Every finding on record at Orange City Nursing and Rehab Center

Based on record review, interviews, and facility policy and procedure review, the facility failed to develop and implement a care plan for anticoagulant use for one (Resident #68) of five residents reviewed for medication use, from a total survey sample of 34 residents. The findings include: A record review revealed that Resident #68 was admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, diabetes mellitus - type 2 due to underlying condition with diabetic kidney disease, and unspecified displaced fracture of the surgical neck of the right humerus. A review of Resident #68's physician's orders revealed an order for Apixaban (anticoagulant) 5 mg (milligrams) by mouth twice daily (order dated 7/12/24). The resident's physician's orders did not include orders to monitor the resident for side effects related to anticoagulant use. A review of the resident's Significant Change MDS (minimum data set) assessment, dated 1/22/25, revealed that the resident scored 15/15 on a BIMS (brief interview for mental status), indicating intact cognition. She was also documented as receiving anticoagulant medication. A review of the resident's care plan (initiated on 7/11/24), revealed no focus area addressing anticoagulant use. A review of the resident's April 2025 MAR (medication administration record) revealed that it did not include a monitoring tool for side effects of anticoagulant use. On 03/27/25 at 2:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) E/Unit Manager. She was asked if a resident was receiving medications and staff were not familiar with the resident, where they would find information about the medications the resident was receiving. She stated, Under the orders. She was asked if the resident was receiving an anticoagulant, what would the physician's orders include. She stated, The type of medication it was, how much they take, monitor for signs and symptoms of bleeding, skin check frequency and those types of things. She was asked where else she would expect to find information about how to care for a resident receiving anticoagulant medications. She replied, It would depend on which anticoagulant they were taking, like for Coumadin, there would be labs ordered and dose changes. She was asked where else information would be found in the resident's record that would inform the nurse about how to care for the resident receiving anticoagulant medications. She stated, The care plan would include information about how to care for the resident taking anticoagulants. She was asked what should be included in the care plan and she replied, Monitoring for signs and symptoms of bleeding; there would be others but I'd have to look; I can't recall off the top of my head, but definitely that should be there. On 03/27/25 at 3:01 PM, another interview was conducted with LPN E/Unit Manager. She was asked to access the anticoagulant care plan for Resident #68 in the electronic medical record (EMR). She was able to provide a care plan focus area for anticoagulant use, but confirmed that the care plan reflected anticoagulant use after the above 2:34 PM interview. She was unable to provide evidence of anticoagulant side effects monitoring on the resident's MAR. A review of the facility's policy and procedure for Anticoagulant Therapy (SHCRC30004.30 - revised 8/2023) revealed: Purpose: To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physicians' orders. 8. Throughout anticoagulant therapy, monitor the resident for signs and symptoms of bleeding . A review of the facility's policy and procedure for Comprehensive Person-Centered Care Plans (SHCO40001.08 - revised 8/2023) revealed: Policy: The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. Fundamental Information: The comprehensive plan of care will include the following: Resident's individual needs . Reflect current standards of professional practice. Include interventions to avoidable decline in function or functional level. Interventions to attempt to manage risk factors. Procedure: 3. Develop goals and approaches for each problem and/or condition that are: Realistic Specific Measurable, and Include interventions/approaches that relate to each stated long- or short-term goal.

Based on a review of resident records, the facility's policy and procedure for CPR; Cardiopulmonary Resuscitation, facility reports, and interviews with staff, the facility failed to act in accordance with the resident's Advance Directives and her Do Not Resuscitate (DNR) status (the desire have CPR withheld in the event her heart or breathing stopped) by providing CPR upon finding her unresponsive with no respirations. This affected one (Resident #1) of nine residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's DNR deprived her of a natural death and likely caused unnecessary pain and bodily damage. Resident #1 expired in the hospital after prolonged life-sustaining efforts had been made and after family discontinued her from life support. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:59 p.m. on [DATE]. On [DATE] at 3:06 p.m., Immediate Jeopardy began. On [DATE] at 2:50 p.m., the Administrator was notified of the IJ determination, IJ Templates were provided, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and after verification of the removal of immediate jeopardy, the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's nursing staff having provided cardiopulmonary resuscitation (CPR) to a resident with a Do Not Resuscitate (DNR) order. The findings include: Cross Reference F578 A closed record review for Resident #1 found she was admitted from the hospital on [DATE]. Her diagnoses included, but were not limited to, toxic encephalopathy (brain dysfunction caused by toxic exposure), other neurological conditions, atrial fibrillation (irregular heartbeat that often causes poor blood flow), hypertension, diabetes mellitus, dementia, malnutrition, and chronic obstructive pulmonary disease/asthma. Resident #1 had a Modification of a Discharge/Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], which revealed admission from a short-term acute care hospital on [DATE]. Resident #1 had an unplanned discharge on [DATE] back to an acute hospital. She was assessed as being independent with daily decision making and required supervision to partial assistance with activities of daily living. Active discharge planning was occurring for Resident #1 to return to the community. Resident #1 was care planned on [DATE] for short-term care and discharge to home, with the goal to verbalize required assistance post-discharge and the services required to meet her needs before discharge. Interventions included: . Resident has been informed of their right to participate in establishing the expected goals and outcomes of care . to be informed, in advance, of changes to the plan of care . Resident has been informed of their right to request, refuse and/or discontinue treatment . Short Term Care. (Photographic evidence obtained) Resident #1 was care planned on [DATE] for Advance Directives in place, however, no code status was noted. A revision to the care plan, dated [DATE], two weeks after her discharge, noted she was a Full Code. The goal was for Resident #1's Advance Directives to be honored by staff. Interventions contradicted the focus area and noted she had a DNR. (Photographic evidence obtained) The electronic medical record (EMR) for Resident #1 contained a Florida DNR form which was signed by the resident and her physician on [DATE]. There was a corresponding physician's order for DNR dated [DATE]; however, this order was discontinued on [DATE] at 3:06 p.m. by LPN A. The reason for discontinuing the DNR order was noted as DC (discharge) home. (Photographic evidence obtained) On [DATE] at 6:38 p.m., LPN A entered an order for Full Code. (Photographic evidence obtained) Resident #1 was last seen by the Advanced Practice Registered Nurse (APRN) on [DATE] for discharge planning. The APRN noted Resident #1 reported no concerns and was medically stable at this time. (Photographic evidence obtained) Nursing progress notes reflected on [DATE], that Resident #1 was alert and oriented x3 (to person, place, and name). On [DATE], she was noted to be disoriented x3 and alert but lethargic. A note dated [DATE] at 5:10 a.m. by Registered Nurse (RN) B, reported that a certified nursing assistant (CNA) came to him to report that Resident #1 was not breathing. RN B checked for a pulse but it was absent. The nurse assigned to the other medication cart called 911, called a Code Blue, and got the crash cart. A subsequent note authored by RN B on [DATE] at 5:18 a.m., reported that emergency medical technicians (EMTs) arrived with the fire department, accessed the resident, and started [chest] compressions. At 5:42 a.m., EMTs left the facility with Resident #1. A review of a facility report revealed that on [DATE] at approximately 5:15 a.m., Resident #1 was found unresponsive by CNA K. She notified RN B, who observed the resident without a pulse or respirations and resuscitation was performed per the active physician's order by RN B, Licensed Practical Nurse (LPN) C and LPN E. It was discovered by RN D through conversation with a family member and a review of the Florida goldenrod form, that Resident #1 had a Do Not Resuscitate status. Resident #1 expired at the hospital at 8:33 a.m. A staff member (LPN A) had inadvertently discharged Resident #1 on [DATE]. Upon immediately realizing her mistake, she reinstated all discharged orders but inadvertently reinstated a Full Code status. The facility's analysis of the incident noted its investigation verified unintentional neglect. Resident #1 had been admitted to the facility on [DATE]. On [DATE], CNA K entered Resident #1's room to provide morning care to Resident #1's roommate. When she went to see Resident #1, the resident was unresponsive. CNA K immediately notified RN B, who assessed Resident #1 and found she had no pulse or respirations. RN B checked Resident #1's code status in the electronic medical record and found orders for a Full Code. He then requested that CNA K retrieve the crash cart and notify LPN C to call a Code Blue overhead. RN B initiated CPR per the active orders in the EMR since Resident #1 was unresponsive and without signs of rigor or advanced death. LPN C called 911, then assisted LPN E and RN B until EMTs arrived and took over resuscitation. Resident #1 was taken to the hospital at 5:18 a.m. with the [NAME] Chest Compression System (mechanical chest compression device) in process. At 9:00 a.m. the weekend supervisor, RN D, was attempting to contact Resident #1's primary contact, since the prior phone call made by LPN C had not been returned. Another family member answered the phone and reported that Resident #1 had a DNR code status and that the family had given these documents to the facility upon her admission. RN B reviewed the medical record and confirmed the presence of the DNR. While reviewing the medical record, the Director of Nursing (DON) and RN D identified that Resident #1 had been mistakenly discharged from the EMR on [DATE] by LPN A. She had inadvertently discharged Resident #1 instead of a different resident with a similar name. LPN A caught her mistake immediately on [DATE] and re-entered Resident #1's physician's orders into the EMR. While doing so, she transcribed the code status as Full Code when it should have been Do Not Resuscitate. Psychological harm to the resident's family was identified during an interview with Resident #1's family member on [DATE] at 12:15 p.m. The family member stated Resident #1 was admitted to the facility with an active DNR order. For some reason on the day of the event, nobody saw it so it was not honored. It was a mistake and the facility apologized. Between facility and hospital staff, they spent an hour resuscitating Resident #1. When the family arrived at the hospital, Resident #1 was inverted. Her eyes were wide open and there were tubes coming out from all over. The hospital reported Resident #1 was bleeding internally, and he saw a tube draining blood protruding from her body. Resident #1 had bruises all over her and a large gash on her chest. It was bad. He explained Resident #1 had specific Advanced Directives; she did not want tubes or life support. RN D spoke with him that morning and admitted that the DNR copy was in her chart the day of the event. He concluded by saying it took one hour to revive Resident #1, only for her daughter to have to go in and unplug her. The facility's policy for CPR; Cardiopulmonary Resuscitation, SHCRC10001.01 (revised [DATE]), read: Policy: The center shall provide basic life support, including CPR, when a resident requires such emergency care, prior to the arrival of of emergency medical services, subject to a physician's order and resident choice indicated in the resident's advanced directives. CPR will be initiated unless: - A valid DNR order is in place . Procedure: 1. In the event of cardiac or respiratory arrest, identify code status. If no DNR order exists, or there are no obvious signs of irreversible death, begin CPR . (Photographic evidence obtained) CNA F was interviewed on [DATE] at 9:14 a.m. She said if she were to find a resident unresponsive, she would notify a nurse immediately. A Code Blue status would be called and the nurse would check the code status. Everyone would come together with the crash cart and CPR would be performed, if appropriate. Resident code statuses were in the electronic medical record and the CNA Kardex (a sheet containing a summary of patient information). LPN G was interviewed on [DATE] at 9:30 a.m. She reported that on admission, the resident's code status was determined through a chart review. If the resident had no Advanced Directives (AD), the admitting nurse obtained one and entered it into the chart the same day. The goldenrod copy (Florida DNR form) was scanned into the computer and the nurse entered the order into the electronic physician's orders. For a resident with a DNR order, the nurse must verify the goldenrod copy was present even though the physician's order and the resident's dashboard instructed DNR. In a second interview on [DATE] at 1055 a.m. she stated that now, once any new order or order change was entered into the EMR, the system asked for a second reviewer. Another nurse must review and sign off on the order before the doctor did. This was also required for discontinued orders. There was also a name alert system for similar or same last names. The admitting nurse entered the name alert onto the EMR dashboard. The unit manager completed chart checks the next morning for all new admissions and name alerts and new orders were checked. This was also checked every morning in the clinical meetings. LPN E was interviewed on [DATE] at 9:36 a.m. She explained that prior to or upon admission, the admitting nurse reviewed the record for Advanced Directives. If there were none in place, and there was no goldenrod DNR form, the resident was deemed a Full Code. The DNR form was scanned into the miscellaneous file in the electronic medical record. If a resident coded, the nurse checked the chart for the physician's order. The code status was on the dashboard in the electronic record. The facility completed Code Blue drills monthly on each of the three shifts. AD training was covered in the drills. LPN E was involved the day staff found Resident #1 unresponsive. A Code Blue was called, the chart was reviewed, and she looked in the electronic record, which contained a physician's order for Full Code. LPN E reported that she initiated CPR and continued until paramedics took over. There was confusion with the situation; the DNR had been misplaced for [Resident #1]. In a second interview on [DATE] at 11:00 a.m., LPN E explained the process for new orders, order changes and new admissions. She stated a second nurse must verify every doctor's order. Also, all new admissions were checked for similar names. The clinical team reviewed this and identified similarities, and the nurse entered the special instruction Name Alert on the EMR dashboard. LPN E pulled up two residents with the same last name in the EMR and showed the NAME ALERT location on the dashboard. RN H was interviewed on [DATE] at 11:48 a.m. She stated on admission, nurses checked the hospital records for ADs. Sometimes the hospital did not send them, so the nurses asked the supervisor or Unit Manager (UM) to locate them. We can also ask the patient if they have a DNR and check the miscellaneous tab for any forms. The DNR should be there in the chart. If a resident came in and wanted to be a Full Code, she notified the social worker and the physician. All patients are Full Code until a DNR order is executed. Upon finding a resident unresponsive, the nurse checked the electronic medical record and verified the order, then went to the miscellaneous tab or hard chart to look for the goldenrod DNR form, if applicable. She added that this month she received training on ADs and how to enter them in the EMR. Also, if the resident had a name like that of another, a name alert went on the chart and in the EMR on the special bar in caps lock. In an interview with the Administrator (and the Director of Clinical Services (DCS) and the Regional Clinical Director (RCD) on [DATE] at 2:08 p.m., the Administrator explained that on Sunday [DATE] at approximately 5:15 a.m., CNA K found Resident #1 unresponsive. CNA K alerted RN B, who checked for Resident #1's code status. They also found LPN C, the other nurse on the floor. He called 911 and announced the Code Blue overhead, then ran to assist with resuscitation efforts. At this time, LPN E was coming in for her shift and went to assist with CPR. EMTs arrived and took over at 5:18 a.m. Resident #1 left with the EMTs. When RN D contacted the family, he was advised that Resident #1 had a DNR order. RN D started to investigate and looked at Resident #1's chart. The electronic medical record reflected that she was a Full Code, but a signed, dated goldenrod DNR form was scanned into the miscellaneous section of the record. The responding nurses followed the Full Code order, but it had been entered into the record incorrectly. The night before, a resident with a very similar name was discharging home. LPN A inadvertently discharged Resident #1 from the electronic medical record instead of the discharging resident, but caught her mistake immediately and entered her back into the system. Unfortunately, she mis-transcribed the Full Code order; she clicked on the wrong box. LPN A thought Resident #1 was a Full Code and thought she was entering the correct status. The DCS added that LPN A had been assigned to this resident before and the DCS didn't know why she entered the order incorrectly. She did immediately realize she had discharged the wrong resident from the system. A root cause analysis was completed and corrective and preventative measures were identified. Audits were completed for 100% of residents (112) charts for code status, which was verified with the physician's orders, and name similarities. The facility implemented a process and educated nurses this same day on sound alike names (the Name Alert on the EMR dashboard and alert stickers on binders). Education about transcribing orders was initiated and 100% of nurses had been trained in all of the above with return demonstration. On admission, a two-person check was done now. This would also be required for re-implementation of physician's orders and order changes. Newly hired nurses would be trained in the same with return demonstration. All policies and procedures were reviewed and remained appropriate. LPN A received verbal 1:1 (one-to-one) education immediately and was very remorseful. The Administrator advised that LPN A was permitted to return to work once the investigation was completed. LPN A received additional training (that had occurred on [DATE], which she produced). An ad hoc QAPI meeting was held on [DATE]; the entire team came in on Sunday ([DATE]) to ensure that everything was in place. Audits were being conducted five times a week for three months, Mon - Friday, and were reviewed during clinical meetings every morning. The order listing reports were being reviewed daily by the staff development coordinator (SDC), the DON and the Administrator. Any order with ADs and all new admissions were being reviewed daily. Stand-up and stand-down daily meetings were also looking at order changes or new orders during the shift. Five sets of residents with similar first or last names were identified during the name audit. There had been one newly hired nurse who was trained in the process on [DATE]. In an interview with RN J on [DATE] at 3:30 p.m., he explained that all DNR documentation would be entered by nursing staff into the EMR to be easily accessed in the event of a resident code. This would facilitate identifying which residents had DNR orders when a code occurred. RN J then advised that each resident's code status and documentation would be double checked by two nurses to ensure accuracy. LPN/Unit Manager (UM) I was interviewed on [DATE] at 11:20 a.m. She explained that recent training had been provided to nurses on Advance Directives. The process was that on admission, she called the physician and reviewed all medication and the code status. In the morning, the entire clinical team reviewed each admission. This was documented. The team reviewed the residents' code status for accuracy. The more eyes the better. We ensure all the batch (physician's) orders are entered in the EMR and any specialty orders are in place. Also, on admission a name alert is done. For instance, we currently have two residents with the same last name on one unit. We put the NAME ALERT in the record under the special instructions tab. This is also double checked in clinical meetings. On occasion, a float nurse comes in, so the name alert is very important. We all received training on this. LPN/UM I conducted huddle meetings with the staff when such pertinent similar information needed to be reviewed. Any accidental discharge and readmission would be treated as a new admission; you had to redo all of it. It is a lot of work but it must be done properly. Now two nurses must sign off on physicians' orders. Also, any verbal orders must receive two nurses signatures. If a family comes in and wants to change an order to a DNR, the form gets printed and the family must sign it. The verbal physician's order is good for 24 hours. The form is faxed to the doctor for a signature and date and the order is entered in the EMR. Once the executed copy is received, the DNR goes into the chart. It is always scanned into the miscellaneous tab. The hard copy goes into the hard chart. At daily stand-up and stand-down meetings, the Administrator asks about ADs, DNRs and order changes for code status. When EMS (emergency medical services) comes in, you better have that ready for them. LPN/UM I concluded by reporting that she was involved in assisting with the daily audits for new admissions and order changes. RN B was interviewed on [DATE] at 1:55 p.m. He stated he worked the overnight shift on weekends and was assigned to Resident #1 the night of the event. It was a quiet night. He was rounding and ready to give medications when a CNA notified him that Resident #1 was unresponsive. Per protocol, he went and checked the electronic record for the code status. Resident #1 had a physician's order for Full Code status; this order was on the electronic record's dashboard and medication screen. Since Resident #1 was documented as a Full Code at that time, he went by the order and started CPR. RN B performed CPR for a bunch of circuits; it was exhausting. LPN C and another nurse came in to help, then paramedics arrived and took over. RN B had the laptop computer with him and relayed the Full Code order to paramedics, who then transported Resident #1 to the hospital. RN B resumed his normal duties. When he came back to work the next day, he was advised that Resident #1 had a DNR order. RN B said, No, she was a Full Code. As a result, he received training on code status and checking orders if they were taken off and put back in. He did a return demonstration. Two nurses must verify orders. RN B was trained on name alerts. They now went in all capital letters in the chart if there were residents with alike names. When there was a DNR form, he put it right in the front of the paper (hard) chart. He was not sure who scanned the forms into the electronic medical records but he checked the EMR. RN D was interviewed on [DATE] at 2:13 p.m. He stated he came in after the event on [DATE] and was told that Resident #1 had coded. CPR was provided and she was sent to the hospital. He thought LPN C phoned the resident's family but nobody answered. RN D went to pass breakfast trays, then attempted to call the family again. He spoke with one of Resident #1's relatives, who asked why Resident #1 was provided CPR and sent to the hospital; Resident #1 had a DNR order. RN B informed him he would investigate that and call back. RN D then called the DON and reported the conversation. She came to the facility and she and RN D found the DNR form in Resident #1's scanned electronic documents. The DON spoke with LPN A, took her statement, and sent her home pending investigation. During the partial extended survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director and a Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attain/maintain regulatory compliance. The Topic/Opportunity identified was: Accuracy of transcription of orders and Advanced Directives: Nurse inadvertently discontinued orders including AD, reinstated with transcription error. Actions included: 1. Ad hoc QAPI meeting held [DATE]. 2. MD (Medical Director) and resident representative notified of AD variance on [DATE]. 3. A statement was obtained from the licensed nurse who transcribed the DNR/Full code order- Completed [DATE]. 4. Facility management identified a Root Cause for the transcription error- Completed [DATE]. 5. 1:1 education with licensed nurse responsible for the error (LPN A)- Completed [DATE]. 6. A complete facility audit was conducted of all resident ADs for accuracy- Completed [DATE] for all 111 residents. 7. A facility audit of sound alike names was conducted and a profile tab was made in the EMR for residents with like names- Completed [DATE] for all 111 residents. 8. Alike resident names were documented as NAME ALERTs in the Care Profile tab in the residents' EMRs- Completed [DATE] for 10 residents who had similar names. Ongoing. 9. All licensed nurses were educated about physician order transcription from discontinued orders in the EMR. Written post-test- Commenced [DATE], completed [DATE] for all 33 nurses including LPN A who was re-educated and provided the post-test after return from suspension [DATE]. One new hire was educated and tested on [DATE]. All nurses were educated about sound alike names and documenting the name alert in the care profile tab in the EMR. Written post-test completed- Commenced [DATE], completed [DATE] for all 33 nurses. LPN A who was included in the initial education on [DATE] was re-educated and provided the post test on return from suspension, [DATE]. One new hire was educated and tested [DATE]. Ongoing. 10. New hires will be educated during orientation on medication order transcription from discontinued orders in EMR, and on identifying sound alike names and documenting name alerts- Completed [DATE] for one newly hired nurse. Ongoing. 11. DNR orders and Full Code orders review extablished to ensure accuracy of ADs in daily clinical meetings- Initiated [DATE]. Ongoing. 12. Sound alike names review initiated in clinical meetings daily to ensure name alerts were in the profile tab of the electronic medical record. Initiated [DATE]. Ongoing. 13. Audits were initiated five times per week for three months during clinicals when resident orders are being reviewed to ensure DNR and Full Code orders are accurate- Commenced [DATE], with subsequent audits completed [DATE], 6, 7, 8, 11, 12, 23, 14, 25, 18 and 19, 2024. Ongoing.

Based on a review of resident records, the facility's policy and procedure for Advance Directives, facility reports, and interviews with staff, the facility failed to act in accordance with the resident's Advance Directives in accordance with her Do Not Resuscitate (DNR) status (the desire have cardiopulmonary resuscitation (CPR) withheld in the event that her heart or breathing stopped) after finding her unresponsive with no respirations. This affected one (Resident #1) of nine residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's DNR status deprived her of a natural death and likely caused unnecessary pain and bodily damage. Resident #1 expired in the hospital after prolonged life-sustaining efforts had been made and her family discontinued her from life support. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:59 p.m. on [DATE]. On [DATE] at 3:06 p.m., Immediate Jeopardy began. On [DATE] at 2:50 p.m., the Administrator was notified of the IJ determination, IJ Templates were provided, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and after verification of the removal of immediate jeopardy, the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's nursing staff having provided cardiopulmonary resuscitation (CPR) to a resident with a Do Not Resuscitate (DNR) order. The findings include: Cross reference F678 A closed record review for Resident #1 found she was admitted from the hospital on [DATE]. Her diagnoses included, but were not limited to, toxic encephalopathy (brain dysfunction caused by toxic exposure), other neurological conditions, atrial fibrillation (irregular heartbeat that often causes poor blood flow), hypertension, diabetes mellitus, dementia, malnutrition, and chronic obstructive pulmonary disease/asthma. Resident #1 had a Modification of a Discharge/Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], which revealed admission from a short-term acute care hospital on [DATE]. Resident #1 had an unplanned discharge on [DATE] back to an acute care hospital. She was assessed as being independent with daily decision making and required supervision to partial assistance with activities of daily living. Active discharge planning was occurring for Resident #1 to return to the community. Resident #1 was care planned on [DATE] for short-term care and discharge to home, with the goal to verbalize required assistance post-discharge and the services required to meet her needs before discharge. Interventions included: . Resident has been informed of their right to participate in establishing the expected goals and outcomes of care . to be informed, in advance, of changes to the plan of care . Resident has been informed of their right to request, refuse and/or discontinue treatment . Short Term Care. (Photographic evidence obtained) Resident #1 was care planned on [DATE] for Advance Directives in place, however, no code status was noted. A revision to the care plan, dated [DATE], two weeks after her discharge, noted she was a Full Code. The goal was for Resident #1's Advance Directives to be honored by staff. Interventions contradicted the focus area and noted she had a DNR. (Photographic evidence obtained) The resident's electronic medical record (EMR) contained a Florida DNR form which was signed by the resident and her physician on [DATE]. There was a corresponding physician's order for DNR dated [DATE]; however, this order was discontinued on [DATE] at 3:06 p.m. by Licensed Practical Nurse (LPN) A. The reason for discontinuing the DNR order was noted as DC (discharge) home. (Photographic evidence obtained) On [DATE] at 6:38 p.m., LPN A entered an order for Full Code in the resident's medical record. (Photographic evidence obtained) Resident #1 was last seen by the Advanced Practice Registered Nurse (APRN) on [DATE] for discharge planning. The APRN noted Resident #1 reported no concerns and was medically stable at this time. (Photographic evidence obtained) Nursing progress notes revealed that on [DATE], Resident #1 was alert and oriented x3 (to person, place, and name). On [DATE], she was noted to be disoriented x3 and alert but lethargic. A nursing progress note, dated [DATE] at 5:10 a.m. by Registered Nurse (RN) B, reported a certified nursing assistant (CNA) came to him to report that Resident #1 was not breathing. RN B checked for the resident's pulse and it was absent. The nurse assigned to the other medication cart called 911, called a Code Blue, and got the crash cart. A subsequent note authored by RN B on [DATE] at 5:18 a.m., reported that emergency medical technicians (EMTs) arrived with the fire department, assessed the resident, and started [chest] compressions. At 5:42 a.m., the EMTs left the facility with Resident #1. A review of a facility report, generated on [DATE], revealed that on [DATE] at approximately 5:15 a.m., Resident #1 was found unresponsive by CNA K. She notified RN B, who observed the resident without a pulse or respirations and resuscitation was performed per the active physician's order by RN B, LPN C and LPN E. It was discovered by RN D, through conversation with a family member and review of the Florida goldenrod form, that Resident #1 had a Do Not Resuscitate (DNR) order. Resident #1 expired at the hospital at 8:33 a.m. A staff member (LPN A) had inadvertently discharged Resident #1 on [DATE]. Upon immediately realizing her mistake, she reinstated all discharged orders but inadvertently reinstated a Full Code status instead of DNR. The facility's analysis of the incident noted its investigation verified unintentional neglect. Resident #1 had been admitted to the facility on [DATE]. On [DATE], CNA K entered Resident #1's room to provide morning care to Resident #1's roommate. When she went to see Resident #1, the resident was unresponsive. CNA K immediately notified RN B, who assessed Resident #1 and found she had no pulse or respirations. RN B checked Resident #1's code status in the electronic medical record and found orders for Full Code. He then requested CNA K retrieve the crash cart and notify LPN C to call a Code Blue overhead. RN B initiated CPR per the orders in the EMR since Resident #1 was unresponsive and without signs of rigor or advanced death. LPN C called 911, then assisted LPN E and RN B until EMTs arrived and took over resuscitation. Resident #1 was taken to the hospital at 5:18 a.m. with the [NAME] Chest Compression System (mechanical chest compression device) in process. At 9:00 a.m., the weekend supervisor, RN D, was attempting to contact Resident #1's primary contact, since the prior phone call made by LPN C had not been returned. Another family member answered the phone and reported Resident #1 had a DNR code status and the family had given these documents to the facility upon her admission. RN B reviewed the medical record and confirmed the presence of the DNR. While reviewing the medical record, the Director of Nursing (DON) and RN D identified that Resident #1 had been mistakenly discharged from the EMR on [DATE] by LPN A. She had inadvertently discharged Resident #1 instead of a different resident with a similar name. LPN A caught her mistake immediately on [DATE] and re-entered Resident #1's physician's orders into the EMR. While doing so, she transcribed the code status as Full Code when it should have been Do Not Resuscitate. Psychological harm to the resident's family was identified during an interview with Resident #1's family member on [DATE] at 12:15 p.m. The family member stated Resident #1 was admitted to the facility with an active DNR order. For some reason on the day of the event, nobody saw it so it was not honored. It was a mistake and the facility apologized. Between facility and hospital staff, they spent an hour resuscitating Resident #1. When the family arrived at the hospital, Resident #1 was inverted. Her eyes were wide open and there were tubes coming out from all over. The hospital reported Resident #1 was bleeding internally, and he saw a tube draining blood protruding from her body. Resident #1 had bruises all over her and a large gash on her chest. It was bad. He explained Resident #1 had specific Advanced Directives; she did not want tubes or life support. RN D spoke with him that morning and admitted that the DNR copy was in her chart the day of the event. He concluded by saying it took one hour to revive Resident #1, only for her daughter to have to go in and unplug her. The facility's policy for Advance Directives (AD), SHCO20003.16 (reviewed [DATE]) revealed: Policy: The resident has the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advanced directive . Procedure: 1. Provide information about ADs (Advance Directoves) to resident . 2. The resident or surrogate will be questioned at the time of admission about the existence of any AD written prior to admission . . 4. The attending physician shall record in the medical record pertinent information related to the formulation or implementation of the AD . . 5. The attending physician must document in the medical record the discussion with the resident or surrogate regarding choices and decisions of Advanced Directives. a. Upon executing any valid AD, the designated paperwork will be placed in the resident's medical record under the AD tab. b. When responding to a call for assistance, health care professionals and emergency personnel will honor the Advance Directive. (Photographic evidence obtained) Certified Nursing Assistant (CNA) F was interviewed on [DATE] at 9:14 a.m. She said if she were to find a resident unresponsive, she would notify a nurse immediately. A Code Blue would be called and the nurse would check the resident's code status. Everyone would come together with the crash cart and CPR would be performed, if appropriate. Resident code statuses were in the electronic medical record and the CNA Kardex (a sheet containing a summary of patient information). LPN G was interviewed on [DATE] at 9:30 a.m. She reported that on admission, a resident's code status was determined through a chart review. If the resident had no Advance Directives (AD), the admitting nurse obtained them and enters them into the chart the same day. The goldenrod copy (Florida DNR form) was scanned into the computer and the nurse entered the order into the electronic physician's orders. For a resident with a DNR order, the nurse must verify the goldenrod copy was present even though the physician's order and the resident's dashboard instructed DNR. In a second interview on [DATE] at 1055 a.m., she stated now, once any new order or order change was entered into the EMR, the system asked for a second reviewer. Another nurse must review and sign off on the order before the doctor did. This was also required for discontinued orders. There was also a name alert system for similar or same last names. The admitting nurse entered the name alert onto the EMR dashboard. The Unit Manager completed chart checks the next morning for all new admissions and name alerts and new orders were checked. This was also checked every morning in the clinical meetings. LPN E was interviewed on [DATE] at 9:36 a.m. She explained that prior to or on admission, the admitting nurse reviewed the record for Advanced Directives. If there were none in place, and no goldenrod DNR form, the resident was deemed a full code. The DNR form was scanned into the miscellaneous file in the electronic medical record. If a resident coded, the nurse checked the chart for the physician's order. The code status was on the dashboard in the electronic record. The facility completed Code Blue drills monthly on each of the three shifts. AD training was covered in the drills. Employee E was involved the day staff found Resident #1 unresponsive. A Code Blue was called, the chart was reviewed, and she looked in the electronic record, which contained a physician's order for full code. LPN E reported that she initiated CPR and continued until paramedics took over. There was confusion with the situation; the DNR had been misplaced for [Resident #1]. In a second interview on [DATE] at 11:00 a.m., LPN E explained the process for new orders, order changes and new admissions. She stated a second nurse must now verify every doctor's order. Also, for all new admissions, they were checked for similar names. The clinical team reviewed this and identified similarities, and the nurse entered the special instruction Name Alert on the EMR dashboard. LPN E pulled up two residents with the same last name in the EMR and showed an example of the NAME ALERT location on the dashboard. RN H was interviewed on [DATE] at 11:48 a.m. She stated on admission, nurses checked the hospital records for ADs. Sometimes the hospital did not send them, so the nurses asked the supervisor or Unit Manager (UM) to locate them. We can also ask the patient if they have a DNR and check the miscellaneous tab for any forms. The DNR should be there in the chart. If a resident came in and wanted to be a Full Code, she notified the social worker and the physician. All patients are Full Code until a DNR order is executed. Upon finding a resident unresponsive, the nurse checked the electronic medical record and verified the order, then went to the miscellaneous tab or hard chart to look for the goldenrod DNR form, if applicable. She added that this month she received training on ADs and how to enter them in the EMR. Also, if the resident had a name like that of another, a name alert went on the chart and in the EMR on the special bar in caps lock. In an interview with the Administrator (and the Director of Clinical Services (DCS) and the Regional Clinical Director (RCD) on [DATE] at 2:08 p.m., the Administrator explained that on Sunday [DATE] at approximately 5:15 a.m., CNA K found Resident #1 unresponsive. CNA K alerted RN B, who checked for Resident #1's code status. They also found LPN C, the other nurse on the floor. He called 911 and announced the Code Blue overhead, then ran to assist with resuscitation efforts. At this time, LPN E was coming in for her shift and went to assist with CPR. EMTs arrived and took over at 5:18 a.m. Resident #1 left with the EMTs. When RN D contacted the family, he was advised that Resident #1 had a DNR order. RN D started to investigate and looked at Resident #1's chart. The electronic medical record reflected that she was a Full Code, but a signed, dated goldenrod DNR form was scanned into the miscellaneous section of the record. The responding nurses followed the Full Code order, but it had been entered into the record incorrectly. The night before, a resident with a very similar name was discharging home. LPN A inadvertently discharged Resident #1 from the electronic medical record instead of the discharging resident, but caught her mistake immediately and entered her back into the system. Unfortunately, she mis-transcribed the Full Code order; she clicked on the wrong box. LPN A thought Resident #1 was a Full Code and thought she was entering the correct status. The DCS added that LPN A had been assigned to this resident before and the DCS didn't know why she entered the order incorrectly. She did immediately realize she had discharged the wrong resident from the system. A root cause analysis was completed and corrective and preventative measures were identified. Audits were completed for 100% of residents (112) charts for code status, which was verified with the physician's orders, and name similarities. The facility implemented a process and educated nurses this same day on sound alike names (the Name Alert on the EMR dashboard and alert stickers on binders). Education about transcribing orders was initiated and 100% of nurses had been trained in all of the above with return demonstration. On admission, a two-person check was done now. This would also be required for re-implementation of physician's orders and order changes. Newly hired nurses would be trained in the same with return demonstration. All policies and procedures were reviewed and remained appropriate. LPN A received verbal 1:1 (one-to-one) education immediately and was very remorseful. The Administrator advised that LPN A was permitted to return to work once the investigation was completed. LPN A received additional training (that had occurred on [DATE], which she produced). An ad hoc QAPI meeting was held on [DATE]; the entire team came in on Sunday ([DATE]) to ensure that everything was in place. Audits were being conducted five times a week for three months, Mon - Friday, and were reviewed during clinical meetings every morning. The order listing reports were being reviewed daily by the staff development coordinator (SDC), the DON and the Administrator. Any order with ADs and all new admissions were being reviewed daily. Stand-up and stand-down daily meetings were also looking at order changes or new orders during the shift. Five sets of residents with similar first or last names were identified during the name audit. There had been one newly hired nurse who was trained in the process on [DATE]. In an interview with RN J on [DATE] at 3:30 p.m., he explained that all DNR documentation would be entered by nursing staff into the EMR to be easily accessed in the event of a resident code. This would facilitate identifying which residents had DNR orders when a code occurred. RN J then advised that each resident's code status and documentation would be double checked by two nurses to ensure accuracy. LPN/Unit Manager (UM) I was interviewed on [DATE] at 11:20 a.m. She explained that recent training had been provided to nurses on Advance Directives. The process was that on admission, she called the physician and reviewed all medication and the code status. In the morning, the entire clinical team reviewed each admission. This was documented. The team reviewed the residents' code status for accuracy. The more eyes the better. We ensure all the batch (physician's) orders are entered in the EMR and any specialty orders are in place. Also, on admission a name alert is done. For instance, we currently have two residents with the same last name on one unit. We put the NAME ALERT in the record under the special instructions tab. This is also double checked in clinical meetings. On occasion, a float nurse comes in, so the name alert is very important. We all received training on this. LPN/UM I conducted huddle meetings with the staff when such pertinent similar information needed to be reviewed. Any accidental discharge and readmission would be treated as a new admission; you had to redo all of it. It is a lot of work but it must be done properly. Now two nurses must sign off on physicians' orders. Also, any verbal orders must receive two nurses signatures. If a family comes in and wants to change an order to a DNR, the form gets printed and the family must sign it. The verbal physician's order is good for 24 hours. The form is faxed to the doctor for a signature and date and the order is entered in the EMR. Once the executed copy is received, the DNR goes into the chart. It is always scanned into the miscellaneous tab. The hard copy goes into the hard chart. At daily stand-up and stand-down meetings, the Administrator asks about ADs, DNRs and order changes for code status. When EMS (emergency medical services) comes in, you better have that ready for them. LPN/UM I concluded by reporting that she was involved in assisting with the daily audits for new admissions and order changes. RN B was interviewed on [DATE] at 1:55 p.m. He stated he worked the overnight shift on weekends and was assigned to Resident #1 the night of the event. It was a quiet night. He was rounding and ready to give medications when a CNA notified him that Resident #1 was unresponsive. Per protocol, he went and checked the electronic record for the code status. Resident #1 had a physician's order for Full Code status; this order was on the electronic record's dashboard and medication screen. Since Resident #1 was documented as a Full Code at that time, he went by the order and started CPR. RN B performed CPR for a bunch of circuits; it was exhausting. LPN C and another nurse came in to help, then paramedics arrived and took over. RN B had the laptop computer with him and relayed the Full Code order to paramedics, who then transported Resident #1 to the hospital. RN B resumed his normal duties. When he came back to work the next day, he was advised that Resident #1 had a DNR order. RN B said, No, she was a Full Code. As a result, he received training on code status and checking orders if they were taken off and put back in. He did a return demonstration. Two nurses must verify orders. RN B was trained on name alerts. They now went in all capital letters in the chart if there were residents with alike names. When there was a DNR form, he put it right in the front of the paper (hard) chart. He was not sure who scanned the forms into the electronic medical records but he checked the EMR. RN D was interviewed on [DATE] at 2:13 p.m. He stated he came in after the event on [DATE] and was told that Resident #1 had coded. CPR was provided and she was sent to the hospital. He thought LPN C phoned the resident's family but nobody answered. RN D went to pass breakfast trays, then attempted to call the family again. He spoke with one of Resident #1's relatives, who asked why Resident #1 was provided CPR and sent to the hospital; Resident #1 had a DNR order. RN B informed him he would investigate that and call back. RN D then called the DON and reported the conversation. She came to the facility and she and RN D found the DNR form in Resident #1's scanned electronic documents. The DON spoke with LPN A, took her statement, and sent her home pending investigation. During the partial extended survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director, and a Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attain/maintain regulatory compliance. The Topic/Opportunity identified was: Accuracy of transcription of orders and Advanced Directives: Nurse inadvertently discontinued orders including AD, reinstated with transcription error. Actions included: 1. Ad hoc QAPI meeting held [DATE]. 2. MD (Medical Director) and resident representative notified of AD variance on [DATE]. 3. A statement was obtained from the licensed nurse who transcribed the DNR/Full code order- Completed [DATE]. 4. Facility management identified a Root Cause for the transcription error- Completed [DATE]. 5. 1:1 education was provided to the licensed nurse responsible for the error (LPN A)- Completed [DATE]. 6. A complete facility audit was conducted of all resident ADs for accuracy- Completed [DATE] for all 111 residents. 7. A facility audit of sound alike names was conducted and a profile tab was made in the EMR for residents with like names- Completed [DATE] for all 111 residents. 8. Alike resident names were documented as NAME ALERTs in the Care Profile tab in the residents' EMRs- Completed [DATE] for 10 residents who had similar names. Ongoing. 9. All licensed nurses were educated about physician order transcription from discontinued orders in the EMR. Written post-test- Commenced [DATE], completed [DATE] for all 33 nurses including LPN A who was re-educated and provided the post-test after return from suspension [DATE]. One new hire was educated and tested on [DATE]. All nurses were educated about sound alike names and documenting the name alert in the care profile tab in the EMR. Written post-test completed- Commenced [DATE], completed [DATE] for all 33 nurses. LPN A who was included in the initial education on [DATE] was re-educated and provided the post test on return from suspension, [DATE]. One new hire was educated and tested [DATE]. Ongoing. 10. New hires will be educated during orientation on medication order transcription from discontinued orders in EMR, and on identifying sound alike names and documenting name alerts- Completed [DATE] for one newly hired nurse. Ongoing. 11. DNR orders and Full Code orders review extablished to ensure accuracy of ADs in daily clinical meetings- Initiated [DATE]. Ongoing. 12. Sound alike names review initiated in clinical meetings daily to ensure name alerts were in the profile tab of the electronic medical record. Initiated [DATE]. Ongoing. 13. Audits were initiated five times per week for three months during clinicals when resident orders are being reviewed to ensure DNR and Full Code orders are accurate- Commenced [DATE], with subsequent audits completed [DATE], 6, 7, 8, 11, 12, 23, 14, 25, 18 and 19, 2024. Ongoing.

Based on observations, record review, and staff interviews, the facility failed provide sufficient kitchen staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition service. Failure to ensure that dietary staff were trained and knowledgeable about the proper procedures for food safety and sanitation had the potential to negatively impact all residents who received meals from the kitchen. The findings include: A kitchen tour was conducted on 05/10/23 at 10:40 a.m. During the tour, Cook D was asked to explain the appropriate method of calibrating a food thermometer. She stated, A glass of water in ice starting at 40 F and up to 165 F. It should be below 40 F for cold food. When asked what the thermometer should read to ensure it was accurate and working appropriately, she replied, 40 F. When asked how often and what training she had in the kitchen for food safety and sanitation, she replied, Not too often. My last training was a couple of years ago. I can't remember, one to two years ago. She reported that she assisted with training new kitchen staff. I train new staff on what I like, I have no manual. When asked what training topics she was teaching, she replied, Pureed and mechanical diets and seasonings. At this time, the Food Service Director was notified that the cook was not knowledgeable of the calibration process or how to read the thermometer for accuracy. He stated another cook was on their way to assist with the meal service. On 05/10/23 at 11:35 a.m., Assistant Food Service Director C entered the kitchen. He was asked to explain the thermometer calibration process. He stated, The thermometer is placed in ice water and should read 10 F. When asked at what temperature the thermometer should read to ensure it was accurate and working appropriately, he replied, 10 F. When asked who was responsible for training dietary staff, he replied, The Food and Nutrition Service Manager and the Assistant Food and Nutrition Service Manager provide monthly in-services. Lunch was scheduled to begin at 11:30 a.m. There were only two cooks in the kitchen at this time. The Assistant Food Service Director was informed that training related to the thermometer calibration process was to be completed prior to serving the lunch meal to ensure the food was safe for residents to consume. On 05/11/23 at 9:15 a.m., a review of the job description titled Food and Nutrition - Cook was signed by Cook D and dated 02/15/19. The summary revealed that the cook prepares palatable, nourishing, well-balanced meals to meet the daily nutritional and special diet needs for each resident. A review of the facility's web-based education module for Safe Food Handling training, dated 03/22/23 for Cook C, revealed it included the thermometer calibration process. A review of the Employee In-Service/Educational Attendance Record titled 3rd Aide Meeting, dated 02/26/22, and In-Service Report titled Explained Correct Thermometer Calibration Method, dated 05/10/23, revealed two Dietary in-services were held for support staff since the facility's last recertification survey. An interview was conducted with Assistant Food Service Director C on 05/11/23 at 12:29 p.m. He confirmed that he and Food Service Director E were responsible for training the Dietary staff. He stated Dietary Aides assisted with training new Dietary Aides about how to set up in the kitchen for each meal service, and Food Service Director E provided training to all new staff at the facility orientation. An interview was conducted with Food Service Director E on 05/11/23 at 12:39 p.m. During orientation, he confirmed that, Generally, training is mostly in the kitchen. New staff are assigned to shadow the most experienced staff for two weeks. We follow and answer questions. We explain dates, time, and temperature; how to work with residents, and how to use and clean equipment. When asked to provide documentation of the training provided, he stated, We try to follow a path, no documentation. Yearly competency reviews include a discussion of job tasks, accomplishments, and opportunities for additional learning. A review of the facility's policy and procedure titled Prepared Food Temperature Record (Revised 02/21/17), revealed the following: Purpose: Ensure food is held and delivered at accepted temperatures to control and reduce the chances of foodborne illness. 2. In the service line - a. If temperatures are less than or equal to 135 degrees fahrenheit for hot foods, reheat to an internal temperature of 165 degrees fahrenheit for 15 seconds. b. If temperatures are great than or equal to 41 degrees fahrenheit for colds foods, chill to an internal temperature of less than or equal to 41 degrees fahrenheit. .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to store food in accordance with professional standards for food service safety, by failing to follow proper food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted on 05/07/23 at 11:11 a.m. During the tour, no date markings were observed on two crates sitting between the shelves and filled with fresh onions; one open carton of cottage cheese, and one open box filled with fresh grapes on the shelf in the walk-in refrigerator. In the dry storage room, there was no date marking observed on two open bundles of bread and one open bag of bagels. (Photographic evidence obtained) Another tour of the kitchen was conducted on 05/08/23 at 9:10 a.m. The same observations made on 05/07/23 at 11:11 a.m. in the walk-in refrigerator were made again. At this time, a new observation of one open bag of English muffins with no date marking was observed on the bread rack in the dry storage room. On the same bread rack, there was no date marking observed on one open bag of bagels. (Photographic evidence obtained) An interview was conducted with Dietary Aide A on 05/11/23 at 8:19 a.m., who confirmed that the facility's policy about date marking was to ensure first in and first out (FIFO). Open food was to be covered and dated the date the item was opened. Leftover bread was wrapped, date marked the date it was opened, and then discarded after three days. An interview was conducted with Dietary Aide B on 05/11/23 at 8:33 a.m., who stated the Dietary Aides were responsible for maintaining the dry storage and Cooks were responsible for maintaining the refrigerator and freezer. She confirmed that once a food item was opened, it was to be wrapped or placed in a container and dated before going back into the refrigerator, freezer, or the dry storage shelf. Opened bread was wrapped and dated before placing it back on the rack. An interview was conducted with Assistant Food Service Director C on 05/11/23 at 12:29 p.m., who confirmed that Dietary Aides were responsible for maintaining the dry storage and Cooks were responsible for maintaining the refrigerator and freezer. He confirmed that when a food item was opened, used, and placed back in the refrigerator or freezer, it was to be taken out of the original package and placed into a container, then labeled, dated, and discarded after three days. He also confirmed that when bread was opened, used and placed back on the bread rack, it was to be wrapped, labeled, dated the date it was opened, and then discarded after three days. A review of the facility's policy and procedure titled Food and Supply Storage (dated 6/26/18) revealed the following: Proper food storage is essential for preserving food quality. This applies to foods stored prior to preparation, and also to prepared foods (leftovers) that are placed in storage. Storage factors that impact the preservation of quality include holding period, temperature, and humidity. Procedures: 2. Rotate stock so that the old supplies are placed in front of the new supplies, ensuring that the product first in will be first out (FIFO). 3. Label each package, box, can, etc. with date of receipt, and when the item was stored after preparation . b. Discard leftover foods that have not been used within 72 hours of preparation . 5. Label opened food items with date opened. (Copy obtained) According to FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-FirstOut (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observation, medical record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for six (Resident #17, #28, #33, #38, #65 and #191) of six residents sampled for nutritional status, from a total of 26 residents in the sample. Inaccurate assessments leave residents at risk for not receiving necessary care and services to ensure their highest practicable functional level and mental or psychosocial well-being. The findings include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K (Swallowing/Nutritional Status) was signed as completed by the Certified Dietary Manager (CDM) and Resident #17 was coded as being on a physician prescribed weight gain regimen. (Copy obtained) A review of Resident #17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no active order for a physician prescribed weight-gain regimen. During an interview with the CDM on 09/02/2021 at 11:07 AM, he was asked about his process for evaluating the residents and completing the MDS. The CDM stated, he takes the information from the dietician and inputs it into the system. He goes by the recommendations of the dietician. When completing Section K of the MDS, he looks for the resident's diagnoses, along with the recommendations and answers the questions to the best of his abilities. 2. Review of the medical record for Resident #28 revealed an admitted [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #28 was coded as being on a physician prescribed weight gain regimen. (Copy obtained) A review of Resident #28's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 has a documented height of 73 inches and a weight of 235 pounds, with a body mass index (BMI) of 31, which according to the CDC (Centers for Disease Control) falls into the obesity range (BMI greater than 30). 3. Review of the medical record for Resident #33 revealed an admitted [DATE] and re-admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #33 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #33 has a documented height of 70 inches and weight of 207 pounds, with a BMI of 31.5. Review of Resident #33's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of the medical record for Resident #38 revealed an admitted [DATE] and re-admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #38 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #38 has a documented height of 61 inches and weight of 184 pounds, with a BMI of 34.8. Review of Resident #38's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Review of the medical record for Resident #65 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #65 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #65 has a documented height of 64 inches and weight of 174 pounds, with a BMI of 29.9, which according to the CDC falls into the overweight range (BMI 25.0 to <30). Review of Resident #65's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6. Review of medical record for Resident #191 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #191 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #191 has a documented height of 62 inches and weight of 196 pounds, with a BMI of 35.8. Review of Resident #191's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Registered Dietetic Technician (DTR) on 9/2/21 at 11:07 AM, he confirmed that Residents #17, #28, #33, #38, #65 and #191 were not on a physician prescribed weight gain regimen and the MDS assessment for each resident had been miscoded. During an interview with the MDS Coordinator on 9/2/21 at 11:50 AM, she confirmed the MDS assessments had been miscoded for Residents #17, #28, #33, #65 and #191. She stated, as an RN, she attests to the best of her knowledge the information is accurate and complete, however, the MDS is interdisciplinary, so other disciplines fill out sections.

Based on observations, record reviews and interviews, the facility failed to ensure that one (Resident #7) of six residents observed during medication administration, was free from unnecessary drugs. The findings include: A medication administration observation was conducted with Employee E, Registered Nurse (RN), for Resident #7 on 1/23/20 at 9:21 a.m., and the following medications were administered: [MEDICATION NAME] (irritable bowel medication) 8 mcg (microgram),1 tablet [MEDICATION NAME] (ammonia reducer/laxative) 30 ml (milliliter) by mouth Losartan Potassium (blood pressure medication) 25 mg (milligram), 1 tablet Magnesium Oxide (supplement) 400 mg, 1 tablet [MEDICATION NAME] (blood pressure medication) 5 mg, 1 tablet [MEDICATION NAME] (laxative) 17 grams with 8 ounces of water [MEDICATION NAME] (blood pressure medication/diuretic) 25 mg, 1 tablet [MEDICATION NAME] (blood pressure medication) 25 mg, ½ tablet to equal a 12.5 mg dose A record review was conducted for Resident #7 revealing that his Losartan Potassium dose was decreased from 25 mg to a half tablet equalling a 12.5 mg dose, which was to start on 1/16/2020. On 1/23/20 at 11:53 a.m., the nurse confirmed that the order for his Losartan Potassium 25 mg had decreased to 12.5 mg on 1/16/20. She reviewed the medication cards in the cart and confirmed that she administered the wrong dose this morning. She stated both cards were in the medication cart, and they failed to remove the 25 mg tablets after the dosage change as they should have. She reviewed both cards and confirmed that only two of the 12.5 mg tablets were missing from the card, since it was delivered to the facility and eight tablets should have been removed. A review of the facility's policy and procedure for medication administration revealed: Diagnostics and Medications SHCR .01A Med Pass with Medication Cart Chapter: Medication Administration Revised: 4/25/2017 Page 1 of 3 Purpose: The nursing staff uses the medication cart to systemically distribute physician-ordered medications to residents. Page 3 18. Remove discontinued medications, and update the medication sheet accordingly.

Based on observations and interviews, the facility failed to provide a safe and sanitary environment for their residents. This affected residents in eight rooms (115, 116, 121, 111, 117, 118, 119 and 106), with the potential to affect all 104 residents residing in the facility. The findings include: A tour was conducted of the facility on 1/22/2020 between 10:30 AM and 11:00 AM. The following concerns were identified: Rooms 115, 116 and 121 had rusted toilet extenders in the bathrooms. rooms [ROOM NUMBERS] had emergency call cords wrapped around the handrails in the bathrooms. Rooms 117, 118 and 119 had unbagged and unlabeled bed pans in the bathrooms. rooms [ROOM NUMBERS] had soiled feeding pumps (dry enteral feeding product on the devices, poles, side rails, floors and walls). room [ROOM NUMBER] had a soiled suction machine at bedside. The canister was observed with unclean water in it and the canister was dated 11/1/2019. (Photographic evidence obtained) A second tour was conducted on 1/23/2020 between 11:30 AM and 11:55 AM. All of the above-noted concerns remained the same. On 1/23/2020 at approximately 12:07 PM a walking tour was conducted with Employee F, Unit Manager, and she reviewed the concerns listed above. She stated that all basins should be labeled and bagged. She confirmed that the toilet extenders had a brown substance on them resembling rust. She stated, That puts the residents at risk. She confirmed that the call light/emergency cords were wrapped around the bathroom handrails. When asked which residents in the room utilized the call lights, she stated, I believe they both do, but I will have to double check. I know Bed A for sure uses it. She was asked about the suction order for the resident in room [ROOM NUMBER], and she stated that she would have to review the resident's orders. She confirmed that the canister should be cleaned and/or changed after each use. She was then shown the enteral feeding pumps soiled with dry feeding product, and she stated that it was the nurses' responsibility to ensure those were clean. She stated that she would have to get housekeeping to come in and clean the floor and the walls. On 1/23/20 at 2:11 PM, Employee F, Unit Manager, stated that the resident in room [ROOM NUMBER] B currently did not have an order for [REDACTED]. She confirmed that she had no idea how long the dirty water had been in the canister at bedside.

Based on observation, record review and staff interview, the facility failed to ensure care and services provided met professional standards of quality, by failing to monitor an apical pulse prior to administration of [MEDICATION NAME] for one (Resident #70) of four residents observed during administration of medication, from a total of 32 sampled residents. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: On 9/26/19 at 9:20 a.m., medication observation was observed for Resident #70. A review of the (MONTH) 2019 MAR, revealed she was ordered the following medications: [REDACTED]. Employee D, Licensed Practical Nurse (LPN), administered all of the medications including the [MEDICATION NAME]. The LPN did not take the resident's pulse prior to administration of the [MEDICATION NAME]. The apical pulse must be monitored for one full minute. If the pulse is below 60, the medication should be held and the physician should be notified. During an interview with the LPN at 9:25 a.m., she was asked what the resident's pulse was prior to the administration of [MEDICATION NAME]. She stated she did not take the pulse, because the Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing on 9/26/19 at 10:45 a.m. She was asked what the protocol was for administration of [MEDICATION NAME], and she stated the pulse must be taken prior to giving the medication. A review of [NAME]' Drug Guide at https://nursing.unboundmedicine.com/nursingcentral/view/[NAME]-Drug-Guide/ /all/[MEDICATION NAME], revealed the following: High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Monitor apical pulse for 1 full minute before administering. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse.

Based on observation, record review and staff interview, the facility failed to ensure a medication error rate of 5 % or less based on two errors from a total of 33 opportunities. The errors affected Resident #13 and Resident # 70, resulting in an error rate of 6.06%. The findings include: 1. On 9/24/19 at 8:45 a.m., medication administration was observed for Resident #13. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Employee C, Registered Nurse (RN), administered the Breo-Ellipta inhaler. She placed the inhaler to the resident's mouth and instructed him to take a deep breath. The RN did not provide him with water to rinse his mouth after use of the inhaler. A review of the manufacturer's instructions included the following: BREO can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. 2. On 9/26/19 at 9:20 a.m., medication observation was observed for Resident #70. A review of the (MONTH) 2019 MAR, revealed she was ordered the following medications: [REDACTED]. Employee D, Licensed Practical Nurse (LPN), administered all of the medications including the [MEDICATION NAME]. The LPN did not take the resident's pulse prior to administration of the [MEDICATION NAME]. The apical pulse must be monitored for one full minute. If the pulse is below 60, the medication should be held and the physician should be notified. During an interview with the LPN at 9:25 a.m., she was asked what the resident's pulse was prior to the administration of [MEDICATION NAME]. She stated she did not take the pulse, because the Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing on 9/26/19 at 10:45 a.m. She was asked what the protocol was for administration of [MEDICATION NAME], and she stated the pulse must be taken prior to giving the medication. A review of [NAME]' Drug Guide at https://nursing.unboundmedicine.com/nursingcentral/view/[NAME]-Drug-Guide/ /all/[MEDICATION NAME], revealed the following: High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Monitor apical pulse for 1 full minute before administering. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse.

Based on record review and staff interview, the facility failed to ensure collaboration of hospice services and care for one (Resident #55) of one sampled residents receiving hospice services from a total of 32 sampled residents. The findings include: A record review for Resident #55 revealed a [AGE] year-old male admitted on [DATE] with a [DIAGNOSES REDACTED]. An interview was conducted with MDS (Minimum Data Set) nurse on 9/26/19 at 9:25 a.m. She was asked if the hospice nurse attended care plan meetings for Resident #55, and she stated she could check the sign-in sheets to see if they attended. The sign-in sheet dated 9/3/19, did not include attendance of the hospice nurse or any representative from hospice. The MDS nurse was asked if hospice had attended any care plan meetings this year, and she said she would need to retrieve the previous sign-in sheets from medical records. The MDS nurse provided a copy of the sign-in sheets for the care plan meetings for the past year, but there were no signatures indicating attendance by the hospice nurse. The MDS nurse stated she had been employed by the facility since (MONTH) 2019 and she had not seen a hospice nurse attend a care plan meeting. A review of the agreement between hospice and the facility revealed: Hospice to participate in development of hospice plan of care, periodic patient evaluation/assessment base don patient need and to participate in interdisciplinary/patient care conferences at the facility.

Based on record reviews and staff interviews, the facility failed to ensure three (Residents #4, #6 and #7) of three residents reviewed for narcotics, from a total of seven sampled residents, had appropriate documentation to account for all of their medications. The findings include: A record review was conducted for Resident #4 which revealed she had an order for [REDACTED]. A record review was conducted for Resident #6 which revealed she had an order for [REDACTED]. Further review of her medical record and EMAR revealed that the medication had not been documented as having been administered to her. A record review was conducted for Resident #7 which revealed that she had an order for [REDACTED].:21 p.m. Further review of her medical record and EMAR revealed that the medication had not been documented as having been administered to her. On 8/9/19 at 3:37 PM, narcotic sheets and EMARs for all three residents (Resident #4, #6, and #7) were reviewed with the Director of Nursing (DON). The Regional Nurse Consultant (RNC) was also present. The DON confirmed that the narcotics were signed off on the narcotic book drug count sheets, however, they were not documented as having been administered to the resident on the EMAR. The DON was unable to explain where the medications went. She stated it was the responsibility of the nurse to sign the narcotics out in the book (on the controlled drug sheet), and to ensure they were documented with the same time as in the EMAR for the resident. She confirmed that there were multiple concerns with all three residents. A review of the facility's policy and procedure for medication administration revealed the following: Diagnostics and Medications Medication Pass Guidelines Chapter: Medication Administration Revised 4/25/2017 Page 1 of 3 Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systematically distribute medications to residents in accordance with state and federal guidelines. Page 3 of 3 Documentation Record the name, dose, route, and time of medication on the Medication Administration Record.

Based on record review and staff interviews, the facility failed to maintain the clinical records within acceptable standards of practices for two (Residents #26 and #55) of 48 sampled Stage II residents. The findings include: A review of behavior monitoring documentation for Resident #26 for the month of (MONTH) (YEAR), revealed multiple omissions on the behavior monitoring form. The behavior monitoring was not documented on 5/10/18, 5/11/18, 5/13-5/16, and 5/18-5/20/18 on day shift, or on 5/19/18 on evening shift. Omissions from 5/21-5/25/18 were explained, as the resident was in the hospital. A review of behavior monitoring documentation for Resident #55 revealed four holes on the behavior monitoring sheet for (MONTH) (YEAR). The behavior monitoring was not documented on 5/2/18 on day shift, on 5/25-26/18 on evening shift, or on 5/26/18 during the night shift. An interview was conducted with Employee I, Unit Manager, on 6/1/18 at 11:58 AM. The Unit Manager confirmed the holes on the behavior monitoring sheets for Residents #26 and #55. The unit manager provided an in-service sheet dated 6/1/18 instructing that behavior monitoring should be documented and monitored. She stated, We started educating staff on the day shift, and will educate the other two shifts.

Based on observations, interviews and medical record review, the facility failed to provide implement residents' care plans for behavior monitoring, restorative services, and assistive devices to maintain vision for 4 (Resident #53,#54, #62 and #68 ) of 48 sampled Stage II residents. The findings include: 1. An interview was conducted with Resident #53 on 5/30/18 at 8:45 AM. The resident reported she wore glasses for her vision, but she did not have any glasses because they were lost. She did not remember the last time she had her glasses. A review of the medical record for Resident #53 revealed an admission date of [DATE]. A review of the Minimum Data Set (MDS) annual assessment dated [DATE], noted that the resident did not have eye glasses. A review of the care plan dated 4/26/18 reported the resident had impaired vision related to unfocused vision. One of the interventions noted on the care plan was to arrange a consultation with the eye care practioner annually and as needed. An interview was conducted with the Social Services Director (SSD) on 6/1/18 at 3:28 PM. The SSD confirmed that the resident had not been seen by an eye physician since admission. An interview was conducted with Employee I, Registered Nurse (RN)/Unit Manager on the South Wing on 6/1/18 at 4:01 PM. Employee I reported that if a resident notified her that they needed to see the eye physician, the SSD would be notified. The mobile eye service came in monthly and as needed. Residents were placed on a list, and the SSD kept up with it and sent them to the eye clinic. 2. An observation was conducted of Resident #68 in his room on 5/30/18 at 2:39 PM. The resident was lying in bed and reported he 'could not handle it', had a headache and nausea. The nurse was notified. The resident did not remember what medications he received. A medical record review was conducted for Resident #68 on 5/30/18. The resident was admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of the physician's orders [REDACTED]. A review of the Minimum Data Set 30-day assessment revealed that the resident was moderately impaired cognitively, and had behavior directed toward others one to three days during the seven-day look back period. The resident received an antipsychotic ([MEDICATION NAME]) seven (7) days during the look back period. A review was conducted of the Medication Administration Record [REDACTED]. A review for behavior monitoring documentation or side effect monitoring documentation revealed that none was found in the medical record. A psychiatric note by an Advanced Registered Nurse Practitioner (ARNP) on 4/6/18 reported the resident was yelling out in the evening and had increased anxiety. The plan of care was reviewed which was updated on 4/12/18. The plan of care noted a focus area for: behavior problem related to awake most nights, noisy, sundowners behaviors present. Calls wife all the time when she is not here, calls out at times, tends to pull away from staff members during transfer. Another focus area included: Potential for adverse side effects due to psychoactive medication use-depression, mood stabilizer with interventions documented to observe behavior every shift and document, and observe for possible side effects every shift. A nursing note dated 5/16/18 documented that the resident was alert with confusion with intervals of outbursts. An interview was conducted with the Director of Nursing (DON) on 6/1/18 at 12:53 PM . The DON confirmed that there was no documentation for behavior monitoring for Resident #68 related to the use of [MEDICATION NAME]. The DON reported a behavior monitoring sheet had now been implemented for the resident, and staff were being in-serviced to make this part of the admission process. An interview was conducted with Employee F, Registered Nurse (RN), on 6/1/18 at 3:24 PM. The RN reported that behaviors were documented in the computer under behavior monitoring. Types of behaviors, goals, interventions, and side effects of the medication were documented on this sheet. The [MEDICAL CONDITION] Medication Assessment and Monitoring policy and procedure revised on 5/23/17 was reviewed on 6/1/18. Noted under Procedure .5 monitoring of residents receiving anitpsychotic medication will be completed by a licensed nurse as per acceptable standards of practice using the behavior monitoring record. Noted under documentation 4. record behavior, interventions, and the effectiveness of interventions taken in the behavior monitoring record. 3. A review of the chart for Resident #54 showed that on 5/14/2018, she had an order for [REDACTED]. Resident #54's records contained a care plan which identified that she had the potential for adverse side effects due to psychoactive medication use. It listed depression and [MEDICAL CONDITION] as diagnoses. The care plan's revision date was documented as 5/31/2018. The care plan detailed that interventions to minimize risk for discomfort or adverse side effects included observation of behavior every shift and documentation of same. It also listed observation for possible side effects every shift. In an attempt to open the Behavior Monitoring form in the facility's electronic record keeping system, a message appeared showing that Resident #54 did not have any behavior monitoring. There was no evidence in the progress notes that every shift, staff were documenting behavior and potential side effects. The Director of Nursing was asked about behavior monitoring on 6/1/2018 at 12:48 PM, and confirmed that residents on [MEDICATION NAME] should have behavior monitoring. 4. During a review of Resident # 62's records, it was discovered that she was on a restorative therapy program. An evaluation in the facility's electronic record keeping system dated 3/29/2018 showed Resident #62 required assistance with ambulation, and a goal was set to preserve her ability to ambulate. The evaluation noted she should walk 60 feet (two repetitions) or as tolerated with assistance, three (3) times a week for 26 weeks. The effective date was listed as 4/1/2018. Resident #62's care plan reflected the information in the evaluation. The care plan stated Resident #62 could not walk independently, and a goal was set for her to walk greater than or equal to 60 feet using contact guard assistance. The date of the care plan's revision was 4/3/2018. It detailed interventions to this goal, including ambulating with Resident #62 60 feet for two repetitions or as tolerated, three times a week for 26 weeks. The care plan listed an effective date of 4/1/2018. The documentation for the time Resident #62 spent receiving these services was reviewed. A flowsheet in the electronic records showed that for the month of (MONTH) (YEAR), she received one day of services on 5/11/2018. All other days were checked under the column Resident Not Available. During an interview on 6/1/2018 at 10:47 AM with the restorative aides, Employees C and D, and the head of the restorative program, Employee E, they were asked about Resident #62's progress. They explained that if a resident was unavailable when they came to provide services, such as in an activity, they returned at a later time to ensure the service was provided. They were asked to review the flowsheet for Resident #62, indicating she was unavailable 11 of 12 days in (MONTH) (YEAR). Upon further review of the flowsheet they confirmed they were unable to provide services for Resident #62. When asked to clarify further, they indicated they became very busy with other people in the program, and they did not always have enough staff to make sure Resident #62 was seen every time she needed to be seen. (Photographic Evidence Obtained)

Based on observation, interview and facility document review, the facility failed to ensure provision of activities of daily living (ADL) for one (Resident #2) of two residents observed for ADL care related to scheduled showering. The findings include: During a tour of the facility conducted on 5/30/2018 at 9:50 M, a call light was on indicating that Resident #2 was in need of assistance in room [ROOM NUMBER]. Employee J, Certified Nursing Assistant (CNA) was observed leaving the hallway this room was located on without responding to the call light. This surveyor approached Resident #2's room, and Employee J, CNA, then hurried into the room first. Employee J was observed hurrying through activity with the A bed resident and then turned her attention to Resident #2. She felt the linens on his bed and stated, You are dry. What do you want me to do for you? She pulled the sheets off of Resident #2 exposing his naked lower body. Employee J was asked to repeat what she said to Resident #2, and she stated again, You are dry, what do you want me to do for you? Resident #2 had difficulty speaking and was trying to communicate with the CNA when she began slathering barrier cream on him and with quick motions waved his sheets back over his body. She was observed hurriedly providing care, and was not listening to the resident. An interview was conducted with Employee L, CNA, on 5/30/2018 at 11:25 AM, and she stated that her goal to answer call lights was to be within three to five minutes. Staff were not supposed to pass a call light that was on, and had to answer that call light responding to the resident's needs. An interview was conducted with Resident #2's wife on 5/31/18 at 1:39 PM. She stated that one night her husband had to call her and tell her that he was thirsty, because he could not find anyone to get him a drink of water. She called the front desk and no one answered. When the receptionist was reached, the receptionist told her that she could not leave her station. During this interview Resident #2's wife stated that she also spoke to the unit manager today about her husband not receiving a bath in a week, and the unit manager showed her the bathing book stating Look, he received a bath on (MONTH) 25, (YEAR). She stated that the unit manager was trying to justify that Resident #2 did get a bath, however, when the wife explained that (MONTH) 25th was last week, the unit manager replied, Oh. Resident #2 was interviewed on 5/31/2018 at 11:25 AM, and he confirmed that he did not refuse bathing/showering on (MONTH) 25, (YEAR). An interview was conducted with Employee K, CNA, on 6/1/18 at 7:15 AM about shower schedules. She pulled out a blank shower form and the shower book schedule. (Copy obtained) His shower schedule was noted as Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift, and the last documented shower was on 5/25/2018. The unit manager was asked for Resident #2's completed shower sheets. An interview was conducted with Resident #2's wife on 6/1/2018 at 2:30 PM, and she stated again that Employee I, South Unit Manager, showed her that Resident #2 was provided a shower on 5/25/2018. She went on to say that the unit manager seemed to think there was nothing wrong with the fact that her husband had not received a shower in a week's time. A review of the South Wing Shower Schedule revealed that Resident #2 had a scheduled shower for Tuesdays and Thursdays during the evening shift (3:00 PM to 11 PM). A review of task completion documentation related to provision of showers revealed that a shower was provided on 5/4/2018. The form was signed not applicable with no explanation for 5/8/2018, the resident was showered on 5/11/2018, he was documented as having refused refused his shower on 5/15/2018, he was documented as having been showered on 5/18/2018, refused on 5/22/2018, and on 5/25/2018, he was documented as not applicable with no explanation. On 5/29/2018, he was documented as having refused, and was also documented as totally dependent for showering. A review of a Grievance Report for Resident #2 dated 5/29/2018 revealed that Resident #2 complained that his call light device works intermittently. On 5/29/2018, the conclusion documented by the nursing home administrator was, Just in case, the call light device will be replaced by maintenance director. Action documented as Taken Call bell replaced by maintenance. A review of the care plan for Resident #2 revealed that bathing preferences included the goal that they would be honored through the next review. Resident #2 was also documented to have had a [MEDICAL CONDITIONS] with a goal to show improvement to maximum potential to perform ADL's by the review date. Interventions were documented as, Document Resident #2's abilities for ADLs and assist him as needed; encourage him to do what he is capable of doing for himself. Documented care plan also revealed that Resident #2 had impaired cognitive/communication ability and difficulty being understood, difficulty understanding others and [MEDICAL CONDITION]. The goal for this was to make needs known when able and ADL care needs would be met. The interventions were documented as allow ample time for resident to respond, monitor physical appearance for non-verbal communication, repeat statements as needed and speak slowly and clearly. The care plan also documented under Self Care Deficit related [MEDICAL CONDITION] intervention for the staff to, Reapproach for ADLs as needed, use simple cues.

Based on observations, interviews and medical record review, the facility failed to provide assistive devices to maintain vision for 1 (Resident #53) of 48 sampled Stage II residents. The findings include: An interview was conducted with Resident #53 on 5/30/18 at 8:45 AM. The resident reported she wore glasses for her vision, but she did not have any glasses because they were lost. She did not remember the last time she had her glasses. A review of Resident #53's medical record revealed an admission date of [DATE]. A review of the Minimum Data Set (MDS) annual assessment dated [DATE], revealed that the resident did not have eye glasses. A review of the care plan dated 4/26/18 revealed that the resident had impaired vision related to unfocused vision. One of the interventions noted on the care plan was to arrange a consultation with the eye care practioner annually and as needed. An interview was conducted with the Social Services Director (SSD) on 6/1/18 at 3:28 PM. The SSD confirmed that the resident had not been seen by an eye physician since admission. An interview was conducted with Employee I, Registered Nurse (RN)/Unit Manager on the South Unit on 6/1/18 at 4:01 PM. Employee I reported that if a resident notified her that they needed to see the eye physician, the SSD would be notified. The mobile eye service came in monthly and as needed. Residents were placed on a list and the SSD kept up with it and sent the residents to the eye clinic.

Based on observations, interviews and record review, the facility failed to ensure that one (Resident #411) of two sampled residents received respiratory care (oxygen therapy) according to professional standards of practice. The findings include: Resident #411 was observed on 5/30/2018 at 9:10 am asleep in bed with an oxygen concentrator located next to her bed. Observations were also made on 5/31/2018 at 8:04 am of the concentrator on in her room, and at 10:46 am on 5/31/2018, she was seen with a portable tank on while she was engaged in therapy. Her records were reviewed to determine how many liters per minute (lpm) of oxygen her physician ordered. She was admitted on [DATE] for short term rehabilitation, and had [DIAGNOSES REDACTED]. In both the hard chart and the electronic records, an order could not be located to determine the lpm ordered. Hospital records showed an Agency for Health Care Administration (AHCA) 3008 form (used by a hospital to communicate a resident's health status when they enter a skilled nursing facility) was completed. The 3008 form showed the resident was ordered 2.5 lpm of oxygen. Resident #411 was interviewed on 5/31/2018 at 10:53 am. She was asked how many lpm of oxygen she was ordered, but she did not know. Her nurse, Employee A, was interviewed at 11:11 am on 5/31/2018. She was asked how she knew what a resident's oxygen concentrator was supposed to be set at. She stated she went into the computer and saw what the doctor ordered. When asked what the order was for Resident #411, she could not locate one. She confirmed a physician would have to be called to clarify what the lpm of oxygen should be. At 1:37 pm on 5/31/2018, Employee A confirmed she was able to clarify with the physician that Resident #411 should be at 2.5 lpm, based on the 3008 information. The physician's orders [REDACTED]. The North Wing Unit Manager, Employee H, was asked about how orders were received for new admissions such as Resident #411. At 1:53 pm on 5/31/2018, she confirmed orders were reviewed from the hospital and were clarified by calling the physician when residents were newly admitted to the facility. The orders were then entered into the resident's electronic record. When asked how they knew what Resident #411's oxygen lpm setting was supposed to be, she reviewed the hard chart and electronic record and verified that it was not entered upon admission. She was asked if the oxygen had been set at 2.5 lpm since admission on 5/25/2018. A review of the progress notes showed staff was documenting it had been running at 2 lpm. Dates it was listed at 2 lpm were 5/29/2018 and 5/30/2018. She also opened the tab entitled 02 sats in the record and it was blank. A review of Resident #411's therapy notes showed that on 5/28/2018, 5/29/2018, and 5/31/2018, the oxygen setting was 2 lpm. The North Wing Unit Manager was asked to provide a copy of the facility's oxygen therapy policy and procedure when she was interviewed at 1:53 pm on 5/31/2018. A review of the documentation provided did not speak directly to obtaining orders for new admissions. It did, however, state that when setting up the oxygen concentrator, to adjust the flow rate as ordered by the physician. When asked for any other policies that spoke to obtaining proper orders for new admissions, the facility's corporate representative said it is not written in a policy but considered a standard of practice on 6/1/2018 at 10:21 am. This was confirmed by the Director of Nursing on 6/1/2018 at 12:48 am. She also said it was not dictated in a written policy but an expectation of the nursing staff to follow through. Photographic Evidence Obtained

Based on observations, record review and interviews, the facility failed to provide behavior monitoring for one (Resident #68) of five sampled residents for unnecessary medications out of a sample of 48 Stage II residents. The findings include: An observation of Resident #68 in his room on 5/30/18 at 2:39 PM, revealed that he was lying in bed. He reported he can not handle it, and stated he had a headache and nausea. The nurse was notified. The resident did not remember what medications he received. A medical record review was conducted for Resident #68 on 5/30/18. He was admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of the physician's orders [REDACTED]. A review of the Minimum Data Set 30-day assessment reported that the resident was moderately impaired cognitively, and had behavior directed toward others one to three days during the seven-day look-back period. The resident received an antipsychotic ([MEDICATION NAME]) seven days during the look-back period. A review was conducted of the Medication Administration Record [REDACTED]. Behavior monitoring documentation and/or side effect monitoring documentation was not found in the medical record. A psychiatric note by an Advanced Registered Nurse Practitioner (ARNP) on 4/6/18 reported that the resident was yelling out in the evening and had increased anxiety. The plan of care was reviewed which was updated on 4/12/18. The plan of care noted a focus area of, Has a behavior problem related to awake most nights, noisy, sundowners behaviors present. Calls wife all the time when she is not here, calls out at times, tends to pull away from staff members during transfer. Another focus area included: Potential for adverse side effects due to psychoactive medication use-depression, mood stabilizer with interventions documented to observe behavior every shift and document and observe for possible side effects every shift. A nursing note dated 5/16/18 noted that the resident was alert with confusion with intervals of outbursts. An interview was conducted with the Director of Nursing (DON) on 6/1/2018 at 12:53 PM . The DON confirmed there was no documentation for behavior monitoring for Resident #68 related to the use of [MEDICATION NAME]. The DON reported a behavior monitoring sheet had now been implemented for the resident, and staff were being in-serviced to make this part of the admission process. An interview was conducted with Employee F, Registered Nurse (RN), on 6/1/2018 at 3:24 PM. The RN reported that behaviors were documented in the computer under behavior monitoring. Types of behaviors, goals, interventions, and side effects of the medications were documented on this sheet. The [MEDICAL CONDITION] Medication Assessment and Monitoring policy and procedure revised on 5/23/17 was reviewed on 6/1/18. Noted under Procedure .5 monitoring of residents receiving anitpsychotic medication will be completed by a licensed nurse as per acceptable standards of practice using the behavior monitoring record. Noted under documentation 4. record behavior, interventions, and the effectiveness of interventions taken in the behavior monitoring record.

Based on observation and staff interviews, the facility failed to monitor expiration dates and remove outdated, expired drugs from one of the facility's two medication rooms, one of five medication carts (for Residents #93 and #77), and failed to clean food debris from one of five medication carts observed. The findings include: On 6/1/18 at 10:57 AM, the North Unit medication room was inspected with Employee H. The one intravenous antibiotic [MEDICATION NAME] two grams for Resident #93 was labeled with an expiration date of 5/29/18, and the other intravenous antibiotic [MEDICATION NAME] two grams for Resident #93 had the expiration date rubbed off of the label. The two intravenous antibiotics were stored in the refrigerator in the medication room. (Photographic evidence obtained) An interview was conducted with Employee H on 6/1/18 at 11:00 AM. The nurse confirmed the antibiotic was expired, and that the other antibiotic expiration label was rubbed off. The nurse stated, I will get rid of these antibiotics right away and call pharmacy for another dose for the resident for his next dose. On 6/1/18 at 11:10 AM, Resident #93's room was entered with Employee H to check the morning dose of intravenous antibiotics' expiration date. The tubing and medication was removed from the pole, and the tubing was not in any of the trash cans in the room. On 6/1/18 at 11:13 AM the medication cart on the North Unit was checked with Employee N. The medication cards for [MEDICATION NAME] 25 milligrams ([MEDICAL CONDITION] medication) were expired on 5/31/18, and there were three cards of the expired medication in the cart. The nurse confirmed she did not give Resident #77 medication from the cards that were expired. (Photographic evidence obtained) An interview with Employee N on 6/1/18 at 11:15 AM the nurse confirmed the three cards of [MEDICATION NAME] were expired. The nurse confirmed she did not give Resident #77 any medication from the three cards with expired medication. The nurse pulled out three different cards from the cart with Lamotrogine which had a later expiration date. On 6/1/18 at 12:02 PM, Employee M's medication cart was checked with the nurse present. In the bottom drawer of the cart there was food debris stuck between two medication cards. The nurse confirmed there was food debris on the two medication cards in the bottom drawer of the medication cart. (Photographic evidence obtained) An interview was conducted with Employee M on 6/1/18 at 12:05 PM. The nurse stated, It looks like an oatmeal crème pie on that card. The nurse stated, Of course we are not to have food around medication carts or eat while passing medications. During an interview with the Director of Nursing on 6/1/18 at 12:42 PM, she stated that the medication carts were audited every week, and the staff would check the carts for cleanliness and expired medications. The carts were to be checked yesterday (5/31/18), but the staff did not get it done.

Based on interview and record review, the facility failed to ensure one (Resident #62) of three sampled residents received restorative nursing services as ordered. The findings include: On 5/30/2018 at 8:45 am, Resident #62 stated she had been through physical therapy, but had not gotten much restorative therapy. During a review of Resident #62's records, it was discovered she was on a restorative therapy program effective 4/1/2018. She was to get a splint on her left elbow, a palm guard, a hand brace, and receive assistance ambulating. An evaluation in the facility's electronic records dated 3/29/2018 showed Resident #62 required assistance with ambulation, and a goal was set to preserve her ability to ambulate. The evaluation noted she should walk 60 feet (two repetitions) or as tolerated with assistance, three times a week for 26 weeks. The effective date was listed as 4/1/2018. Resident #62's care plan reflected the information in the evaluation. The care plan stated Resident #62 could not walk independently, and a goal was set for her to walk greater than or equal to 60 feet using contact guard assistance. The date of the care plan's revision was 4/3/2018. It detailed interventions to this goal, including ambulating with Resident #62 60 feet for two repetitions or as tolerated, three times a week for 26 weeks. The care plan listed an effective date as 4/1/2018. Her care plan also listed she had a contracture and was to receive assistance with supportive devices. Her left palm protector and left elbow splint were listed as interventions. The care plan showed it was revised on 3/18/2018. During an interview on 6/1/2018 at 10:47 am with the restorative aides, Employees C and D, and the head of the restorative program, Employee E, they were asked about Resident #62's progress. They provided flow sheets for the month of (MONTH) (YEAR) which showed she was getting her hand brace, palm guard, and elbow splint. They said she was to walk with a hemiwalker with two people. They were asked if she had a history of [REDACTED]. she was open to working with them. A review of the flowsheet they were documenting the elbow splint use on showed blanks on Thursday 5/24/2018, Friday 5/25/2018, and Tuesday 5/29/2018. Employees C and D were asked about the blanks, and said if they did not put it on that flowsheet, it would be documented in the electronic record. They were asked why there was no chart/form for documenting the ambulation, and they explained the ambulation was strictly documented in the electronic record. The progress notes were reviewed with them, and Employee E acknowledged the documentation did not state clearly that the specific devices were used; only that the resident was in the program. The documentation for the time Resident #62 spent receiving restorative ambulation was reviewed. A flowsheet in the electronic records showed that for the month of (MONTH) (YEAR), she received one day of services on 5/11/2018. All other days were checked under the column Resident Not Available. Restorative aides C and D explained that if a resident was unavailable when they came to provide services, such as in an activity, they returned at a later time to ensure the service was provided. They were asked to review the flowsheet for Resident #62's ambulation, indicating she was unavailable 11 of 12 days in (MONTH) (YEAR). Upon further review of the flowsheet they confirmed they were unable to provide services for Resident #62. When asked to clarify further, they indicated that they became very busy with other people in the program, and they did not always have enough staff to make sure Resident #62 was seen every time she needed to be. They confirmed Employees C and D were full time restorative aides, but the other restorative staff was assigned floor duties, and were not always available to help complete restorative therapy tasks. Photographic Evidence Obtained