stated Resident # 1's wishes to not be resuscitated. The facility changed a physician order [REDACTED]. and failed to ensure that nursing staff had advance directive information, including State of Florida Do Not Resuscitate orders (DNRs) available for review in case of an emergency. The Facility neglected Resident # 1 by initiating CPR in violation of his written and expressed wishes to not be resuscitated. The facility's failure to prevent neglect of Resident # 1 by omission of services needed to honor his wishes represented a system wide failure. This failure resulted in findings of Immediate Jeopardy Past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings Included: 1. Resident # 1 was admitted to the facility from a local hospital on [DATE]. On [DATE], at 12:02 p.m., Resident # 1 was found in his room without pulse and respirations and two licensed nurses (Staff A, Staff I) initiated and performed Cardio [MEDICAL CONDITION] Resuscitation on Resident # 1 for nine minutes, violating his right to have his advance directives honored and his expressed wishes followed, until Resident # 1 was pronounced as deceased by emergency medical services personnel. A phone interview was conducted with the family member and Power of Attorney (POA) for Resident # 1, on [DATE] at 1:08 p.m. She stated that she had taken care of Resident # 1 for five years and that he was only at the facility for four days before he died . She stated he had a DNR and she made sure the facility had this paperwork. She stated when he was admitted he was weak, had an infection, his kidneys were bad and he had refused [MEDICAL TREATMENT]. She stated he had been admitted to the facility for rehabilitation and she had expected him to bounce back. She stated he was alert, able to speak for himself and his mind was sharp. She stated she had visited him two to three times a day while he was at the facility and had last seen him the evening before and he was doing okay when she left. She stated on [DATE] she was coming to visit him around lunchtime and when she got there, she saw a fire truck pulling out of the parking lot. She walked onto the facility and was walking down the hallway towards his room when a nurse ran up behind her, grabbed her arm and said, Don't go in there. She stated she asked what was happening and the nurse told her he had just passed away and that they had attempted to resuscitate him. She stated she told the nurse I gave you an order to call me, he passed away without me, why did you try to resuscitate him, why did you call them (emergency services) and not me? She stated she went in Resident # 1's room, sat by his bed and he was gone, he was still warm. She stated, He would not have wanted to be resuscitated, he would have wanted me to hold his hand and be with him when he died . Why resuscitate his poor soul if he was ready to go? The POA stated that a manager, who she believed to be the Administrator, called her and said he was sorry and that the girls got panicky because no one dies here. She stated, I asked them, the nurses, what happened, all they said was his heart stopped. I don't know why they called the fire department. On [DATE] at 11:57 a.m., a phone interview was conducted with Staff G, per a Licensed Practical Nurse (LPN) who conducted the nursing admission of Resident #1. She stated that Resident # 1 came with paperwork from the hospital which included a PASRR, 3008, History and Physicals and a signed DNR. She stated he seemed to be alert and confused and no one was with him when he was admitted . She stated that she did the admission nursing note in the electronic medical record and the other LPN who was on duty (Staff E) obtained the physician orders. She stated she did not upload the hospital paperwork, including the DNR, into the electronic medical record, but, instead put the paperwork in a folder and placed it in a black plastic shelf on the nursing station desk. She stated that she did not upload the hospital paperwork into the electronic medical record, as she was not completely sure how to use the scanning machine. She stated she did not think it was anyone's specific responsibility to upload it into the electronic record, just that when the admission was done it was scanned in the computer. An interview was held with the Regional Director of Clinical Operations on [DATE] at 8:40 am. She stated Staff G was asked as part of the facility investigation why she did not put the golden rod copy of the DNR in the DNR binder and Staff G told them that she thought someone else would do it. Review of the Admission/Readmission Nursing note, completed by Staff G, on [DATE] at 2:10 a.m., revealed: Code Status: (admission paperwork related to code status has been reviewed with resident/or surrogate decision maker and he/she indicated he/she wants the following in the event of a cardiopulmonary arrest): Do Not Resuscitate. MD contacted and order obtained per above resident/ decision maker request? Yes. Review of (MONTH) (YEAR) physician orders [REDACTED]. A baseline care plan was developed at the time of admission for Resident has chosen Do Not Resuscitate (DNR). Goal, If the resident's heart stops, or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Included in the Interventions was Resident is do not resuscitate status (DNR). Review of the Physician order [REDACTED]. An undated Authorization for Treatment from, signed by the POA, was documented as uploaded in to the electronic record on [DATE]. An interview was conducted with Staff H, a 7 a.m. to 7 p.m. LPN, on [DATE] at 10:30 a.m. She stated that on [DATE] she brought the Authorization for Treatment form and other forms including the Pneumococcal Informed Consent, Influenza Immunization Informed Consent and Wound Disclosure and Acknowledgement Form to Resident # 1 for him to sign. She stated he was sleepy and very weak and the POA was present. She stated Resident # 1 indicated that he wanted the POA to sign the forms. There was no documentation found in the resident's record regarding this contact or any documentation of a discussion with the resident or POA regarding designation of the POA to be the health care surrogate and/or health care proxy for Resident # 1. An interview was conducted with the Admissions Director on [DATE] at 9:00 a.m. She stated that when a resident is admitted from the hospital the hospital will send the 3008, the medication list, any prescriptions and any advance directives the resident has. She stated the hospital paperwork usually comes in with the transport person and the nurse is responsible for obtaining it from transport. She stated she was responsible for the admission packet and the informed consents are the nurse's responsibility to obtain. She stated that double checking the advance directive would be the responsibility of the admitting nurse and that it would be the responsibility of Social Services to review the Advance Directives booklet with the resident. On [DATE], the Administrator was asked to provide a copy of the signed and competed Admission Agreement for Resident # 1. On [DATE] at 10:05 a.m., the Administrator and the Admissions Director stated there was no signed and completed admission agreement for Resident # 1. The Admissions Director stated she did go speak to Resident # 1 on Friday [DATE]. She stated, He seemed out of it, I said I would come back later to revisit him. She stated the POA came in Friday [DATE] right before the Admission Director was leaving for the day. The POA provided a copy of the POA paperwork to her. She stated I took it from her, I didn't know what we had and what we didn't have for him. She stated she put the POA paperwork on the Social Service Director's desk. She stated the POA was to come back on Monday [DATE] to complete and sign the admission paperwork but by the time she came in on Monday [DATE], Resident # 1 was deceased . An interview was held with the DON, on [DATE] at 10:09 a.m. She stated that there is a clinical meeting held daily and new admissions are discussed and reviewed at this meeting the day after they are admitted . She stated this clinical meeting is held at approximately 9:00 a.m. each day. She stated the clinical meeting is held with all department managers, the Administrator, Therapy, Social Service Director, the Clinical Educator, MDS, Business office, medical records, housekeeping and maintenance. She stated Resident # 1 was reviewed on Friday [DATE] at the clinical meeting. The DON stated, on [DATE] I believe I was the only clinical person that day at the meeting. She stated she could not locate Resident # 1's hospital paperwork for review at the time of clinical meeting. She stated that she was not sure if the facility even had records for him. She checked the box at the nurses' station, checked with medical records and could not locate any paperwork. She stated she called the nurse who did the admission for Resident # 1 and was told that there was hospital paperwork and she left it on the desk, and she did not ask her to come in and assist with locating the paperwork. She stated, we looked in desk drawers, shelves, behind the printer, looked behind everything. She stated she also checked with therapy and they did not have them. She stated she called the hospital and spoke with someone in medical records (she stated she did not know the name of the person she spoke with). She stated she informed the medical records person that they needed medical records for Resident # 1 because she could not locate them. She stated she was told that the hospital would try to locate them and send them but As far as I know we didn't get any paperwork from the hospital. She stated that she left the facility between 6:30 and 7 pm. that night, [DATE], without locating the hospital paperwork for Resident # 1 or receiving any paperwork from the hospital. She stated she did notify the nurses who were working that we had missing paperwork and they were to continue looking for it. She stated she also told the nurse she had called the hospital for the paperwork. She stated that the expectation was that the admitting nurse would scan the hospital documents into the electronic clinical record before the end of their shift. She provided a list of residents who were reviewed at the clinical meeting that day and Resident # 1's name was included on the list. She stated the only document she reviewed at the clinical meeting was the admission-nursing note in the electronic clinical record. She provided a staff sign in sheet for this meeting, which was entitled Morning Business Meeting. Review of the sign in sheet revealed that the Social Service Director was not present. There was no documentation found in the clinical record for Resident # 1 that indicated that his hospital paperwork could not be located and reviewed and that the hospital was contacted to send the paperwork. There was no documentation that the resident's wishes regarding CPR or Advance Directive information were reviewed for Resident # 1 on [DATE]. On [DATE], the Social Service Director wrote a late entry for [DATE] in the progress note section of the electronic record which stated Upon arrival to my office on [DATE] writer discovered copy of POA (financial only) paperwork on my desk for resident. This writer then went to speak with resident to discuss any additional advance directives he may have and to complete my initial Social Services Initial Evaluation. Attempt was made, however resident was very sleepy and did not want to discuss at that time. This writer then proceeded to search for any additional paperwork in all mailboxes in the copy room, the nurse's station and spoke with nurses on the unit. No additional paperwork was located. This writer also checked DNR binder located at the nurses station to determine if DNR had been placed in the binder, no document was located. Discussion held with unit nurse at which time this writer explained inability to locate any paperwork to support a DNR and requested nurse to obtain an order for [REDACTED]. An interview was held with the Social Service Director, on [DATE] at approximately 1:30 p.m. She stated she was not working on [DATE]. She stated she came in on [DATE] and was reviewing Resident # 1's record for Advance Directives. She stated she noticed there was a physician's orders [REDACTED]. She stated there was nothing in her mailbox and nothing in the medical records box to be scanned. She stated she looked everywhere and could not find a DNR. She stated she told the nurse that there was a physician's orders [REDACTED]. She stated she did not call the POA to discuss the Advance Directives including DNR and did not notify administration that she was unable to locate this information. There was no documentation that the Social Service Director attempted to approach the resident again regarding his wishes regarding CPR, the DNR and any other Advance Directives. There was no documentation that she attempted to contact the family member, who was listed on the Face Sheet in the electronic medical record as the Emergency contact and POA, related to her knowledge of the resident's wishes, the DNR or any further advance directive information. An interview was conducted with Staff D, an LPN who provided care to Resident # 1 on [DATE] during the 7 a.m. to 7 p.m. shift on [DATE] at approximately 2:30 p.m. She stated that the Social Service Director was reviewing charts and told her that there was no DNR for Resident # 1 so the order for DNR should be changed to a full code. She stated, I changed it, I don't know where the DNR was, I didn't see the DNR, there was an order for [REDACTED]. She stated she did not talk to the resident or contact the resident's family member, who was listed as emergency contact and POA in the electronic medical record, regarding the resident's wishes for CPR. [DATE] 12: 00 Health Status note: Note Text: South CNA notified writer that member looks like he wasn't breathing, assisted by staff members with crash cart, noted member with no pulse or respiration, 911 Called by CNA. No DNR on file. Began CPR with assistance of another nurse at 12:05 p.m. Paramedics arrived and took over procedure. Pronounced deceased by paramedic at 12:12 p.m. (Physician aware). On phone with Dr. as POA walked into building then POA was made aware. Review of a progress note for Resident # 1, dated [DATE] at 19:33 and entitled Discharge Summary, revealed: 12:02 pm CNA informed to nurse that resident did not appear to be breathing. Nurse unable to palpitate a pulse or B/P and no respirations noted. Per chart review, resident a Full Code. 12:03 p.m. CPR initiated, 911 call made. 12:12 p.m. EMS responded and pronounced resident as deceased . 12:20 p.m. (Physician's office) notified. Order received from (physician) to release body to funeral home. Resident's (family member) also POA of resident's finances notified. Resident's body released to (funeral home) at (family member's) request. An interview was conducted with Staff B, a CNA, on [DATE] at 1:00 p.m. She stated she was not assigned to Resident # 1 or assigned to the wing that he resided on and did not know the resident. She stated that the Activity Director had asked her to go and find out what Resident # 1 did for a living and what his religion was. She stated she went in his room to ask him and he was lying on the bed. She stated, He was looking pale, looking funny. I called his name and touched him, no response; I did not feel his heart beating. She stated she went out of the room, called a nurse to come to the room, and got the crash cart, DNR binder and code documentation. She stated she gave these to another CNA who took them in to the resident's room and she went back to her wing. An interview was conducted with Staff A, an LPN, on [DATE] at 12:15 p.m. She stated that, on [DATE], the CNA came to her and told her that Resident # 1 was not breathing. She stated she went to check the resident and he was not breathing. She stated she felt for a pulse and listened for a heartbeat, which were not present. She stated he seemed to be at normal body temperature. She checked the electronic medical record and there was no DNR, he was listed as a Full Code, and she checked the DNR binder and there was no DNR. She stated that someone grabbed the crash cart and CPR was started. She stated another nurse, the MDS Coordinator (Staff I) performed the CPR with her. She stated Staff I did chest compressions and she did the ambu bag. She stated EMS asked her how long they had been doing CPR and when it was started. She stated that she does not remember what they said but they (EMS) did not attempt resuscitation and did not transport him to the hospital. She stated, They pronounced him and left. Staff A stated the protocol is to first check the electronic medical record for the order and second check the DNR binder for the DNR. She stated the electronic medical record is the main chart for the resident. Staff A stated she did not know Resident # 1, as she was not the nurse assigned to Resident # 1 that day and she had not taken care of him during his stay. She stated she was calling the POA when the POA came into the building. She stated that the POA was upset that he died but the POA told her she was expecting him to pass away. She stated, She didn't seem too happy about the CPR part, she did not say it to me but I could tell by her facial expression while she was talking to another staff person. She stated she heard the POA say why did you do CPR, I thought you had all the paperwork, An interview was conducted with Staff I, an LPN who is the MDS Coordinator, on [DATE] at 12:45 p.m. She stated she did participate in the code for Resident # 1 on [DATE]. She stated that Staff A asked her to check the code status and it said Full Code in the electronic medical record in the computer. She stated she told Staff A that it said Full Code and Staff A told her that there was no DNR in the binder either so they proceeded with CPR. She stated that when EMS came, they asked what time the code started, looked at him, rolled him over and noticed pooling, pronounced him deceased and left. She stated he was warm to the touch. She stated she had not met Resident # 1 as he was a new admission and it was Monday. A phone interview was conducted with Staff C, an LPN, on [DATE] at 1:16 p.m. She stated that she was the nurse who was assigned to provide care for Resident # 1 on [DATE]. She stated that [DATE] was the first time she cared for him, she stated that in the morning of [DATE], she had gone in his room to give him his medication and he was lethargic but alert enough to be wakened by voice. She stated she asked him if he was in pain and he mumbled no. She stated she popped her head in throughout the morning to check on him and he did not seem critical. She stated she had asked therapy about him because she did not know him and one of the therapists told her that he was lethargic like that when they had seen him the other day, She stated she had gone on her lunch break when she got a phone call and found out that a code had been initiated on him. She stated she spoke with EMS on the phone, told them what he had been like that day. She stated she knew in the computer that he was documented as Full Code. She stated she found out after the fact there was a DNR. She stated we did not have the DNR or the DNR order in the computer or the DNR binder. She stated, I looked myself after the fact, we had an assessment where he was documented as a DNR, an order for [REDACTED]. During an interview with the Director of Nursing (DON), on [DATE] at 10:09 a.m., she stated that the paperwork from the hospital went missing and was not located and uploaded to the electronic medical record until after Resident # 1 died . A review of Resident #1's document file in the electronic medical record revealed the following listed documents that included: 1. 3008, pdf, listed as category other, upload date listed [DATE], uploaded by Director of Nursing (DON). A review of the 3008 document revealed an AHCA form ,[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer form. The form was dated and signed by a physician on [DATE]. The form stated in the comments section, Patient is DNR. 2. DNR, pdf, listed as category other, upload date listed as [DATE], uploaded by DON. A review of the DNR pdf revealed a document titled: A State of Florida Do Not Resuscitate Order. The document was signed by Resident #1 and a physician on [DATE]. 3. Funeral Home Rep signature, listed as category other, upload date listed as [DATE], uploaded by DON. 4. 3008, pdf, listed as category physician orders, upload date listed as [DATE], uploaded by Medical Records Coordinator (MRC). 5. H & P, pdf, listed as category MD/ARNP H&P, upload date listed as [DATE], uploaded by MRC. 6. H &P, pdf, listed as category other, upload date listed as [DATE], uploaded by MRC. A review of the H & P listed as category MD/ARNP H& P revealed it included a Nephrology Progress note, dated [DATE], which indicated: Assessment: Acute kidney injury superimposed on [MEDICAL CONDITION], Probable progressive renal dysfunction secondary to dehydration; Stage ,[DATE] [MEDICAL CONDITION] (CKD); Anasarca; [DIAGNOSES REDACTED] on exam; Volume overload; URI versus congestion; [MEDICAL CONDITION]; Contraction metabolic alkalosis with Hypercalcemia; [MEDICAL CONDITION] of chronic disease; Human Metapneumovirus; [MEDICATION NAME]; Elevated d- dimer . Plan: .At this time we recommend that patient go on [MEDICAL TREATMENT]. Patient at this time refuses. Had a long discussion with patient to make sure he understood in regards to [MEDICAL TREATMENT]. He states 'he does not want to go on the artificial kidney machine.' . Palliative care following, patient is now a DO NOT RESUSCITATE . Hospice pending. A review of the latter H&P, listed as category other, revealed a document titled: A Palliative Care Consult note, dated [DATE]. The consult note stated, Palliative care visit to patient at bedside. Patient was full code. Now he is DO NOT RESUSCITATE. Discussed with the patient his goals of care. Explained palliative care and the services provided by this program. Patient reports he does not desire [MEDICAL TREATMENT] even though he is stage IV-5 CKD. He does not desire a PEG tube. He does not desire to be resuscitated if his heart were to fail. Per nursing he is not eating. Patient reports his goal is to return home and receive care there. He states to call his (family member) .Call to patient's (family member). (Family member) is now the patients caregiver .Reviewed with patient's (family member) the desires of the patient .She also understands that he does not want CPR and supports his decision to be a DO NOT RESUSCITATE. Order placed for DO NOT RESUSCITATE. Collaborated with nursing and they will assemble the appropriate forms for signing. On [DATE] at 3:57 p.m. the DON was interviewed regarding when and how the hospital paperwork for Resident #1 was located. She stated it was the entire packet that came with him (Resident #1) from the hospital that was missing. She further stated that she was the one that found the packet of paperwork on [DATE] after had died . On [DATE] at approximately 3:57 p.m., the DON showed the surveyor where Resident #1's hospital medical packet of papers had been found. She took the surveyor to the singular nursing station located at the entrance to the facility. The black bin referenced by Staff G, the admitting LPN, was located on the inside corner of the nursing station. (Photographic evidence obtained on [DATE] at 12:30 p.m.) The length of the counter, walk way and into the small room behind the nurses' station was approximately 16 feet. The DON escorted the surveyor to the small room, non- doored room, approximately 6 feet by 8 feet in size located behind the nurse's station. The room was observed to have a fax machine sitting on a 2 drawer file cabinet and a 3 shelf rolling black cart with a portable lap top on it both of which were against the farthest wall in the room. The DON stated she (had) bent down and saw paper sticking out underneath a cart in the small room off of the nurse's station and when she looked further she found the entire hospital packet underneath and behind the cart. The DON demonstrated how she bent down and where the paperwork was located. (Photographic evidence obtained on [DATE] at 12:30 p.m.) Abuse and Neglect policy 1. A review of the facility Standards and Guidelines: SG ANE and Investigations, policy number 12.08.009, issued [DATE], last revised [DATE], Standards: It will be the standard of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. It will be the standard of this facility to ensure that all alleged violation of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/designee. Appropriate agencies will be notified in accordance with existing laws. Definitions included, but, not limited to: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Neglect is the failure of the facility , its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Person-Centered care. For purposes of this subpart, person-centered care means to focus on the resident as the focus of control and support the resident in making his/her own choices and having control over their daily lives. The Seven (7) components regarding this regulation include 1) Screening, 2) Training, 3) Prevention, 4) Identification, 5) Investigation, 6) Protection and 7) Reporting/Response. Guidelines included: 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, & grievances. They will also be given the name of the facility's designated abuse contact person as well as numbers for state agencies. This will be done through: Resident council; Family council; In-service training; 1:1 if indicated; information posted in facility. The facility environment will be monitored to prevent any potential ANE through: Routine monitoring of the physical layout for unsafe or unsupervised areas to minimize occurrence. Monitoring staff actions while caring for residents Monitoring those who come into contact with residents (non-staff). Monitoring of residents with needs and behaviors that might lead to conflict. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Meeting. ADMISSIONS POLICY A review of the Standards and Guidelines: SG Admissions Policy, policy number 12.03.006, issued [DATE], revised [DATE], documented standard: It will be the standard of this facility to provide appropriate admission guidelines when admitting residents to the facility in accordance with federal guidelines. The facility will evaluate/assess and document the resident's condition upon admission, confirm orders with the physician and obtain appropriate demographic and contact information. The Guidelines included: 5. A prospective resident for admission will have their care needs compared to the facility's clinical capabilities list and communicated with the facility staff prior to admission. 6. At the time each resident is admitted , the facility must have physician orders [REDACTED]. In the event the resident arrives to the facility without specific instructions, the nursing staff should reach out to the medical director or physician assigned to the newly admitted resident to receive orders for care and services. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. 7. The admissions staff or designee will complete an admission agreement with each newly admitted resident or resident representative including the full listing of resident rights. 8. The newly admitted resident should have diet/type of nourishment, medications and treatments and advance directives verified by the physician, communicated to the pharmacy for delivery and transcribed to the MAR/TAR or entered into the electronic health record. DETERMINATION OF Code Status A review of the facility Standards and Guidelines: SG Determination of Code Status, policy number 12.01.024, issued ,[DATE], documented the Standard: The resident's Code Status will be determined by a physician's orders [REDACTED].#DH 1896) and /or documented evidence of resident wishes being in place. Guideline: 1. Upon admission, the nurse completing the admission assessment will ascertain resident's wishes as to desired code status in the event of a cardiopulmonary arrest (Full Code or DNR). In the event the resident is incapacitated or unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate decision maker will be asked what the resident's wishes are. 2. Upon determination of resident/responsible party wishes, the nurse will document those

Based on an interview with a resident's family, observation, interviews with t,[DATE]he facility's nursing and administrative staff and Medical Director, review of clinical and hospital records and facility policies and procedures, it was determined that the facility neglected a resident by failing to provide the required structures and processes to honor the resident's Advance Directives including his written and expressed wishes to have Cardiopulmonary Resuscitation (CPR) withheld in the event his heart failed. This affected one (#1) of fifteen sampled residents whose final, known and documented wishes, were not carried out. The Facility lost Resident # 1's State of Florida Do Not Resuscitate (DNR) order, changed a physician order [REDACTED].# 1's stated wishes at admission to not be resuscitated. The facility initiated CPR on Resident # 1, an [AGE] year old alert resident in spite of Resident # 1 signing a DNR order which the facility had on admission, the resident's stated wishes at admission to not be resuscitated and hospital paperwork which accompanied the patient on admission which clearly stated the patient's wishes to not be resuscitated if his heart should fail. The facility's failure to provide the required structures and processes, follow their policies and procedures and honor Resident # 1's Advance Directives represented a system wide failure that could also lead to failure to provide CPR when wanted by a resident. These failures resulted in findings of Immediate Jeopardy Past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings include: 1. Resident #1 was an [AGE] year old male, originally admitted to the facility on [DATE] at approximately 7:00 p.m. The medical record portrayed that Resident #1 was found with no pulse or respiration on [DATE] at 12:02 p.m. and Cardiopulmonary Resuscitation was initiated and maintained for approximately 9 minutes, paramedics arrived at the facility and took over the procedure and subsequently pronounced Resident #1 deceased at 12:12 p.m. A phone interview was conducted with the family member and Power of Attorney (POA) for Resident # 1, on [DATE] at 1: 08 p.m. She stated that she had taken care of Resident # 1 for five years and that he was only at the facility for four days before he died . She stated he had a DNR and she made sure the facility had this paperwork. She stated when he was admitted he was weak, had an infection, his kidneys were bad and he had refused [MEDICAL TREATMENT]. She stated he had been admitted to the facility for rehabilitation and she had expected him to bounce back. She stated he was alert, able to speak for himself and his mind was sharp. She stated she had visited him two to three times a day while he was at the facility and had last seen him the evening before and he was doing okay when she left. She stated on [DATE] she was coming to visit him around lunchtime and when she got there, she saw a fire truck pulling out of the parking lot. She walked onto the facility and was walking down the hallway towards his room when a nurse ran up behind her, grabbed her arm and said, Don't go in there. She stated she asked what was happening and the nurse told her he had just passed away and that they had attempted to resuscitate him. She stated she told the nurse I gave you an order to call me, he passed away without me, why did they try to resuscitate him, why did you call them (emergency services) and not me. She stated she went in Resident # 1's room, sat by his bed and he was gone, he was still warm. She stated, He would not have wanted to be resuscitated, he would have wanted me to hold his hand and be with him when he died . Why resuscitate his poor soul if he was ready to go. The POA stated that a manager, who she believed to be the Administrator, called her and said he was sorry and that the girls got panicky because no one dies here. She stated, I asked them, the nurses, what happened, all they said was his heart stopped. I don't know why they called the fire department. A review of Resident #1's electronic record revealed an Admission Nursing Note, dated [DATE], that collected admission details regarding Resident #1. The form documented that the resident arrived at the facility via stretcher. In section 11 for code status: (admission paperwork related to code status has been reviewed with resident/or surrogate decision maker and he/she indicated he/she wants the following in the event of a cardiopulmonary arrest): The box for Do Not Resuscitate was checked as the resident's choice. The box after this was checked that the Medical doctor had been contacted and an order had been obtained per the resident/decision maker request. The next box documented that the baseline care plan for Resident #1 was that: Resident has chosen Do Not Resuscitate (DNR). The next box documented the Goal of the baseline care plan was that If the resident's heart stops, or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Included in the Interventions was Resident is do not resuscitate status (DNR). The Narrative note, that was signed by Staff Member G, Licensed Practical Nurse (LPN), e-signed on [DATE], documented: Resident admitted around 7pm from (hospital) due to acute [MEDICAL CONDITIONS], Acute kidney injury, [MEDICAL CONDITION], fluid overload. Resident is alert and oriented to self with confusion. Able to follow simple directions. Hard of hearing .medications reviewed with (Doctor) and orders entered into system for pharmacy. Resident's caregiver notified of arrival . The Admission Nursing Note was e-signed by the Director of Nursing on [DATE]. On [DATE] at 11: 57 a.m., a phone interview was conducted with Staff G, LPN who conducted the nursing admission of Resident #1. She stated that Resident # 1 came with paperwork from the hospital which included a PASRR (Preadmission Screening and Resident Review), 3008, History and Physicals and a signed DNR. She stated he seemed to be alert and confused and no one was with him when he was admitted . She stated that she did the admission nursing note in the electronic medical record and the other LPN who was on duty (Staff E) obtained the physician orders. She stated she did not upload the hospital paperwork, including the DNR, into the electronic medical record, but, instead put the paperwork in a folder and placed it in a black plastic shelf on the nursing station desk. She stated that she did not upload the hospital paperwork into the electronic medical record, as she was not completely sure how to use the scanning machine. She stated she did not think it was anyone's specific responsibility to upload it into the electronic record, just that when the admission was done it was scanned in the computer. An interview was held with the Regional Director of Clinical Operations on [DATE] at 8: 40 am. She stated Staff G was asked as part of the facility investigation why she did not put the golden rod copy of the DNR in the DNR binder and Staff G told them that she thought someone else would do it. During an interview with the Director of Nursing (DON), on [DATE] at 10: 09 a.m., she stated that the paperwork from the hospital went missing and was not located and uploaded to the electronic medical record until after Resident # 1 died . A review of Resident #1's document file in the electronic medical record revealed the following listed documents that included: 1. 3008, pdf, listed as category other, upload date listed [DATE], uploaded by Director of Nursing (DON). A review of the 3008 document revealed an AHCA form ,[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer form. The form was dated and signed by a physician on [DATE]. The form stated in the comments section, Patient is DNR. 2. DNR, pdf, listed as category other, upload date listed as [DATE], uploaded by DON. A review of the DNR pdf revealed a document titled: A State of Florida Do Not Resuscitate Order. The document was signed by Resident #1 and a physician on [DATE]. 3. Funeral Home Rep signature, listed as category other, upload date listed as [DATE], uploaded by DON. 4. 3008, pdf, listed as category physician orders, upload date listed as [DATE], uploaded by Medical Records Coordinator (MRC). 5. H & P, pdf, listed as category MD/ARNP H&P, upload date listed as [DATE], uploaded by MRC. 6. H &P, pdf, listed as category other, upload date listed as [DATE], uploaded by MRC. A review of the H & P listed as category MD/ARNP H& P revealed it included a Nephrology Progress note, dated [DATE], which indicated Assessment: Acute kidney injury superimposed on [MEDICAL CONDITION], Probable progressive renal dysfunction secondary to dehydration; Stage ,[DATE] [MEDICAL CONDITION]; Anasarca; [DIAGNOSES REDACTED] on exam; Volume overload; URI versus congestion; [MEDICAL CONDITION]; Contraction metabolic alkalosis with Hypercalcemia; [MEDICAL CONDITION] of chronic disease; Human Metapneumovirus; [MEDICATION NAME]; Elevated d- dimer . Plan: .At this time we recommend that patient go on [MEDICAL TREATMENT]. Patient at this time refuses. Had a long discussion with patient to make sure he understood in regards to [MEDICAL TREATMENT]. He states 'he does not want to go on the artificial kidney machine.' . Palliative care following, patient is now a DO NOT RESUSCITATE . Hospice pending. A review of the latter H&P, listed as category other, revealed a document titled: A Palliative Care Consult note, dated [DATE]. The consult note stated, Palliative care visit to patient at bedside. Patient was full code. Now he is DO NOT RESUSCITATE. Discussed with the patient his goals of care. Explained palliative care and the services provided by this program. Patient reports he does not desire [MEDICAL TREATMENT] even though he is stage IV-5 CKD. He does not desire a PEG tube. He does not desire to be resuscitated if his heart were to fail. Per nursing he is not eating. Patient reports his goal is to return home and receive care there. He states to call his (family member) .Call to patient's (family member). (Family member) is now the patients caregiver .Reviewed with patient's (family member) the desires of the patient .She also understands that he does not want CPR and supports his decision to be a DO NOT RESUSCITATE. Order placed for DO NOT RESUSCITATE. Collaborated with nursing and they will assemble the appropriate forms for signing. An interview was held with the DON, on [DATE] at 10: 09 a.m. She stated that there is a clinical meeting held daily and new admissions are discussed and reviewed at this meeting the day after they are admitted . She stated this clinical meeting is held at approximately 9: 00 a.m. each day. She stated the clinical meeting is held with all department managers, the Administrator, Therapy, Social Service Director, the Clinical Educator, MDS, Business office, medical records, housekeeping and maintenance. She stated Resident # 1 was reviewed on Friday [DATE]. The DON stated, on [DATE] I believe I was the only clinical person that day at the meeting. She stated that the expectation was that the admitting nurse would scan the hospital documents into the electronic clinical record before the end of their shift. She stated she could not locate Resident # 1's hospital paperwork for review at the time of clinical meeting. She stated that she was not sure if the facility even had records for him. She checked the box at the nurses' station, checked with medical records and could not locate any paperwork. She stated she called the nurse who did the admission for Resident # 1 and was told that there was hospital paperwork and she left it on the desk, and she did not ask her to come in and assist with locating the paperwork. She stated, we looked in desk drawers, shelves, behind the printer, looked behind everything. She stated she also checked with therapy and they did not have them. She stated she called the hospital and spoke with someone in medical records (she stated she did not know the name of the person she spoke with). She stated she informed the medical records person that they needed medical records for Resident # 1 because she could not locate them. She stated she was told that the hospital would try to locate them and send them but As far as I know we didn't get any paperwork from the hospital. She stated that she left the facility between 6: 30 and 7 pm. that night, [DATE], without locating the hospital paperwork for Resident # 1 or receiving any paperwork from the hospital. She stated she did notify the nurses who were working that we had missing paperwork and they were to continue looking for it. She stated she also told the nurse she had called the hospital for the paperwork. She provided a list of residents who were reviewed at the clinical meeting that day and Resident #1's name was included on the list. She stated the only document she reviewed at the clinical meeting was the admission-nursing note in the electronic clinical record. She provided a staff sign in sheet for this meeting, which was entitled Morning Business Meeting. Review of the sign in sheet revealed that the Social Service Director was not present. There was no documentation found in the clinical record for Resident # 1 that indicated that his hospital paperwork could not be located and reviewed and that the hospital was contacted to send the paperwork. There was no documentation that the resident's wishes regarding CPR or Advance Directive information were reviewed for Resident # 1 on [DATE]. An interview was held with the Social Service Director, on [DATE] at approximately 1: 30 p.m. She stated she was not working on [DATE]. She stated she came in on [DATE] and was reviewing Resident # 1s record for Advance Directives. She stated she noticed there was a physician's orders [REDACTED]. She stated there was nothing in her mailbox and nothing in the medical records box to be scanned. She stated she looked everywhere and could not find a DNR. She stated she told the nurse that there was a physician's orders [REDACTED]. She stated she did not call the POA to discuss the Advance Directives including DNR and did not notify administration that she was unable to locate this information. On [DATE], the Social Service Director wrote a late entry for [DATE] in the progress note section of the electronic record which stated Upon arrival to my office on [DATE] writer discovered copy of POA (financial only) paperwork on my desk for resident. This writer then went to speak with resident to discuss any additional advance directives he may have and to complete my initial Social Services Initial Evaluation. Attempt was made, however resident was very sleepy and did not want to discuss at that time. This writer then proceeded to search for any additional paperwork in all mailboxes in the copy room, the nurse's station and spoke with nurses on the unit. No additional paperwork was located. This writer also checked DNR binder located at the nurses station to determine if DNR had been placed in the binder, no document was located. Discussion held with unit nurse at which time this writer explained inability to locate any paperwork to support a DNR and requested nurse to obtain an order for [REDACTED]. Medical records explained that they couldn't find the paperwork on Friday [DATE]. There was no documentation that the Social Service Director attempted to approach the resident again regarding his wishes regarding CPR, the DNR and any other Advance Directives. There was no documentation that she attempted to contact the family member, who was listed on the Face Sheet in the electronic medical record as the Emergency contact and POA, related to her knowledge of the resident's wishes, the DNR or any further advance directive information. An interview was conducted with Staff D, an LPN who provided care to Resident # 1 on [DATE] during the 7 a.m. to 7 p.m. shift on [DATE] at approximately 2: 30 p.m. She stated that the Social Service Director was reviewing charts and told her that there was no DNR for Resident # 1 so the order for DNR should be changed to a full code. She stated, I changed it, I don't know where the DNR was, I didn't see the DNR, there was an order for [REDACTED]. No, I did not call the doctor to change the order, I just changed it, it was stupid, I was not thinking. She confirmed she changed the DNR to Full Code in the electronic medical record. She stated she did not talk to the resident or contact the resident's family member, who was listed as emergency contact and POA in the electronic medical record, regarding the resident's wishes for CPR. A review of progress notes for Resident # 1 revealed: [DATE] 15:41 Health Status Note: Resident was sleeping this am when the nurse went to give him his medications. Resident woke when this nurse said his name. Resident took a bite of his medications this am but spit most of them out. When asked if he was in any pain resident stated no and shook his head. CNAs then brought resident his breakfast. A review of Resident # 1's record revealed a physician order, dated [DATE] with a start date of [DATE] for CBC ( Complete Blood Count) with Diff (Differential), CMP ( Complete Metabolic Profile), one time a day for baseline Documentation in the record revealed that the lab work had been drawn. The lab results report, found in the electronic record revealed the results were reported to the facility on [DATE] at 2: 49 pm, after the death of Resident # 1. Significant lab values reported were: BUN 124 mg/dl Reference range ,[DATE]; BUN Creatinine Ratio (Trans) 38.9 reference range 6XXX,[DATE].0; eGFR (Non- African American) 16.3 Reference range ,[DATE] mL/min/1.73m^2 - Stage 4 CKD ( [MEDICAL CONDITION]) [DATE] 12: 00 Health Status note: Note Text: South CNA notified writer that member looks like he wasn't breathing, assisted by staff members with crash cart, noted member with no pulse or respiration, 911 Called by CNA. No DNR on file. Began CPR with assistance of another nurse at 12: 05 p.m. Paramedics arrived and took over procedure. Pronounced deceased by paramedic at 12: 12 p.m. (Physician aware). On phone with Dr. as POA walked into building then POA was made aware. Review of a progress note for Resident # 1, dated [DATE] at 19: 33 and titled Discharge Summary, revealed: 12: 02 pm CNA informed to nurse that resident did not appear to be breathing. Nurse unable to palpitate a pulse or B/P and no respirations noted. Per chart review, resident a Full Code. 12: 03 p.m. CPR initiated, 911 call made. 12: 12 p.m. EMS responded and pronounced resident as deceased . 12 20 p.m. (Physician's office) notified. Order received from (physician) to release body to funeral home. Resident's (family member) also POA of resident's finances notified. Resident's body released to (funeral home) at (family member's) request. An interview was conducted with Staff B, an LPN, on [DATE] at 1:00 p.m. She stated she was not assigned to Resident # 1 or assigned to the wing that he resided on and did not know the resident. She stated that the Activity Director had asked her to go and find out what Resident # 1 did for a living and what his religion was. She stated she went in his room to ask him and he was lying on the bed. She stated, He was looking pale, looking funny. I called his name and touched him, no response; I did not feel his heart beating. She stated she went out of the room, called a nurse to come to the room, and got the crash cart, DNR binder and code documentation. She stated she gave these to another CNA who took them in to the resident's room and she went back to her wing. An interview was conducted with Staff A, an LPN, on [DATE] at 12: 15 p.m. She stated that, on [DATE], the CNA came to her and told her that Resident # 1 was not breathing. She stated she went to check the resident and he was not breathing. She stated she felt for a pulse and listened for a heartbeat, which were not present. She stated he seemed to be at normal body temperature. She checked the electronic medical record and there was no DNR, he was listed as a Full Code, and she checked the DNR binder and there was no DNR. She stated that someone grabbed the crash cart and CPR was started. She stated another nurse, the MDS Coordinator (Staff I) performed the CPR with her. She stated Staff I did chest compressions and she did the ambu bag. She stated EMS asked her how long they had been doing CPR and when it was started. She stated that she does not remember what they said but they (EMS) did not attempt resuscitation and did not transport him to the hospital. She stated, They pronounced him and left. Staff A stated the protocol is to first check the electronic medical record for the order and second check the DNR binder for the DNR. She stated the electronic medical record is the main chart for the resident. Staff A stated she did not know Resident # 1, as she was not the nurse assigned to Resident # 1 that day and she had not taken care of him during his stay. She stated she was calling the POA when the POA came into the building. She stated that the POA was upset that he died but the POA told her she was expecting him to pass away. She stated, She didn't seem too happy about the CPR part, she did not say it to me but I could tell by her facial expression while she was talking to another staff person. She stated she heard the POA say why did you do CPR, I thought you had all the paperwork, An interview was conducted with Staff I, an LPN who is the MDS Coordinator, on [DATE] at 12: 45 p.m. She stated she did participate in the code for Resident # 1 on [DATE]. She stated that Staff A asked her to check the code status and it said Full Code in the electronic medical record in the computer. She stated she told Staff A that it said Full Code and Staff A told her that there was no DNR in the binder either so they proceeded with CPR. She stated that when EMS came, they asked what time the code started, looked at him, rolled him over and noticed pooling, pronounced him deceased and left. She stated he was warm to the touch. She stated she had not met Resident # 1 as he was a new admission and it was Monday. A phone interview was conducted with Staff C, an LPN, on [DATE] at 1: 16 p.m. She stated that she was the nurse who was assigned to provide care for Resident # 1 on [DATE]. She stated that [DATE] was the first time she cared for him, she stated that in the morning of [DATE], she had gone in his room to give him his medication and he was lethargic but alert enough to be wakened by voice. She stated she asked him if he was in pain and he mumbled no. She stated she popped her head in throughout the morning to check on him and he did not seem critical. She stated she had asked therapy about him because she did not know him and one of the therapists told her that he was lethargic like that when they had seen him the other day, She stated she had gone on her lunch break when she got a phone call and found out that a code had been initiated on him. She stated she spoke with EMS on the phone, told them what he had been like that day. She stated she knew in the computer that he was documented as Full Code. She stated she found out after the fact there was a DNR. She stated we did not have the DNR or the DNR order in the computer or the DNR binder. She stated, I looked myself after the fact, we had an assessment where he was documented as a DNR, an order for [REDACTED]. An interview was conducted on [DATE] at 3:57 p.m. with the DON. She stated it was the entire packet that came with him (Resident #1) from the hospital that was missing. She further stated that she was the one that found the packet of paperwork on [DATE] after had died . On [DATE] at approximately 3:57 p.m., the DON showed the surveyor where Resident #1's hospital medical packet of papers had been found. She took the surveyor to the singular nursing station located at the entrance to the facility. The black bin referenced by Staff G, the admitting LPN, was located on the inside corner of the nursing station. (Photographic evidence obtained on [DATE] at 12:30 p.m.) The length of the counter, walk way and into the small room behind the nurses' station was approximately 16 feet. The DON escorted the surveyor to the small room, non- doored room, approximately 6 feet by 8 feet in size located behind the nurse's station. The room was observed to have a fax machine sitting on a 2 drawer file cabinet and a 3 shelf rolling black cart with a portable lap top on it both of which were against the farthest wall in the room. The DON stated she (had) bent down and saw paper sticking out underneath a cart in the small room off of the nurse's station and when she looked further she found the entire hospital packet underneath and behind the cart. The DON demonstrated how she bent down and where the paperwork was located. (Photographic evidence obtained on [DATE] at 12:30 p.m.) 2. A review of the facility Standards and Guidelines: SG ANE and Investigations, policy number 12.08.009, issued [DATE], last revised [DATE], Standards: It will be the standard of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/designee. Appropriate agencies will be notified in accordance with existing laws. Definitions included, but, not limited to: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Neglect is the failure of the facility , its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Person-Centered care. For purposes of this subpart, person-centered care means to focus on the resident as the focus of control and support the resident in making his/her own choices and having control over their daily lives. A review of the Standards and Guidelines: SG Admissions Policy, policy number 12.03.006, issued [DATE], revised [DATE], documented standard: It will be the standard of this facility to provide appropriate admission guidelines when admitting residents to the facility in accordance with federal guidelines. The facility will evaluate/assess and document the resident's condition upon admission, confirm orders with the physician and obtain appropriate demographic and contact information. The Guidelines included: 5. A prospective resident for admission will have their care needs compared to the facility's clinical capabilities list and communicated with the facility staff prior to admission. 6. At the time each resident is admitted , the facility must have physician orders [REDACTED]. In the event the resident arrives to the facility without specific instructions, the nursing staff should reach out to the medical director or physician assigned to the newly admitted resident to receive orders for care and services. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. 7. The admissions staff or designee will complete an admission agreement with each newly admitted resident or resident representative including the full listing of resident rights. 8. The newly admitted resident should have diet/type of nourishment, medications and treatments and advance directives verified by the physician, communicated to the pharmacy for delivery and transcribed to the MAR/TAR or entered into the electronic health record. A review of the facility Standards and Guidelines: SG Determination of Code Status, policy number 12.01.024, issued ,[DATE], documented the Standard: The resident's Code Status will be determined by a physician's orders [REDACTED].#DH 1896) and /or documented evidence of resident wishes being in place. Guideline: 1. Upon admission the nurse completing the admission assessment will ascertain resident's wishes as to desired code status in the event of a cardiopulmonary arrest (Full Code or DNR). In the event the resident is incapacitated or unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate decision maker will be asked what the resident's wishes are. 2. Upon determination of resident/responsible party wishes, the nurse will document those wishes in the admission nursing assessment. 3. If the resident/responsible party elects a DNR, the resident and or responsible party will sign and date the State of Florida DNR order form (#DH1986), available at . 4. The nurse will contact the attending physician and obtain order for Full Code or DNR per resident or responsible party wishes. In the event of a DNR order given via telephone, two nurses shall witness . 5. If the physician is present in the facility, the physician may date and sign the State of Florida Do Not Resuscitate Order form on site. 6. Upon receipt of either verbal, telephone, or direct order for code status, the nurse noting such order shall enter the code status into the electronic health record and validate such order can be visualized in the record, the eMar and the point of care kiosk. The nurse shall check that any prior advanced Directive order which exist are discontinued at the same time the new order is being entered. 7. The electronic record (including electronic chart, point of care kiosk or eMAR) will serve as the primary source of validation of code status should a resident be found un-responsive. 8. After signatures have been obtained by the resident and/or responsible party, the resident's attending physician will sign and date the State of Florida DNR Order form (#DH 1896), either in person at the time of the order, or at their next visit to that record. 9. The original ., will be maintained in the Advance Directives section of the medical chart and scanned into the Document's section of the electronic health record. 10. A Code Status binder will be maintained at each nurse's station. Copies of State of Florida DNR order Forms, documentation of verbal wishes of resident, and/or physician orders [REDACTED]. The binder will be checked and updated weekly by Social Services or their designee. Revision dates will be clearly designated in the bottom right hand corner of the list. A review of the facility Standards and Guidelines: SG Determination of Code Status, policy number 12.01.024, issued ,[DATE], documented the Standard: The resident's Code Status (TRUNCATED)

Based on interviews with the facility's nursing and administrative staff, a family member and facility Medical Director, review of clinical and hospital records and facility policies and procedures, it was determined that facility administration failed to utilize resources effectively and efficiently to protect the rights of 1 ( # 1) of 15 sampled residents related to implementation of Advance Directives. Facility administration failed to ensure that Resident #'1s expressed wishes, related to Advanced Directives and end of life decisions, were honored and violated his right to refuse treatment. Facility administration failed to ensure that the policies and procedures put in place for Advance Directives, Determination of Code status, Code Blue, and placement of the advance directives information in the resident's record were followed and failed to ensure that nursing staff had advance directive information, including a State of Florida Do Not Resuscitate order, available for review in case of emergency. The facility initiated Cardiopulmonary Resuscitation (CPR) on Resident # 1, an [AGE] year old alert resident, four days after admission. The resident was admitted from a hospital with paperwork, which included a signed DNR (Do Not Resuscitate) order, a hospital palliative care consult note, which detailed Resident # 1's wishes to not have his heart resuscitated if his heart were to fail. Resident #1 stated on admission that he did not want to be resuscitated. Resident # 1 was in failing health at the time of admission and arrived with hospital nephrology consult documentation, which reflected significant renal dysfunction, Stage ,[DATE] [MEDICAL CONDITION] and other multiple comorbidities and refusal of [MEDICAL TREATMENT]. Facility administration was aware on [DATE] that Resident # 1's hospital Advance Directive information, including the DNR, was unable to be located. Despite this, minimal attempts were made to locate the documentation with no follow up or documented attempts to reach out to the known family/ POA for Advance Directive information from [DATE] to [DATE] when CPR was performed, contrary to Resident #1's wishes and advance directives. The Social Service Director, whose Job Description reflected she reported to the Administrator, was aware that Advance Directive information was missing for Resident #1 and Resident # 1's wishes and code status were unclear on [DATE] and she did not report this to administration. The actions of the Social Service Director contributed to the violation of rights and failure to honor Resident # 1's advance directives and wishes when the resident's heart failed on [DATE]. The failure of administration, to utilize available resources effectively and efficiently represented a system wide failure resulting in findings of Immediate Jeopardy Past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings Included: 1. The Job Description for the Administrator included: Job Title: Administrator Department: Administration/ Operations Reports to: Regional Director of Operations General Purpose: Manage, lead and direct the overall operations of the facility in accordance with customer needs, regulations, and company policies. With focus on maintaining excellent care for the residents/patients, support and encouragement of employees, and achieving the facility's business objectives. B. Facility Management Duties . Monitors each departments activities, communicates polices, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed. Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility, moral of the staff, and ensures resident needs are being addressed. Provide leadership to maintain interdepartmental teamwork, Ensures consultants and other support resources are appropriately utilized. C. Compliance Management: Duties: Develops and maintain written policies and procedures that govern efficient day-to-day operation of the facility. Maintain a working knowledge of and ensure compliance with all governmental regulations including risk management function. The Administrator performs the role of the facility risk manager. I. Resident Rights and Positive Relationships: Duties: Demonstrate strong ethical practices regarding individual /resident rights. Provide education to staff, physicians and family members concerning sensitivity and compliance with regard to Resident Rights. Promote positive relationships with residents providing leadership as a resident advocate supporting autonomy and choice. Understand, comply with and promote all rules and regulations regarding resident rights; promote positive relationships with residents, visitors, and regulators, to including presenting a professional appearance. Other Job Functions: A. Ethics and Compliance: Duties: Exhibits and promotes expected ethical and legal standards. Reinforces through example and conducts training on the expectation that all employees confirm to these ethical and legal standards, including matters related to resident abuse or neglect. Maintains compliance in promoting patient privacy, HIPPA regulations and confidentiality in the delivery of care. Safeguards patient's medical, financial and personal information. The Job Description for the Director of Nursing included: Division/Department: Nursing Administration Job Title: Director of Nursing Reports to: Administrator General Description: Responsible for planning, coordination, implementation, evaluation and supervision of the nursing services. The Director of Nursing Services is responsible for maintaining consistent, safe and effective nursing practices and the management of the overall operation of the Nursing Department in accordance with policies, standards of nursing practices and regulatory requirements. Establish processes that are outcome focused as to maintain the highest possible level of care and services for each resident, while achieving the facility's business objectives. Essential Job Functions: A. Facility Management: Duties: Conduct regular rounds to monitor delivery of service, operation of department, cleanliness and appearance of the facility and residents to assure nursing practices and delivery of nursing services provide a comfortable, clean and safe environment. Provides leadership to the nursing department in accordance with guidelines and regulations concerning the delivery of care to assure appropriate nursing services are delivered. Coordinates the implementation of formalized processes, interpret/train and monitors effectiveness of systems. Develop and maintain nursing care objectives and standards of nursing care practices for facility. Monitor departmental activities, communicates standards and guidelines, evaluate performance providing feedback and direction as needed Assumes administrative responsibility for the facility in the absence of the Administrator. Comply with, support and enforce policies involving Risk Management. B. Nursing Care and Documentation: Duties: Develop and maintain nursing standards and service objectives that govern efficient day-to-day operation of the nursing department. Provides nursing assessment and acceptance of admissions . Review documentation, the delivery of nursing care according to physician's orders [REDACTED]. Conduct regular rounds to monitor resident activities. Ensure the completion of the RAI process, including the MDS, RAP, summary, development and implementation of the Plan of Care. Monitor IP[NAME] interdisciplinary team conferences. Manage nursing functions for admission, transfer and discharges of residents. Establish and maintain systems including chart audits for appropriate physician orders, 24- hour documentation, appropriate medication, lab, x-ray, incident reports etc., regarding patient services. Instruct nursing staff on appropriate required action. F. Customer Services & Communication Function: Duties: Demonstrate positive customer service in performance of job duties. Assign duties and delegate responsibilities to nursing personnel according to their abilities and resident needs. Promote [MEDICATION NAME] resident care services. Establish and maintain positive interactions with residents, families, visitors and co-workers. Resolve customer issues and/or concerns to achieve positive outcomes. I. Resident's Rights and Positive Relationships Function: Duties: Understand, comply with and promote all rules and regulations regarding residents' rights; promote positive relationships with residents, visitors and regulators, to include presenting a professional appearance. J. Ethics and Compliance: Duties: Maintains expected ethical and legal standards including matters related to resident abuse or neglect, by personally complying with laws and the maintenance or applicable policies and procedures to safeguard the residents. When in doubt about whether a particular activity is proper, refrains from the activity and obtains guidance from the Administrator, Risk Management or consultant staff. Reinforces through example and provides training on the expectation that all employees conform to these ethical and legal standards. Responds promptly and thoroughly when problems are reported. Maintains compliance in promoting patient privacy, HIPPA regulations and confidentiality in the delivery of care. Safeguards patients' medical, financial and personal information. The Job Description for the Social Service Director (undated) included: Reports to the Administrator. General Function: Assist the Social Services Director/ Coordinator in identifying and providing for each resident's social, emotional and psychological needs and the continuing development of the resident's full potential during his/her stay at the facility and to assist in the planning for his/her discharge. Essential Job Functions: B. Departmental Functions: Duties: Actively participate in the pre-admission screening of all potential residents, provide information to residents and families during admission. Orient the resident to the long-term care environment and facility adjustment upon placement. D Resident's Rights Functions: Duties: Understand, comply with and promote all rules regarding resident's rights. E. Ethics and Compliance: Duties: Exhibits expected ethical and legal standards. When in doubt about whether a particular activity is proper, refrains from the activity and obtains guidance from their supervisor or the Administrator. 2. Resident #1 was found unresponsive on [DATE], four days following admission on [DATE]. The medical record portrayed the course of events as follows: [DATE] 12:00 Health Status note : Note Text: South CNA notified writer that member looks like he wasn't breathing, assisted by staff members with crash cart, noted member with no pulse or respiration, 911 Called by CNA. No DNR on file. Began CPR with assistance of another nurse at 12:05 p.m. Paramedics arrived and took over procedure. Pronounced deceased by paramedic at 12:12 p.m. (Physician aware). On phone with Dr. as POA walked into building then POA was made aware. Review of a progress note for Resident # 1, dated [DATE] at 19:33 and entitled Discharge Summary, revealed: 12:02 pm CNA informed to nurse that resident did not appear to be breathing. Nurse unable to palpitate a pulse or B/P and no respirations noted. Per chart review, resident a Full Code. 12:03 p.m. CPR initiated, 911 call made. 12:12 p.m. EMS responded and pronounced resident as deceased . 12:20 p.m. (Physician's office) notified. Order received from (physician) to release body to funeral home. Resident's (family member) also POA of resident's finances notified. Resident's body released to (funeral home) at (family member's) request. A phone interview was conducted with the family member and Power of Attorney (POA) for Resident # 1, on [DATE] at 1:08 p.m. She stated she had taken care of Resident # 1 for five years and that he was only at the facility for four days before he died . She stated he had a DNR and she made sure the facility had this paperwork. She stated when he was admitted he was weak, had an infection, his kidneys were bad and he had refused [MEDICAL TREATMENT]. She stated he had been admitted to the facility for rehabilitation and she had expected him to bounce back. She stated he was alert, able to speak for himself and his mind was sharp. She stated she had visited him two to three times a day while he was at the facility and had last seen him the evening before and he was doing okay when she left. She stated on [DATE] she was coming to visit him around lunchtime and when she got there, she saw a fire truck pulling out of the parking lot. She walked into the facility and was walking down the hallway towards his room when a nurse ran up behind her, grabbed her arm and said, Don't go in there. She stated she asked what was happening and the nurse told her he had just passed away and that they had attempted to resuscitate him. She stated she told the nurse I gave you an order to call me, he passed away without me, why did you try to resuscitate him, why did you call them (emergency services) and not me. She stated she went in Resident # 1's room, sat by his bed and he was gone, he was still warm. She stated, He would not have wanted to be resuscitated, he would have wanted me to hold his hand and be with him when he died . Why resuscitate his poor soul if he was ready to go? The POA stated that a manager, who she believed to be the Administrator, called her and said he was sorry and that the girls got panicky because no one dies here. She stated, I asked them, the nurses, what happened, all they said was his heart stopped. I don't know why they called the fire department. A review of Resident #1's document file in the electronic medical record found a listing of documents which included: 1. 3008, pdf, listed as category other, upload date listed [DATE], uploaded by Director of Nursing (DON). A review of the 3008 document revealed an AHCA form ,[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer form. The form was dated and signed by a physician on [DATE]. The form stated in the comments section, Patient is DNR. 2. DNR, pdf, listed as category other, upload date listed as [DATE], uploaded by DON. A review of the DNR pdf revealed a document titled: A State of Florida Do Not Resuscitate Order. The document was signed by Resident #1 and a physician on [DATE]. 3. Funeral Home Rep signature, listed as category other, upload date listed as [DATE], uploaded by DON. 4. 3008, pdf, listed as category physician orders, upload date listed as [DATE], uploaded by Medical Records Coordinator (MRC). 5. H & P, pdf, listed as category MD/ARNP H&P, upload date listed as [DATE], uploaded by MRC. 6. H &P, pdf, listed as category other, upload date listed as [DATE], uploaded by MRC. A review of the H & P listed as category MD/ARNP H& P revealed it included a Nephrology Progress note, dated [DATE], which indicated Assessment: Acute kidney injury superimposed on [MEDICAL CONDITION], Probable progressive renal dysfunction secondary to dehydration; Stage ,[DATE] [MEDICAL CONDITION]; Anasarca; [DIAGNOSES REDACTED] on exam; Volume overload; URI versus congestion; [MEDICAL CONDITION]; Contraction metabolic alkalosis with Hypercalcemia; [MEDICAL CONDITION] of chronic disease; Human Metapneumovirus; [MEDICATION NAME]; Elevated d- dimer . Plan: .At this time we recommend that patient go on [MEDICAL TREATMENT]. Patient at this time refuses. Had a long discussion with patient to make sure he understood in regards to [MEDICAL TREATMENT]. He states 'he does not want to go on the artificial kidney machine.' . Palliative care following, patient is now a' DO NOT RESUSCITATE' . Hospice pending. A review of the latter H&P, listed as category other, revealed a document titled: A Palliative Care Consult note, dated [DATE]. The consult note stated, Palliative care visit to patient at bedside. Patient was full code. Now he is 'DO NOT RESUSCITATE'. Discussed with the patient his goals of care. Explained palliative care and the services provided by this program. Patient reports he does not desire [MEDICAL TREATMENT] even though he is stage IV-5 CKD ([MEDICAL CONDITION]). He does not desire a PEG tube. He does not desire to be resuscitated if his heart were to fail. Per nursing he is not eating. Patient reports his goal is to return home and receive care there. He states to call his (family member) .Call to patient's (family member). (Family member) is now the patient's caregiver .Reviewed with patient's (family member) the desires of the patient .She also understands that he does not want CPR and supports his decision to be a 'DO NOT RESUSCITATE'. Order placed for 'DO NOT RESUSCITATE'. Collaborated with nursing and they will assemble the appropriate forms for signing. On [DATE] at 11: 57 a.m., a phone interview was conducted with Staff G, a Licensed Practical Nurse (LPN) who conducted the nursing admission of Resident #1 on [DATE]. She stated that Resident # 1 came with paperwork from the hospital which included a PASRR, 3008, History and Physical and a signed DNR. She stated he seemed to be alert and confused and no one was with him when he was admitted . She stated that she did the admission nursing note in the electronic medical record and the other LPN, who was on duty (Staff E), obtained the physician orders. She stated she did not upload the hospital paperwork, including the DNR, into the electronic medical record but, instead, put the paperwork in a folder and placed it in a black plastic shelf on the nursing station desk. She stated that she did not upload the hospital paperwork into the electronic medical record, as she was not completely sure how to use the scanning machine. She stated she did not think it was anyone's specific responsibility to upload it into the electronic record, just that when the admission was done it was scanned in the computer. An interview was held with the Regional Director of Clinical Operations on [DATE] at 8:40 am. She stated Staff G was asked as part of the facility investigation why she did not put the golden rod copy of the DNR in the DNR binder and Staff G told them that she thought someone else would do it. Review of the Admission/Readmission Nursing note, completed by Staff G, on [DATE] at 2:10 a.m., found: Code Status: (admission paperwork related to code status has been reviewed with resident/or surrogate decision maker and he/she indicated he/she wants the following in the event of a cardiopulmonary arrest): Do Not Resuscitate. MD contacted and order obtained per above resident/ decision maker request? Yes. Review of (MONTH) (YEAR) physician orders [REDACTED]. During an interview with the Director of Nursing (DON), on [DATE] at 10:09 a.m., she stated that the paperwork from the hospital went missing and was not located and uploaded to the electronic medical record until after Resident # 1 died . Review of the nursing admission narrative note, completed for Resident # 1 on [DATE] found, Resident admitted around 7 p.m. from (hospital) due to acute [MEDICAL CONDITIONS], acute kidney injury, [MEDICAL CONDITION], Fluid Overload. Resident is alert and oriented to self with confusion, able to follow simple directions. Hard of hearing. No signs of hearing aids in belonging. Resident on 2:3 L NC cont. Current O2, 95%. No complaints at this time. Medications reviewed with (physician) and orders entered into system for pharmacy. Resident's caregiver notified of arrival. Call light within reach, will continue to monitor. A review of Resident # 1's record revealed a physician order, dated [DATE] with a start date of [DATE], for CBC (Complete Blood Count) with Diff (Differential), CMP ( Complete Metabolic Profile), one time a day for baseline. Documentation in the record revealed that the lab work had been drawn. The lab results report, found in the electronic record reflected the results were reported to the facility on [DATE] at 2:49 pm, after the death of Resident # 1. Significant lab values reported were: BUN 124 mg/dl Reference range ,[DATE]; BUN Creatinine Ratio (Trans) 38.9 reference range 6XXX,[DATE].0; eGFR (Non- African American) 16.3 Reference range ,[DATE] mL/min/1.73m^2 - Stage 4 CKD ( [MEDICAL CONDITION]) The Director of Nursing and the Administrator were aware on the morning of [DATE] that there was missing documentation for Resident # 1. An interview was held with the DON, on [DATE] at 10:09 a.m. She stated that there is a clinical meeting held daily and new admissions are discussed and reviewed at this meeting the day after they are admitted . She stated this clinical meeting is held at approximately 9:00 a.m. each day. She stated the clinical meeting is held with all department managers, the Administrator, Therapy, Social Service Director, the Clinical Educator, MDS, Business office, medical records, housekeeping and maintenance. She stated Resident # 1 was reviewed on Friday, [DATE]. The DON stated, on [DATE], I believe I was the only clinical person that day at the meeting. She stated that the expectation was that the admitting nurse would scan the hospital documents into the electronic clinical record before the end of their shift. She stated she could not locate Resident # 1's hospital paperwork for review at the time of clinical meeting. She stated that she was not sure if the facility even had records for him. She checked the box at the nurses' station, checked with medical records and could not locate any paperwork. She stated she called the nurse who did the admission for Resident # 1 and was told that there was hospital paperwork and she left it on the desk, however, she did not ask her to come in and assist with locating the paperwork. She stated, we looked in desk drawers, shelves, behind the printer, looked behind everything. She stated she also checked with therapy and they did not have them. She stated she called the hospital and spoke with someone in medical records (she stated she did not know the name of the person she spoke with). She stated she informed the medical records person that they needed medical records for Resident # 1 because she could not locate them. She stated she was told that the hospital would try to locate them and send them but As far as I know we didn't get any paperwork from the hospital. She stated that she left the facility between 6:30 and 7 pm. that night, [DATE], without locating the hospital paperwork for Resident # 1 or receiving any paperwork from the hospital. She stated she did notify the nurses who were working that we had missing paperwork and they were to continue looking for it. She stated she also told the nurse she had called the hospital for the paperwork. She provided a list of residents who were reviewed at the clinical meeting that day and Resident # 1's name was included on the list. She stated the only document she reviewed at the clinical meeting was the admission-nursing note in the electronic clinical record. She provided a staff sign in sheet for this meeting, which was entitled Morning Business Meeting. Review of the sign in sheet revealed that the Social Service Director was not present. There was no documentation found in the clinical record for Resident # 1 that indicated that his hospital paperwork could not be located and reviewed and that the hospital was contacted to send the paperwork. There was no documentation that the resident's wishes regarding CPR or Advance Directive information were reviewed for Resident # 1 on [DATE]. Review of the staff sign in sheet for this meeting held on [DATE], revealed that both the Administrator and the Director of Nursing were present at this meeting. The DON stated that she could not locate the hospital paperwork for Resident # 1 for review of Resident # 1 at the clinical meeting. The Administrator, by his presence at this meeting would have known that hospital paperwork for Resident # 1 could not be located. An interview was conducted with Staff B, a CNA, on [DATE] at 1:00 p.m. She stated she was not assigned to Resident # 1 or assigned to the wing that he resided on and did not know the resident. She stated that the Activity Director asked her to go and find out what Resident # 1 did for a living and what his religion was. She stated she went in his room to ask him and he was lying on the bed. She stated, He was looking pale, looking funny. I called his name and touched him, no response; I did not feel his heart beating. She stated she went out of the room, called a nurse to come to the room, and got the crash cart, DNR binder, and code documentation. She stated she gave these to another CNA who took them in to the resident's room and she went back to her wing. An interview was conducted with Staff A, an LPN, on [DATE] at 12:15 p.m. She stated that, on [DATE], the CNA came to her and told her that Resident # 1 was not breathing. She stated she went to check the resident and he was not breathing. She stated she felt for a pulse and listened for a heartbeat, which were not present. She stated he seemed to be at normal body temperature. She checked the electronic medical record and there was no DNR. He was listed as a Full Code, and she checked the DNR binder and there was no DNR. She stated that someone grabbed the crash cart and CPR was started. She stated another nurse, the MDS Coordinator (Staff I) performed the CPR with her. She stated Staff I did chest compressions and she did the ambu bag. She stated EMS asked her how long they had been doing CPR and when it was started. She stated that she does not remember what they said but they (EMS) did not attempt resuscitation and did not transport him to the hospital. She stated, They pronounced him and left. Staff A stated the protocol was to first check the electronic medical record for the order and, second, check the DNR binder for the DNR. She stated the electronic medical record was the main chart for the resident. Staff A stated she did not know Resident # 1, as she was not the nurse assigned to Resident # 1 that day and she had not taken care of him during his stay. She stated she was calling the POA when the POA came into the building. She stated that the POA was upset that he died but the POA told her she was expecting him to pass away. She stated, She didn't seem too happy about the CPR part, she did not say it to me but I could tell by her facial expression while she was talking to another staff person. She stated she heard the POA say why did you do CPR, I thought you had all the paperwork? An interview was conducted with Staff I, an LPN, who is the MDS Coordinator, on [DATE] at 12:45 p.m. She stated she did participate in the code for Resident # 1 on [DATE]. She stated that Staff A asked her to check the code status and it said Full Code in the electronic medical record in the computer. She stated she told Staff A that it said Full Code and Staff A told her that there was no DNR in the binder either so they proceeded with CPR. She stated that when EMS came, they asked what time the code started, looked at him, rolled him over and noticed pooling, pronounced him deceased and left. She stated he was warm to the touch. She stated she had not met Resident # 1 as he was a new admission and it was Monday. A phone interview was conducted with Staff C, an LPN, on [DATE] at 1:16 p.m. She stated that she was the nurse who was assigned to provide care for Resident # 1 on [DATE]. She stated that [DATE] was the first time she cared for him, she stated that in the morning of [DATE], she had gone in his room to give him his medication and he was lethargic but alert enough to be wakened by voice. She stated she asked him if he was in pain and he mumbled no. She stated she popped her head in throughout the morning to check on him and he did not seem critical. She stated she had asked therapy about him because she did not know him and one of the therapists told her that he was lethargic like that when they had seen him the other day, She stated she had gone on her lunch break when she got a phone call and found out that a code had been initiated on him. She stated she spoke with EMS on the phone, told them what he had been like that day. She stated she knew in the computer that he was documented as Full Code. She stated she found out after the fact there was a DNR. She stated we did not have the DNR or the DNR order in the computer or the DNR binder. She stated, I looked myself after the fact, we had an assessment where he was documented as a DNR, an order for [REDACTED]. An interview was held with the Social Service Director, on [DATE] at approximately 1:30 p.m. She stated she was not working on [DATE]. She stated she came in on [DATE] and was reviewing Resident # 1s record for Advance Directives. She stated she noticed there was a physician's orders [REDACTED]. She stated there was nothing in her mailbox and nothing in the medical records box to be scanned. She stated she looked everywhere and could not find a DNR. She stated she told the nurse that there was a physician's orders [REDACTED]. She stated she did not call the POA to discuss the Advance Directives, including DNR, and did not notify administration that she was unable to locate this information. During a follow-up interview with the Social Worker at 9:45 am on 3/ ,[DATE], the staff member recalled that when she was unable to locate the paperwork, she didn't know what to do, it was my first instance of this and it was Saturday. On [DATE], the Social Service Director wrote a late entry for [DATE] in the progress note section of the electronic record which stated, Upon arrival to my office on [DATE] writer discovered copy of POA (financial only) paperwork on my desk for resident. This writer then went to speak with resident to discuss any additional advance directives he may have and to complete my initial Social Services Initial Evaluation. Attempt was made, however resident was very sleepy and did not want to discuss at that time. This writer then proceeded to search for any additional paperwork in all mailboxes in the copy room, the nurse's station and spoke with nurses on the unit. No additional paperwork was located. This writer also checked DNR binder located at the nurses station to determine if DNR had been placed in the binder. No document was located. Discussion held with unit nurse at which time this writer explained inability to locate any paperwork to support a DNR and requested nurse to obtain an order for [REDACTED]. There was no documentation that the Social Service Director attempted to approach the resident again regardin (TRUNCATED)

Based on interviews with the facility's nursing and administrative staff, a family member and facility Medical Director, review of clinical and hospital records and facility policies and procedures, it was determined that the facility failed to protect the rights of 1 (#1) of 15 sampled residents related to the formulation of Advance Directives. The facility failed to honor Resident # 1's expressed wishes related to Advance Directives and end of life decisions. The facility failed to honor, and in fact lost, a State of Florida Do Not Resuscitate order executed by Resident # 1. The facility failed to follow its own policies and procedures for Advance Directives, Determination of Code status Code Blue and placement of the advance directives information in the resident's record and failed to ensure that nursing staff had advance directive information, including State of Florida Do Not Resuscitate orders (DNRs) available for review in case of an emergency. The facility initiated CPR on Resident # 1, an [AGE] year old alert resident who was admitted to the facility with paperwork which included a signed DNR order, a hospital palliative care consult note which detailed Resident # 1's wishes to not have his heart resuscitated if his heart were to fail and who stated on admission that he did not want to be resuscitated. The facility failed to honor Resident # 1's expressed wishes and violated his right to refuse treatment. The facility failed to protect the resident from unwanted potentially violent interventions in his last moments of life. The facility's failure to follow their policies and procedures represented a system wide failure that could also lead to failure to provide CPR when wanted by a resident. Failure of the facility staff to implement advance directives correctly resulted in findings of Immediate Jeopardy Past noncompliance on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Findings Included: 1. Resident # 1 was admitted to the facility from a local hospital on [DATE]. On [DATE] at 11: 57 a.m., a phone interview was conducted with Staff G, per a Licensed Practical Nurse (LPN) who conducted the nursing admission of Resident #1. She stated that Resident # 1 came with paperwork from the hospital which included a PASRR, 3008, History and Physicals and a signed DNR. She stated he seemed to be alert and confused and no one was with him when he was admitted . She stated that she did the admission nursing note in the electronic medical record and the other LPN who was on duty (Staff E) obtained the physician orders. She stated she did not upload the hospital paperwork, including the DNR, into the electronic medical record but instead put the paperwork in a folder and placed it in a black plastic shelf on the nursing station desk. She stated that she did not upload the hospital paperwork into the electronic medical record, as she was not completely sure how to use the scanning machine. She stated she did not think it was anyone's specific responsibility to upload it into the electronic record, just that when the admission was done it was scanned in the computer. An interview was held with the Regional Director of Clinical Operations on [DATE] at 8: 40 am. She stated Staff G was asked as part of the facility investigation why she did not put the golden rod copy of the DNR in the DNR binder and Staff G told them that she thought someone else would do it. Review of the Admission/Readmission Nursing note, completed by Staff G, on [DATE] at 2:10 a.m., revealed: Code Status: (admission paperwork related to code status has been reviewed with resident/or surrogate decision maker and he/she indicated he/she wants the following in the event of a cardiopulmonary arrest): Do Not Resuscitate. MD contacted and order obtained per above resident/ decision maker request? Yes. Review of (MONTH) (YEAR) physician orders [REDACTED]. On [DATE], at 12:02 p.m., Resident # 1 was found in his room without pulse and respirations and two licensed nurses (Staff A, Staff I) initiated and performed Cardio [MEDICAL CONDITION] Resuscitation on Resident # 1 for nine minutes, violating his right to have his advance directives honored and his expressed wishes followed, until Resident # 1 was pronounced as deceased by emergency medical services personnel. A phone interview was conducted with the family member and Power of Attorney (POA) for Resident # 1, on [DATE] at 1:08 p.m. She stated that she had taken care of Resident # 1 for five years and that he was only at the facility for four days before he died . She stated he had a DNR and she made sure the facility had this paperwork. She stated when he was admitted he was weak, had an infection, his kidneys were bad and he had refused [MEDICAL TREATMENT]. She stated he had been admitted to the facility for rehabilitation and she had expected him to bounce back. She stated he was alert, able to speak for himself and his mind was sharp. She stated she had visited him two to three times a day while he was at the facility and had last seen him the evening before and he was doing okay when she left. She stated on [DATE] she was coming to visit him around lunchtime and when she got there, she saw a fire truck pulling out of the parking lot. She walked into the facility and was walking down the hallway towards his room when a nurse ran up behind her, grabbed her arm and said, Don't go in there. She stated she asked what was happening and the nurse told her he had just passed away and that they had attempted to resuscitate him. She stated she told the nurse I gave you an order to call me, he passed away without me, why did you try to resuscitate him, why did you call them (emergency services) and not me? She stated she went in Resident # 1's room, sat by his bed and he was gone, he was still warm. She stated, He would not have wanted to be resuscitated, he would have wanted me to hold his hand and be with him when he died . Why resuscitate his poor soul if he was ready to go? The POA stated that a manager, who she believed to be the Administrator, called her and said he was sorry and that the girls got panicky because no one dies here. She stated, I asked them, the nurses, what happened, all they said was his heart stopped. I don't know why they called the fire department. 2. During the phone interview with Staff G,, the admitting nurse, on [DATE] at 11:57 a.m., she stated that the hospital paperwork that accompanied Resident # 1 to the facility upon admission on [DATE] included a 3008, PASRR, History and Physical and DNR. During an interview with the Director of Nursing (DON), on [DATE] at 10:09 a.m., she stated that the paperwork from the hospital went missing and was not located and uploaded to the electronic medical record until after Resident # 1 died . A review of Resident #1's document file in the electronic medical record revealed the following listed documents that included: 1. 3008, pdf, listed as category other, upload date listed [DATE], uploaded by Director of Nursing (DON). A review of the 3008 document revealed an AHCA form ,[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer form. The form was dated and signed by a physician on [DATE]. The form stated in the comments section, Patient is DNR. 2. DNR, pdf, listed as category other, upload date listed as [DATE], uploaded by DON. A review of the DNR pdf revealed a document titled: A State of Florida Do Not Resuscitate Order. The document was signed by Resident #1 and a physician on [DATE]. 3. Funeral Home Rep signature, listed as category other, upload date listed as [DATE], uploaded by DON. 4. 3008, pdf, listed as category physician orders, upload date listed as [DATE], uploaded by Medical Records Coordinator (MRC). 5. H & P, pdf, listed as category MD/ARNP H&P, upload date listed as [DATE], uploaded by MRC. 6. H &P, pdf, listed as category other, upload date listed as [DATE], uploaded by MRC. A review of the H & P listed as category MD/ARNP H& P revealed it included a Nephrology Progress note, dated [DATE], which indicated Assessment: Acute kidney injury superimposed on [MEDICAL CONDITION], Probable progressive renal dysfunction secondary to dehydration; Stage ,[DATE] [MEDICAL CONDITION]; Anasarca; [DIAGNOSES REDACTED] on exam; Volume overload; URI versus congestion; [MEDICAL CONDITION]; Contraction metabolic alkalosis with Hypercalcemia; [MEDICAL CONDITION] of chronic disease; Human Metapneumovirus; [MEDICATION NAME]; Elevated d- dimer . Plan: .At this time we recommend that patient go on [MEDICAL TREATMENT]. Patient at this time refuses. Had a long discussion with patient to make sure he understood in regards to [MEDICAL TREATMENT]. He states 'he does not want to go on the artificial kidney machine.' . Palliative care following, patient is now a 'DO NOT RESUSCITATE' . Hospice pending. A review of the latter H&P, listed as category other, revealed a document titled: A Palliative Care Consult note, dated [DATE]. The consult note stated, Palliative care visit to patient at bedside. Patient was full code. Now he is 'DO NOT RESUSCITATE'. Discussed with the patient his goals of care. Explained palliative care and the services provided by this program. Patient reports he does not desire [MEDICAL TREATMENT] even though he is stage IV-5 CKD ([MEDICAL CONDITION]). He does not desire a PEG tube. He does not desire to be resuscitated if his heart were to fail. Per nursing he is not eating. Patient reports his goal is to return home and receive care there. He states to call his (family member) .Call to patient's (family member). (Family member) is now the patients caregiver .Reviewed with patient's (family member) the desires of the patient .She also understands that he does not want CPR and supports his decision to be a 'DO NOT RESUSCITATE'. Order placed for 'DO NOT RESUSCITATE'. Collaborated with nursing and they will assemble the appropriate forms for signing. Review of the nursing admission narrative note, completed for Resident # 1 on [DATE] revealed, Resident admitted around 7 p.m. from (hospital) due to acute [MEDICAL CONDITIONS], Acute kidney injury, [MEDICAL CONDITION], Fluid Overload. Resident is alert and oriented to self with confusion, able to follow simple directions. Hard of hearing. No signs of hearing aids in belonging. Resident on 2:3 L NC cont. Current O2, 95%. No complaints at this time. Medications reviewed with (physician) and orders entered into system for pharmacy. Resident's caregiver notified of arrival. Call light within reach, will continue to monitor. An undated Authorization for Treatment from, signed by the POA, was documented as uploaded in to the electronic record on [DATE]. An interview was conducted with Staff H, a 7 a.m. to 7 p.m. LPN, on [DATE] at 10:30 a.m. She stated that on [DATE] she brought the Authorization for Treatment form and other forms including the Pneumococcal Informed Consent, Influenza Immunization Informed Consent and Wound Disclosure and Acknowledgement Form to Resident # 1 for him to sign. She stated he was sleepy and very weak and the POA was present. She stated Resident # 1 indicated that he wanted the POA to sign the forms. There was no documentation found in the resident's record regarding this contact or any documentation of a discussion with the resident or POA regarding designation of the POA to be the health care surrogate and/or health care proxy for Resident # 1. An interview was conducted with the Admissions Director on [DATE] at 9:00 a.m. She stated that when a resident is admitted from the hospital the hospital will send the 3008, the medication list, any prescriptions and any advance directives the resident has. She stated the hospital paperwork usually comes in with the transport person and the nurse is responsible from obtaining it from transport. She stated she was responsible for the admission packet and the informed consents are the nurse's responsibility to obtain. She stated that double checking the advance directive would be the responsibility of the admitting nurse and that it would be the responsibility of Social Services to review the Advance Directives booklet with the resident. An interview was held with the DON, on [DATE] at 10:09 a.m. She stated that there is a clinical meeting held daily and new admissions are discussed and reviewed at this meeting the day after they are admitted . She stated this clinical meeting is held at approximately 9:00 a.m. each day. She stated the clinical meeting is held with all department managers, the Administrator, Therapy, Social Service Director, the Clinical Educator, MDS, Business office, medical records, housekeeping and maintenance. She stated Resident # 1 was reviewed on Friday [DATE]. The DON stated, on [DATE], I believe I was the only clinical person that day at the meeting. She stated that the expectation was that the admitting nurse would scan the hospital documents into the electronic clinical record before the end of their shift. She stated she could not locate Resident # 1's hospital paperwork for review at the time of clinical meeting. She stated that she was not sure if the facility even had records for him. She checked the box at the nurses' station, checked with medical records and could not locate any paperwork. She stated she called the nurse who did the admission for Resident # 1 and was told that there was hospital paperwork and she left it on the desk, she did not ask her to come in and assist with locating the paperwork. She stated, we looked in desk drawers, shelves, behind the printer, looked behind everything. She stated she also checked with therapy and they did not have them. She stated she called the hospital and spoke with someone in medical records. She stated she did not know the name of the person she spoke with. She stated she informed the medical records person that they needed medical records for Resident # 1 because she could not locate them. She stated she was told that the hospital would try to locate them and send them but As far as I know we didn't get any paperwork from the hospital. She stated that she left the facility between 6:30 and 7 pm. that night, [DATE], without locating the hospital paperwork for Resident # 1 or receiving any paperwork from the hospital. She stated she did notify the nurses who were working that we had missing paperwork and they were to continue looking for it. She stated she also told the nurse she had called the hospital for the paperwork. She provided a list of residents who were reviewed at the clinical meeting that day and Resident # 1's name was included on the list. She stated the only document she reviewed at the clinical meeting was the admission-nursing note in the electronic clinical record. She provided a staff sign in sheet for this meeting, which was entitled Morning Business Meeting. Review of the sign in sheet revealed that the Social Service Director was not present. There was no documentation found in the clinical record for Resident # 1 that indicated that his hospital paperwork could not be located and reviewed and that the hospital was contacted to send the paperwork. There was no documentation that the resident's wishes regarding CPR or Advance Directive information were reviewed for Resident # 1 on [DATE]. An interview was held with the Social Service Director, on [DATE] at approximately 1:30 p.m. She stated she was not working on [DATE]. She stated she came in on [DATE] and was reviewing Resident # 1s record for Advance Directives. She stated she noticed there was a physician's orders [REDACTED]. She stated there was nothing in her mailbox and nothing in the medical records box to be scanned. She stated she looked everywhere and could not find a DNR. She stated she told the nurse that there was a physician's orders [REDACTED]. She stated she did not call the POA to discuss the Advance Directives including DNR and did not notify administration that she was unable to locate this information. On [DATE], the Social Service Director wrote a late entry for [DATE] in the progress note section of the electronic record which stated Upon arrival to my office on [DATE] writer discovered copy of POA (financial only) paperwork on my desk for resident. This writer then went to speak with resident to discuss any additional advance directives he may have and to complete my initial Social Services Initial Evaluation. Attempt was made, however resident was very sleepy and did not want to discuss at that time. This writer then proceeded to search for any additional paperwork in all mailboxes in the copy room, the nurse's station and spoke with nurses on the unit. No additional paperwork was located. This writer also checked DNR binder located at the nurses station to determine if DNR had been placed in the binder, no document was located. Discussion held with unit nurse at which time this writer explained inability to locate any paperwork to support a DNR and requested nurse to obtain an order for [REDACTED]. Medical records explained that they couldn't find the paperwork on Friday [DATE]. There was no documentation that the Social Service Director attempted to approach the resident again regarding his wishes regarding CPR, the DNR and any other Advance Directives.There was no documentation that she attempted to contact the family member, who was listed on the Face Sheet in the electronic medical record as the Emergency contact and POA, related to her knowledge of the resident's wishes, the DNR or any further advance directive information. An interview was conducted with Staff D, an LPN who provided care to Resident # 1 on [DATE] during the 7 a.m. to 7 p.m. shift on [DATE] at approximately 2:30 p.m. She stated that the Social Service Director was reviewing charts and told her that there was no DNR for Resident # 1 so the order for DNR should be changed to a full code. She stated, I changed it, I don't know where the DNR was, I didn't see the DNR, there was an order for [REDACTED]. No, I did not call the doctor to change the order, I just changed it, it was stupid, I was not thinking. She confirmed she changed the DNR to Full Code in the electronic medical record. She stated she did not talk to the resident or contact the resident's family member, who was listed as emergency contact and POA in the electronic medical record, regarding the resident's wishes for CPR. A review of progress notes for Resident # 1 revealed: [DATE] 15:41 Health Status Note: Resident was sleeping this am when the nurse went to give him his medications. Resident woke when this nurse said his name. Resident took a bite of his medications this am but spit most of them out. When asked if he was in any pain resident stated no and shook his head. CNA's then brought resident his breakfast. A review of Resident # 1's record revealed a physician order, dated [DATE] with a start date of [DATE] for CBC ( Complete Blood Count) with Diff (Differential), CMP ( Complete Metabolic Profile), one time a day for baseline Documentation in the record revealed that the lab work had been drawn. The lab results report, found in the electronic record revealed the results were reported to the facility on [DATE] at 2:49 pm, after the death of Resident # 1. Significant lab values reported were: BUN 124 mg/dl Reference range ,[DATE]; BUN Creatinine Ratio (Trans) 38.9 reference range 6XXX,[DATE].0; eGFR (Non- African American) 16.3 Reference range ,[DATE] mL/min/1.73m^2 - Stage 4 CKD ( [MEDICAL CONDITION]) [DATE] 12:00 Health Status note : Note Text: South CNA notified writer that member looks like he wasn't breathing, assisted by staff members with crash cart, noted member with no pulse or respiration, 911 Called by CNA. No DNR on file. Began CPR with assistance of another nurse at 12:05 p.m. Paramedics arrived and took over procedure. Pronounced deceased by paramedic at 12:12 p.m. (Physician aware). On phone with Dr. as POA walked into building then POA was made aware. Review of a progress note for Resident # 1, dated [DATE] at 19:33 and entitled Discharge Summary, revealed: 12:02 pm CNA informed to nurse that resident did not appear to be breathing. Nurse unable to palpitate a pulse or B/P and no respirations noted. Per chart review, resident a Full Code. 12:03 p.m. CPR initiated, 911 call made. 12:12 p.m. EMS responded and pronounced resident as deceased . 12 20 p.m. (Physician's office) notified. Order received from (physician) to release body to funeral home. Resident's (family member) also POA of resident's finances notified. Resident's body released to (funeral home) at (family member's) request. An interview was conducted with Staff B, a CNA, on [DATE] at 1:00 p.m. She stated she was not assigned to Resident # 1 or assigned to the wing that he resided on and did not know the resident. She stated that the Activity Director had asked her to go and find out what Resident # 1 did for a living and what his religion was. She stated she went in his room to ask him and he was lying on the bed. She stated, He was looking pale, looking funny. I called his name and touched him, no response; I did not feel his heart beating. She stated she went out of the room, called a nurse to come to the room, and got the crash cart, DNR binder and code documentation. She stated she gave these to another CNA who took them in to the resident's room and she went back to her wing. An interview was conducted with Staff A, an LPN, on [DATE] at 12:15 p.m. She stated that, on [DATE], the CNA came to her and told her that Resident # 1 was not breathing. She stated she went to check the resident and he was not breathing. She stated she felt for a pulse and listened for a heartbeat, which were not present. She stated he seemed to be at normal body temperature. She checked the electronic medical record and there was no DNR, he was listed as a Full Code, and she checked the DNR binder and there was no DNR. She stated that someone grabbed the crash cart and CPR was started. She stated another nurse, the MDS Coordinator (Staff I) performed the CPR with her. She stated Staff I did chest compressions and she did the ambu bag. She stated EMS asked her how long they had been doing CPR and when it was started. She stated that she does not remember what they said but they (EMS) did not attempt resuscitation and did not transport him to the hospital. She stated, They pronounced him and left. Staff A stated the protocol is to first check the electronic medical record for the order and second check the DNR binder for the DNR. She stated the electronic medical record is the main chart for the resident. Staff A stated she did not know Resident # 1, as she was not the nurse assigned to Resident # 1 that day and she had not taken care of him during his stay. She stated she was calling the POA when the POA came into the building. She stated that the POA was upset that he died but the POA told her she was expecting him to pass away. She stated, She didn't seem too happy about the CPR part, she did not say it to me but I could tell by her facial expression while she was talking to another staff person. She stated she heard the POA say why did you do CPR, I thought you had all the paperwork, An interview was conducted with Staff I, an LPN who is the MDS Coordinator, on [DATE] at 12:45 p.m. She stated she did participate in the code for Resident # 1 on [DATE]. She stated that Staff A asked her to check the code status and it said Full Code in the electronic medical record in the computer. She stated she told Staff A that it said Full Code and Staff A told her that there was no DNR in the binder either so they proceeded with CPR. She stated that when EMS came, they asked what time the code started, looked at him, rolled him over and noticed pooling, pronounced him deceased and left. She stated he was warm to the touch. She stated she had not met Resident # 1 as he was a new admission and it was Monday. A phone interview was conducted with Staff C, an LPN, on [DATE] at 1:16 p.m. She stated that she was the nurse who was assigned to provide care for Resident # 1 on [DATE]. She stated that [DATE] was the first time she cared for him, she stated that in the morning of [DATE], she had gone in his room to give him his medication and he was lethargic but alert enough to be wakened by voice. She stated she asked him if he was in pain and he mumbled no. She stated she popped her head in throughout the morning to check on him and he did not seem critical. She stated she had asked therapy about him because she did not know him and one of the therapists told her that he was lethargic like that when they had seen him the other day, She stated she had gone on her lunch break when she got a phone call and found out that a code had been initiated on him. She stated she spoke with EMS on the phone, told them what he had been like that day. She stated she knew in the computer that he was documented as Full Code. She stated she found out after the fact there was a DNR. She stated we did not have the DNR or the DNR order in the computer or the DNR binder. She stated, I looked myself after the fact, we had an assessment where he was documented as a DNR, an order for [REDACTED]. 3. Policies Reviewed: ADMISSIONS POLICY A review of the Standards and Guidelines: SG Admissions Policy, policy number 12.03.006, issued [DATE], revised [DATE], documented standard: It will be the standard of this facility to provide appropriate admission guidelines when admitting residents to the facility in accordance with federal guidelines. The facility will evaluate/assess and document the resident's condition upon admission, confirm orders with the physician and obtain appropriate demographic and contact information. The Guidelines included: 5. A prospective resident for admission will have their care needs compared to the facility's clinical capabilities list and communicated with the facility staff prior to admission. 6. At the time each resident is admitted , the facility must have physician orders [REDACTED]. In the event the resident arrives to the facility without specific instructions, the nursing staff should reach out to the medical director or physician assigned to the newly admitted resident to receive orders for care and services. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. 7. The admissions staff or designee will complete an admission agreement with each newly admitted resident or resident representative including the full listing of resident rights. 8. The newly admitted resident should have diet/type of nourishment, medications and treatments and advance directives verified by the physician, communicated to the pharmacy for delivery and transcribed to the MAR/TAR or entered into the electronic health record. DETERMINATION OF Code Status A review of the facility Standards and Guidelines: SG Determination of Code Status, policy number 12.01.024, issued ,[DATE], documented the Standard: The resident's Code Status will be determined by a physician's orders [REDACTED].#DH 1896) and /or documented evidence of resident wishes being in place. Guideline: 1. Upon admission, the nurse completing the admission assessment will ascertain resident's wishes as to desired code status in the event of a cardiopulmonary arrest (Full Code or DNR). In the event the resident is incapacitated or unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate decision maker will be asked what the resident's wishes are. 2. Upon determination of resident/responsible party wishes, the nurse will document those wishes in the admission nursing assessment. 3. If the resident/responsible party elects a DNR, the resident and or responsible party will sign and date the State of Florida DNR order form (#DH1986), available at . 4. The nurse will contact the attending physician and obtain order for Full Code or DNR per resident or responsible party wishes. In the event of a DNR order given via telephone, two nurses shall witness . 5. If the physician is present in the facility, the physician may date and sign the State of Florida Do Not Resuscitate Order form on site. 6. Upon receipt of either verbal, telephone, or direct order for code status, the nurse noting such order shall enter the code status into the electronic health record and validate such order can be visualized in the record, the eMAR and the point of care kiosk. The nurse shall check that any prior advanced Directive order which exist are discontinued at the same time the new order is being entered. 7. The electronic record (including electronic chart, point of care kiosk or eMAR) will serve as the primary source of validation of code status should a resident be found un-responsive. 8. After signatures have been obtained by the resident and/or responsible party, the resident's attending physician will sign and date the State of Florida DNR Order form (#DH 1896), either in person at the time of the order, or at their next visit to that record. 9. The original ., will be maintained in the Advance Directives section of the medical chart and scanned into the Document's section of the electronic health record. 10. A Code Status binder will be maintained at each nurse's station. Copies of State of Florida DNR order Forms, documentation of verbal wishes of resident, and/or physician orders [REDACTED]. The binder will be checked and updated weekly by Social Services or their designee. Revision dates will be clearly designated in the bottom right hand corner of the list. 11. The Director of Nursing Services, Social Services Director or member of the nursing staff or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 12. The nurse or Nurse Supervisor should inform emergency medical personnel of a resident's advance directive when transfer from the facility via ambulance or other means is made. 13. Inquiries concerning advance directives should be referred to the Administrator, Director of Nursing services and/ or to the Social Service Director. SG Code Blue A review of the facility Standards and Guidelines: SG Code Blue, Policy Number 12.01.013, issued [DATE], revised on [DATE], the Standard: CPR will be provided to all residents who are found in cardio-Pulmonary arrest unless such resident has a DNR order written by physician on their medical records or shows signs of obvious clinical death as described by the American Heart Association. All licensed staff will be CPR certified biannually. Guidelines: 1. When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident's code status (see Determination of Code Status Policy). Confirm DNR status with the physician's written order, PCC code status section, and/or state approved canary yellow DNR order form. 2. In the event that the resident is identified as full code, the staff member finding the resident will Call for help stating Code Blue 3 times, including the unit, floor, and room number/area (i.e.