Every finding on record at North Park Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation.The facility failed to ensure food items were properly stored in the refrigerator.The facility failed to ensure products were labeled as to the contents of the container. The facility failed to ensure thorough cleaning of the inside of the freezer. These failures could place residents at risk of food-borne illnesses.Findings Included: Observations during the initial visit on 7/27/26 9:14AM revealed the following:Refrigerator:*1 pound pail of cream cheese icing with an unsealed lid and exposed to air.*2 cups of apple sauce in a container with an unsealed lid and exposed to air.*1 plastic container with what appeared to be sliced tomatoes unlabeled.*1 plastic bag of a yellow substance unlabeled, which appeared to be shredded cheese.*1 plastic bag of a brown substance unlabeled, which appeared to be meat product.*6 individual cups of orange-colored liquid unlabeled, which appeared to be orange juice.Freezer*1 brown paper bag unlabeled, unsealed after opening exposed to air, unable to identify the product.* Multiple colored substances spilt in the bottom of the freezer.Dry Storage:*8 plastic containers of unlabeled products, which appeared to be dry cereal.*1 plastic bag of bacon bits unsealed after opening exposed to air.*1 25-pound bag of unsealed flour after opening exposed to air.*1 plastic container of dry milk powder with an unsealed lid exposed to air.*1 10-pound bag of bowtie macaroni product unsealed after opening, exposed to air. On 7/29/26 at 10:39AM subsequent kitchen observation and interview revealed the spilled multiple-colored substances in the freezer remained. Interview with the Corporate Dietary Director she stated when food products were not sealed properly, they could cause cross-contamination and in turn cause residents to become ill. She stated that when the refrigerators and freezers were not kept free of spills and not cleaned, then cross-contamination could occur and in-turn caused residents to become ill. She stated staff had been in-serviced on cleaning, storage, labeling. She stated the staff would be in-serviced again. Interview on 7/29/26 10:44AM the Kitchen Supervisor stated if products are not labeled as to what they are then a resident may get something that is not good for them. Stated open containers can become contaminated with micro pathogens. She stated cleanliness is important because germs can get into food and residents can become ill. She stated the cleaning schedules are posted all around in the kitchen and pointed in multiple directions. Interview on 7/29/26 at 10:49AM with the [NAME] stated labeling was important because the product could be out of date and needs to know if the product is what the label states. The [NAME] stated cleaning is important so that bad bacteria does not grow. She stated open containers can cause contamination and cause residents to get sick Interview on 7/29/26 at 10:55AM with The Dietary Aide stated items need labels to know what the item is before serving it to the resident and know if it is out of date otherwise the resident could get sick. She stated cleaning is important to keep cross contamination away and needed to clean up any spills quickly. She stated she knows where the cleaning charts are located in the kitchen. She stated open packages can allow for contamination and for things get into the product. She stated she has been in-serviced. Interview on 7/29/26 at 1:30PM with Administrator revealed the dietary staff have been in-serviced recently. She stated changes in staff have occurred with the voluntary resignation of the Dining Director and beginning in-servicing again with the dietary department. The Administrator stated her expectations for the dietary department were to put into action the in-service knowledge they have. Record Review of the facility's policy Dietary Services Policy and Procedure Manual 2012, sub section Food Storage and Supplies stated the following:We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.Procedure:3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly.Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 (500 and 600 Halls) of 6 halls reviewed for environment. The facility failed to ensure the walls, floors, and bathrooms were in good repair for rooms 505, 507, 605, 607, 608, and 610. This failure places residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observation on 4/24/24 at 11:14 AM in room [ROOM NUMBER]A revealed there were multiple scratches in the paint on the walls alongside the bed. Observation on 4/24/24 at 11:16 AM in room [ROOM NUMBER] B revealed the walls alongside and behind his bed had large scrapes in the paint. The scrapes alongside hid bed formed an arc that appeared to have been caused when the head of his bed was raised and lowered. Observation on 4/25/24 at 11:35 AM in the bathroom shared by rooms [ROOM NUMBERS] revealed there was chipped paint along both the door trims. There was a large area beneath the sink approximately 2 feet in diameter with a thick white substance where, it appeared, repairs had been made. An Observation on 4/25/24 at 12:49 PM in the bathroom shared between rooms [ROOM NUMBERS] revealed the base of the door jamb leading to room [ROOM NUMBER] was completely rotted away along the bottom, approximately 3 inch section, exposing rotted wood and debris inside. The white paint above the rotted area was scraped and chipped exposing approximately 12 inches of wood beneath. The linoleum was separated and bubbling along that area. The linoleum extended up the walls inside the bathroom and was peeling away from the wall all along the back wall behind the toilet and the side wall leading to the door that connected the bathroom to room [ROOM NUMBER]. The linoleum was beige in color but had a large black/gray stain that extended from the left side of toilet to the left side wall of the bathroom. An Observation on 4/25/24 at 12:54 PM in the bathroom shared by rooms [ROOM NUMBERS] revealed the area surrounding the plumbing beneath the sink appeared as though a portion of the wall had been cut away then placed back leaving open holes and gaps in the wall. The area extending beneath the opening and the floor had, what appeared to be, a thick layer of uneven plaster covering the area from beneath the sink to the adjacent wall on the left side. The linoleum was bubbled up near the door jamb for room [ROOM NUMBER]. The door jamb on room [ROOM NUMBER]'s side of the bathroom had damaged areas in the wood at the bottom, scrapes and missing paint exposing the wood beneath. There was a hole in the door leading to room [ROOM NUMBER] that was approximately 2 inches by 3 inches along the edge of the door between the middle and bottom hinges . During an interview on 4/25/24 at 1:00 PM, LVN B, 600 Hall Charge Nurse, stated the facility used an app to report any maintenance issues found or maintenance complaints from the residents. She stated she had used the app to report issues such as light bulbs needing replacement or toilets not functioning. She stated she did not recall reporting any cosmetic issues using the app and had not thought to do so. She stated she had seen previously seen maintenance staff making rounds and doing touch up work and thought they monitored it. She stated she was not aware of the issues in resident's bathrooms. During an interview with the Administrator on 4/25/24 at 4:30 PM, she stated the facility utilized an app to report any issues related to maintenance that were found in the facility and all nursing staff were trained on it's use . A request was made for maintenance logs. In another interview with the Administrator on 4/26/25 at 7:40 AM, she stated daily rounds were conducted by management staff and all issues found were documented on work orders and they had plans in place. The Administrator stated the building was older one and they major projects going on at that time that required the maintenance staff's attention. In an interview on 4/26/24 at 9:48 AM, the DON stated he would expect the nursing staff to report any maintenance or environmental issues. He stated they could log into the maintenance and report anything. The DON stated the risk of having scratch and chipped paint, rotted wood, and rooms in disrepair were that it was not clean and could make the residents feel like no one cared about them. During an interview on 4/26/24 at 10:25 AM, LVN C, 500 Hall Charge Nurse, stated he was aware there were some maintenance issues in the facility as it was an old building. He stated they had an app and were able to enter any issues there and he felt like the maintenance department did a good job at addressing things like lights, bed issues, and plumbing problems very quickly. He stated he had not reported any cosmetic issues recently because he believed there were already work orders placed for them. He stated he frequently saw maintenance staff touching up paint and performing repairs. He stated risks included residents may not feel good about looking at it and the bathrooms could be unsanitary. During an interview and observations with the Maintenance Director on 4/26/24 at 11:23 AM, he explained he had only been at the facility a few weeks. He stated he had a list of items to address but had to start with the high priority items and they had had some major work done on the facility recently. The Maintenance Director stated they utilized an app so that staff could enter any issues they found which would generate a work order. He stated he and his assistant also entered any issues they found while working in the vicinity. When shown the walls in rooms [ROOM NUMBERS], he stated he was aware there were issues like this and they worked to touch-up paint whenever they could. He stated he had asked the CNAs to take care when moving the beds so they were not directly against the walls causing the scratches. When shown the issues in the bathroom shared by rooms [ROOM NUMBERS], the Maintenance Director stated it appeared some plumbing work was done and they still needed to complete the work on the walls. He stated wall repairs were challenging because there was usually sanding involved and that meant coordinating moving a resident from the area because of the dust generated and possible respiratory concerns. When shown the rotted wood and flooring concerns in the bathroom between rooms [ROOM NUMBERS], the Maintenance Director stated he had not previously seen the issues and did not recall being informed about it. The Maintenance Director stated the risks to residents may be concerned for their safety or feel embarrassment if having guests visit. In another interview with the Administrator on 4/26/24 at 2:05 PM, she stated she was aware of the concern areas found during the survey and stated they were working to correct all the issues. She stated they were handling larger life-safety issues first and had lots of items to address. She stated the risks for residents included overall safety from possibly tripping on flooring, hygiene, and cleanliness. She stated residents should feel they were in a comfortable homelike environment. Record review of facility maintenance logs dated 4/26/24 revealed the following entries: Entry dated 4/04/24 at 12:32 PM: Floor in bathroom is coming up. Notes: put floor threshold back, used floor adhesive to secure. Entry dated 4/25/24 at 5:21 PM: room [ROOM NUMBER]. Bathroom flooring needs to be replaced. Entry dated 4/25/24 at 5:16 PM: room [ROOM NUMBER]. Paint touch up needed in the room. Entry dated 4/25/24 at 5:16 PM: room [ROOM NUMBER]: A,B, and bathroom paint needs to be re-painted. Record review of the facility's undated policy titled, Resident Rights provided by the Administrator reflected the following: .Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. a. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior

Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected a resident's status for one of eighteen residents (Resident #4) reviewed for accuracy of assessments. The facility failed to ensure Resident #4's MDS Assessment accurately reflected their urinary status. This failure could place residents at risk of not having their needs identified and not receiving necessary care. Findings include: Review of Resident #4's Face Sheet, dated 04/26/24, reflected he was a [AGE] year-old male who initially admitted to the facility on [DATE]. Review of Resident #4's MDS Assessment, dated 03/08/24, reflected Resident #4 had diagnoses including parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and dysphagia (difficulty swallowing). The MDS Assessment reflected Resident #4 utilized an indwelling urinary catheter (a catheter that is left in the bladder and that collects urine by attaching to a drainage bag). Review of Resident #4's MDS Assessment (State Optional), dated 03/08/24, did not address whether or not Resident #4 utilized a urinary catheter. Review of Resident #4's Physician's Orders, dated 04/26/24, reflected Resident #4 previously had a urinary catheter that was discontinued on 01/12/21. Review of Resident #4's Care Plan, dated 02/23/24, reflected he had bladder incontinence. Identified goals included for Resident #4 to remain free from skin breakdown due to incontinence and the use of adult briefs. Interventions included staff cleaning Resident #4's peri-area with each incontinent episode. Observation of Resident #4 on 04/24/24 at 12:33PM revealed he was clean, well-groomed, and appropriately dressed. He was free from any odors. He displayed no obvious signs or symptoms of distress. Resident #4 was not observed to utilize a catheter. An interview with Resident #4 was attempted on 04/24/24 at 12:33PM; however, Resident #4 was unable to participate in an interview due to his cognitive status. During an interview with LVN E on 04/26/24 at 1:09PM, she stated she had worked at the facility for a couple of years and provided regular care for Resident #4. LVN E stated to her knowledge, Resident #4 had never utilized a urinary catheter. During an interview with the MDS Nurse G on 04/26/24 at 1:44PM, she stated Resident #4 did not utilize a urinary catheter. She stated there was a documentation error on the MDS Assessment that was completed on 03/08/24. MDS Nurse G said she thought she had rectified the documentation error when she completed an updated MDS Assessment (the State Optional assessment); however, it did not appear as though the error had been corrected. MDS Nurse G said the risk of inaccurate MDS Assessments included potential funding discrepancies and inaccurate quality measures. Review of the facility's Minimum Data Set (MDS) Policy for MDS Assessment Data Accuracy, dated 02/2021, reflected, .Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status .

Based on record review and interviews, the facility failed to complete an accurate PASARR evaluation on residents prior to admission and after admission for 1 of 7 residents reviewed for PASARR screenings (Resident #19). The facility did not correctly identify Resident #19 has having mental illness diagnoses and failed to correct his PASARR Level 1 screen to reflect the information. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Record review of resident #19's Admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] from another nursing facility. Record review of Resident #19's Admission MDS assessment dated [DATE] revealed he had moderately impaired cognition and active diagnoses including traumatic brain injury (brain damage caused by an outside force such as a blow to the head during an accident) , depression, bipolar disorder, and post-traumatic stress disorder (PTSD). Record review of Resident #19's Quarterly MDS assessment dated [DATE] also revealed he had moderately impaired cognition and active diagnoses including traumatic brain injury, depression, bipolar disorder, and post-traumatic stress disorder. Record review of resident #19's History and Physical dated 3/1/24 reflected his diagnoses included bipolar disorder, PTSD, and traumatic brain injury. Record review of Resident #19's PASRR Level 1 Screening dated 1/12/24 reflected he had no indicators for mental illness. An observation of Resident #19 on 4/24/24 at 11:10 AM revealed he was dressed and sleeping in his bed. He did not respond to a knock on his door. In another observation and interview on 4/25/24 at 11:54 AM revealed Resident #19 was lying in bed, he was dressed appeared disheveled. He denied complaints and stated he was sleepy because he had stayed up late watching movies. During an interview on 4/25/24 at 12:05 PM, LVN B stated Resident #19 refused care and showers at times. She stated the CNA's made attempts to talk him into care but they did not press him because he would become agitated. During an interview on 4/26/24 at 9:13 AM, MDS Nurse A stated she submitted PASARR forms for the facility. She stated she had received Resident #19's PASRR Level 1 Screening form from his transferring facility. She stated she did not recall noticing he had no indicators for Mental Illness on the form and should have verified it. During a follow-up interview with MDS Nurse A on 4/26/24 at 11:42 AM, she stated she had just submitted a correction form to the State. She stated the risk for inaccurate PASARR forms was a resident could miss out on potential services that may be available for them. During an interview with the Administrator on 4/26/24 at 2:05 PM, she stated she had been made aware of the inaccurate PASARR screen. The Administrator stated failing to have Level 2 screenings completed placed residents at risk for not being provided proper services. Record review of the facility's policy and procedure titled, PASRR Level 1 Screen Policy and Procedure, dated Revised 3/6/19 reflected: Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via [computer portal] timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible Procedure: 1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of admission or prior to admission. A PL1 is obtained for every individual, regardless of payment type, seeking admission to a Medicaid-certified NF. 2. The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1 Screening Form. 3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of Admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of the PL1 is correct (i.e. correct day, month and year) and review each item on the PL1 to ensure accuracy and prevent a regulatory problem

Based on observation, interview, and record review, the facility failed to ensure residents were free of accident hazards and received adequate supervision to prevent elopement for 1 of 6 residents (Resident #20) reviewed for accidents and hazards. The facility failed to ensure that after hours when there was not a front entry receptionist that the front door was secure before Resident #20 successfully eloped on 04/21/24 to the front patio. This failure placed residents at risk of elopements. The findings were: Record Review Resident #20 with admitted [DATE] care plan that was implemented on 03/07/24 reflected problem.Resident#20 is at risk for wandering., with interventions of Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise. Record review of elopement assessments for 02/01/24 through 04/25/24 revealed the following: - 02/20/24 revealed the resident scored a 7. - 03/06/24 revealed the resident scored a 21. - 04/22/24 revealed the resident scored a score of 24. An elopement assessment score of 10 or greater indicate the resident is considered an elopement risk. Record review of progress note dated 04/21/2024 at 10:06pm revealed, with resident diagnoses: Cognitive communication deficit, need for assistance with personal care, unspecified, vascular dementia, and unspecified severity, with agitation. Author: LVN F wrote, Resident found out of the facility propelling wheelchair herself, staff found her by the facility parking way. Resident on 15min check, RP notified, will continue monitoring. Record review of psychological assessment completed on 4/2/24 reveal the resident's history of present illness of declining cognition and wandering out of her RP's house while living with the RP in November and December of 2023. Record review of the BIMS (Brief Interview for Mental Status) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. BIMS was completed on 4/16/24 with a score of 7 indicating severe cognition impairment. BIMS revealed resident used a manual wheelchair for mobility. An observation on 04/24/24 at 10:00am revealed Resident #20 on 4/24/2024 on the secure unit sitting up in a recliner in her room, without a wander guard. Observations throughout the investigation 04/24/24 to 04/26/24 revealed a busy street the front entrance of the facility. Interview on 04/25/24 at 09:10 AM with LVN D indicated she had worked at the facility since 2017 but for the past 2 years was an as needed worker. LVN D was working on the 300hall/secure unit. LVN D showed surveyor each of the doors in the 300 hall/unit; there were a total of 3 doors and 2 gates. LVN D revealed she did not have the code to open the gates. LVN D was unable to identify which residents on the 300 hall/secure unit had the wander guards and was unfamiliar if there were a list. LVN D said there was no routine for checking the doors and locks. Nurses and aids interact with the residents ongoing throughout their shift along with routinely, no more than every 2 hours check on residents that are in their room. Interview on 04/26/24 at 09:43 AM Aide A that worked on the secure 300 hall/unit said one way to prevent residents for elopement risk was to watch the residents closely especially on 300 hall/secure unit. Interview on 4/25/24 at 10:00am with the Administrator clarified resident #20 was on the 500 hall when she eloped and after the elopement was moved with her RP's consent to the 300 hall/secure unit. The Administrator discussed which doors in the entire facility had the wander guard alarm, there were a total of 3. 1-the front door, 2-patio door where the resident's go to smoke, 2-door to laundry. The Administrator revealed the 2 gates on the 300hall/secure unit patio have a keypad but no alarms. The Administrator revealed the exterior door leading to the patio does not sound but had a keypad. The Administrator revealed resident#20 did not have a wander guard because she is on the 300hall/secure unit. Resident had wander guard when she was on the 500 hall. The Administrator revealed the staff on the 500 hall had completed personal care with the resident at 9:45/9:50pm on the night resident #20 eloped. Aides check on the residents at minimum every 2 hours, when they ring their call light and as needed. Interview on 4/25/24 at 10:30am with LVN C, who works on the 500 hall, on 4/25/24 at 10:25am who works on the 500 hall but did not work the night of the elopement on 4/21/24 at 1:52pm LVN C revealed resident#20 would wander/wheel around the facility, but he never saw resident #20 pushing on a door trying to leave. Supervision described as closely watching the residents and at minimum make compliance checks every 2 hours when the resident is in their room. During a telephone interview at 10:45am on 4/25/24 with Aide B stated she had moved her car from the back of the building to the front of the building. Aide B revealed she saw the patient sitting in her wheelchair out front of the facility alone. Aide B assisted the resident back into the building. Aide B reported another Aide was inside the building approaching the front door. Aide B reported the door alarm was not going off. Interview on 4/25/24 at 12:49pm RP acknowledged Resident #20 had a wander guard while on the 500 hall but did not have a wander guard now due to being on the secure 300 hall/unit. Interview 4/25/24 with Aide C said she was familiar with resident #20 stating she knew resident #20 wandered the halls but never saw her try to exit the building. Interview on 4/25/24 at 1:15am with DON said he would have to investigate why the nurse checked off on the Q15 (every 15 minute) minute check list if the LVN E nurse said the resident did not have a wander guard. 4/26/24 at 1:15pm I worked with the various nursing staff on each hall to test each resident's wander guard using the wand for the one resident that did not want to get out of bed. The other 4 were taken to the front door to test the wander guard. As each resident approached the front door a beeping sound began to go off. When staff put in the door code and opened the door as the resident was at the door a loud alarm went off requiring the nurse to put in the code to cancel the alarm. Interview on 04/26/24 at 10:04 AM LVN E last in-service on Abuse Neglect and Exploitation was weekly. Elopement training is often and last week was last time. She said ways to help prevent elopement are to keep completing 15min checks, know resident needs and habits, keep busy with activities, do rounds. Interview on 4/26/24 at 10:30am with Maintenance Specialist indicated there are 3 doors that trigger the wander guards- the front door, the door that leads to the smoking patio, and the door that leads to the laundry building. The door that leads to the smoking patio and the door that leads to the laundry building were tested by Maintenance Specialist using the wander guard pocket Tag reader device; both doors tested positive meaning the alarm sounded as it should if someone is going out of the door. Maintenance Specialist revealed doors are tested monthly and he keeps a log. If doors are not working properly the residents could get out of the building without staff knowing. The resident getting out without staff could be harmful if a resident falls, is out in extreme weather of rain, sleet, heat, or cold. If the resident may not be able to get back into the building if they get out without the alarm going off or if staff do not assist them outside. Record Review of facility's policy Elopement Prevention , dated January 2023, reflected the following: Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment 2. Identify the cause of wandering. 3. Intervention Strategies 4. Environmental Modification Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of elopement attempts. i. Examples of these devices: ii. Wanderguard System (locking or alarming) 1. Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record. 2. Function of the resident's device will be verified at least daily and documented on a treatment of other flow record. 3. Function of the alarm system will be verified each week and documented in a maintenance log. o Keypad exit magnetic locks. o Keyed Alarms o Secured Unit Fire exit doors on the secure unit will meet the following criteria: The lock must be electro-magnetic. The lock must release when any one of the following occurs: The fire alarm or sprinkler system are activated. Power failure to the facility Activation of a switch or button located at the monitoring station and the main nurse's station. o A keypad or buttons may be located at the control door for routine use by staff. o A manual fire pull must be located within five feet of each exit door with a sign stating, Pull to release door in an emergency. o Staff must be trained in the methods of releasing the door device. Or a combination of the above 2. All other exits not considered fire exits will be locked when not occupied by staff members. 3. All exit devices will be maintained by the manufacture's recommendations and function of each device will be verified weekly, and a log maintained.

Based on record review and interview, the facility failed to inform resident in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option for 1 (Resident #1) of 5 residents reviewed for resident rights in that: LVN A failed to obtain a signed consent prior to Resident #1 receiving psychoactive medication Sertraline HCl (a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) used to manage and treat the major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder) on admission. This failure could affect all residents receiving antidepressant medications potentially voiding their opportunity to make choices about their care. Findings include: Record review of Resident #1's face sheet dated 05/26/23 revealed a [AGE] year-old male admitted to the facility. His diagnoses included dementia with agitation, Alzheimer's, anxiety disorder, impulse disorder, and depression. Record Review of Resident #1's Quarterly MDS dated [DATE] indicated antidepressant medication to be prescribed by physician and revealed a BIMS score of 1 indicating the resident is severely impaired for cognition. Record Review of Resident #1's care plan dated 07/07/23 indicated antidepressant medication as prescribed by physician. The care plan reflected facility staff would educate the resident/family/caregivers about risks, benefits, and the side effects. Record review of Resident #1's Physician orders dated 05/27/23 revealed orders for: Sertraline HCl Oral Tablet 25 mg, Give 1 tablet by mouth in the morning related to depression. Record review of Resident #1's MAR revealed he received Sertraline HCl Oral Tablet 25 mg from 05/27/23 through 07/20/23. Review of Resident #1's EMR on 07/25/23 revealed no consent documented for Sertraline HCl. Record review of the facility copy of Resident #1's durable POA dated 04/20/23 reflected he had a designated RP to make health care decisions. In an interview on 07/26/23 at 11:06 AM, LVN A stated she admitted Resident #1 on 05/26/23. LVN A stated as admitting nurse she was responsible for obtaining Resident #1's consent for Sertraline HCl, however the DON also obtains consents and monitors nursing records. LVN A stated she knew residents' consents were to be documented in EMR. LVN A stated should a resident not be alert to provide consent she would contact RP receive their consent and document it in the residents' EMR. LVN A stated she forgot to obtain consent for Resident #1's Sertraline HCl. She stated she spoke with Resident #1's RP at admission about his psychotropic medications. She stated the RP was aware of Resident #1's psychotropic medications because he took them at his previous facility. LVN A stated the risk of not obtaining consent for medications should anything happen; the family could state they did not know or agree with the treatment. In an interview on 07/26/23 at 1:45 PM, the DON stated before administering psychotropic medications a consent should be obtained by an alert resident or RP. The DON stated LVN A should have received consent for Resident #1's Sertraline HCl from his RP. The DON stated LVN A should have entered the consent into Resident #1's EMR. The DON stated he entered consents into Resident #1's EMR for two other psychotropic medications. The DON reviewed Resident #1's EMR and stated there was no consent for Sertraline HCl, and it was his oversight. The DON stated he understood the risks of not obtaining consent for psychotropic medications as they could be considered restraints. The DON stated the consent indicates the reasons for the medication and discloses the side effects. The DON stated the facility should not administer a medication without the family being notified. The DON stated he reviewed all medications with Resident #1's RP. In a phone interview on 07/26/23 at 2:58 PM, the RP for Resident #1 stated the facility called twice to change Resident #1's psychotropic medication. The RP stated he was not sure what facility Resident #1 started Sertraline HCl but he knew Resident #1 had been taking the medication for at least one year. The RP stated he had provided consent for other psychotropic medications for Resident #1 but did not remember if he had provided consent for Sertraline HCL. Record review of the facility policy titled, Psychotropic Drugs, dated 10/25/17 reflected . Consent A psychotropic consent form explains the risks and benefits of psychotropic medication. The resident or their representative must provide document consent prior to administration of a newly ordered psychotropic medication. Consent for antipsychotics must be in a written form. Phone or verbal consent is not allowed. Permission given by or a request made by the resident and/or representative does not serve as a sole justification for the medication itself.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 4 residents reviewed for ADLs. The facility failed to ensure Resident#1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included Alzheimer's disease (the most common type of dementia), and dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), type 2 diabetes Miletus. Resident #1 required extensive assistance of one-person with personal hygiene. A record review of Resident #1's Comprehensive Care Plan, revised 06/08/23, reflected Focus: [Resident #1] has an ADL self-care performance deficit related to Confusion, Disease Process, impaired balance. Goal: Resident will improve current level of function in SPECIFY ADLs through the review date. Interventions: PERSONAL HYGIENE/ORAL CARE: The Resident is totally dependent on (1) staff for personal hygiene and oral care. An observation on 07/07/23 at 09:59 am revealed Resident #1 was laying in his bed. His nails on both hands were approximately 0.3 centimeter in length extending from the tip of his fingers. The nails underside had a dark brown colored residue. Resident #1 was confused and unable to answer questions. Interview on 07/07/2023 at 10:43 AM, CNA K stated residents' fingernails care was provided by CNAs during the resident's' shower days. For Resident#1 shower days were Monday's, Wednesday's, Friday's, and he was due for shower today in the afternoon. She further stated Resident#1 likes to eat food with his fingers. Interview on 07/07/2023 at 10:58 AM, LVN N stated residents' nails care was provided regularly by LVNs, and CNAs during resident's' shower days or on daily basis. LVN N acknowledged Resident #1's fingernails were sharp looking, and dirty. LVN N stated she would clean and trim Resident #1's fingernails. Interview on 07/07/2023 at 12:50 PM, the ADON stated Resident #1 was very confused, unable to verbalize or report his needs, unless he was hungry. The ADON stated nail care should be completed by CNAs, and nurses at least weekly on residents' shower days, and as needed. The ADON stated residents having long and dirty nails could be an infection control issue, and residents could get sick. Review of the facility's policy titled, Nail Care dated 2003, reflected, . Goals: 1. Nail care will be performed regularly and safely. 2. Resident will be free from infection. 3. Use a soft brush if necessary to cleans under and around the nails. 4. Remove debris from under the nails with an orange stick while soaking. 14. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (400 hall) of four halls reviewed for environment. The facility failed to ensure one dirty breakfast tray was removed from on top of a treatment cart. The facility failed to ensure thickened orange juice, applesauce, and pudding were covered while on top of a medication cart. These failure could place residents at risk of not having a sanitary environment. Findings included: An observation of the 400 hall on 07/07/23 at 10:20 AM revealed a dirty breakfast tray was left on the treatment cart. An observation of the 400 hall on 07/07/23 at 10:26 AM revealed a container of applesauce and pudding open and exposed to air on top of the medication cart. An observation of the 400 hall on 07/07/23 at 10:45 AM revealed a container of thickened orange juice open and exposed to air on top of the medication cart. An interview with CNA A on 07/07/23 at 11:32 AM revealed she helped remove dirty breakfast trays from residents' rooms on the 400 hall. She stated dirty breakfast trays were removed from residents rooms before lunch trays arrived. She stated dirty trays were supposed to be placed on the meal cart. She stated dirty breakfast trays were not supposed to be left on top of the treatment cart. She stated she did not know how long the dirty breakfast tray was left on top of the treatment cart. She stated there was one CNA to twenty-one residents on the 400 hall. She stated sometimes dirty breakfast trays were not placed in the appropriate area because she had other tasks to complete. She stated there were no infection control risks because the dirty breakfast tray was not returning to a resident's room. An interview with LVN B on 07/07/23 at 2:10 PM revealed any facility staff could remove dirty breakfast trays from residents' rooms on the 400 hall. She stated the dirty breakfast tray was supposed to be placed on the meal cart and returned to the kitchen. She stated the dirty breakfast tray was not supposed to be left on top of the treatment cart. She stated sometimes facility staff was distracted and placed dirty trays anywhere. She stated she did not notice the dirty breakfast tray on top of the treatment cart. She stated there was an infection control issue because the resident's germs from the dirty breakfast tray could spread to the treatment cart. She stated the containers of applesauce, pudding, and thickened orange juice on top of the medication cart was not supposed to be open and exposed to air. She stated the container of applesauce and pudding had been left open and exposed to air since the previous shift (10:00 PM - 6:00 AM). She stated she should have disposed of the container of applesauce and pudding at the beginning of her shift (6:00 AM) on 07/07/23. She stated she forgot to cover the thickened orange juice while passing medication. She stated she should have disposed of the container of applesauce, pudding, and thickened orange juice because of infection control issues. She stated residents were at risk of getting sick if the containers of applesauce, pudding, and thickened orange juice was consumed. An interview with the ADON on 07/07/23 at 12:29 PM revealed dirty breakfast trays were not supposed to be left on top of the treatment cart for infection control issues. She stated the dirty breakfast trays were supposed to be placed on the meal cart. She stated the residents were at risk of cross contamination because the dirty breakfast tray was left on top of the treatment cart. She stated the containers of applesauce, pudding, and thickened orange juice were not supposed to be open and exposed to air on top of the medication cart. She stated applesauce, pudding, and thickened orange juice was used with crushed medications during medication pass. She stated she was unaware the containers of applesauce and pudding were left on the medication cart from the previous shift (10:00 PM - 6:00 AM). She stated the containers of applesauce and pudding were removed from the top of the medication cart. She stated the residents were at risk of becoming sick if consumed. Review of facility policy, Infection Control Plan: Overview, dated 2019, reflected: The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #10 and #46) reviewed for transfers. The facility failed to ensure Resident #10 and #46 were transferred appropriately per the resident's plan of care. This failure could place residents at risk of not receiving adequate supervision and assistive devices to prevent injury. Findings included: Review of Resident #10's face sheet dated 2/15/23 reflected he was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Admitting diagnoses included depressive disorder, pain, stiffness of unspecified knee, weakness, muscle weakness and atrophy, contracture of left knee, abnormal posture, and aged related osteoporosis without current pathological fracture. Review of the Quarterly MDS (Minimum Data Set) assessment, dated 12/23/22 reflected Resident #10 had severe cognitive impairment, he required extensive assistance with transfers and had functional limitation in range of motion to bilateral lower extremities. Review of the comprehensive care plan, revised 4/13/22, reflected Resident #10 had an activities of daily living self-care performance deficit related to cerebrovascular disease. Intervention was for the resident to be transferred by a mechanical lift with two staff assistance. Observation on 2/14/23 at 11:33 AM, revealed LVN A and the restorative aide transferring Resident #10 from the bed to the wheelchair. Both staff positioned the resident on the side of the bed and each staff placed their hands underneath the resident's shoulder and picked the resident from the bed to the chair. The restorative aide had a gait belt around her waist. In an interview on 2/14/23 at 1:30 PM, LVN A stated when transferring the resident alone the staff was supposed to use the gait belt but when transferring a resident with two staff, they did not need a gait belt. LVN A stated they could transfer the resident lifting the resident by the pants. LVN A changed his statement and stated they needed a gait belt to transfer the resident. LVN A stated they were supposed to use the gait belt to prevent harming the resident or causing a shoulder dislocation. LVN A also stated the staff were supposed to use the required transfer per the plan of care. In an interview on 2/15/23 on 1:50 PM, the restorative aide she stated she assisted in the therapy department and assisted with transfers in the facility. She also stated she trained the aides on the proper ways transfer with Hoyer lift, use of gait belt, and sit to stand transfers. The restorative aide stated the staff were to use the gait belt on the resident, but she had a large gait belt, and the small gait belt was in the gym area, and it was far, and the resident was ready to be transferred. The Restorative aide stated the staff were to use the required transfer per the plan of care. She stated the staff were to use the gait belt for every transfer to prevent resident harm or shoulder dislocation. Review of Resident #46's face sheet dated 2/15/23 reflected the resident was admitted on [DATE]. Her admitting diagnoses included dementia, history of falling, major depression and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] reflected Resident #46 was severely impaired with cognitive skills for daily decision making, needed extensive assistance with transfer, and during transitions and walking she was not steady, only able to stabilize with staff assistance. Review of Resident #46's care plan revised 8/23/21 reflected the resident had activities of daily living deficit related to dementia. Intervention on transfer reflected the resident required extensive assistance of one staff for transferring. Observation on 2/14/23 at 1:10 PM revealed CNA B and ADON C transferring Resident #46 from the wheelchair to bed. Both staff gloved and ADON C was behind the resident holding the wheelchair and CNA B was in front of Resident #46 and placed her hands underneath the resident ' s arms and picked the resident from the wheelchair to the bed. Then they both assisted the resident to reposition in bed. In an interview on 2/14/23 at 1:22 PM with CNA B said Resident #46 required one staff for transfer and that was why she transferred her by herself. When asked if she was supposed to use any assistive device to transfer the resident, she stated she was supposed to use the gait belt to transfer the resident, but she did not have one with her, but she was able to access the gait belt. CNA B stated she was supposed to use a gait belt to prevent harming the resident or the resident falling. CNA B stated she had been in-serviced on transfers using the gait belt. In an interview on 2/14/23 at 1:34 PM, ADON C stated she asked CNA B to get the gait belt, but CNA B did not, surveyor was in the room and never heard ADON C telling CNA B to go get the gait belt. ADON C stated she could have stopped CNA B from transferring the resident until she had the gait belt for the transfer. ADON C stated transfer was to be completed with a gait belt to prevent resident injury from shoulder dislocation or fall. In an interview on 2/15/23 at 10:47 AM with the DON he stated the facility had completed in-service on transfer upon hire, yearly and when the facility had incident of fall. The DON stated the facility completed transfer Inservice in January and on 2/14/23 after it was reported on the improper transfers. The DON stated the residents were supposed to be transferred per each resident's plan of care. The DON stated the staff were not supposed to pick the residents underneath their arms because it could cause injury like shoulder dislocation. The DON stated he was responsible to make sure the transfers were, completed properly and most of the time he would randomly observe the staff transferring the residents. Provided the transfer in-services completed on 2/14/22 and they were reviewed. Review of the facility policy dated 2003 and titled Moving a Resident, bed to chair/chair to bed reflected, .The purpose is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident 9. If moving a resident from bed to chair; .h. Position a gait belt around the resident ' s waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the resident, but not so tight that you cannot firmly grasp the belt without making the patient comfortable.10. If moving a resident from chair to bed. e. Position a gait belt around the resident ' s waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the resident, but not so tight that you cannot firmly grasp the belt without making the patient comfortable.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's freezer on 02/13/23 at 9:50 AM revealed: - 1 cup of orange sherbet open and exposed to air; - 1 box of double chocolate cookie dough open and exposed to air; and - 1 box of frozen pie dough sheets. Observation of the facility's dry storage on 02/13/23 at 9:54 AM revealed: -1 bag of long grain parboiled rice open and exposed to air; and - 1 bag of large lima beans open and exposed to air. Observation of the facility's freezer located in the dining room on 02/13/23 at 9:58 AM revealed: - 1 box of swai fillets open and exposed to air. In an interview with the Dietary Manager on 02/15/23 at 3:15 PM, revealed he checked the freezers and dry storage Monday through Friday. He stated the weekend dietary staff were responsible for checking the freezers and dry storage on the weekends. He stated he did not know why items in the freezers and dry storage were unsealed. He stated improper food storage could cause residents to get sick. Review of the facility policy titled Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #38) of four residents reviewed for resident rights. The facility failed to place a privacy bag over Resident #38's catheter bag while he was outside of his room. This failure could place residents at risk for decreased dignity and privacy. Findings included: Review of Resident #38's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 08/25/21. His diagnoses included: heart failure, hypertension, peripheral vascular disease, obstructive uropathy, anxiety disorder, and chronic obstructive pulmonary disease. He was understood, understood others, and had clear speech. His BIMS score (15) revealed he was cognitively intact. There was no evidence of delirium or psychotic behaviors. He had an indwelling catheter. Review of Resident #38's physician orders dated 02/25/23 reflected, Foley catheter #18/10 to straight drainage due to obstructive uropathy. Catheter care every shift. Catheter tubing to be free of kinks and properly secured to prevent trauma and assure proper function. Cover drainage bag with privacy cover. Measure output and observe for signs and symptoms of infection every shift. In an observation and interview with Resident #38 on 02/14/23 at 3:54 PM revealed his catheter bag was hooked with a clip to the arm of his wheelchair without a privacy cover. Resident #38 was in the hall with his catheter bag visible to others. He stated he wanted a privacy cover for his catheter bag. He stated he was once provided a privacy bag but did not recall how long ago. He stated a privacy cover would prevent others from seeing his catheter bag. He stated his dignity was affected without a privacy cover on his catheter bag. Interview with LVN D on 02/14/23 at 4:00 PM revealed Resident #38 did not have a privacy cover for his catheter bag. She stated the facility did not have any privacy covers. She stated management was informed about the need to order more privacy covers for catheter bags. She stated the purpose of privacy bags was to conceal a resident's catheter bag. She stated residents did not want their urine visible to others. She stated privacy bags were to be used when a resident was outside of their room. She stated Resident #38's dignity could be affected due to not having a privacy cover for his catheter bag. Interview with the DON on 02/15/23 at 12:45 PM revealed Resident #38 was supposed to have a privacy cover on his catheter bag while outside of his room. He stated his expectation was for all staff to ensure residents had a privacy cover on their catheter bags while outside of his room. He stated the facility was not out of privacy bags. He stated Resident #38's dignity was affected by not having a privacy cover on his catheter bag. Interview with the Administrator on 02/15/23 revealed the facility did not have a policy regarding privacy covers for catheter bags.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #66) of four residents observed for indwelling urinary catheters. The facility failed ensure Resident #66's drainage urine bag was below his bladder to prevent urine from flowing back into the bladder. These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #66's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 11/22/22. His diagnoses included: hypertension, neurogenic bladder, obstructive uropathy, diabetes mellitus, hyperlipidemia, cerebrovascular accident, Non-Alzheimer's Dementia, seizure disorder, malnutrition, depression, and dysphagia. He was usually understood, usually understood others, and had unclear speech. His BIMS score (6) revealed he was severely cognitively impaired. There was no evidence of delirium or psychotic behaviors. He had an indwelling catheter. Review of Resident #66's Care Plan, undated, revealed he had an indwelling catheter due to neurogenic bladder. His goals were to show no signs and symptoms of urinary infection through review date. He was to also be/remain free from catheter related trauma through review date. His interventions were to have a 16fr and 10cc foley catheter. His catheter bag and tubing were to be positioned below the bladder level. In an observation and interview with Resident #66 on 02/14/23 at 3:14 PM, revealed his catheter bag was lying beside him in bed. His catheter bag contained an output of 350 ml of urine. His catheter tubing appeared to be cloudy. His urine appeared to be amber colored. Resident #66 did not respond to questions regarding his catheter bag. Interview with LVN D on 02/14/23 at 3:20 PM, revealed she did not know why Resident #66 had his catheter bag laying beside him in bed. She stated his catheter bag was supposed to be clipped to the bed and hung below his bladder. She stated the catheter bag was supposed to be hung below the bladder to prevent urine from flowing back to the bladder. She stated Resident #66 could be at risk of an infection due to the catheter bag not being hung below his bladder. Interview with CNA E on 02/15/23 at 1:40 PM revealed Resident #66's catheter bag was not supposed to be laying beside him in bed. She stated his catheter bag was supposed to be hung on the side of his bed and below his bladder. She stated she provided care to Resident #66 and forgot to replace his catheter bag. She stated he was at risk for bladder issues due to his catheter bag not being hung below the bladder for easy flow of urine. Interview with the DON on 02/15/23 at 12:57 PM revealed all resident catheter bags were to be kept below their bladder. He stated nursing staff were responsible for ensuring Resident #66's catheter bag was hung below his bladder. He stated Resident #66's catheter bag was not supposed to be lying next to him in bed. He stated he was at risk of an infection due to urine going back up the tube. Review of the facility policy titled, Catheter Care, dated 02/13/07, revealed The bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for one (Resident #9) of six residents reviewed for medication storage. The facility failed to ensure Resident #9 did not have prescription pills and unsecured medication in his room on 02/13/23. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Review of Resident #9's MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 07/06/22. His diagnosis included: hypotension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, Dementia, hemiplegia, seizure disorder, and depression. He was understood, understood others, and had clear speech. His BIMS score (8) revealed he had moderate cognitive impairment. There was no evidence of delirium or psychotic behaviors. Review of Resident #9's physician orders dated 02/15/23 reflected the following medications: - Allopurinol tablet 300 mg give 1 tablet by mouth in the morning for inflammation. - Apixaban tablet 2.5 mg give 1 tablet by mouth two times a day for anticoagulant related to unspecified atrial fibrillation - Calcium 600+D tablet 600-400 mg unit give 1 tablet by mouth in the morning for supplements - FerrouSul tablet 325 mg give 1 tablet by mouth in the morning for supplement. - Levetiracetam tablet 500 mg give 1 tablet by mouth two times a day related to unspecified convulsions - Metformin HCl tablet 500 mg give 1 tablet by mouth two times a day related to type 2 diabetes mellitus without complications There were no physician orders for Ascorbic acid tablet 500 mg or Zinc tablet 50 mg. Review of Resident #9's MAR dated 01/01/23 to 01/31/23 reflected the resident was given the following medication by LVN F: - Allopurinol tablet 300 mg scheduled for 7:00 AM - Ascorbic acid tablet 500 mg scheduled for 8:00 AM - Calcium 600+D tablet 600-400 mg scheduled for 7:00 AM - FerrouSul tablet 325 mg scheduled for 7:00 AM - Zinc tablet 50 mg scheduled for 8:00 AM - Apixaban tablet 2.5 mg scheduled for 7:00 AM - Levetiracetam tablet 500 mg scheduled for 7:00 AM - Metformin HCl tablet 500 mg scheduled for 7:00 AM In an observation on 02/13/23 between 10:58 AM and 11:15 AM revealed there were 6 different pills in a plastic medication cup on Resident #9's beside table. Resident #9 was observed sleeping in his bed. In an interview with Resident #9 on 02/13/23 at 11:32 AM revealed he had taken his medication that was left on his bedside table. He stated he did not want to answer any more questions and wanted to be left alone. Interview with LVN F on 02/13/23 at 12:19 PM revealed she left Resident #9's morning medications on his bedside table and left the room to take other residents' vitals. She stated she later returned to his room and supervised him taking his medications. She stated she was never supposed to leave his medications unsupervised on his bedside table. She stated Resident #9 was not supposed to self-administer his own medication. She stated she did not know what medications she administered to him but could check his MAR. She stated Resident #9 was at risk of not taking his medications or some else could have come in his room and taken his medication. Interview with the DON on 02/15/23 at 1:00 PM, revealed Resident #9's medications were not to be left on his bedside table. He stated LVN F was supposed to administer medications and supervise Resident #9. He stated Resident #9 was at risk of not taking medication or another resident could have gone into his room and taken the medications. Interview with Administrator on 02/15/23 revealed the facility did not provide a policy regarding medication storage.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of six residents observed for infection control in that: 1. CNA B failed to perform hand hygiene during incontinent care for Resident #2. Findings included: 1. Review of Resident #2's Face Sheet 2/15/23 reflected a [AGE] year-old male with an admitted [DATE]. Primary diagnoses included anxiety, lack of coordination, bipolar and muscle wasting and atrophy. Review of Resident #2's Care Plan revised 11/11/19 reflected, . [Resident #2] has an ADL self-care performance deficit r/t Bipolar Disorder .Interventions .Toilet use .requires up to limited assist x 1 staff for toileting. Observation on 2/14/23 at 12: 45 PM revealed CNA B providing incontinent care to Resident #2. CNA B gloved, Resident #2 was resting in bed and CNA B informed the resident she was going to provide him with incontinent care. CNA B gloved and took off the resident's dirty brief, the resident was moderately soiled with urine. CNA B cleaned the resident with wipes, after cleaning the resident she proceeded to applying the resident's clean brief without any form of hand hygiene. With the same dirty gloves CNA B assisted the resident to put on his pants. When CNA B was done assisting the resident, she got the trash and left the room without any form of hand hygiene. In an interview on 02/14/23 at 1:22 PM with CNA B she said she realized she did not change the gloves between care. CNA B stated she was supposed to change gloves after taking the resident's dirty brief off. Asked about completing hand hygiene she stated she was supposed to wash hands after cleaning the resident to prevent the spread of infections. She stated she had been in-serviced on infection control a few weeks ago In an interview on 02/15/23 at 10:54 AM with the DON he said when providing incontinent care the staff was supposed to complete hand hygiene before, in between care after the staff was done cleaning the resident and before applying the clean brief and after completing the resident care. The DON stated the staff was supposed to complete hand hygiene during incontinent care to prevent the spread of infection. The DON stated the facility completed in-service on infection control in January. Review of the facility policy, not dated and titled Fundamentals of Infection Control Precautions, reflected, .Hand Hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .When hands are visibly soiled (hand washing with soap and water); Before and after the resident direct contact (for which hand hygiene is indicated by acceptable professional practice)

Based on interview and record review the facility failed to ensure that one (Resident #29) of three residents reviewed for urinary catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to ensure Resident #29 had a foley catheter inserted as ordered by the physician. This failure could place residents at risk for infection and not receiving services as needed. The findings were: Record review of Resident #29' s face sheet dated 11/21/22, revealed an 83- year-old female admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included pneumonia, Atrial fibrillation, and Pressure Ulcer of the Sacral region. Review of Resident #29's MDS dated [DATE] revealed the resident had one stage 4 pressure ulcer. The pressure ulcer was present before admission. The resident had a BIMS, indicating she was unable to complete the assessment. The resident was incontinent of bladder. Record review of Resident #29's care plan dated 10/04/22 revealed she had a stage 4 pressure ulcer to the sacral. The facility would ensure Resident #29's pressure ulcer would show signs of healing and remain free of infection. The facility would follow the physicians order and administered medication as ordered. The resident had issues with communication. Resident #29's care plan revealed she was bladder incontinence, the facility would monitor for signs and symptoms of an UTI(urinary Tract Infection) and pain. Record review of Resident # 29's Order Summary Report dated 11/21/22 revealed Insert: Indwelling urinary Catheter (16FR/5-10cc balloon size) due to stage 4 pressure ulcer to sacral with closed drainage system, every shift for wound care. The start date of the order was 10/10/22. Review of Resident #29's progress notes for the following dated revealed the following: 10/10/22 at 11:02: Resident #29's seen by the wound doctor for the sacral area. Continue with current treatment. Wound care doctor spoke with Resident #29's family member. Also, an order received to insert foley catheter for wound healing. Completed by LVN B 10/10/22 at 11:26 pm: This nurse was unsuccessful in inserting a foley catheter, incoming nurse notified. Completed by LVN C 10/11/22 at 02:44 am and 02:45 am: foley not inserted at this time. Supplies not on hand at this time. Completed by LVN D 10/12/22 at 03:24 am: No foley at this time yet, supplies not available. Completed by LVN D 10/13/22 at 12:10 am , no catheter at this time. 10/13/22 10:18: Resident # 29 was transferred to a hospital related to lethargic and low oxygen. Record review of the progress notes for Resident #29 from 10/10/22 to 10/13/22 revealed no evidence the physician had been notified the Catheter had not been inserted as order by the physician. Review of the Treatment Administration Record for Resident #29 for October 2022 revealed LVN C had marked on 10/10/22, 10/11/22 and 10/12/22 the catheter had been inserted. An interview with RN B on 11/21/22 at 1:29 pm revealed she was the wound care nurse. She completed wound care rounds with the physician and received the order for the foley catheter to be inserted for Resident #29. LVN C was instructed to insert the catheter. She stated the catheter for Resident #29 had not been inserted before she discharged from the facility. An interview with LVN C on 11/21/22 at 2:09 pm revealed he documented the catheter had been inserted on 10/10/22, 10/11/22 and 10/12/22 on the resident Treatment Administration Record . He documented the catheter was inserted by mistake, he misread the order. He stated the catheter had not been inserted because the supplies the facility had, did not fit the requirement for the resident. He documented on the progress notes correctly that the catheter had not inserted. He did not contact the physician to inform the physician he had not inserted the catheter. An interview with the DON on 11/21/22 at 2:31 pm revealed Resident #29 had an order for insertion of a catheter. The DON stated the facility did not have the proper catheter to fit Resident #29. Once the correct supplies were obtained on 10/13/22 the resident had discharged to the hospital. He stated the nurse should have contacted the physician once the catheter was not inserted as ordered. An interview with the Physician on 11/21/22 at 2:43 pm revealed she did not recall being notified the catheter was not inserted as ordered for Resident #29. She stated the resident was sent to the hospital unrelated to catheter insertion. Review of the facility;s Physician Orders policy dated 2015, the facility would ensure the accuracy and completeness of the medication orders and treatment orders.

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 (Resident #36) of 5 residents reviewed for storage of medications. RN A failed to ensure Resident #36 took his medications which resulted in unlabeled medication at his bedside. This failure could place residents at risk for health complications. Findings included: Review of Resident #36's Face Sheet, dated 12/07/21, revealed he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis (scaring of the lungs), chronic obstructive pulmonary disease ([CONDITION(S)]), [CONDITION(S)] (A-Fib-Congestive Heart Failure), urinary tract infection, gastro-[CONDITION(S)] reflux disease (Acid Reflux), and hypertension (High Blood Pressure). Review of Resident #36's MDS dated , 10/21/21, indicated Resident #36 was cognitively intact and required limited assistance with bed mobility and assistance with transfers, eating, toileting, and personal hygiene. Review of Resident #36's Physician Orders dated 10/15/21, on 12/07/21, revealed Resident #36 was ordered: Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth in the morning for Heart health.; [MEDICATION(S)] Tablet 25 MG . Give 1 tablet by mouth in the morning for [CONDITION(S)] ; [MEDICATION(S)] Sodium Tablet 100 MG Give 1 tablet by mouth one time a day for constipation.; Folic Acid Tablet 1 MG Give 1 tablet by mouth in the morning for Supplement.; [MEDICATION(S)] Tablet 5 MG . Give 1 tablet by mouth in the morning for [CONDITION(S)] ; [MEDICATION(S)]-M Tablet . Give 1 tablet by mouth in the morning for Supplement.; [MEDICATION(S)] Tablet 100 MG Give 1 tablet by mouth in the morning for Supplement.; and [MEDICATION(S)] HCL Tablet 50 MG Give 1 tablet by mouth two times a day for [CONDITION(S)] related to Essential . Hypertension During an observation and interview on 12/06/21 at 9:26 AM with Resident #36 revealed several pills of medication in a cup on the table next to Resident #36. Resident #36 was observed picking up the cup and taking the medications and drinking a cup of water without the nurse being present in the room. Resident #36 stated normally the nurse stood next to him when he was taking his medication but today, he wanted to take his medication with his breakfast, so he asked the nurse to leave it. He stated this was the first time the nurse had left the medication for him to take alone. He stated he had the medication for about 15 minutes before taking it. During an interview on 12/06/21 at 2:24 PM with RN A revealed when he went into the room of Resident #36, the resident had told him he would take his medication after breakfast. RN A stated he went back to the room and observed Resident #36 taking his medication. RN A stated he did not observe anyone else around when he observed Resident #36 take his medication. After being informed there was no nurse present in the room when Resident #36 took his medications RN A stated he was mistaking Resident #36 with someone else. RN A stated he was not present when Resident #36 took his medication. RN A stated he did not normally leave medication with Resident #36 but last time Resident #36 got annoyed when he did not leave the medication. RN A stated this was the first time he had left Resident #36's medication for him to take alone. RN A stated a risk of Resident #36 taking his medication alone may cause his blood pressure to go to high if he did not take the medication. RN A stated the policy on administering medication was to know the medication, the strength of the medication and know the time the medication must be given. RN A stated medication could be given one hour before or one hour after it was prescribed to be given. RN A stated the time the medication was given should be documented. RN A stated documenting the time the medication was given was important to ensure the medication was not given to close to the next dose of medication. When RN A was asked how he can be sure the patient took the medication, he stated, I cannot be sure; the resident can lie. RN A stated it was not safe for a resident to be given medications and not be supervised to take them. RN A stated the facility policy was to make sure the resident was supervised when taking medications. RN A stated he did not know the last in-service he had on medication administration. RN A stated he made a mistake by leaving Resident #36's medications with him to take unsupervised. During an interview on 12/07/21 at 9:11 AM with the DON revealed it is not the policy for a nurse to leave medication with the resident to take it without supervision. He stated RN A should have taken the medication out of the room with him if Resident #36 did not want to take the medication at the prescribed time. He stated RN A should not have allowed Resident #36 to decide the medications should be left for him to take unsupervised. He stated the risk of Resident #36 having access to his own medication is that he could have a bad reaction to the medication while the nurse was not in the room. He stated Resident #36 could have also dumped the medication in the trash and not taken it at all. He stated if Resident #36 did not take the medication at the appropriate time it could have a negative interaction with other prescribed medications that the patient is scheduled to take later. Record review revealed a certificate of successful completion of Medication Management & You (Licensed Nurses), dated 5/25/21, for RN A. Record review revealed a certificate of successful completion of Omniview-Medications Pass Fundamentals Part 1, dated 5/28/21, for RN A. The facility policy, revised 01/01/13, titled 6.0 General Dose Preparation and Medication Administration reflected, Procedure . 5. During medication administration . 5.9 Observe the resident's consumption of the medication(s).

Tag: F550 S/S D Surveyor Name(s): [NAME] Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement or his or her quality of life for one (Resident #62) resident who was reviewed for dignity. The facility did not ensure staff treated Resident #62 with courtesy and respect, based on the following: 1) How staff spoke to resident #62 regarding her breathing concerns related to oxygen tank setting levels; 2) In completing a grievance form that did not express resident's issues from the resident's point of view and in resident #62's own wording. This failure could place residents at risk for loss of dignity and self-worth. Findings included: Record Review of the face sheet from 12/07/21 at 10:25:16 CT for Resident #62 revealed she is a [AGE] year-old female with an admitted [DATE]. Her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Dependence of supplemental oxygen noted 08/08/2019 on admission. The MDS (Minimum Data Set) version 3.0, dated 11/17/21 included the following sections, which pertained to the MDS for resident #62: Section C Cognitive Impairment, revealed that the Brief Interview for Mental Status (BIMS) score was 12 (range 00-15 for score). A BIMS score of 12 indicates mild cognitive impairment, such as in memory or judgment). The MDS, Section B, Hearing, Speech, and Vision indicates that resident is able to make herself understood, is able to express ideas and wants with both verbal and non-verbal expressions and is able to understand others. For the MDS Section G, Functional Status, Activities of Daily Living (ADLs), resident #62 transfers to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) with limited assistance. MDS Section G, functional status, GO400 reveals mobility devices used include a walker and a wheelchair. Health Conditions, Section J of the MDS indicates shortness of breath or trouble breathing when lying flat. Section O, Special Treatments, Procedures and Programs of the MDS indicates that resident receives oxygen therapy. Record Review of Resident #62's Care Plan, dated 11/29/2021, revealed, Focus: [Resident #62] has a behavior problem-noncompliance with oxygen as ordered and is manipulative. Goal revealed, [Resident #62] will have fewer episodes of non-oxygen use by review. Interventions Tasks revealed, Allow choices within individual's decision-making abilities date initiated: 08/21/2019. Anticipate and meet the resident's needs. 08/25/21. Interventions/tasks revealed, Check oxygen saturations each (q) shift, frequently, date initiated 08/23/2019). Educate the resident/family/caregivers on successful coping and interaction. The resident needs encouragement and active support by family/caregivers when the resident uses these strategies, per social worker, date initiated 08/21/2019. Per nursing, Encourage pursed lip breathing and sitting 90 degrees when having shortness of breath, date initiated 08/23/2019. Observed resident #62 discussion with surveyor nurse regarding turning up level of oxygen tank because she needs the oxygen to breathe. Nurse RN B was asked to come into room to speak with the nurse surveyor. Resident #62 shook her head and appeared flustered when RN B stated, She (Resident #62) always turns it down (referencing the oxygen tank setting). It's fine. and RN B also said in front of the resident, She changes her settings., (settings is referring to the number of 0-10 on the oxygen tank). Observed that resident had a 3-liter oxygen tank on back of her wheel chair with tubing as well as a 2 liter oxygen tank at bedside. An interview on 12/06/21 at 9:44 AM with Resident #33 revealed he noticed that Resident #62 needed more oxygen and that Resident #62 used two oxygen tanks. One tank was portable for use whenever resident #62 leaves the room. Resident #33 stated he sees resident #62 daily or almost daily and they are friends. Resident #33 stated Resident #62 had used one of the oxygen tanks, looked down, and she had 0 oxygen left on one of her tanks on Saturday, 12/04/21. Resident #33 stated Resident #62 went out of the hall to tell the aide (aide's identify unknown) she needed another oxygen tank, and stated the aide told her she was not going to give her one; that she had already been through 2 tanks (as of Saturday this past week. In a group meeting of 7 residents on 12/06/21 at 10:11 AM, Resident #33 stated Resident #62 ran out of oxygen. Resident #33 explained that Resident #62 told him that she was grabbed by the arm and was told she had been through too many oxygen tanks on 12/04/21 which occurred at 9:30 AM or 10:00 AM. Resident #33 stated he did not know the name of the staff on duty, but RN A was the male nurse on the hall who helped resident #62 He stated RN B was the nurse who was rude to the resident on 12/04/21. Resident #33 stated Resident #62 went to get the other tank and the aide did not want to give it to her. He stated Resident #62 told the staff she had left the tank on by accident, was chastised by the aide, was told she used too much oxygen and told to go find her nurse. He stated Resident #62 went to another room looking for the nurse (nurse's name unknown). Resident #33 stated he heard shouting and they (Resident #33 and Resident #62) went to the oxygen tanks and Resident #33 was told he needed to stay 10-15 feet away. He stated the nurse (nurse's name unknown) and Resident #62 went to get the oxygen tank and Resident #62 said her right arm was grabbed and it did hurt. He stated he (Resident #33) looked at Resident #62's arm and did not see any bruises at the time. Resident #48 stated that this was not the first time Resident #62 had an issue with her oxygen running out. Interview on 12/07/21 at 2:10 PM with the Director of Nursing revealed Resident #33 called the cops Saturday (12/11/21) because he was not happy with the situation regarding Resident #62's oxygen. The DON stated Resident #33 was hypervigilant and he has been accusatory in the past. When the DON was asked if it was a common problem that resident #62 was using up her oxygen too fast and changing or messing with the settings, the DON replied not that he knew of-she (resident #62) left on her oxygen, and it ran out. The DON added that education provided to resident #62 Saturday night was about oxygen use, not turning it on high. When the DON was asked what was resident #62's response when you talk to her about turning the oxygen on high, the DON said she may not hear it, but she says she feels it and she doesn't look at the setting. RN B was the weekend supervisor and unit coordinator RN. When the DON was asked if someone said they had trouble breathing or needed oxygen, would it be a priority for you, the DON responded that if a resident expects oxygen, it's a priority and that the expectation would be to check vital signs if waiting on oxygen. Surveyor related to the DON is that the perception of resident #62 is that the nurse argued with her, told her she did not need the oxygen, scolded her for using too much oxygen, and it led to feelings of anxiety. The DON relayed that the resident wanted her oxygen turned up, that initially resident #62 was not given an oxygen tank and resident #62 was told she would have to wait because the nurse did not have the key. When the DON was asked how long resident #62 had to wait for a key, the DON stated it must have brief-she gets anxiety. When the DON was asked what was resident #62's demeanor when she requested the oxygen tank and did not get it, the DON responded that she was upset because everything takes too long. Record Review of 12/07/21 at 4:30 PM from electronic health record revealed order for Oxygen at 2_L/min via nasal Cannula (tubing that carries oxygen through the nose) every shift for [CONDITION(S)] phone active order of 09/03/2020. Record Review on 12/07/21 at 4:30 PM from electronic health record revealed progress note documented by RN B dated 12/15/21 at 8:52 AM as follows: Resident is still an active smoker. Non-compliant with safety measures. Resident always complains of shortness of breath after smoking. Resident has tendency of increasing flow rate to 10 liters without consulting with nurse; she is supposed to be on 2 liters. Patient constantly education on the dangers of increasing flow rate. She verbalizes understanding but is still non-compliant. Interview with Resident #62 on 12/07/21 at 2:59 PM revealed, when asked the main reason she turned the oxygen up, Resident #62 replied it was because she was out of oxygen; she was trying to get the oxygen to come out. When asked, Do you feel the need to turn it up, how did you feel and did you feel short of breath, Resident #62 responded, Yes, and that she felt dizzy. When asked if the nurses checked on her or checked her pulse oxygen (pulse ox) when she was out of breath, Resident #62 responded, Yes. Resident #62 stated RN B did not check on her or check her pulse saturation and was not a good nurse at all. Resident #62 stated they (nurses aides, names unknown) told her she used too much of the other oxygen (pointed to 3 liter tank on wheel chair) and RN B said they had just changed it. Resident #62 stated it made her feel mad, very mad. She stated, I almost wanted to cry. All of them were jumping on me, it felt like, resident #62 stated in relation to the oxygen level of her tank and the comments made by RN B on 12/04/21. Surveyor observed resident #62 shake her head back and forth and folded her arms for a moment. Resident #62 states that she got into it with RN B (on Saturday, and She (RN B) has made me feel uncomfortable On 12/04/21. When asked, what RN B's demeanor was when she would tell her the oxygen was up too high, Resident #62 responded, It's mean. and that RN B was the only one that would yell at her. Continuing the interview with Resident #62 on 12/07/21 at 2:59 PM regarding questions about the Administrator, Resident #62 stated, I feel like the Administrator does not take the time to listen to me and she automatically takes their (the staff's) side, and that is what happened again this time until you all said something to her. Then she talked to us separately; [Resident #33], then to me to get the story. Resident #62 added that every time she told the Administrator something, She always makes it sound like it is my fault. I had no oxygen. Resident #62 stated she went to the 400 Hall to get a nurse (RN C) to help her and RN C ended up changing the oxygen tank for her. Resident #62 stated the incident that took place Saturday (12/04/21) lasted about 7 minutes. Resident #62 stated she was having difficulty breathing and she told RN B she had difficulty. Resident #62 said they (staff) told her to go to her room, but she wanted to get her oxygen, and she told RN B, You can't deny me oxygen Resident #62 stated RN B continued to argue with her, Resident #33 was trying to assist her and that was when Resident #33 called police. Resident #62 explained that a nurse grabbed her arm because they didn't want her to go outside and get oxygen because it's their job. Resident #62 stated RN B had changed Resident #62's oxygen a few hours ago, but sometimes it just leaks out and sometimes she might forget to turn it off. Resident #62 stated, when she told RN B the oxygen leaked, she responded, No, it don't and continued to tell her she used too much. Resident #62 stated RN B saw that Resident #62 had the number up to 10 LPM - Liters Per Minute. and she (Resident #62) did that because there was no oxygen in the tank. She stated she was trying to get fumes or anything out of it. She stated, When I can't breathe it's very, very scary. She stated RN B had yelled at her several times. She stated she quit saying something about it because nobody did anything about it. She stated she would tell the Administrator or the DON. I told RN B if a grievance form was written out for me to throw that away because it's not true, what they write. I hope she threw it away, because it's not right. Record Review of a grievance form, dated 12/04/2021, completed by the Administrator related to RN B and Resident #62 revealed, Resident upset about education of oxygen. Stated that she doesn't put it on 8-10 LPM but nurses think she does. It leaks. The resolution of grievance/complaint revealed, [RN B] provided her with new tank. Education provided. [RN B] showed up a few hours later per Administrator request. Administrator followed-up resident and upset that this nurse think she puts it (oxygen setting) up. Stated she only puts it up to 3 (12/06/2021). Interview on 12/06/21 at 3:21 PM with the Administrator revealed that when the administrator was asked about who completed the grievance, the administrator revealed that she completed the grievance using what RN B said and what the resident had said (both in the same grievance). Administrator said, about Resident #62: She will always say her tank is leaking. When asked if the resident read the grievance or saw the grievance, the administrator replied, No. The Administrator stated resident #62 added something more about her oxygen while they were talking, and the Administrator said, I asked her, Why didn't you tell me this before? When the Administrator was asked if she thought there was anything wrong with the tone of the grievance, the Administrator stated, I'm writing this on behalf of [resident #62]. That's how I usually do it. The Administrator Interview with Administrator on 12/07/21 at 4:10 PM revealed the grievance log for resident #62 was dated 12/04/21. The Administrator states that she signed the grievance log on 12/05/21 and further stated that she put 12/06/21 as the date signed instead of 12/05/21 as the date signed. The Administrator stated that the grievance log information was provided by RN B, who only works weekends, but used to work evenings. The grievance log, combining the explanation of what RN B stated and the Administrator's interview with resident #62 stated: Resident upset about education of oxygen. States she does not put it on 8-10 but the nurse thinks she does. It leaks. She was provided with a new tank. Education provided. [RN B] followed up with her a few hours later per administrator (admin) request. I followed up. The Administrator stated that she was told resident #62 was upset-She was being educated that her oxygen was on 10 and the nurses were trying to tell her the issues of having it on 10 as she is on 2 or 3 liters. The Administrator stated that when she spoke to [resident #62] yesterday (12/05/21), resident #62 stated, I don't know why they always get upset about me and my oxygen. The Surveyor relayed to the Administrator that Resident #62 was aware that RN B was writing a grievance and told RN B she did not want it filed on her behalf. The Administrator wrote the grievance for resident #62. Surveyor relayed to the Administrator that the purpose of a grievance is for the resident to file the grievance from the resident's perception, not the perception of staff or Administration of what happened. The Administrator stated that she writes grievances for the residents because some residents are not able to read. When asked if resident #62 is able to read, the Administrator replied, Yes. The Administrator stated that she does not ask the residents what they think about what she wrote for their grievance. When the Administrator was asked if she spoke with resident #33 who made the police report, the Administrator replied she did not think she needed to talk to him at the time. The Administrator states she talked to resident #62, and resident #62 told her she did not feel threatened and did not remember if her arm was grabbed. According to Residents' Rights, Nursing Facilities posted at facilities, source Texas Health and Human Services, reveals that Dignity and respect .you have the right to: Be treated with dignity, courtesy, consideration and respect .Freedom of choice .you have the right to: Make your own choices regarding personal affairs, care, benefits and services Participation in your care .you have the right to: Receive all care necessary to have the highest possible level of health Refuse treatment, care, or services Complaints .You have the right to: Complain about care or treatment and receive a prompt response to resolve the complaint withaout fear of reprisal or discrimination. Record Review of facility's policy entitled Abuse & Neglect Prohibition, revised August 2017, chapter on Resident Rights, revealed: Each resident has the right to be free from abuse, neglect mistreatment . and further reflected, Neglect means a failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . and Prevention includes: Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect and to intervene as appropriate. Record Review revealed 29 employees signed an attendance form on Resident Rights, dated 07/27/2020, Inservice, (attached to the Abuse & Neglect Prohibition chapter on resident rights). RN B was not listed as having signed the attendance form.

Based on observation, interview and record review, the facility failed to ensure that each resident receives, and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community for two (09/16/20 lunch and 09/17/19 lunch) of two observed meals. The facility failed to ensure meals were consistently served at posted meal times. This failure placed residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings included: Interview with Resident #50 on 09/17/20 at 1:48 p.m. revealed he normally received his meal at 1:00 p.m. but the time had been getting later and later recently. Observation on 09/16/20 at 1:00PM of the facility's posted meal times in the dining room revealed the following: Lunch 12:10 PM Observation of meal delivery revealed the following: -09/16/20 Food carts brought to out and set on hall 100 at 1:20 p.m. (1 hour and 10 minutes after posted lunch time). -09/16/20 last hall tray served on hall 100 at 1:49 p.m. (1 hour and 39 minutes after posted meal time). -09/17/20 Food cart delivered to Hall 400 at 1:53 p.m. (1 hour and 43 minutes after posted meal time). -09/17/20 last tray served on last hall 400 delivered at 2:04 p.m. (1 hour and 54 minutes after posted meal time) Interview with the Dietary Manager on 09/18/19 at 1:25 p.m. revealed she currently had a plan in place to deal with meals being served late. She stated several residents changed their mind regarding what they wanted to eat during meal service and it would put the kitchen behind. The Dietary Manager stated they normally served the 100 hall last but on 09/17/20 they changed the serving schedule. She stated they served the 400 hall last on 09/18/20 and she did not know why. Review of the facility's policy titled Frequency of Meals, dated September 2017, revealed, 3. The Dining Services Director will ensure that each meal is served within the designated time frame unless there is an emergency situation or a resident request.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for all residents. The facility failed to ensure the ceiling above the laundry area was in good repair and provided a sanitary area for resident's clothes to be laundered. This failure could place residents at risk of not having sanitary clothing and laundry. Findings included: Observation of the laundry room on 05/11/20 at 11:20 AM revealed the entire ceiling directly above the clean linen folding table was damaged with the ceiling material separating. The ceiling appeared to be damaged from a water leak. The ceiling had circles of different shades of brown and appeared to be damp. When the door opened particles from the ceiling fell on the folding table and floor. Review of the maintenance log dated March 2020 to 05/11/20 revealed no written report for the laundry room ceiling . Interview with the Maintenance Supervisor on 05/11/20 at 11:35 AM revealed he did not always log repairs. He stated he had not checked the laundry room ceiling because he never looked up. Interview with the Laundry Aide on 05/11/20 at 1:30 PM revealed ceiling particles fell on residents' clean laundry. She stated she continuously wiped the folding table off and shook particles off of the clothes. She stated she informed her boss about the ceiling particles falling on residents' clean clothes. She stated pieces from the ceiling fall on the clothes every time the door opens. Interview with the Housekeeping Supervisor on 05/11/20 at 1:36 PM revealed there were people working on the roof a week or two ago. He stated he was not informed of any leaks in the laundry room. He stated he never knew the ceiling was falling but would report it to the Maintenance Supervisor. Interview with the Maintenance Supervisor on 05/11/20 at 1:45 PM revealed the brown spots on the ceiling were the color of the dry wall. He stated there were no water leaks or moisture. He stated spackle would be used to cover the brown spots and the ceiling would be fixed by 05/13/20. He stated the ceiling needed to be repaired because particles falling on residents' clothing and the folding table made the area unsanitary . Interview with the Administrator on 05/12/20 at 2:16PM revealed she was not aware laundry room ceiling was in need of repair. She stated she did not know if the ceiling has water damage. She stated the housekeeping department would have reported the issue especially if there were particles falling from the ceiling onto resident clothes. She stated the Maintenance Supervisor was able to repair the ceiling and hire a contractor if needed. She stated ceiling particles falling on resident clothing was an infection control issue. She stated she planned to in-service the housekeeping department. Review of the facility's policy titled Maintenance Department dated February 2018, revealed, The department will do on-going monitoring of the facility for areas needing repair and, if needed, will report to the supervisor for approval of the repairs needed. Leaks and areas of moisture should be fixed promptly and drywall, ceiling tiles and other materials should be replaced.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for one (hall 500) of two medication carts reviewed. The facility failed to lock medication cart 1 located on Hall 500. This failure could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions. Findings included: Observation on 05/12/20 from 8:30 AM to 8:40 AM revealed medication cart 1 was unlocked and unattended on Hall 500. All of the drawers of the medication cart 1 could be opened and the medication was easily accessible. The cart was unattended for approximately 10 minutes. Residents were observed on 500 hall. Interview with LVN A on 05/12/20 at 8:40 AM revealed anyone could access medications if the cart was left unlocked. He stated residents could take the wrong medication and cause harm to themselves. He stated another resident's medication would be gone. He stated the medication cart was to be locked when stepping away. He stated he left the medication cart unlocked to assist a resident on hall 500. He stated he received an in-service every month regarding medication carts being locked. He stated his last training was in April 2020. Interview with ADON A on 05/12/20 at 12:40 PM revealed his expectation was the medication cart was to be locked when not in use and visible on the hall throughout the shift. He stated if the medication cart was not locked, the resident or someone could tamper with the medications and ingest medications. He stated it could compromise the resident's safety if medications were consumed when not scheduled. He stated nurses have received training regarding locking the medication cart. He stated nurses were trained when hired and the last re-education was May 2020. Interview with ADON B on 05/12/20 at 1:05 PM revealed the medication cart should have been locked when not attended. She stated someone or a resident could access the cart and steal the medication. She stated a resident could overdose and another resident would be without medication resulting in harm. She stated nurses received medication storage training at hire and ongoing. She stated the last medication storage training was December 2019. Interview with the DON on 05/12/20 at 1:29 PM revealed he expected medication carts to be locked. He stated an unlocked medication cart could lead to a drug diversion, overdosing, and missing medications. He stated the nurses received education about medication storage 2 to 3 months ago. Review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/01/07, revealed, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency care medical personnel and subject to related physician orders [REDACTED].#1) of seven residents reviewed for Advance Directives. 1. LVN A, who was CPR certified, failed to immediately start CPR and utilize the AED (Automated External Defibrillator) when he determined Resident #1 did not have a pulse or respirations on [DATE] at 5:35 p.m. LVN A left Resident #1 in his room to retrieve the crash cart and other staff members to assist. 2. LVN B, LVN C, LVN D, RN E and RN F failed to utilize the AED (Automated External Defibrillator) and initiate chest compressions when LVN A determined Resident #1 did not have a pulse or respirations. Chest compressions were not initiated on Resident #1 until the arrival of EMS at 5:50 p.m. which was 15 minutes after the resident was first assessed to have no vital signs. Resident #1 was transported to the hospital by the paramedics on [DATE] and expired on [DATE] due to diffuse [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect the 61 residents who were full code status, by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings Included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired and required extensive assistance with most ADLs. Resident #1's Care plan dated [DATE] did not address the resident's code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning he wanted all life-saving measures to be taken if he was found without a pulse and respirations) with an order date if [DATE]. Review of Resident #1's nurses' note dated [DATE] at 6:48 p.m., by LVN A, reflected, SBAR ( Situation, Background, Assessment, Request) Summary .Resident was unresponsive in the dining room .Sent to the hospital for further evaluation . Last vital signs documented were on [DATE] at 8:50 a.m. Resident #1's nurses' note dated [DATE] at 4:07 p.m., by LVN A, reflected, Late Entry. Resident was observed on [DATE] at about 5:35 p.m. in the dinning (sic) room having difficulty drinking from his cup while eating dinner. Nurse notified, rushed to the scene and found resident eyes rolling over. Resident was rushed to his room for further evaluation. Unable to get vitals from resident code blue was called, immediately CPR initiated and 911 called in. When paramedics arrived they continued CPR and they left the facility with resident at about 6:40 p.m. for (local hospital) for further evaluation. Resident's (family member) was notified at about 6:45 p.m. and PA was also notified at about 7:00 p.m. In an Interview with LVN A on [DATE] at 11:30 a.m., he stated when he first observed Resident # 1 on [DATE], he was having difficulty holding his cup while he was in the dining room. He stated then the resident's eyes rolled back in his head. He stated he went to get a wheelchair to take the resident out of the dining room so he could assess the resident. He stated one of the CNAs helped him get the resident in the wheelchair. He stated he was not sure if the resident was breathing at that time or not. He stated he told the CNAs to call for help. He stated when he got the resident in his room, he attempted to obtain a pulse and blood pressure and found the resident to have no pulse, blood pressure or respirations. He stated he left the room to retrieve the crash cart, which was stored outside of the unit which he state took less than five minutes. He stated he and LVN B arrived about the same time, and they transferred the resident from the wheelchair onto the floor. He stated they initiated CPR at that time. He stated they did not utilize the AED. He stated he never thought about using the AED. In an interview with CNA H on [DATE] at 2:45 p.m., she stated on [DATE] sometime after 5:00 p.m., she was in the dining room feeding another resident, when she noticed Resident # 1 holding his cup in the air and he was not moving. She stated she and LVN A rushed to the resident. She stated she held the resident up and LVN A ran across the hall and retrieved a wheelchair. She stated while she was holding the resident, he slumped over and his eyes were rolled back in his head and his tongue was hanging out to the side and was blue in color. She stated she and LVN A transferred the resident to the wheelchair and the LVN took him to his room and told her to call for help. She stated she left the unit and told the nurse at the first station, who called the code blue. She stated she saw LVN A come off the unit to get the crash cart. She stated all of the nurse's ran to Resident #1's room. She stated when she walked by the resident's room she saw the resident on the floor and one of the nurse's had put the AMBU (resuscitator) bag over his face. She stated she did not see anyone doing chest compressions. She stated she thought the ambulance arrived within six to ten minutes after she alerted the other nurse's. In an interview with LVN B on [DATE] at 12:40 p.m. he stated that on [DATE] a code blue was called on the locked unit between 5:30 p.m. and 6:00 p.m. He stated when he passed by where the crash cart was stored, he noticed the back board was still in the room, so he grabbed the board. He stated he and LVN A arrived to Resident #1's room with the crash cart and back board. He stated he asked if the resident was a full code and LVN A stated he was. He stated the resident was sitting up in a wheelchair and his eyes were open and appeared fixed. He stated the resident was not breathing. He stated he and LVN A transferred the resident onto the floor and he placed the AMBU bag over the resident's nose and mouth and attempted to give him rescue breaths. He stated he palpated a very faint carotid pulse. He stated they placed a pulse oximeter (device that measures oxygen level in the blood and heart rate), on the resident's finger, and it showed nothing. He stated they did not start chest compression since the resident had a faint pulse. He stated there was another nurse present, but he could not remember who it was. He stated it was very chaotic. He stated he did not think to grab the AED when he grabbed the back board. He stated when the paramedics arrived they started chest compressions. In an interview with LVN C on [DATE] at 12:40 p.m., she stated she responded to the code blue on [DATE]. She stated when she arrived in the room there were several staff members in the room. She stated LVN A and B were on the floor with the resident and she thought they were doing CPR. She stated she did not retrieve the AED or assist with the code. She stated she was not sure how long it took for EMS to arrive or how long they were in the building. In a follow up Interview with LVN A on [DATE] at 1:10 p.m. when asked if he had initiated chest compressions, as he had previously stated, he stated, no I did not. He stated, he was trying to get everything in the room they were going to need. He stated he was overwhelmed and under prepared and just needed help. Review of LVN A's CPR certification record, reflected he was CPR certified through the American Heart Association on [DATE]. In an interview with RN E on [DATE] at 4:00 p.m., she stated she heard the code blue called and rushed to the unit. She stated when she arrived to the room she observed the resident lying on the floor. LVN B was providing breaths with the AMBU bag. She stated the resident initially had a pulse, but when she checked it after about two minutes he did not have a pulse. She stated it was just a few minutes after they found no pulse that EMS arrived. She stated chest compressions were never started by any of the staff prior to the arrival of EMS. She stated no one had grabbed the AED. She stated there was a lot of staff in the room. In an interview with RN F on [DATE] at 4:15 p.m., he stated when he heard the code blue he left his hall and went to the locked unit. He stated he arrived at the room along with LVN A and LVN B who were pushing the crash cart into the room. He stated the resident was slumped over in his wheelchair. He stated LVN A and LVN B placed the resident on the floor on the backboard. He stated LVN B placed the AMBU bag on the resident trying to provide breaths. He stated someone else was checking for a pulse, but stated he was not sure who it was. He stated he did not think the resident had a pulse, but stated he was only in the room a few minutes before EMS arrived. He stated he did not see anyone start chest compressions. He stated he did not think to get the AED. In an interview with LVN D on [DATE] at 9:30 a.m., he stated on [DATE] around 5:00 p.m. they had a code blue on the locked unit. He stated when he arrived at the unit there were numerous staff members present. He stated the resident was on the floor on the back board. He stated someone had already called 911. He stated he was not sure who tried to take vital signs. He stated one of the nurse's said the resident had a pulse so CPR was never started. Review of the EMS Patient Care Record, dated [DATE], reflected, .Call received 5:45 p.m. On Scene 5:50 p.m. was called to [MEDICAL CONDITION]. While en route to call dispatch updated crew that this was now a CPR. Upon arrival pt. (patient) was found lying supine on floor of room with NH (nursing home) staff around. No CPR was being performed. Pt was checked for pulse and found to have none. Pt was warm to touch. Manual CPR was started .After 2 minutes of CPR rhythm was checked and pt. was found to have sinus rhythm on monitor with carotid pulse. Compressions were paused. Pt still did not have any breathing. ET (endotracheal tube- used to open airway) was attempted to be placed .at the same time .another crew member informed us that pt.'s pulse dropped from 75 to 50. Intubation was halted .Pt rechecked to confirm pulse but had none .CPR was resumed and pt. was moved to stretcher .Pt care was transferred to facility ER physician . Departure time was noted as 6:11 p.m. Review of the Hospital record dated [DATE], reflected, [AGE] year-old male reports to ED (emergency department) at 6:21 p.m. in [MEDICAL CONDITION] Pt was successfully intubated .Pt was admitted to ICU . Review of the Hospital Casemangement report dated [DATE], reflected, .This pt. continues to require intubation This pts family plans to withdraw support and admit PT to inpatient hospice this Friday evening . Review of the Hospital discharge summary dated [DATE], reflected, .Patient was seen by neurologist and had a CT of the head, which indicated diffuse [MEDICAL CONDITION] injury. Patient was readmitted under inpatient hospice care on [DATE] .he was extubated and was continued on comfort measure. Patient passed away on [DATE] . In an interview with the Health Information Coordinator on [DATE] at 7:25 a.m., she stated she had received a request from the POA for Resident #1 requesting a copy of the notes from the day Resident # 1 was transferred to the hospital. She stated she faxed him a copy of the Nurse's progress note and the SBAR on [DATE]. She stated on [DATE] he called again and had some questions as to why our notes indicated the resident had a blood pressure and pulse when the hospital records reflected he was in full arrest. She stated the Medical director was in the building, so she asked the Medical Director to speak with the family. She stated the Medical director and the staff spoke to LVN A and determined he had failed to clear out the resident's previous vital signs that had been taken earlier in the day, so the system automatically picked up the latest set of vital signs on the SBAR report. She stated that was when it was discovered that LVN A left the resident in his room unresponsive, and went to get the crash cart instead of starting CPR immediately. In an interview with ADON G on [DATE] at 1:25 p.m. she stated the Medical director asked them on [DATE] to look into the incident that had occurred on [DATE] with Resident #1. She stated it was discovered that LVN A observed Resident #1 in the dining room having difficulty and he took him to his room to assess him. He stated he could not find any vital signs, and that was when he left the resident to go and get the crash cart. She stated he told them he called the code blue and had someone call 911. She stated he told them he went back to the room and started CPR. She stated she just assumed he had done chest compressions. She stated after the incident they in serviced the nursing staff on the ,[DATE] p.m. shift on [DATE] on code response and AED and implemented a Code Worksheet to document all of the information during the code. She stated they did a mock code with those present at the in-service. In an interview on [DATE] with the Medical Director at 1:45 p.m., she stated she had spoken with the Administrator, DON, ADON's, CNA's who worked on the unit and LVN A about the details of what led up to Resident #1's change in condition on [DATE]. She stated the family was concerned that he had been left alone in his room eating, but through her investigation it was determined he was in the dining room with staff and other residents when he became unresponsive. She stated LVN A told them he had removed the resident from the dining room and took him to his room where he determined the resident had no pulse. He then called for help and left the resident's room to retrieve the crash cart. The Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. She stated she instructed the Administrative staff to complete an in- service on CPR and response time to all of the staff. In an interview with the Administrator on [DATE] at 9:25 a.m., she stated she had been on medical leave until [DATE] and her DON had also been on medical leave until [DATE]. She stated the facility had an Administrator in training covering for her and they had an interim DON covering for the current DON. In an interview with the Interim DON on [DATE] at 1:25 p.m., she stated she had filled in for about six weeks while the DON was on leave. She stated she vaguely remembered the incident that occurred on [DATE]. She stated the Medical Director had spoken with the family and had asked that they do training on the nursing staff on how to respond to a code and the initiation of CPR. She stated they did a Mock CPR drill for some of the staff on 1st and 2nd shift, but had not gotten around to the night shift. Review of the In-service Records reflected nine direct care staff were in serviced on CPR Procedure. Of the Nine participants only three of the six nurses (LVN A, LVN B and LVN C) who were involved in the incident on [DATE] received the in service training on [DATE]. No additional training was done until [DATE]. Interview with the AIT (Administrator in Training) on [DATE] at 2:05 p.m. revealed she was aware that Resident #1 had to be sent to theER on [DATE] due to being unresponsive. She stated she was made aware of the family's concerns about the medical records and the Medical Director had spoken to the family after she had talked with LVN A. She stated it was her understanding that the nurse left the resident in his room to retrieve the crash cart. She stated the Medical Director had wanted in-services done with the staff. She stated she knew in-services were done on the ,[DATE] p.m. shift and that the reminder of the staff was to be scheduled when time permitted. She stated she did not know of any disciplinary actions against any of the nurses. In an interview with the Administrator and the DON on [DATE] at 4:45 p.m., the Administrator stated she felt that if she and the DON had not both been out on leave, this incident would have been investigated in much greater detail and staff would have been in serviced and or disciplined. The DON stated with being back one day, she had not had the opportunity to look into this situation until today. She stated she would be initiating in-services on the entire staff on the facility's expectations for emergency management, CPR and the AED. The DON stated she hated that her staff were poorly prepared to manage this emergency. Record Review on [DATE] of all the facility's Nurses' CPR certification revealed nurses were CPR certified on all shifts. Review of the facility's undated policy, Cardiopulmonary resuscitation (CPR), two person, reflected , .the step-by-step guide for CPR recommended by the American Heart Association .Assess the patient to determine whether they are unresponsive .shout for nearby help and activate the emergency response system .check for pulse .open the airway .Provide rescue breathing .have a coworker retrieve an automated external defibrillator (AED) .Place the patient supine on a firm surface .Immediately begin chest compressions until the AED .is ready for use .Use the AED .to evaluate the patient's rhythm as soon as its ready .both rescuers should continue administering CPR until advanced cardiac life support providers take over or until normal breath and effective circulation return . The facility's policy, Medical Emergency Management, dated February 2017, reflected, The facility ensure residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive .The facility will maintain an Automated External Defibrillator (AED) if required by state regulation . The facility's policy, Abuse & Neglect Prohibition, dated [DATE], reflected, Each resident has the right to be free from .neglect .Definitions .Neglect means a failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm . The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions .check for no breathing .immediately begin CPR, and use the AED .(retrieved on [DATE]). The Administrator was notified on [DATE] at 10:55 a.m. that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:12 p.m. and included: (Name) licensed nurse failed to remain with the resident on [DATE], to initiate CPR once vital signs were not obtained. 1. The licensed nurse identified in the Immediate Jeopardy was terminated on [DATE]. The resident identified in the Immediate Jeopardy no longer resides at this facility. 2. All licensed nurses will be re-educated on Medical Emergency Management Policy and Procedure by the DON by 2pm on [DATE]. Any licensed nurse who has not received the re-education will not be allowed to clock in and work until they have received the education. 3. The content of the re-education is as follows: Call for help and stay with the patient (use call light or yell or assistance) The nurse will determine if the resident has a pulse or breath sounds If victim is unresponsive shout for nearby help. Assess for breathing and pulse. -If the patient is breathing and has a pulse, closely monitor until emergency staff arrives. -If a patient is not breathing but has a pulse, start rescue breaths. -If the patient has no pulse, begin CPR ***The nurse in charge of the code will continue to provide CPR while sending other staff members to call 911, obtain the crash cart, AED, and backboard. Staff will continue interventions until emergency assistance arrives. The Director of Nursing will monitor progress by performing Mock Codes and evaluate the nurse's performance. Evaluations checklist will be performed on participants. Re-education will be performed for anyone who is not able to perform the procedure adequately. Post test will be given to all nurses. The Director of Nursing will report progress of this process to the QAPI Committee monthly x 3 month. Interviews on [DATE] from 9:50 a.m. to 4:35 p.m. revealed six of six Charge Nurses representing all three shifts (LVNs D, I, J, C B and K) all understood to initiate CPR and utilize the AED immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interview on [DATE] at 8:15 a.m. with the Administrator and DON stated they had in serviced the majority of the staff, not only the Nurse's but all staff. The administrator stated the remainder of the staff would not be allowed to clock in until they complete the in service training and check offs. Interviews on [DATE] from 8:25 a.m. to 9:45 a.m. revealed six of six Charge nurse's representing all three shifts and weekends (LVNs L, M, O, P and RN's N and E) revealed they had received in- service training and understood to initiate CPR and utilized the AED immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of facility staffing reflected the last date LVN A worked was [DATE]. On [DATE] at 9:53 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided a list on [DATE] of 61 residents with full code status.

Based on interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #1) of 7 residents reviewed for neglect. 1. LVN A failed to immediately start CPR and utilize the AED (Automated External Defibrillator) when he determined Resident #1 did not have a pulse or respirations on [DATE] at 5:35 p.m. LVN A left Resident #1 in his room to retrieve the crash cart and other staff members to assist. 2. LVN A, LVN B, LVN C, LVN D, RN E and RN F failed to utilize the AED (Automated External Defibrillator) and initiate chest compressions when LVN A determined Resident #1 did not have a pulse or respirations. Chest compressions were not initiated on Resident #1 until the arrival of EMS at 5:50 p.m. which was 15 minutes after the resident was first assessed to have no vital signs. Resident #1 was transported to the hospital by the paramedics on [DATE] and expired on [DATE] due to diffuse [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect the 61 residents who were full code status, by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings Included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired and required extensive assistance with most ADLs. Resident #1's Care plan dated [DATE] did not address the resident's code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning he wanted all life-saving measures to be taken if he was found without a pulse and respirations) with an order date if [DATE]. Review of Resident #1's nurses' note dated [DATE] at 6:48 p.m., by LVN A, reflected, SBAR ( Situation, Background, Assessment, Request) Summary .Resident was unresponsive in the dining room .Sent to the hospital for further evaluation . Last vital signs documented were on [DATE] at 8:50 a.m. Resident #1's nurses' note dated [DATE] at 4:07 p.m., by LVN A, reflected, Late Entry. Resident was observed on [DATE] at about 5:35 p.m. in the dinning (sic) room having difficulty drinking from his cup while eating dinner. Nurse notified, rushed to the scene and found resident eyes rolling over. Resident was rushed to his room for further evaluation. Unable to get vitals from resident code blue was called, immediately CPR initiated and 911 called in. When paramedics arrived they continued CPR and they left the facility with resident at about 6:40 p.m. for (local hospital) for further evaluation. Resident's (family member) was notified at about 6:45 p.m. and PA was also notified at about 7:00 p.m. In an Interview with LVN A on [DATE] at 11:30 a.m., he stated when he first observed Resident # 1 on [DATE], he was having difficulty holding his cup while he was in the dining room. He stated then the resident's eyes rolled back in his head. He stated he went to get a wheelchair to take the resident out of the dining room so he could assess the resident. He stated one of the CNAs helped him get the resident in the wheelchair. He stated he was not sure if the resident was breathing at that time or not. He stated he told the CNAs to call for help. He stated when he got the resident in his room, he attempted to obtain a pulse and blood pressure and found the resident to have no pulse, blood pressure or respirations. He stated he left the room to retrieve the crash cart, which was stored outside of the unit which he state took less than five minutes. He stated he and LVN B arrived about the same time, and they transferred the resident from the wheelchair onto the floor. He stated they initiated CPR at that time. He stated they did not utilize the AED. He stated he never thought about using the AED. In an interview with CNA H on [DATE] at 2:45 p.m., she stated on [DATE] sometime after 5:00 p.m., she was in the dining room feeding another resident, when she noticed Resident # 1 holding his cup in the air and he was not moving. She stated she and LVN A rushed to the resident. She stated she held the resident up and LVN A ran across the hall and retrieved a wheelchair. She stated while she was holding the resident, he slumped over and his eyes were rolled back in his head and his tongue was hanging out to the side and was blue in color. She stated she and LVN A transferred the resident to the wheelchair and the LVN took him to his room and told her to call for help. She stated she left the unit and told the nurse at the first station, who called the code blue. She stated she saw LVN A come off the unit to get the crash cart. She stated all of the nurse's ran to Resident #1's room. She stated when she walked by the resident's room she saw the resident on the floor and one of the nurse's had put the AMBU (resuscitator) bag over his face. She stated she did not see anyone doing chest compressions. She stated she thought the ambulance arrived within six to ten minutes after she alerted the other nurse's. In an interview with LVN B on [DATE] at 12:40 p.m. he stated that on [DATE] a code blue was called on the locked unit between 5:30 p.m. and 6:00 p.m. He stated when he passed by where the crash cart was stored, he noticed the back board was still in the room, so he grabbed the board. He stated he and LVN A arrived to Resident #1's room with the crash cart and back board. He stated he asked if the resident was a full code and LVN A stated he was. He stated the resident was sitting up in a wheelchair and his eyes were open and appeared fixed. He stated the resident was not breathing. He stated he and LVN A transferred the resident onto the floor and he placed the AMBU bag over the resident's nose and mouth and attempted to give him rescue breaths. He stated he palpated a very faint carotid pulse. He stated they placed a pulse oximeter (device that measures oxygen level in the blood and heart rate), on the resident's finger, and it showed nothing. He stated they did not start chest compression since the resident had a faint pulse. He stated there was another nurse present, but he could not remember who it was. He stated it was very chaotic. He stated he did not think to grab the AED when he grabbed the back board. He stated when the paramedics arrived they started chest compressions. In an interview with LVN C on [DATE] at 12:40 p.m., she stated she responded to the code blue on [DATE]. She stated when she arrived in the room there were several staff members in the room. She stated LVN A and B were on the floor with the resident and she thought they were doing CPR. She stated she did not retrieve the AED or assist with the code. She stated she was not sure how long it took for EMS to arrive or how long they were in the building. In a follow up Interview with LVN A on [DATE] at 1:10 p.m. when asked if he had initiated chest compressions, as he had previously stated, he stated, no I did not. He stated, he was trying to get everything in the room they were going to need. He stated he was overwhelmed and under prepared and just needed help. Review of LVN A's CPR certification record, reflected he was CPR certified through the American Heart Association on [DATE]. In an interview with RN E on [DATE] at 4:00 p.m., she stated she heard the code blue called and rushed to the unit. She stated when she arrived to the room she observed the resident lying on the floor. LVN B was providing breaths with the AMBU bag. She stated the resident initially had a pulse, but when she checked it after about two minutes he did not have a pulse. She stated it was just a few minutes after they found no pulse that EMS arrived. She stated chest compressions were never started by any of the staff prior to the arrival of EMS. She stated no one had grabbed the AED. She stated there was a lot of staff in the room. In an interview with RN F on [DATE] at 4:15 p.m., he stated when he heard the code blue he left his hall and went to the locked unit. He stated he arrived at the room along with LVN A and LVN B who were pushing the crash cart into the room. He stated the resident was slumped over in his wheelchair. He stated LVN A and LVN B placed the resident on the floor on the backboard. He stated LVN B placed the AMBU bag on the resident trying to provide breaths. He stated someone else was checking for a pulse, but stated he was not sure who it was. He stated he did not think the resident had a pulse, but stated he was only in the room a few minutes before EMS arrived. He stated he did not see anyone start chest compressions. He stated he did not think to get the AED. In an interview with LVN D on [DATE] at 9:30 a.m., he stated on [DATE] around 5:00 p.m. they had a code blue on the locked unit. He stated when he arrived at the unit there were numerous staff members present. He stated the resident was on the floor on the back board. He stated someone had already called 911. He stated he was not sure who tried to take vital signs. He stated one of the nurse's said the resident had a pulse so CPR was never started. Review of the EMS Patient Care Record, dated [DATE], reflected, .Call received 5:45 p.m. On Scene 5:50 p.m. was called to [MEDICAL CONDITION]. While en route to call dispatch updated crew that this was now a CPR. Upon arrival pt. (patient) was found lying supine on floor of room with NH (nursing home) staff around. No CPR was being performed. Pt was checked for pulse and found to have none. Pt was warm to touch. Manual CPR was started .After 2 minutes of CPR rhythm was checked and pt. was found to have sinus rhythm on monitor with carotid pulse. Compressions were paused. Pt still did not have any breathing. ET (endotracheal tube- used to open airway) was attempted to be placed .at the same time .another crew member informed us that pt.'s pulse dropped from 75 to 50. Intubation was halted .Pt rechecked to confirm pulse but had none .CPR was resumed and pt. was moved to stretcher .Pt care was transferred to facility ER physician . Departure time was noted as 6:11 p.m. Review of the Hospital record dated [DATE], reflected, [AGE] year-old male reports to ED (emergency department) at 6:21 p.m. in [MEDICAL CONDITION] Pt was successfully intubated .Pt was admitted to ICU . Review of the Hospital Casemangement report dated [DATE], reflected, .This pt. continues to require intubation This pts family plans to withdraw support and admit PT to inpatient hospice this Friday evening . Review of the Hospital discharge summary dated [DATE], reflected, .Patient was seen by neurologist and had a CT of the head, which indicated diffuse [MEDICAL CONDITION] injury. Patient was readmitted under inpatient hospice care on [DATE] .he was extubated and was continued on comfort measure. Patient passed away on [DATE] . In an interview with the Health Information Coordinator on [DATE] at 7:25 a.m., she stated she had received a request from the POA for Resident #1 requesting a copy of the notes from the day Resident # 1 was transferred to the hospital. She stated she faxed him a copy of the Nurse's progress note and the SBAR on [DATE]. She stated on [DATE] he called again and had some questions as to why our notes indicated the resident had a blood pressure and pulse when the hospital records reflected he was in full arrest. She stated the Medical director was in the building, so she asked the Medical Director to speak with the family. She stated the Medical director and the staff spoke to LVN A and determined he had failed to clear out the resident's previous vital signs that had been taken earlier in the day, so the system automatically picked up the latest set of vital signs on the SBAR report. She stated that was when it was discovered that LVN A left the resident in his room unresponsive, and went to get the crash cart instead of starting CPR immediately. In an interview with ADON G on [DATE] at 1:25 p.m. she stated the Medical director asked them on [DATE] to look into the incident that had occurred on [DATE] with Resident #1. She stated it was discovered that LVN A observed Resident #1 in the dining room having difficulty and he took him to his room to assess him. He stated he could not find any vital signs, and that was when he left the resident to go and get the crash cart. She stated he told them he called the code blue and had someone call 911. She stated he told them he went back to the room and started CPR. She stated she just assumed he had done chest compressions. She stated after the incident they in serviced the nursing staff on the ,[DATE] p.m. shift on [DATE] on code response and AED and implemented a Code Worksheet to document all of the information during the code. She stated they did a mock code with those present at the in-service. In an interview on [DATE] with the Medical Director at 1:45 p.m., she stated she had spoken with the Administrator, DON, ADON's, CNA's who worked on the unit and LVN A about the details of what led up to Resident #1's change in condition on [DATE]. She stated the family was concerned that he had been left alone in his room eating, but through her investigation it was determined he was in the dining room with staff and other residents when he became unresponsive. She stated LVN A told them he had removed the resident from the dining room and took him to his room where he determined the resident had no pulse. He then called for help and left the resident's room to retrieve the crash cart. The Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. She stated she instructed the Administrative staff to complete an in- service on CPR and response time to all of the staff. In an interview with the Administrator on [DATE] at 9:25 a.m., she stated she had been on medical leave until [DATE] and her DON had also been on medical leave until [DATE]. She stated the facility had an Administrator in training covering for her and they had an interim DON covering for the current DON. In an interview with the Interim DON on [DATE] at 1:25 p.m., she stated she had filled in for about six weeks while the DON was on leave. She stated she vaguely remembered the incident that occurred on [DATE]. She stated the Medical Director had spoken with the family and had asked that they do training on the nursing staff on how to respond to a code and the initiation of CPR. She stated they did a Mock CPR drill for some of the staff on 1st and 2nd shift, but had not gotten around to the night shift. Review of the In-service Records reflected nine direct care staff were in serviced on CPR Procedure. Of the Nine participants only three of the six nurses (LVN A, LVN B and LVN C) who were involved in the incident on [DATE] received the in service training on [DATE]. No additional training was done until [DATE]. Interview with the AIT (Administrator in Training) on [DATE] at 2:05 p.m. revealed she was aware that Resident #1 had to be sent to theER on [DATE] due to being unresponsive. She stated she was made aware of the family's concerns about the medical records and the Medical Director had spoken to the family after she had talked with LVN A. She stated it was her understanding that the nurse left the resident in his room to retrieve the crash cart. She stated the Medical Director had wanted in-services done with the staff. She stated she knew in-services were done on the ,[DATE] p.m. shift and that the reminder of the staff was to be scheduled when time permitted. She stated she did not know of any disciplinary actions against any of the nurses. In an interview with the Administrator and the DON on [DATE] at 4:45 p.m., the Administrator stated she felt that if she and the DON had not both been out on leave, this incident would have been investigated in much greater detail and staff would have been in serviced and or disciplined. The DON stated with being back one day, she had not had the opportunity to look into this situation until today. She stated she would be initiating in-services on the entire staff on the facility's expectations for emergency management, CPR and the AED. The DON stated she hated that her staff were poorly prepared to manage this emergency. Record Review on [DATE] of all the facility's Nurses' CPR certification revealed nurses were CPR certified on all shifts. Review of the facility's undated policy, Cardiopulmonary resuscitation (CPR), two person, reflected , .the step-by-step guide for CPR recommended by the American Heart Association .Assess the patient to determine whether they are unresponsive .shout for nearby help and activate the emergency response system .check for pulse .open the airway .Provide rescue breathing .have a coworker retrieve an automated external defibrillator (AED) .Place the patient supine on a firm surface .Immediately begin chest compressions until the AED .is ready for use .Use the AED .to evaluate the patient's rhythm as soon as its ready .both rescuers should continue administering CPR until advanced cardiac life support providers take over or until normal breath and effective circulation return . The facility's policy, Medical Emergency Management, dated February 2017, reflected, The facility ensure residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive .The facility will maintain an Automated External Defibrillator (AED) if required by state regulation . The facility's policy, Abuse & Neglect Prohibition, dated [DATE], reflected, Each resident has the right to be free from .neglect .Definitions .Neglect means a failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm . The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions .check for no breathing .immediately begin CPR, and use the AED .(retrieved on [DATE]). The Administrator was notified on [DATE] at 10:55 a.m. that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:12 p.m. and included: (Name) licensed nurse failed to remain with the resident on [DATE], to initiate CPR once vital signs were not obtained. 1. The licensed nurse identified in the Immediate Jeopardy was terminated on [DATE]. The resident identified in the Immediate Jeopardy no longer resides at this facility. 2. All licensed nurses will be re-educated on Medical Emergency Management Policy and Procedure by the DON by 2pm on [DATE]. Any licensed nurse who has not received the re-education will not be allowed to clock in and work until they have received the education. 3. The content of the re-education is as follows: Call for help and stay with the patient (use call light or yell or assistance) The nurse will determine if the resident has a pulse or breath sounds If victim is unresponsive shout for nearby help. Assess for breathing and pulse. -If the patient is breathing and has a pulse, closely monitor until emergency staff arrives. -If a patient is not breathing but has a pulse, start rescue breaths. -If the patient has no pulse, begin CPR ***The nurse in charge of the code will continue to provide CPR while sending other staff members to call 911, obtain the crash cart, AED, and backboard. Staff will continue interventions until emergency assistance arrives. The Director of Nursing will monitor progress by performing Mock Codes and evaluate the nurse's performance. Evaluations checklist will be performed on participants. Re-education will be performed for anyone who is not able to perform the procedure adequately. Post test will be given to all nurses. The Director of Nursing will report progress of this process to the QAPI Committee monthly x 3 month. Interviews on [DATE] from 9:50 a.m. to 4:35 p.m. revealed six of six Charge Nurses representing all three shifts (LVNs D, I, J, C B and K) all understood to initiate CPR and utilize the AED immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interview on [DATE] at 8:15 a.m. with the Administrator and DON stated they had in serviced the majority of the staff, not only the Nurse's but all staff. The administrator stated the remainder of the staff would not be allowed to clock in until they complete the in service training and check offs. Interviews on [DATE] from 8:25 a.m. to 9:45 a.m. revealed six of six Charge nurse's representing all three shifts and weekends (LVNs L, M, O, P and RN's N and E) revealed they had received in- service training and understood to initiate CPR and utilized the AED immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of facility staffing reflected the last date LVN A worked was [DATE]. On [DATE] at 9:53 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided a list on [DATE] of 61 residents with full code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibited neglect for one (Resident #1) of seven resident's reviewed for neglect. Based on interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #1) of 7 residents reviewed for neglect. 1. LVN A failed to immediately start CPR and utilize the AED (Automated External Defibrillator) when he determined Resident #1 did not have a pulse or respirations on [DATE] at 5:35 p.m. LVN A left Resident #1 in his room to retrieve the crash cart and other staff members to assist. 2. LVN A, LVN B, LVN C, LVN D, RN E and RN F failed to utilize the AED (Automated External Defibrillator) and initiate chest compressions when LVN A determined Resident #1 did not have a pulse or respirations. Chest compressions were not initiated on Resident #1 until the arrival of EMS at 5:50 p.m. which was 15 minutes after the resident was first assessed to have no vital signs. Resident #1 was transported to the hospital by the paramedics on [DATE] and expired on [DATE] due to diffuse [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect the 61 residents who were full code status, by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings Included: Review of the facility's undated policy, Cardiopulmonary resuscitation (CPR), two person, reflected , .the step-by-step guide for CPR recommended by the American Heart Association .Assess the patient to determine whether they are unresponsive .shout for nearby help and activate the emergency response system .check for pulse .open the airway .Provide rescue breathing .have a coworker retrieve an automated external defibrillator (AED) .Place the patient supine on a firm surface .Immediately begin chest compressions until the AED .is ready for use .Use the AED .to evaluate the patient's rhythm as soon as its ready .both rescuers should continue administering CPR until advanced cardiac life support providers take over or until normal breath and effective circulation return . The facility's policy, Medical Emergency Management, dated February 2017, reflected, The facility ensure residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive .The facility will maintain an Automated External Defibrillator (AED) if required by state regulation . The facility's policy, Abuse & Neglect Prohibition, dated [DATE], reflected, Each resident has the right to be free from .neglect .Definitions .Neglect means a failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm . Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired and required extensive assistance with most ADLs. Resident #1's Care plan dated [DATE] did not address the resident's code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning he wanted all life-saving measures to be taken if he was found without a pulse and respirations) with an order date if [DATE]. Review of Resident #1's nurses' note dated [DATE] at 6:48 p.m., by LVN A, reflected, SBAR ( Situation, Background, Assessment, Request) Summary .Resident was unresponsive in the dining room .Sent to the hospital for further evaluation . Last vital signs documented were on [DATE] at 8:50 a.m. Resident #1's nurses' note dated [DATE] at 4:07 p.m., by LVN A, reflected, Late Entry. Resident was observed on [DATE] at about 5:35 p.m. in the dinning (sic) room having difficulty drinking from his cup while eating dinner. Nurse notified, rushed to the scene and found resident eyes rolling over. Resident was rushed to his room for further evaluation. Unable to get vitals from resident code blue was called, immediately CPR initiated and 911 called in. When paramedics arrived they continued CPR and they left the facility with resident at about 6:40 p.m. for (local hospital) for further evaluation. Resident's (family member) was notified at about 6:45 p.m. and PA was also notified at about 7:00 p.m. In an Interview with LVN A on [DATE] at 11:30 a.m., he stated when he first observed Resident # 1 on [DATE], he was having difficulty holding his cup while he was in the dining room. He stated then the resident's eyes rolled back in his head. He stated he went to get a wheelchair to take the resident out of the dining room so he could assess the resident. He stated one of the CNAs helped him get the resident in the wheelchair. He stated he was not sure if the resident was breathing at that time or not. He stated he told the CNAs to call for help. He stated when he got the resident in his room, he attempted to obtain a pulse and blood pressure and found the resident to have no pulse, blood pressure or respirations. He stated he left the room to retrieve the crash cart, which was stored outside of the unit which he state took less than five minutes. He stated he and LVN B arrived about the same time, and they transferred the resident from the wheelchair onto the floor. He stated they initiated CPR at that time. He stated they did not utilize the AED. He stated he never thought about using the AED. In an interview with CNA H on [DATE] at 2:45 p.m., she stated on [DATE] sometime after 5:00 p.m., she was in the dining room feeding another resident, when she noticed Resident # 1 holding his cup in the air and he was not moving. She stated she and LVN A rushed to the resident. She stated she held the resident up and LVN A ran across the hall and retrieved a wheelchair. She stated while she was holding the resident, he slumped over and his eyes were rolled back in his head and his tongue was hanging out to the side and was blue in color. She stated she and LVN A transferred the resident to the wheelchair and the LVN took him to his room and told her to call for help. She stated she left the unit and told the nurse at the first station, who called the code blue. She stated she saw LVN A come off the unit to get the crash cart. She stated all of the nurse's ran to Resident #1's room. She stated when she walked by the resident's room she saw the resident on the floor and one of the nurse's had put the AMBU (resuscitator) bag over his face. She stated she did not see anyone doing chest compressions. She stated she thought the ambulance arrived within six to ten minutes after she alerted the other nurse's. In an interview with LVN B on [DATE] at 12:40 p.m. he stated that on [DATE] a code blue was called on the locked unit between 5:30 p.m. and 6:00 p.m. He stated when he passed by where the crash cart was stored, he noticed the back board was still in the room, so he grabbed the board. He stated he and LVN A arrived to Resident #1's room with the crash cart and back board. He stated he asked if the resident was a full code and LVN A stated he was. He stated the resident was sitting up in a wheelchair and his eyes were open and appeared fixed. He stated the resident was not breathing. He stated he and LVN A transferred the resident onto the floor and he placed the AMBU bag over the resident's nose and mouth and attempted to give him rescue breaths. He stated he palpated a very faint carotid pulse. He stated they placed a pulse oximeter (device that measures oxygen level in the blood and heart rate), on the resident's finger, and it showed nothing. He stated they did not start chest compression since the resident had a faint pulse. He stated there was another nurse present, but he could not remember who it was. He stated it was very chaotic. He stated he did not think to grab the AED when he grabbed the back board. He stated when the paramedics arrived they started chest compressions. In an interview with LVN C on [DATE] at 12:40 p.m., she stated she responded to the code blue on [DATE]. She stated when she arrived in the room there were several staff members in the room. She stated LVN A and B were on the floor with the resident and she thought they were doing CPR. She stated she did not retrieve the AED or assist with the code. She stated she was not sure how long it took for EMS to arrive or how long they were in the building. In a follow up Interview with LVN A on [DATE] at 1:10 p.m. when asked if he had initiated chest compressions, as he had previously stated, he stated, no I did not. He stated, he was trying to get everything in the room they were going to need. He stated he was overwhelmed and under prepared and just needed help. Review of LVN A's CPR certification record, reflected he was CPR certified through the American Heart Association on [DATE]. In an interview with RN E on [DATE] at 4:00 p.m., she stated she heard the code blue called and rushed to the unit. She stated when she arrived to the room she observed the resident lying on the floor. LVN B was providing breaths with the AMBU bag. She stated the resident initially had a pulse, but when she checked it after about two minutes he did not have a pulse. She stated it was just a few minutes after they found no pulse that EMS arrived. She stated chest compressions were never started by any of the staff prior to the arrival of EMS. She stated no one had grabbed the AED. She stated there was a lot of staff in the room. In an interview with RN F on [DATE] at 4:15 p.m., he stated when he heard the code blue he left his hall and went to the locked unit. He stated he arrived at the room along with LVN A and LVN B who were pushing the crash cart into the room. He stated the resident was slumped over in his wheelchair. He stated LVN A and LVN B placed the resident on the floor on the backboard. He stated LVN B placed the AMBU bag on the resident trying to provide breaths. He stated someone else was checking for a pulse, but stated he was not sure who it was. He stated he did not think the resident had a pulse, but stated he was only in the room a few minutes before EMS arrived. He stated he did not see anyone start chest compressions. He stated he did not think to get the AED. In an interview with LVN D on [DATE] at 9:30 a.m., he stated on [DATE] around 5:00 p.m. they had a code blue on the locked unit. He stated when he arrived at the unit there were numerous staff members present. He stated the resident was on the floor on the back board. He stated someone had already called 911. He stated he was not sure who tried to take vital signs. He stated one of the nurse's said the resident had a pulse so CPR was never started. Review of the EMS Patient Care Record, dated [DATE], reflected, .Call received 5:45 p.m. On Scene 5:50 p.m. was called to [MEDICAL CONDITION]. While en route to call dispatch updated crew that this was now a CPR. Upon arrival pt. (patient) was found lying supine on floor of room with NH (nursing home) staff around. No CPR was being performed. Pt was checked for pulse and found to have none. Pt was warm to touch. Manual CPR was started .After 2 minutes of CPR rhythm was checked and pt. was found to have sinus rhythm on monitor with carotid pulse. Compressions were paused. Pt still did not have any breathing. ET (endotracheal tube- used to open airway) was attempted to be placed .at the same time .another crew member informed us that pt.'s pulse dropped from 75 to 50. Intubation was halted .Pt rechecked to confirm pulse but had none .CPR was resumed and pt. was moved to stretcher .Pt care was transferred to facility ER physician . Departure time was noted as 6:11 p.m. Review of the Hospital record dated [DATE], reflected, [AGE] year-old male reports to ED (emergency department) at 6:21 p.m. in [MEDICAL CONDITION] Pt was successfully intubated .Pt was admitted to ICU . Review of the Hospital Casemangement report dated [DATE], reflected, .This pt. continues to require intubation This pts family plans to withdraw support and admit PT to inpatient hospice this Friday evening . Review of the Hospital discharge summary dated [DATE], reflected, .Patient was seen by neurologist and had a CT of the head, which indicated diffuse [MEDICAL CONDITION] injury. Patient was readmitted under inpatient hospice care on [DATE] .he was extubated and was continued on comfort measure. Patient passed away on [DATE] . In an interview with the Health Information Coordinator on [DATE] at 7:25 a.m., she stated she had received a request from the POA for Resident #1 requesting a copy of the notes from the day Resident # 1 was transferred to the hospital. She stated she faxed him a copy of the Nurse's progress note and the SBAR on [DATE]. She stated on [DATE] he called again and had some questions as to why our notes indicated the resident had a blood pressure and pulse when the hospital records reflected he was in full arrest. She stated the Medical director was in the building, so she asked the Medical Director to speak with the family. She stated the Medical director and the staff spoke to LVN A and determined he had failed to clear out the resident's previous vital signs that had been taken earlier in the day, so the system automatically picked up the latest set of vital signs on the SBAR report. She stated that was when it was discovered that LVN A left the resident in his room unresponsive, and went to get the crash cart instead of starting CPR immediately. In an interview with ADON G on [DATE] at 1:25 p.m. she stated the Medical director asked them on [DATE] to look into the incident that had occurred on [DATE] with Resident #1. She stated it was discovered that LVN A observed Resident #1 in the dining room having difficulty and he took him to his room to assess him. He stated he could not find any vital signs, and that was when he left the resident to go and get the crash cart. She stated he told them he called the code blue and had someone call 911. She stated he told them he went back to the room and started CPR. She stated she just assumed he had done chest compressions. She stated after the incident they in serviced the nursing staff on the ,[DATE] p.m. shift on [DATE] on code response and AED and implemented a Code Worksheet to document all of the information during the code. She stated they did a mock code with those present at the in-service. In an interview on [DATE] with the Medical Director at 1:45 p.m., she stated she had spoken with the Administrator, DON, ADON's, CNA's who worked on the unit and LVN A about the details of what led up to Resident #1's change in condition on [DATE]. She stated the family was concerned that he had been left alone in his room eating, but through her investigation it was determined he was in the dining room with staff and other residents when he became unresponsive. She stated LVN A told them he had removed the resident from the dining room and took him to his room where he determined the resident had no pulse. He then called for help and left the resident's room to retrieve the crash cart. The Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. She stated she instructed the Administrative staff to complete an in- service on CPR and response time to all of the staff. In an interview with the Administrator on [DATE] at 9:25 a.m., she stated she had been on medical leave until [DATE] and her DON had also been on medical leave until [DATE]. She stated the facility had an Administrator in training covering for her and they had an interim DON covering for the current DON. In an interview with the Interim DON on [DATE] at 1:25 p.m., she stated she had filled in for about six weeks while the DON was on leave. She stated she vaguely remembered the incident that occurred on [DATE]. She stated the Medical Director had spoken with the family and had asked that they do training on the nursing staff on how to respond to a code and the initiation of CPR. She stated they did a Mock CPR drill for some of the staff on 1st and 2nd shift, but had not gotten around to the night shift. Review of the In-service Records reflected nine direct care staff were in serviced on CPR Procedure. Of the Nine participants only three of the six nurses (LVN A, LVN B and LVN C) who were involved in the incident on [DATE] received the in service training on [DATE]. No additional training was done until [DATE]. Interview with the AIT (Administrator in Training) on [DATE] at 2:05 p.m. revealed she was aware that Resident #1 had to be sent to theER on [DATE] due to being unresponsive. She stated she was made aware of the family's concerns about the medical records and the Medical Director had spoken to the family after she had talked with LVN A. She stated it was her understanding that the nurse left the resident in his room to retrieve the crash cart. She stated the Medical Director had wanted in-services done with the staff. She stated she knew in-services were done on the ,[DATE] p.m. shift and that the reminder of the staff was to be scheduled when time permitted. She stated she did not know of any disciplinary actions against any of the nurses. In an interview with the Administrator and the DON on [DATE] at 4:45 p.m., the Administrator stated she felt that if she and the DON had not both been out on leave, this incident would have been investigated in much greater detail and staff would have been in serviced and or disciplined. The DON stated with being back one day, she had not had the opportunity to look into this situation until today. She stated she would be initiating in-services on the entire staff on the facility's expectations for emergency management, CPR and the AED. The DON stated she hated that her staff were poorly prepared to manage this emergency. Record Review on [DATE] of all the facility's Nurses' CPR certification revealed nurses were CPR certified on all shifts. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions .check for no breathing .immediately begin CPR, and use the AED .(retrieved on [DATE]). The Administrator was notified on [DATE] at 10:55 a.m. that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:12 p.m. and included: (Name) licensed nurse failed to remain with the resident on [DATE], to initiate CPR once vital signs were not obtained. 1. The licensed nurse identified in the Immediate Jeopardy was terminated on [DATE]. The resident identified in the Immediate Jeopardy no longer resides at this facility. 2. All licensed nurses will be re-educated on Medical Emergency Management Policy and Procedure by the DON by 2pm on [DATE]. Any licensed nurse who has not received the re-education will not be allowed to clock in and work until they have received the education. 3. The content of the re-education is as follows: Call for help and stay with the patient (use call light or yell or assistance) The nurse will determine if the resident has a pulse or breath sounds If victim is unresponsive shout for nearby help. Assess for breathing and pulse. -If the patient is breathing and has a pulse, closely monitor until emergency staff arrives. -If a patient is not breathing but has a pulse, start rescue breaths. -If the patient has no pulse, begin CPR ***The nurse in charge of the code will continue to provide CPR while sending other staff members to call 911, obtain the crash cart, AED, and backboard. Staff will continue interventions until emergency assistance arrives. The Director of Nursing will monitor progress by performing Mock Codes and evaluate the nurse's performance. Evaluations checklist will be performed on participants. Re-education will be performed for anyone who is not able to perform the procedure adequately. Post test will be given to all nurses. The Director of Nursing will report progress of this process to the QAPI Committee monthly x 3 month. Interviews on [DATE] from 9:50 a.m. to 4:35 p.m. revealed six of six Charge Nurses representing all three shifts (LVNs D, I, J, C B and K) all understood to initiate CPR and utilize the AED immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interview on [DATE] at 8:15 a.m. with the Administrator and DON stated they had in serviced the majority of the staff, not only the Nurse's but all staff. The administrator stated the remainder of the staff would not be allowed to clock in until they complete the in service training and check offs. Interviews on [DATE] from 8:25 a.m. to 9:45 a.m. revealed six of six Charge nurse's representing all three shifts and weekends (LVNs L, M, O, P and RN's N and E) revealed they had received in- service training and understood to initiate CPR and utilized the AED immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of facility staffing reflected the last date LVN A worked was [DATE]. On [DATE] at 9:53 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided a list on [DATE] of 61 residents with full code status.

Based on interview and record review, the facility failed to provide services, as outlined by the comprehensive care plan, that met professional standards of quality for one (Resident #1) of seven residents reviewed for neglect. 1. LVN A, who was CPR certified, failed to immediately start CPR and utilize the AED (Automated External Defibrillator) when he determined Resident #1 did not have a pulse or respirations on [DATE] at 5:35 p.m. LVN A left Resident #1 in his room to retrieve the crash cart and other staff members to assist. 2. LVN B, LVN C, LVN D, RN E and RN F failed to utilize the AED (Automated External Defibrillator) and initiate chest compressions when LVN A determined Resident #1 did not have a pulse or respirations. Chest compressions were not initiated on Resident #1 until the arrival of EMS at 5:50 p.m. which was 15 minutes after the resident was first assessed to have no vital signs. Resident #1 was transported to the hospital by the paramedics on [DATE] and expired on [DATE] due to diffuse [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect the 61 residents who were full code status, by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings Included: The Texas Administrative Code Rule §217.11 reflected, The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired and required extensive assistance with most ADLs. Resident #1's Care plan dated [DATE] did not address the resident's code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning he wanted all life-saving measures to be taken if he was found without a pulse and respirations) with an order date if [DATE]. Review of Resident #1's nurses' note dated [DATE] at 6:48 p.m., by LVN A, reflected, SBAR ( Situation, Background, Assessment, Request) Summary .Resident was unresponsive in the dining room .Sent to the hospital for further evaluation . Last vital signs documented were on [DATE] at 8:50 a.m. Resident #1's nurses' note dated [DATE] at 4:07 p.m., by LVN A, reflected, Late Entry. Resident was observed on [DATE] at about 5:35 p.m. in the dinning (sic) room having difficulty drinking from his cup while eating dinner. Nurse notified, rushed to the scene and found resident eyes rolling over. Resident was rushed to his room for further evaluation. Unable to get vitals from resident code blue was called, immediately CPR initiated and 911 called in. When paramedics arrived they continued CPR and they left the facility with resident at about 6:40 p.m. for (local hospital) for further evaluation. Resident's (family member) was notified at about 6:45 p.m. and PA was also notified at about 7:00 p.m. In an Interview with LVN A on [DATE] at 11:30 a.m., he stated when he first observed Resident # 1 on [DATE], he was having difficulty holding his cup while he was in the dining room. He stated then the resident's eyes rolled back in his head. He stated he went to get a wheelchair to take the resident out of the dining room so he could assess the resident. He stated one of the CNAs helped him get the resident in the wheelchair. He stated he was not sure if the resident was breathing at that time or not. He stated he told the CNAs to call for help. He stated when he got the resident in his room, he attempted to obtain a pulse and blood pressure and found the resident to have no pulse, blood pressure or respirations. He stated he left the room to retrieve the crash cart, which was stored outside of the unit which he state took less than five minutes. He stated he and LVN B arrived about the same time, and they transferred the resident from the wheelchair onto the floor. He stated they initiated CPR at that time. He stated they did not utilize the AED. He stated he never thought about using the AED. In an interview with CNA H on [DATE] at 2:45 p.m., she stated on [DATE] sometime after 5:00 p.m., she was in the dining room feeding another resident, when she noticed Resident # 1 holding his cup in the air and he was not moving. She stated she and LVN A rushed to the resident. She stated she held the resident up and LVN A ran across the hall and retrieved a wheelchair. She stated while she was holding the resident, he slumped over and his eyes were rolled back in his head and his tongue was hanging out to the side and was blue in color. She stated she and LVN A transferred the resident to the wheelchair and the LVN took him to his room and told her to call for help. She stated she left the unit and told the nurse at the first station, who called the code blue. She stated she saw LVN A come off the unit to get the crash cart. She stated all of the nurse's ran to Resident #1's room. She stated when she walked by the resident's room she saw the resident on the floor and one of the nurse's had put the AMBU (resuscitator) bag over his face. She stated she did not see anyone doing chest compressions. She stated she thought the ambulance arrived within six to ten minutes after she alerted the other nurse's. In an interview with LVN B on [DATE] at 12:40 p.m. he stated that on [DATE] a code blue was called on the locked unit between 5:30 p.m. and 6:00 p.m. He stated when he passed by where the crash cart was stored, he noticed the back board was still in the room, so he grabbed the board. He stated he and LVN A arrived to Resident #1's room with the crash cart and back board. He stated he asked if the resident was a full code and LVN A stated he was. He stated the resident was sitting up in a wheelchair and his eyes were open and appeared fixed. He stated the resident was not breathing. He stated he and LVN A transferred the resident onto the floor and he placed the AMBU bag over the resident's nose and mouth and attempted to give him rescue breaths. He stated he palpated a very faint carotid pulse. He stated they placed a pulse oximeter (device that measures oxygen level in the blood and heart rate), on the resident's finger, and it showed nothing. He stated they did not start chest compression since the resident had a faint pulse. He stated there was another nurse present, but he could not remember who it was. He stated it was very chaotic. He stated he did not think to grab the AED when he grabbed the back board. He stated when the paramedics arrived they started chest compressions. In an interview with LVN C on [DATE] at 12:40 p.m., she stated she responded to the code blue on [DATE]. She stated when she arrived in the room there were several staff members in the room. She stated LVN A and B were on the floor with the resident and she thought they were doing CPR. She stated she did not retrieve the AED or assist with the code. She stated she was not sure how long it took for EMS to arrive or how long they were in the building. In a follow up Interview with LVN A on [DATE] at 1:10 p.m. when asked if he had initiated chest compressions, as he had previously stated, he stated, no I did not. He stated, he was trying to get everything in the room they were going to need. He stated he was overwhelmed and under prepared and just needed help. Review of LVN A's CPR certification record, reflected he was CPR certified through the American Heart Association on [DATE]. In an interview with RN E on [DATE] at 4:00 p.m., she stated she heard the code blue called and rushed to the unit. She stated when she arrived to the room she observed the resident lying on the floor. LVN B was providing breaths with the AMBU bag. She stated the resident initially had a pulse, but when she checked it after about two minutes he did not have a pulse. She stated it was just a few minutes after they found no pulse that EMS arrived. She stated chest compressions were never started by any of the staff prior to the arrival of EMS. She stated no one had grabbed the AED. She stated there was a lot of staff in the room. In an interview with RN F on [DATE] at 4:15 p.m., he stated when he heard the code blue he left his hall and went to the locked unit. He stated he arrived at the room along with LVN A and LVN B who were pushing the crash cart into the room. He stated the resident was slumped over in his wheelchair. He stated LVN A and LVN B placed the resident on the floor on the backboard. He stated LVN B placed the AMBU bag on the resident trying to provide breaths. He stated someone else was checking for a pulse, but stated he was not sure who it was. He stated he did not think the resident had a pulse, but stated he was only in the room a few minutes before EMS arrived. He stated he did not see anyone start chest compressions. He stated he did not think to get the AED. In an interview with LVN D on [DATE] at 9:30 a.m., he stated on [DATE] around 5:00 p.m. they had a code blue on the locked unit. He stated when he arrived at the unit there were numerous staff members present. He stated the resident was on the floor on the back board. He stated someone had already called 911. He stated he was not sure who tried to take vital signs. He stated one of the nurse's said the resident had a pulse so CPR was never started. Review of the EMS Patient Care Record, dated [DATE], reflected, .Call received 5:45 p.m. On Scene 5:50 p.m. was called to [MEDICAL CONDITION]. While en route to call dispatch updated crew that this was now a CPR. Upon arrival pt. (patient) was found lying supine on floor of room with NH (nursing home) staff around. No CPR was being performed. Pt was checked for pulse and found to have none. Pt was warm to touch. Manual CPR was started .After 2 minutes of CPR rhythm was checked and pt. was found to have sinus rhythm on monitor with carotid pulse. Compressions were paused. Pt still did not have any breathing. ET (endotracheal tube- used to open airway) was attempted to be placed .at the same time .another crew member informed us that pt.'s pulse dropped from 75 to 50. Intubation was halted .Pt rechecked to confirm pulse but had none .CPR was resumed and pt. was moved to stretcher .Pt care was transferred to facility ER physician . Departure time was noted as 6:11 p.m. Review of the Hospital record dated [DATE], reflected, [AGE] year-old male reports to ED (emergency department) at 6:21 p.m. in [MEDICAL CONDITION] Pt was successfully intubated .Pt was admitted to ICU . Review of the Hospital Casemangement report dated [DATE], reflected, .This pt. continues to require intubation This pts family plans to withdraw support and admit PT to inpatient hospice this Friday evening . Review of the Hospital discharge summary dated [DATE], reflected, .Patient was seen by neurologist and had a CT of the head, which indicated diffuse [MEDICAL CONDITION] injury. Patient was readmitted under inpatient hospice care on [DATE] .he was extubated and was continued on comfort measure. Patient passed away on [DATE] . In an interview with the Health Information Coordinator on [DATE] at 7:25 a.m., she stated she had received a request from the POA for Resident #1 requesting a copy of the notes from the day Resident # 1 was transferred to the hospital. She stated she faxed him a copy of the Nurse's progress note and the SBAR on [DATE]. She stated on [DATE] he called again and had some questions as to why our notes indicated the resident had a blood pressure and pulse when the hospital records reflected he was in full arrest. She stated the Medical director was in the building, so she asked the Medical Director to speak with the family. She stated the Medical director and the staff spoke to LVN A and determined he had failed to clear out the resident's previous vital signs that had been taken earlier in the day, so the system automatically picked up the latest set of vital signs on the SBAR report. She stated that was when it was discovered that LVN A left the resident in his room unresponsive, and went to get the crash cart instead of starting CPR immediately. In an interview with ADON G on [DATE] at 1:25 p.m. she stated the Medical director asked them on [DATE] to look into the incident that had occurred on [DATE] with Resident #1. She stated it was discovered that LVN A observed Resident #1 in the dining room having difficulty and he took him to his room to assess him. He stated he could not find any vital signs, and that was when he left the resident to go and get the crash cart. She stated he told them he called the code blue and had someone call 911. She stated he told them he went back to the room and started CPR. She stated she just assumed he had done chest compressions. She stated after the incident they in serviced the nursing staff on the ,[DATE] p.m. shift on [DATE] on code response and AED and implemented a Code Worksheet to document all of the information during the code. She stated they did a mock code with those present at the in-service. In an interview on [DATE] with the Medical Director at 1:45 p.m., she stated she had spoken with the Administrator, DON, ADON's, CNA's who worked on the unit and LVN A about the details of what led up to Resident #1's change in condition on [DATE]. She stated the family was concerned that he had been left alone in his room eating, but through her investigation it was determined he was in the dining room with staff and other residents when he became unresponsive. She stated LVN A told them he had removed the resident from the dining room and took him to his room where he determined the resident had no pulse. He then called for help and left the resident's room to retrieve the crash cart. The Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. She stated she instructed the Administrative staff to complete an in- service on CPR and response time to all of the staff. In an interview with the Administrator on [DATE] at 9:25 a.m., she stated she had been on medical leave until [DATE] and her DON had also been on medical leave until [DATE]. She stated the facility had an Administrator in training covering for her and they had an interim DON covering for the current DON. In an interview with the Interim DON on [DATE] at 1:25 p.m., she stated she had filled in for about six weeks while the DON was on leave. She stated she vaguely remembered the incident that occurred on [DATE]. She stated the Medical Director had spoken with the family and had asked that they do training on the nursing staff on how to respond to a code and the initiation of CPR. She stated they did a Mock CPR drill for some of the staff on 1st and 2nd shift, but had not gotten around to the night shift. Review of the In-service Records reflected nine direct care staff were in serviced on CPR Procedure. Of the Nine participants only three of the six nurses (LVN A, LVN B and LVN C) who were involved in the incident on [DATE] received the in service training on [DATE]. No additional training was done until [DATE]. Interview with the AIT (Administrator in Training) on [DATE] at 2:05 p.m. revealed she was aware that Resident #1 had to be sent to theER on [DATE] due to being unresponsive. She stated she was made aware of the family's concerns about the medical records and the Medical Director had spoken to the family after she had talked with LVN A. She stated it was her understanding that the nurse left the resident in his room to retrieve the crash cart. She stated the Medical Director had wanted in-services done with the staff. She stated she knew in-services were done on the ,[DATE] p.m. shift and that the reminder of the staff was to be scheduled when time permitted. She stated she did not know of any disciplinary actions against any of the nurses. In an interview with the Administrator and the DON on [DATE] at 4:45 p.m., the Administrator stated she felt that if she and the DON had not both been out on leave, this incident would have been investigated in much greater detail and staff would have been in serviced and or disciplined. The DON stated with being back one day, she had not had the opportunity to look into this situation until today. She stated she would be initiating in-services on the entire staff on the facility's expectations for emergency management, CPR and the AED. The DON stated she hated that her staff were poorly prepared to manage this emergency. Record Review on [DATE] of all the facility's Nurses' CPR certification revealed nurses were CPR certified on all shifts. Review of the facility's undated policy, Cardiopulmonary resuscitation (CPR), two person, reflected , .the step-by-step guide for CPR recommended by the American Heart Association .Assess the patient to determine whether they are unresponsive .shout for nearby help and activate the emergency response system .check for pulse .open the airway .Provide rescue breathing .have a coworker retrieve an automated external defibrillator (AED) .Place the patient supine on a firm surface .Immediately begin chest compressions until the AED .is ready for use .Use the AED .to evaluate the patient's rhythm as soon as its ready .both rescuers should continue administering CPR until advanced cardiac life support providers take over or until normal breath and effective circulation return . The facility's policy, Medical Emergency Management, dated February 2017, reflected, The facility ensure residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive .The facility will maintain an Automated External Defibrillator (AED) if required by state regulation . The facility's policy, Abuse & Neglect Prohibition, dated [DATE], reflected, Each resident has the right to be free from .neglect .Definitions .Neglect means a failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm . The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions .check for no breathing .immediately begin CPR, and use the AED .(retrieved on [DATE]). The Administrator was notified on [DATE] at 10:55 a.m. that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:12 p.m. and included: (Name) licensed nurse failed to remain with the resident on [DATE], to initiate CPR once vital signs were not obtained. 1. The licensed nurse identified in the Immediate Jeopardy was terminated on [DATE]. The resident identified in the Immediate Jeopardy no longer resides at this facility. 2. All licensed nurses will be re-educated on Medical Emergency Management Policy and Procedure by the DON by 2pm on [DATE]. Any licensed nurse who has not received the re-education will not be allowed to clock in and work until they have received the education. 3. The content of the re-education is as follows: Call for help and stay with the patient (use call light or yell or assistance) The nurse will determine if the resident has a pulse or breath sounds If victim is unresponsive shout for nearby help. Assess for breathing and pulse. -If the patient is breathing and has a pulse, closely monitor until emergency staff arrives. -If a patient is not breathing but has a pulse, start rescue breaths. -If the patient has no pulse, begin CPR ***The nurse in charge of the code will continue to provide CPR while sending other staff members to call 911, obtain the crash cart, AED, and backboard. Staff will continue interventions until emergency assistance arrives. The Director of Nursing will monitor progress by performing Mock Codes and evaluate the nurse's performance. Evaluations checklist will be performed on participants. Re-education will be performed for anyone who is not able to perform the procedure adequately. Post test will be given to all nurses. The Director of Nursing will report progress of this process to the QAPI Committee monthly x 3 month. Interviews on [DATE] from 9:50 a.m. to 4:35 p.m. revealed six of six Charge Nurses representing all three shifts (LVNs D, I, J, C B and K) all understood to initiate CPR and utilize the AED immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interview on [DATE] at 8:15 a.m. with the Administrator and DON stated they had in serviced the majority of the staff, not only the Nurse's but all staff. The administrator stated the remainder of the staff would not be allowed to clock in until they complete the in service training and check offs. Interviews on [DATE] from 8:25 a.m. to 9:45 a.m. revealed six of six Charge nurse's representing all three shifts and weekends (LVNs L, M, O, P and RN's N and E) revealed they had received in- service training and understood to initiate CPR and utilized the AED immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of facility staffing reflected the last date LVN A worked was [DATE]. On [DATE] at 9:53 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided a list on [DATE] of 61 residents with full code status.

Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of seven residents reviewed for change in condition . 1. LVN A failed to immediately start CPR and utilize the AED (Automated External Defibrillator) when he determined Resident #1 did not have a pulse or respirations on [DATE] at 5:35 p.m. LVN A left Resident #1 in his room to retrieve the crash cart and other staff members to assist. 2. LVN A, LVN B, LVN C, LVN D, RN E and RN F failed to utilize the AED (Automated External Defibrillator) and initiate chest compressions when LVN A determined Resident #1 did not have a pulse or respirations. Chest compressions were not initiated on Resident #1 until the arrival of EMS at 5:50 p.m. which was 15 minutes after the resident was first assessed to have no vital signs. Resident #1 was transported to the hospital by the paramedics on [DATE] and expired on [DATE] due to diffuse [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect the 61 residents who were full code status, by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings Included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired and required extensive assistance with most ADLs. Resident #1's Care plan dated [DATE] did not address the resident's code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning he wanted all life-saving measures to be taken if he was found without a pulse and respirations) with an order date if [DATE]. Review of Resident #1's nurses' note dated [DATE] at 6:48 p.m., by LVN A, reflected, SBAR ( Situation, Background, Assessment, Request) Summary .Resident was unresponsive in the dining room .Sent to the hospital for further evaluation . Last vital signs documented were on [DATE] at 8:50 a.m. Resident #1's nurses' note dated [DATE] at 4:07 p.m., by LVN A, reflected, Late Entry. Resident was observed on [DATE] at about 5:35 p.m. in the dinning (sic) room having difficulty drinking from his cup while eating dinner. Nurse notified, rushed to the scene and found resident eyes rolling over. Resident was rushed to his room for further evaluation. Unable to get vitals from resident code blue was called, immediately CPR initiated and 911 called in. When paramedics arrived they continued CPR and they left the facility with resident at about 6:40 p.m. for (local hospital) for further evaluation. Resident's (family member) was notified at about 6:45 p.m. and PA was also notified at about 7:00 p.m. In an Interview with LVN A on [DATE] at 11:30 a.m., he stated when he first observed Resident # 1 on [DATE], he was having difficulty holding his cup while he was in the dining room. He stated then the resident's eyes rolled back in his head. He stated he went to get a wheelchair to take the resident out of the dining room so he could assess the resident. He stated one of the CNAs helped him get the resident in the wheelchair. He stated he was not sure if the resident was breathing at that time or not. He stated he told the CNAs to call for help. He stated when he got the resident in his room, he attempted to obtain a pulse and blood pressure and found the resident to have no pulse, blood pressure or respirations. He stated he left the room to retrieve the crash cart, which was stored outside of the unit which he state took less than five minutes. He stated he and LVN B arrived about the same time, and they transferred the resident from the wheelchair onto the floor. He stated they initiated CPR at that time. He stated they did not utilize the AED. He stated he never thought about using the AED. In an interview with CNA H on [DATE] at 2:45 p.m., she stated on [DATE] sometime after 5:00 p.m., she was in the dining room feeding another resident, when she noticed Resident # 1 holding his cup in the air and he was not moving. She stated she and LVN A rushed to the resident. She stated she held the resident up and LVN A ran across the hall and retrieved a wheelchair. She stated while she was holding the resident, he slumped over and his eyes were rolled back in his head and his tongue was hanging out to the side and was blue in color. She stated she and LVN A transferred the resident to the wheelchair and the LVN took him to his room and told her to call for help. She stated she left the unit and told the nurse at the first station, who called the code blue. She stated she saw LVN A come off the unit to get the crash cart. She stated all of the nurse's ran to Resident #1's room. She stated when she walked by the resident's room she saw the resident on the floor and one of the nurse's had put the AMBU (resuscitator) bag over his face. She stated she did not see anyone doing chest compressions. She stated she thought the ambulance arrived within six to ten minutes after she alerted the other nurse's. In an interview with LVN B on [DATE] at 12:40 p.m. he stated that on [DATE] a code blue was called on the locked unit between 5:30 p.m. and 6:00 p.m. He stated when he passed by where the crash cart was stored, he noticed the back board was still in the room, so he grabbed the board. He stated he and LVN A arrived to Resident #1's room with the crash cart and back board. He stated he asked if the resident was a full code and LVN A stated he was. He stated the resident was sitting up in a wheelchair and his eyes were open and appeared fixed. He stated the resident was not breathing. He stated he and LVN A transferred the resident onto the floor and he placed the AMBU bag over the resident's nose and mouth and attempted to give him rescue breaths. He stated he palpated a very faint carotid pulse. He stated they placed a pulse oximeter (device that measures oxygen level in the blood and heart rate), on the resident's finger, and it showed nothing. He stated they did not start chest compression since the resident had a faint pulse. He stated there was another nurse present, but he could not remember who it was. He stated it was very chaotic. He stated he did not think to grab the AED when he grabbed the back board. He stated when the paramedics arrived they started chest compressions. In an interview with LVN C on [DATE] at 12:40 p.m., she stated she responded to the code blue on [DATE]. She stated when she arrived in the room there were several staff members in the room. She stated LVN A and B were on the floor with the resident and she thought they were doing CPR. She stated she did not retrieve the AED or assist with the code. She stated she was not sure how long it took for EMS to arrive or how long they were in the building. In a follow up Interview with LVN A on [DATE] at 1:10 p.m. when asked if he had initiated chest compressions, as he had previously stated, he stated, no I did not. He stated, he was trying to get everything in the room they were going to need. He stated he was overwhelmed and under prepared and just needed help. Review of LVN A's CPR certification record, reflected he was CPR certified through the American Heart Association on [DATE]. In an interview with RN E on [DATE] at 4:00 p.m., she stated she heard the code blue called and rushed to the unit. She stated when she arrived to the room she observed the resident lying on the floor. LVN B was providing breaths with the AMBU bag. She stated the resident initially had a pulse, but when she checked it after about two minutes he did not have a pulse. She stated it was just a few minutes after they found no pulse that EMS arrived. She stated chest compressions were never started by any of the staff prior to the arrival of EMS. She stated no one had grabbed the AED. She stated there was a lot of staff in the room. In an interview with RN F on [DATE] at 4:15 p.m., he stated when he heard the code blue he left his hall and went to the locked unit. He stated he arrived at the room along with LVN A and LVN B who were pushing the crash cart into the room. He stated the resident was slumped over in his wheelchair. He stated LVN A and LVN B placed the resident on the floor on the backboard. He stated LVN B placed the AMBU bag on the resident trying to provide breaths. He stated someone else was checking for a pulse, but stated he was not sure who it was. He stated he did not think the resident had a pulse, but stated he was only in the room a few minutes before EMS arrived. He stated he did not see anyone start chest compressions. He stated he did not think to get the AED. In an interview with LVN D on [DATE] at 9:30 a.m., he stated on [DATE] around 5:00 p.m. they had a code blue on the locked unit. He stated when he arrived at the unit there were numerous staff members present. He stated the resident was on the floor on the back board. He stated someone had already called 911. He stated he was not sure who tried to take vital signs. He stated one of the nurse's said the resident had a pulse so CPR was never started. Review of the EMS Patient Care Record, dated [DATE], reflected, .Call received 5:45 p.m. On Scene 5:50 p.m. was called to [MEDICAL CONDITION]. While en route to call dispatch updated crew that this was now a CPR. Upon arrival pt. (patient) was found lying supine on floor of room with NH (nursing home) staff around. No CPR was being performed. Pt was checked for pulse and found to have none. Pt was warm to touch. Manual CPR was started .After 2 minutes of CPR rhythm was checked and pt. was found to have sinus rhythm on monitor with carotid pulse. Compressions were paused. Pt still did not have any breathing. ET (endotracheal tube- used to open airway) was attempted to be placed .at the same time .another crew member informed us that pt.'s pulse dropped from 75 to 50. Intubation was halted .Pt rechecked to confirm pulse but had none .CPR was resumed and pt. was moved to stretcher .Pt care was transferred to facility ER physician . Departure time was noted as 6:11 p.m. Review of the Hospital record dated [DATE], reflected, [AGE] year-old male reports to ED (emergency department) at 6:21 p.m. in [MEDICAL CONDITION] Pt was successfully intubated .Pt was admitted to ICU . Review of the Hospital Casemangement report dated [DATE], reflected, .This pt. continues to require intubation This pts family plans to withdraw support and admit PT to inpatient hospice this Friday evening . Review of the Hospital discharge summary dated [DATE], reflected, .Patient was seen by neurologist and had a CT of the head, which indicated diffuse [MEDICAL CONDITION] injury. Patient was readmitted under inpatient hospice care on [DATE] .he was extubated and was continued on comfort measure. Patient passed away on [DATE] . In an interview with the Health Information Coordinator on [DATE] at 7:25 a.m., she stated she had received a request from the POA for Resident #1 requesting a copy of the notes from the day Resident # 1 was transferred to the hospital. She stated she faxed him a copy of the Nurse's progress note and the SBAR on [DATE]. She stated on [DATE] he called again and had some questions as to why our notes indicated the resident had a blood pressure and pulse when the hospital records reflected he was in full arrest. She stated the Medical director was in the building, so she asked the Medical Director to speak with the family. She stated the Medical director and the staff spoke to LVN A and determined he had failed to clear out the resident's previous vital signs that had been taken earlier in the day, so the system automatically picked up the latest set of vital signs on the SBAR report. She stated that was when it was discovered that LVN A left the resident in his room unresponsive, and went to get the crash cart instead of starting CPR immediately. In an interview with ADON G on [DATE] at 1:25 p.m. she stated the Medical director asked them on [DATE] to look into the incident that had occurred on [DATE] with Resident #1. She stated it was discovered that LVN A observed Resident #1 in the dining room having difficulty and he took him to his room to assess him. He stated he could not find any vital signs, and that was when he left the resident to go and get the crash cart. She stated he told them he called the code blue and had someone call 911. She stated he told them he went back to the room and started CPR. She stated she just assumed he had done chest compressions. She stated after the incident they in serviced the nursing staff on the ,[DATE] p.m. shift on [DATE] on code response and AED and implemented a Code Worksheet to document all of the information during the code. She stated they did a mock code with those present at the in-service. In an interview on [DATE] with the Medical Director at 1:45 p.m., she stated she had spoken with the Administrator, DON, ADON's, CNA's who worked on the unit and LVN A about the details of what led up to Resident #1's change in condition on [DATE]. She stated the family was concerned that he had been left alone in his room eating, but through her investigation it was determined he was in the dining room with staff and other residents when he became unresponsive. She stated LVN A told them he had removed the resident from the dining room and took him to his room where he determined the resident had no pulse. He then called for help and left the resident's room to retrieve the crash cart. The Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. She stated she instructed the Administrative staff to complete an in- service on CPR and response time to all of the staff. In an interview with the Administrator on [DATE] at 9:25 a.m., she stated she had been on medical leave until [DATE] and her DON had also been on medical leave until [DATE]. She stated the facility had an Administrator in training covering for her and they had an interim DON covering for the current DON. In an interview with the Interim DON on [DATE] at 1:25 p.m., she stated she had filled in for about six weeks while the DON was on leave. She stated she vaguely remembered the incident that occurred on [DATE]. She stated the Medical Director had spoken with the family and had asked that they do training on the nursing staff on how to respond to a code and the initiation of CPR. She stated they did a Mock CPR drill for some of the staff on 1st and 2nd shift, but had not gotten around to the night shift. Review of the In-service Records reflected nine direct care staff were in serviced on CPR Procedure. Of the Nine participants only three of the six nurses (LVN A, LVN B and LVN C) who were involved in the incident on [DATE] received the in service training on [DATE]. No additional training was done until [DATE]. Interview with the AIT (Administrator in Training) on [DATE] at 2:05 p.m. revealed she was aware that Resident #1 had to be sent to theER on [DATE] due to being unresponsive. She stated she was made aware of the family's concerns about the medical records and the Medical Director had spoken to the family after she had talked with LVN A. She stated it was her understanding that the nurse left the resident in his room to retrieve the crash cart. She stated the Medical Director had wanted in-services done with the staff. She stated she knew in-services were done on the ,[DATE] p.m. shift and that the reminder of the staff was to be scheduled when time permitted. She stated she did not know of any disciplinary actions against any of the nurses. In an interview with the Administrator and the DON on [DATE] at 4:45 p.m., the Administrator stated she felt that if she and the DON had not both been out on leave, this incident would have been investigated in much greater detail and staff would have been in serviced and or disciplined. The DON stated with being back one day, she had not had the opportunity to look into this situation until today. She stated she would be initiating in-services on the entire staff on the facility's expectations for emergency management, CPR and the AED. The DON stated she hated that her staff were poorly prepared to manage this emergency. Record Review on [DATE] of all the facility's Nurses' CPR certification revealed nurses were CPR certified on all shifts. Review of the facility's undated policy, Cardiopulmonary resuscitation (CPR), two person, reflected , .the step-by-step guide for CPR recommended by the American Heart Association .Assess the patient to determine whether they are unresponsive .shout for nearby help and activate the emergency response system .check for pulse .open the airway .Provide rescue breathing .have a coworker retrieve an automated external defibrillator (AED) .Place the patient supine on a firm surface .Immediately begin chest compressions until the AED .is ready for use .Use the AED .to evaluate the patient's rhythm as soon as its ready .both rescuers should continue administering CPR until advanced cardiac life support providers take over or until normal breath and effective circulation return . The facility's policy, Medical Emergency Management, dated February 2017, reflected, The facility ensure residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive .The facility will maintain an Automated External Defibrillator (AED) if required by state regulation . The facility's policy, Abuse & Neglect Prohibition, dated [DATE], reflected, Each resident has the right to be free from .neglect .Definitions .Neglect means a failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm . The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions .check for no breathing .immediately begin CPR, and use the AED .(retrieved on [DATE]). The Administrator was notified on [DATE] at 10:55 a.m. that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:12 p.m. and included: (Name) licensed nurse failed to remain with the resident on [DATE], to initiate CPR once vital signs were not obtained. 1. The licensed nurse identified in the Immediate Jeopardy was terminated on [DATE]. The resident identified in the Immediate Jeopardy no longer resides at this facility. 2. All licensed nurses will be re-educated on Medical Emergency Management Policy and Procedure by the DON by 2pm on [DATE]. Any licensed nurse who has not received the re-education will not be allowed to clock in and work until they have received the education. 3. The content of the re-education is as follows: Call for help and stay with the patient (use call light or yell or assistance) The nurse will determine if the resident has a pulse or breath sounds If victim is unresponsive shout for nearby help. Assess for breathing and pulse. -If the patient is breathing and has a pulse, closely monitor until emergency staff arrives. -If a patient is not breathing but has a pulse, start rescue breaths. -If the patient has no pulse, begin CPR ***The nurse in charge of the code will continue to provide CPR while sending other staff members to call 911, obtain the crash cart, AED, and backboard. Staff will continue interventions until emergency assistance arrives. The Director of Nursing will monitor progress by performing Mock Codes and evaluate the nurse's performance. Evaluations checklist will be performed on participants. Re-education will be performed for anyone who is not able to perform the procedure adequately. Post test will be given to all nurses. The Director of Nursing will report progress of this process to the QAPI Committee monthly x 3 month. Interviews on [DATE] from 9:50 a.m. to 4:35 p.m. revealed six of six Charge Nurses representing all three shifts (LVNs D, I, J, C B and K) all understood to initiate CPR and utilize the AED immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interview on [DATE] at 8:15 a.m. with the Administrator and DON stated they had in serviced the majority of the staff, not only the Nurse's but all staff. The administrator stated the remainder of the staff would not be allowed to clock in until they complete the in service training and check offs. Interviews on [DATE] from 8:25 a.m. to 9:45 a.m. revealed six of six Charge nurse's representing all three shifts and weekends (LVNs L, M, O, P and RN's N and E) revealed they had received in- service training and understood to initiate CPR and utilized the AED immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of facility staffing reflected the last date LVN A worked was [DATE]. On [DATE] at 9:53 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided a list on [DATE] of 61 residents with full code status.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident#3) of five sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #3 fell on [DATE] and sustained a hematoma to his forehead measuring 8.0 cm x 8.0 cm with a 2.0 cm abrasion. The resident fell again on 04/06/2012, without serious injury. The resident had a third fall on 06/01/2012 at which time he sustained a serious laceration to his left brow along with multiple facial fractures. The care-planned nursing interventions to address the resident's falls were not individualized to take into account the resident's severe cognitive impairment and short-term memory deficits. Adequate supervision to prevent these falls also was not provided in a manner sufficient to prevent the resident from falling when he was known to stand and ambulate independently with a hurried, running gait. This failure could result in the facility's 14 residents, including Resident #3, who resided in the facility's only secured unit, and placed them at risk for sustaining serious injuries, and experiencing undue pain and discomfort. Findings included: 1) Resident #3's quarterly MDS assessment signed by the RN Assessment Coordinator on 03/06/2012 reflected the Assessment Reference Date was 02/21/2012. The active [DIAGNOSES REDACTED]. The assessment reflected the BIMS was unable to be completed via resident interview due to the resident's inability to complete one or more questions of the interview. The staff assessment of the resident's cognitive skills for daily decision-making reflected he had severe cognitive impairment with both short-term and long-term memory problems. The MDS assessment further reflected Resident #3 required supervision as defined by oversight, encouragement or cueing while transferring between surfaces, and during locomotion off the unit. Resident #3's balance was assessed as unsteady, but he was able to stabilize without staff assistance when moving from being seated to a standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers. In addition, the resident was assessed to be frequently incontinent of bladder and always continent of bowel. The assessment also reflected Resident #3 had experienced one fall without injury since the prior assessment. Resident #3's annual MDS assessment signed by the RN Assessment Coordinator on 05/08/2012 reflected the Assessment Reference Date was 04/20/2012. The active [DIAGNOSES REDACTED]. The assessment reflected the BIMS was unable to be completed via resident interview due to the resident's inability to complete one or more questions of the interview. The staff assessment of the resident's cognitive skills for daily decision-making reflected he had severe cognitive impairment with both short-term and long-term memory problems. The MDS assessment further reflected Resident #3 required supervision as defined by oversight, encouragement or cueing while transferring between surfaces, when walking in the corridors on the unit, and during locomotion on/off the unit. Resident #3's balance was assessed as unsteady, but he was able to stabilize without staff assistance when moving from being seated to a standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers. In addition, the resident was assessed to be frequently incontinent of bladder and always continent of bowel. The assessment also reflected Resident #3 had experienced two or more falls with injury since admission/entry, reentry, or prior assessment. 2) During observation rounds conducted with LVN A, a 6:00 AM - 2:00 PM charge nurse on the facility's only secured unit, on 06/11/2012 at 9:20 AM, Resident #3 was observed ambulating down the hall with a shuffling gait. The resident was observed with a large, dark purple bruise along the left jawline, a large, dark purple bruise near the left eye, and a smaller, yellow bruise near the left eye. LVN A stated Resident #3 had fallen two weeks prior. She stated she noticed he often got into a hurry trying to get back to his room from the dining room after meals, and she stated she thought that was why he had the most recent fall two weeks ago, as it happened after breakfast. She stated he seemed to need to toilet after his meals. Since the fall, she stated she moved a table, which was near the bathroom door, to give the resident more space to ambulate. She stated the resident had a weak gait and used a walker to assist with ambulation. 3) An Incident/Accident Report, dated 03/18/2012, reflected Resident #3 fell at 10:00 AM in the Hall 300 dining room and sustained a hematoma to his forehead measuring 8.0 cm x 8.0 cm with a 2.0 cm abrasion. The Incident/Accident Investigation Follow-Up report completed by the facility's only ADON on 03/20/2012 reflected: "DESCRIPTION OF INCIDENT/ACCIDENT Resident fell in dining room. Hematoma and abrasion noted on forehead. Dr. & family notified. Sent to ___ (hospital) for evaluation. SUMMARY OF INVESTIGATION (Reasonable Conclusion) Res. stated that he "tripped & hit head on floor." No (symbol used) other injuries noted besides hematoma & abrasion on forehead. Ambulated to feet without (symbol used) difficulty. Poor safety awareness r/t dementia dx. First aid provided & pt transported for eval to ___ (hospital). PAST INTERVENTIONS ATTEMPTED (Include Dates) Res. encouraged to ask for assistance. RECOMMENDATIONS/NEW INTERVENTIONS Care plan. Neuro checks. Interdisciplinary post fall review. Change of condition. Med regimen review. Cont previous plan of care. Therapy referral." Resident #3's Comprehensive Plan of Care, dated 03/18/2012, reflected: "RAP/Problem/Need Resident at risk for falls as evidenced by cognitive impairment...Resident will not allow gait belt to be used - doesn't like people close to him - causes undue anxiety. Goal Dignity will be maintained. Resident will not experience falls or injuries from falls over the next 90 days. Approach 1) Encourage resident to ask for assistance of staff. 2) Ensure call light is in reach, answer promptly. 3) Therapy to eval and treat per orders. 4) Anticipate needs, provide prompt assistance. 5) Assure lighting is adequate and areas are free of clutter. 6) Encourage socialization and activity attendance - as tolerated. 7) falling star program." 4) An Incident/Accident Report, dated 04/06/2012, reflected at 8:30 AM on that date Resident #3 was found lying on his left side on the floor. The resident was noted to have slight redness to his left arm, his left index finger was swollen, and a red bruise was noted to the left lower rib area. The INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP signed and completed by the ADON on 04/09/2012 reflected: "DESCRIPTION OF INCIDENT/ACCIDENT Res. found lying on (his) (L) side on the floor. Slight redness to (L) arm and (L) index finger noted with (symbol used) swelling & bruising. (L) lower rib noted with (symbol used) redness. Able to move all extremities. SUMMARY OF INVESTIGATION (Reasonable Conclusion) Res. found on (the) floor. Unable to recall incident r/t dx of dementia. Xray ordered for (L) index finger for bruising with (symbol used) negative results. WCTM until resolved. No (symbol used) c/o pain. PAST INTERVENTIONS ATTEMPTED (Include Dates) Encourage res. to ask for assistance. RECOMMENDATIONS/NEW INTERVENTIONS Care plan. Therapy referral. Med regimen review. Change of condition. Interdisciplinary post fall review. Neuro checks. X-ray. Skin condition records. Cont previous plan of care." Resident #3's Comprehensive Plan of Care, dated 04/06/2012, reflected: "RAP/Problem/Need Fall. Abn. Gait Goal No fall with occur next 90 days. Approach Resident Education." 5) An Incident/Accident Report, dated 06/01/2012, reflected on that date at 8:30 AM Resident #3 was found lying on the floor on his right side. A skin tear, which was bleeding, was observed above the resident's left eyebrow. Redness was observed to the resident's left arm. The resident was alert at the time he was found. The report reflected Resident #3 was sent to the hospital emergency room immediately. The Incident/Accident Investigation Follow-Up Report, dated 06/04/2012, reflected: "DESCRIPTION OF INCIDENT/ACCIDENT Res. noted lying on (the) floor on (his) (R) side. S/T noted above (L) eyebrow with (symbol used) serous exudate. Alert. Redness noted on (his) (L) arm. SUMMARY OF INVESTIGATION (Reasonable Conclusion) Res. noted on (the) floor with (symbol used) (a) laceration above (L) eye. Nurse called for help. Aid provided. Res. transported to (the) ER for attention to (the) laceration. Appeared to have spilled water out of jug on (the) floor and slipped on the way to the bathroom. PAST INTERVENTIONS ATTEMPTED (Include Dates) Call light within reach. Attempt to remove all environmental hazards. Res. encouraged to ask for assistance. RECOMMENDATIONS/NEW INTERVENTIONS Care plan. Therapy Referral. Med. Regimen Review. Transport to ER. Interdisciplinary Post Fall Review. First Aid Neuro Checks. Pain evaluation." The ADON signed as the person completing this form on 06/04/2012. Review of Resident #3's Comprehensive Plan of Care, dated 06/02/2012, reflected: "RAP/Problem/Need Fall. Abn. Gait S/T (L) eyebrow Goal No fall with occur next 90 days. Approach Staff Training First Aid Assistive Device." 6) Resident #3's hospital Physician Clinical Report for his hospitalization on [DATE] reflected: "HISTORY OF PRESENT ILLNESS Chief Complaint - FALL. Location of injuries - face. The injury occurred just prior to arrival. fell ; slipped (SLIPPED ON WET FLOOR IN BEDROOM). Occurred at home. The patient complains of mild pain. The patient sustained a blow to the head. No neck pain or loss of consciousness... Exam: CT facial bones History: Fall ...Findings: Multiple facial fractures are visualized. These include: Anterior aspect of the left maxillary sinus with 5 mm depression, lateral wall of the left maxillary sinus, medial wall of the left maxillary sinus, left and right nasal bones, left lateral orbit, left zygomatic arch... CLINICAL IMPRESSION Multiple deep lacerations to face and left eyelid. Complicated repair. Vomiting. Contusion to the the face. Fall." 7) LVN A was interviewed on 06/13/2012 at 11:35 AM regarding Resident #3. She stated typically after breakfast Resident #3 asked to go to the bathroom or to go to sleep. She stated she had observed he was often in a hurried motion when he was going to his room. She stated she would have to educate him each time to ask for help or to slow down. She stated after his fall on 06/01/2012, she decided to move a table located near the bathroom into Resident #3's room, because she thought it might help him get around better in the room. LVN A stated Resident #3's normal gait was a hurried gait. She stated he had worked with the Physical Therapist, but she did not know if he was receiving restorative nursing services. LVN A stated she was off the unit when Resident #3 fell on [DATE]. She stated CNA B was on the unit at the time, and she (CNA B) summoned her (LVN A) back to the unit. She stated when she saw the resident, he was alert. She denied observing a liquid on the floor near the resident, and she stated the cause of the fall was unknown. When asked if Resident #3 was able to tell her what happened, she stated he was not at "a level" where he could recall what happened. When asked what the significance the Falling Star Program was, she stated it was supposed to make the staff watch the residents more closely, like Resident #3. She stated her intervention for Resident #3 after his fall was to move the table in his room. 8) CNA B, a 6:00 AM - 2:00 PM nurse aide on the secured unit, was interviewed on 06/13/2012 at 11:45 AM regarding Resident #3. She stated he normally walked back to his room after each meal. She stated when Resident #3 had his most recent fall on 06/01/2012, she was in the hallway when she heard a loud noise. CNA B stated when she got to the room, Resident #3 was lying on the floor face down, and he was bleeding. She stated she noticed water on the floor around him, and she surmised he had spilled the recently filled water pitcher she had placed in the room. CNA B was asked if Resident #3 was on a toileting program, and she stated he was not. When asked about the resident's gait, she stated he had a good gait. 9) RNA H was interviewed on 06/13/2012 at 11:48 AM regarding Resident #3. She stated she was still providing restorative nursing services to Resident #3, which included working on his gait. She explained he began using a walker after his last fall on 06/01/2012. She stated he had a shuffling gait, and she thought he might be falling, because his feet got stuck while shuffling. When asked about the Falling Star Program, she stated residents were placed on the program if they had a fall. She stated the falling star was supposed to alert all staff to keep a closer eye on that particular resident and to provide more assistance as needed. 10) The MDS Coordinator was interviewed on 06/13/2012 at 2:30 PM regarding Resident #3's comprehensive care plans addressing falls. At that time, she reviewed the care plans for Resident #3, and she agreed resident education would not be an appropriate approach for a resident with severe cognitive impairment. She stated she did not develop the care plans for Resident #3. She stated another employee, who no longer worked at the facility, was responsible for developing the care plans. The MDS Coordinator was told LVN A associated Resident #3's falls with having to go to the bathroom after meals. The MDS Coordinator asked if he was on a toileting program, and the surveyor informed her he was not on a toileting program according to CNA B. She stated it might be something to look at care planning, and she stated she would develop a care plan for a toileting program for the resident. 11) The ADON was interviewed on 06/13/2012 at 2:55 PM regarding Resident #3's falls. She stated after Resident #3 had been picked up by therapy, after one of his falls, he began using a walker. She stated Resident #3's medications were also reviewed. In addition, she stated she and LVN A rearranged Resident #3's room and moved a dresser out of the way, because she thought Resident #3 may have been trying to overcompensate when maneuvering in the room. When asked about care-planned nursing interventions being individualized for Resident #3's falls, she agreed and acknowledged most of the care planned interventions were the general care plan approaches generated by the care plan program. She agreed the intervention on 04/06/2012 to educate the resident would not be a suitable intervention for Resident #3, who had severe cognitive impairment in addition to an intellectual disability. She agreed resident education would not work with residents on the secured unit. 12) The facility's current Fall Management policy and procedure, dated February 2010, reflected: "FALLING STAR PROGRAM 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall... 5. Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks...." 13) The facility's Resident Roster, dated 06/11/2012, reflected there were 14 residents, who resided on Hall 300, the facility's only secured unit.