Every finding on record at Plaza Health and Rehab

Based on interview and record review, the facility failed to ensure complete and accurate records for 1 of 4 residents, Resident #6, reviewed for intravenous medication management.Findings include: Review of Resident #6's nursing admission assessment dated [DATE] read, Section 12. Intravenous Access Devices: 1. Does the resident have a vascular device in place? Yes. What type of device is present? a) PICC [peripherally inserted central catheter] Line. Review of Resident #6's physician order dated 11/06/2025 read, PICC line can be removed at the end of IV [intravenous] [NAME] [antibiotics]. Review of Resident #6's physician order dated 11/6/2025 read, Piperacillin Sod-Tazobactam [antibiotic] solution reconstituted 3-0.375 GM [gram] use 3.375 gram intravenously [IV] every 6 hours for ESBL [extended-spectrum beta-lactamase] Pseudomonas until 12/05/2025 05:59. Review of Resident #6's care plan dated 11/05/2025 read, Focus: [Resident #6's name] is at risk for complications r/t [related to] receiving IV therapy. Currently has (central) IV line located (LUE) [left upper extremity]. Is receiving (IV ABX) [intravenous antibiotics] for the treatment of: (ESBL/Pseudomonas). Interventions: Administer IV (fluids/meds) as ordered, observe for effectiveness and for adverse SEs [side effects]. Perform IV flushes as ordered. Change IV tubing per protocol. Perform IV site care as ordered, observe site for sx/sx [signs/symptoms] of infection/infiltration; notify physician if noted. Labs as ordered; report findings to physician and pharmacy prn [as needed]. Vital signs as ordered and PRN. Encourage resident to notify staff of pain at IV site upon onset. Observe for sx/sx of fluid volume overload; report to physician if noted. Review of Resident #6's health status note dated 12/07/2025 read, Removed IV at 1700 [5:00 PM] on 12/7/25. Review of Resident #6's physician orders revealed there were no orders for PICC line dressing changes. Review of Resident #6's medication administration record and treatment administration record for November 2025 and December 2025 revealed there was no documentation that PICC dressing changes were completed. During an interview on 12/09/2025 at 3:24 PM, Staff A, LPN [licensed practical nurse] Unit Manager reviewed Resident #6's admission Summary and physician orders with the surveyor, and stated, [Resident #6's name] had a PICC line when she came in. We have to select the orders when residents come in with a PICC line. It's not an automatic order, but we go to the batch orders to select which ones we need. Normally I would order to change the dressings, order flushes, and observe for signs and symptoms of infection. If there is an order for a PICC dressing change, it would be on the MAR [medication administration record] for the nurse to document. Nurses do the PICC line dressing changes. I would expect the nurses to look at the date on the PICC dressing when they are assessing it. I expect the nurses to know that PICC dressings should be changed every seven days. If there is no order, I expect the nurses to put in an order and document that they changed the dressing. I do try to check on the nurses' documentation. I can't say I did or didn't forget to put in the order for the PICC dressing change. Review of the policy and procedure, titled, PICC IV Line, with an issue date of 4/01/2022, read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and at federal regulations. Licensed nurses shall provide care according to state and federal law. Dressing changes: 1. Sterile dressing change using transparent dressing is performed: At least weekly. 2. Dressing changes will be documented in the clinical record.

Based on record review and interview, the facility failed to coordinate assessments for the residents with newly diagnosed mental disorders for 2 of 3 residents reviewed (Residents #8 and #16).Findings include: 1) Review of Resident #8's admission record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including post-traumatic stress disorder (onset date of 12/20/2023), anxiety disorder (onset date of 9/19/2023), bipolar disorder (onset date of 4/22/2025), major depressive disorder (onset date of 4/22/2025), generalized anxiety disorder (4/22/2025), and brief psychotic disorder (onset date of 10/17/2023). Review of Resident #8’s Care Plan Note from mental health provider with the date of service 8/26/2025 read, “Rationale behind diagnosis: MDD [Major Depressive Disorder], Recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use or organic brain pathology… Bipolar Disorder: The patient’s history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient. There is no consistent substance use or organic brain disorder to explain these consistent mood symptoms. As bipolar disorder is a lifelong disorder, mood stabilizer medicine needs to be continued on a long-term basis… PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology.” Review of Resident #8’s Preadmission Screening and Resident Review (PASRR) dated 8/23/2023 showed it documented Resident #8’s secondary diagnosis as dementia. The PASSR documented, “No diagnosis of Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required.” under Section IV. PASRR Screen Completion. There was no updated PASRR form completed for Resident #8 with the diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder. During an interview on 9/5/2025 at 11:30 AM, the Social Services Director stated that the process regarding PASRRs was that for new admissions, the PASRR was reviewed for accuracy and if there were changes, the PASRR was updated. During an interview on 9/5/2025 at approximately 12:05 PM, the Social Services Director stated that they would be updating Resident #8's PASRR, and it should have been updated when new diagnoses were identified. 2) Review of Resident #16’s admission record showed the resident was most recently admitted on [DATE] with diagnoses including paranoid schizophrenia with onset date of 5/13/2024. Review of Resident #16’s psychiatry subsequent note with date of service 6/18/2024 read, “Rationale behind diagnosis… Schizophrenia (Not fully confirmed): The history of this patient shows that the patient has chronic and consistent psychosis. These symptoms cause significant distress and functional impairment to the patient. The patent has had a history of psychosis for more than one month, causing emotional and behavioral disturbance for six months or more. There is no consistent substance use or organic brain disorder to explain these chronic and consistent psychotic symptoms. The psychotic symptoms occur independent of exacerbation of other psychiatric comorbidities, and these psychotic symptoms cause severe distress to the patient.” Review of Resident #16’s PASRR dated 5/7/2024 showed it documented anxiety disorder and depressive disorder as mental illness under Section I. PASSR Screen Decision-Making. There was no psychotic disorder, paranoid schizophrenia or schizophrenia (not fully confirmed) documented. The PASSR documented, “No diagnosis of Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required.” under Section IV. PASRR Screen Completion. During an interview on 9/5/2025 at 9:30 AM, the Regional Nurse Consultant confirmed Resident #16’s PASRR did not document Residen#16’s diagnoses of psychotic disorder, paranoid schizophrenia or schizophrenia (not fully confirmed). Review of the facility policy and procedure titled Role of Admissions and Social Services in PASRR” last reviewed on 1/15/2025 read, “Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.”

Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 1 of 6 residents reviewed for medication administration (Resident #89).Findings include: Review of Resident #89's physician order dated 5/27/2025 read, Midodrine HCl Oral Tablet 2.5 MG [milligram] (Midodrine HCl), Give 1 tablet by mouth three times a day for Orthostatic hypotension, Hold for SBP [Systolic Blood Pressure] of greater than 130. Review of Resident #89's Medication Administration Record (MAR) for July 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: X for BP (blood pressure) and pulse and code 9 (other- see nurse's notes) on 7/8/2025 at 1:00 PM, 142/65 (systolic/diastolic blood pressure) for BP and 96 for pulse and checkmark for administration of the medication on 7/14/2025 at 5:00 PM, and X for BP and pulse and code 4 (held per parameters) on 7/27/2025 at 9:00 AM. Review of Resident #89's medical records showed no progress notes related to Midodrine HCl 2.5 MG tablet on 7/8/2025 at 1:00 PM and all blood pressures for 7/8/2025 were documented as having a systolic blood pressure of less than 130. Further review showed no blood pressure and notes documented for Midodrine HCl 2.5 MG tablet on 7/27/2025 at 9:00 AM. Review of Resident #89's MAR for August 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: NA (Not Applicable) for BP and pulse and checkmark for administration of the medication on 8/1/2025 at 5:00 PM, 132/69 for BP and 92 for pulse and checkmark for administration of the medication on 8/6/2025 at 5:00 PM, NA for BP and pulse and checkmark for administration of the medication on 8/12/2025 at 5:00 PM, 131/74 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 5:00 PM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/18/2025 at 9:00 AM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 1:00 PM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 5:00 PM, and 132/64 for BP and 74 for pulse and checkmark for administration of the medication on 8/31/2025 at 5:00 PM. Review of Resident #89's MAR for September 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: 131/66 for BP and 68 for pulse and checkmark for administration of the medication on 9/1/2025 at 5:00 PM, and 131/66 for BP and 68 for pulse and checkmark for administration of the medication on 9/2/2025 at 5:00 PM. Review of Resident #89's physician order dated 5/10/2025 read, Novolog FlexPen 100 UNIT/ML [milliliter] Solution pen-injector, Inject 8 unit subcutaneously before meals for DM [Diabetes Mellitus]. Review of Resident #89's MAR for June 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 4 (held per parameters) on 6/1/2025 at 11:30 AM, pl (Sic.) on 6/2/2025 at 6:30 AM, no entries on 6/3/2025 at 6:30 AM, 14 (insulin coverage not needed) on 6/7/2025 at 6:30 AM, pl on 6/15/2025 at 6:30 AM, pl on 6/16/2025 at 6:30 AM, and 14 on 6/27/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 6/1/2025 at 11:30 AM, 6/2/2025 at 6:30 AM, 6/3/2025 at 6:30 AM, 6/7/2025 at 6:30 AM, 6/15/2025 at 6:30 AM, 6/16/2025 at 6:30 AM, and 6/27/2025 at 6:30 AM. Review of Resident #89's MAR for July 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: no entries on 7/7/2025 at 6:30 AM, code 4 on 7/19/2025 at 11:30 AM, code 14 on 7/21/2025 at 6:30 AM, pl on 7/27/2025 at 6:30, and code 14 on 7/29/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 7/7/2025 at 6:30 AM, 7/19/2025 at 11:30 AM, 7/27/2025 at 6:30, and 7/29/2025 at 6:30 AM. Further review showed a note documenting blood sugar as 89 on 7/21/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's MAR for August 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 14 on 8/4/2025 at 6:30 AM, code 14 on 8/5/2025 at 6:30 AM, code 4 on 8/7/2025 at 6:30 AM, pl on 8/17/2025 at 6:30 AM, code 14 on 8/18/2025 at 6:30 AM, no entries on 8/19/2025 at 11:30 AM, code 14 on 8/24/2025 at 11:30 AM, no entries on 8/29/2025 at 6:30 AM, and code 4 on 8/31/2025 at 11:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 8/4/2025 at 6:30 AM, 8/5/2025 at 6:30 AM, 8/7/2025 at 6:30 AM, 8/18/2025 at 6:30 AM, 8/19/2025 at 11:30 AM, 8/24/2025 at 11:30 AM, 8/29/2025 at 6:30 AM, and 8/31/2025 at 11:30 AM. Further review showed a note documenting blood sugar as 108 on 8/17/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's MAR for September 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 14 on 9/1/2025 at 6:30 AM, code 4 on 9/1/2025 at 11:30 AM, code 14 on 9/2/2025 at 6:30 AM, code 4 on 9/2/2025 at 11:30 AM, and code 14 on 9/3/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 9/1/2025 at 11:30 AM, 9/2/2025 at 6:30 AM, 9/2/2025 at 11:30 AM, and 9/3/2025 at 6:30 AM. Further review showed a note documenting blood sugar as 117 on 9/1/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's physician order dated 5/10/2025 read, Novolog FlexPen 100 UNIT/ML Solution pen-injector, Inject as per sliding scale; if 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units, subcutaneously before meals and at bedtime for DM.” Review of Resident #89's MAR for June 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: no entries on 6/3/2025 at 6:00 AM, 196 for BS (blood sugar) and 3 (absent from building) on 6/19/2025 at 4:00 PM, 293 for BS and code 3 on 6/19/2025 at 9:00 PM, no entries on 6/24/2025 at 9:00 PM, and no entries on 6/26/2025 at 9:00 PM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale on 6/3/2025 at 6:00 AM, 6/19/2025 at 4:00 PM, 6/19/2025 at 9:00 PM, 6/24/2025 at 9:00 PM, and 6/26/2025 at 9:00 PM. Review of Resident #89's MAR for July 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: 205 for BS and code 15 (pulse below 60/minute) on 7/27/2025 at 6:00 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale on 7/27/2025 at 6:00 AM. Review of Resident #89's MAR for August 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: no entries on 8/1/2025 at 9:00 PM, 290 for BS and code 9 (other see nurse's notes) on 8/11/2025 at 6:00 AM, 152 for BS and pl on 8/17/2025 at 6:00 AM, and no entries on 8/29/2025 at 6:00 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale on 8/1/2025 at 9:00 PM, 8/17/2025 at 6:00 AM, and 8/29/2025 at 6:00 AM. Further review showed a note for 8/11/2025 at 6:00 AM that read, “Blood Sugar 290. Sprint soft drink at bedside.” During an interview on 9/5/2025 at 8:42 AM, the Director of Nursing (DON) stated that if she held a scheduled dose of insulin because the blood sugar was low, she would call the doctor and document the order [to give or hold insulin]. It would be the same for blood pressure medications. During an interview on 9/5/2025 at 8:50 AM, Staff I, Licensed Practical Nurse (LPN), stated, Set doses [of insulin] at mealtimes are usually because the resident is expected to spike [their blood sugar with eating]. I would give the morning dose [of the scheduled insulin] right before their meal, and then do the sliding scale after they eat. If the blood sugar was low, I would reach out to the doctor. I would give the blood sugar result and get an order to hold or give the insulin. I would actually write a note [not just use number codes within the MAR]. I may check 9, but I would write a note saying, Don't give per MD [Medical Doctor], or get a one-time order to give [the insulin]. The note is also to communicate with everyone. I would call the doctor if a resident's blood pressure was above the parameter for [administering] Midodrine. I would still let them know. I would still reach out, even if I planned on giving the medication, but I would double check [the blood pressure]. During an interview on 9/5/2025 at 11:03 AM, Physician #1 stated, “[Resident #89's name] is a brittle diabetic. If they check the blood sugar in the morning and it is low, I expect to be called. If it [the blood sugar] is 50-60, I consider that too low, and I expect to be contacted. They would need to contact me to see whether to hold the insulin or do something else to prevent worsening hypoglycemia. For the Midodrine, if it [the systolic blood pressure] is 131, they should hold it per protocol and document it. If the blood pressure is low, they should reach out to me. If they are not giving Midodrine when the blood pressure is within the parameter, she could have worsening hypotension, and if they are holding it when it exceeds parameters, she could have hypertension. I would be more concerned if they are giving the Midodrine when it is above parameters, due to supine hypertension.” Review of the facility policy and procedure titled “Medication Administration” last reviewed on 1/15/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication of refusals of medication by the resident. Procedure: 3. Medications should be administered in a timely manner in accordance with the physician's orders.

Based on observation and interview, the facility failed to ensure food was served in a safe manner for 3 of 12 residents observed for meal service.Findings include:During a tour of the kitchen on 07/24/2025 at 12:15 PM, three black serving trays were observed in the dish cleaning area. The three trays were chipped resulting in sharp jagged edges. During an interview on 7/24/25 at 12:15 PM, the Food Services Director stated, Trays [food trays] with jagged edges could cause bleeding to the residents with fragile skin and should not be used.During an observation on 07/24/2025 at 4:55 PM, the dinner trays were being passed out to residents residing on the F Villa. Three of the food trays that were taken to residents' rooms were observed to have chips out of them resulting in jagged edges. (Photographic Evidence Obtained)

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 1 of 3 residents reviewed for discharge, Resident #172. Findings include: Review of Resident #172's physician order dated 3/19/2024 read, [Resident #172's name] will discharge home to wife on 3/23/24. Review of Resident #172's Nursing Home Transfer and Discharge Notice dated 3/21/2024 showed the resident will be discharged home. Review of Resident #172's Discharge Interdisciplinary Summary signed on 3/25/2024 at 9:03 AM read, Home Health with hospital bed, 20-inch-high back wheelchair and Hoyer lift, discharged home. Review of Resident #172's Minimum Data Set (MDS) dated [DATE] read, A2105. Discharge Status . 04. Short Term General Hospital (acute hospital). During an interview on 6/19/2024 at 9:52 AM, the MDS Coordinator stated, The discharge status was coded wrong. It's an error. The patient was discharged home with home health and not the hospital. I should have coded the discharge status as 12, which would read home with home health care. During an interview on 6/29/2024 at 10:10 AM, the Director of Nursing stated, [Resident #172's name] was discharged home and the discharge status was coded wrong to read the resident went to the hospital.

Based on observation, interview, and record review, the facility failed to ensure PICC (Peripherally Inserted Central Catheter) line dressing was changed in accordance with professional standards of practice and intravenous (IV) site was assessed for 1 resident with PICC line, Resident #122 (Photographic evidence obtained). Findings include: Review of Resident #122's admission record showed the resident was admitted to the facility on [DATE] with diagnoses that include acute bronchitis, cellulitis of the left lower limb, sepsis, and pneumonia. During an observation on 6/17/2024 at 9:50 AM, Resident #122 had a midline IV line in his right arm. There was gauze under the transparent dressing covering the IV insertion site into the arm and the insertion site was not visible. The gauze had a small amount of dried red residue on it and the transparent dressing securing the IV and gauze to the arm was loose and raised from the arm at the bottom of the dressing. Review of Resident #122's physician order dated 6/13/2024 read, Insert midline. May use lidocaine one time only for antibiotics for 1 day. Review of the document titled IV ACCESS, INC. dated 6/13/2024 at 8:13 PM read, Patient Name: [Resident #122's name] . Reason for visit: New order, Midline . Line Placed: Y [Yes], Arm R [Right], Vein: Basilic. Review of Resident #122's physician order dated 6/13/2024 read, Ceftriaxone Sodium Injection Solution Reconstituted 1 GM [gram] (Ceftriaxone Sodium). Use 1 gram intravenously every 12 hours for Acute Bronchitis for 5 days. Review of Resident #122's physician order dated 6/14/2024 read, Normal Saline Flush Solution (Sodium Chloride Flush). Use 10 ml [milliliters] intravenously every shift for IV access. Review of Resident #122's physician order dated 6/14/2024 read, Monitor IV site for signs and symptoms of infection and report if redness, edema, warmth or drainage to MD [Medical Doctor]. every shift. Review of Resident #122's Medication Administration Record (MAR) showed that the resident received Ceftriaxone Sodium Injection Solution through the midline IV in the right arm on 6/15/2024 at 6:26 AM and 5:07 PM, on 6/16/2024 at 5:55 AM and 6:09 PM, and on 6/17/2024 at 5:31 AM. Review of Resident #122's MAR showed that the resident received Normal Saline Flush Solution through the midline IV in the right arm on 6/15/2024 at 12:12 AM, 4:01 AM, 7:54 AM, and 5:07 PM, on 6/16/2024 at 12:44 AM, 2:41 PM, 8:59 PM, and 6/17/2024 at 12:55 AM, and 2:25 PM. Review of Resident #122's MAR showed the order for changing midline dressing every shift and PRN (as needed) with the start date of 6/14/2024 and discontinuation date of 6/19/2024. There were no entries documented for 6/14/2024, 6/15/2024, and 6/16/2024 under PRN. Review of Resident #122's MAR showed staff initials indicating administration of monitoring IV site for signs and symptoms of infection on 6/14/2024 in the evening and night shifts, and on 6/15/2024, 6/16/2024, 6/17/2024, and 6/18/2024 in the day, evening and night shifts. During an interview on 6/19/2024 at 4:34 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, stated, We go by the policy for PICC dressing changes. After the midline IV is inserted, the dressing needs to be changed and the gauze covering the IV entrance site needs to be removed after 24 hours. When the dressing is changed at 24 hours, they [the nurses] do not reapply the gauze over the IV entrance site. We cannot assess the site appropriately with the gauze covering the site because the entrance into the skin and the surrounding skin is not visible. During an interview on 6/20/2024 at 6:51 AM, Staff C, LPN, stated, He [Resident #122] had gauze covering the IV entrance site under the dressing, so I couldn't assess the site initially. The bottom end of the dressing was loose, so I lifted it a little so I could see the IV entrance into the skin. I couldn't assess the entrance site for redness, swelling, or kinks in the line when it was covered with gauze. During a telephone interview on 6/20/2024 at 10:38 AM, Staff B, Registered Nurse (RN), stated, The initial midline dressing needs to be changed after a day. With the gauze covering the entrance site, you can't see to assess for patency or infection. I guess I should have changed it [Resident #122's midline IV dressing] before I administered the medication or flushed the IV. Not changing the dressing when soiled or leaving the gauze in place increases the risk of infection and the gauze being left in place obstructs the view of the entrance site. You can't appropriately assess the site with the gauze in place. During an interview on 6/20/2024 at 11:17 AM, the Director of Nursing (DON) stated, Our policy for midline IVs is to change the dressing and remove the gauze 24 hours after initial placement. It is difficult to assess the entrance site of the IV with the gauze in place covering the site. Leaving the gauze in place after 24 hours creates an increased risk of infection. Review of the facility policy and procedure titled P&P PICC IV Line last reviewed on 1/17/2024 showed that it read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law . Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post-insertion or upon admission if not dated upon admission; At least weekly; If the integrity of the dressing has been compromised (wet, loose, or soiled). 2. dressing changes will be documented in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored, covered, labeled, or discarded in the areas of the kitchen walk-in cooler and walk-in freezer, and failed to maintain sanitary standards in the walk-in cooler and walk-in freezer and for the kitchen equipment (Photographic evidence obtained). Findings include: During an observation while conducting the initial walk-through of the kitchen on 6/17/2024 at 9:00 AM with the Registered Dietician (RD), there was a large amount of ice buildup on the door and walls of the walk-in freezer and on two boxes of food stored on top shelf in the walk-in freezer. There was a large metal pan containing red gelatin with a serving scoop in the container. The pan of red gelatin was covered in a clear wrap with no identifying label or date. In the walk-in cooler, there was a large pot of a liquid substance with a clear plastic cover with no identifying label or date, a gallon of almond milk with initials of MB, and a large clear container with pasta type food with no identifying label with a date of 6/7. There were six 10-pound rolls of raw ground beef stored on sheet pan with no date, with a red colored substance on the sheet pan. There were two 5-gallon containers stored on the floor of the walk-in cooler. There was a pan with lettuce and slices of tomatoes in a clear pan partially covered with a clear wrap. There was a small plate of sliced cheese in the clear pan with the lettuce and sliced tomatoes with no label or date. There was a large clear pan of raw chicken wrapped in clear plastic with a date of 6/13. The pan of wrapped chicken was placed on top of 3 cases of sliced garlic Texas toast. In the dishwashing area, there was a wad of dirty gloves in the bottom of the sanitizing portion of the 3-compartment sink. During an interview on 6/17/2024 at 9:25 AM, the RD confirmed the buildup of ice in the freezer and stated he wasn't sure why there was an ice buildup. The RD confirmed that the scoop was left in the pan of red gelatin and stated utensils should not be left stored in the food pans. The RD confirmed items of the large pot, and large clear containers, and pan of lettuce, tomato slices and cheese did not have an identifying label or date and there should have been labels and dates on each of the containers. The RD stated he could not state whether the red substance on the sheet pan with the ground beef was blood or splashes from something. The RD confirmed the pan of raw chicken was stored on top of the cases of garlic toast and stated that the raw chicken should not have been stored on the boxes of ready to serve garlic toast and should have been discarded according to the 6/13 date. The RD confirmed the 5-gallon containers were not on a shelf and stated the 5-gallon containers should not have been on the floor. The RD confirmed the gloves in the 3-compartment sink and stated the dirty gloves should not have been left in the clean sanitizing sink. During an observation while conducting the follow up walk-through of the kitchen on 6/18/2024 at 6:38 AM with the RD, the ice machine had a black/gray substance around the opening of the ice machine. There was a sign reading Do Not Use on a 3-door reach-in cooler and a sign on the top convection oven, with no lockout tagout. The 3-compartment sink was overflowing with water and when the drain was opened, the water exited to the floor and not down a drainpipe affixed to the sink. There was standing water from the 3-compartment sink area extending into the kitchen floor area. During an interview on 6/18/2024 at 6:43 AM, the RD stated he was not sure why the equipment was not working. The RD confirmed the black/gray substance was visible around the opening of the ice machine. During an interview on 6/18/2024 at 6:45 AM, the Morning [NAME] stated the former dietary director had taken the shelves out of the oven, had cleaned the oven, and when it was turned back on, smoke was observed, so the sign was put on the oven. During an interview on 6/19/2024 at 12:03 PM, the Administrator stated she was not aware of the problems with the equipment in the kitchen. Review of the facility policy and procedure titled P&P Refrigerated Storage revised on 10/1/2023 read, Policy: Foods and Nutrition Services (FNS) staff should maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled and maintained by dietary staff . Procedure . 3. Dietary staff will store raw food (e.g. beef, fish, lamb, pork, and poultry) separate from each and on shelves below fruit, vegetables, or other ready-to-eat foods to prevent meat juices from dripping onto these foods. 4. Dietary staff will label, date, and monitor refrigerated food, including but not limited to leftovers to ensure use by use-by-dates, or frozen (where applicable) or discarded. Review of the facility policy and procedure titled Standards and Guidelines: Ice Machine cleaning/sanitizing dated 11/22 read, Standard: It is the policy of this policy to ensure ice machines are cleaned and sanitized on a regular basis.

Based on record review and interview, the facility failed to ensure complete medical records were maintained for 2 of 3 residents reviewed for laboratory result reporting, Residents #34 and #128. Findings include: Review of Resident #34's admission record showed the resident was admitted on [DATE] with diagnoses that include multiple sclerosis, other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, stage 2 (mild) chronic kidney disease, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, neuromuscular dysfunction of bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and unspecified dementia. Review of Resident #34's physician order dated 6/12/2024 read, U/A [urinalysis] with C&S [Culture and Sensitivity] one time only for odor. Review of Resident #34's lab results reported on 6/15/2024 at 12:18 PM read, Urine Culture: Growth/col [colony]/cnt [count]. Greater than 100,000 colony forming unit per ml [milliliter]. Organism. Providencia stuartii. Review of Resident #34's nursing progress notes from 6/15/2024 through 6/19/2024 showed no notes related to physician notification of urine culture results. During an interview on 6/19/2024 at 2:20 PM, the Director of Nursing (DON) stated, The doctor was actually here and reviewed the resident when he was notified of the blood sugar of 36. I was here that day, and I actually called the doctor about his urine test results and he didn't want them treated because he felt he was colonized and on hospice. I did not document my call to the doctor, and I really should have documented this in the record. Review of Resident #128's admission record showed the resident was admitted on [DATE] with the diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, other seizures, unspecified osteoarthritis, major depressive disorder, sequelae of cerebral infarction, and urinary tract infection. Review of Resident #128's physician order dated 5/21/2024 read, U/A with C&S one time only for 1 day. Review of Resident #128's lab results reported on 5/24/2024 at 2:46 PM read, Urine Culture: Growth/col/cnt greater than 100,000 colony forming units per ml. Organism Escherichia coli. Review of Resident #128's nursing progress notes from 5/22/2024 through 5/28/2024 showed no notes related to physician notification of urine culture results. During an interview on 6/19/2024 at 2:29 PM, the Director of Nursing (DON) stated, The doctor told me he was aware of her urine culture, and I don't know why he decided to treat it after that. The nurse should have documented that she called him. I do expect the nurses to fully document any communication with the doctor. The DON stated there was no policy and procedure for documentation.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 4 residents reviewed for peripheral intravenous catheters (Resident #406 and Resident #413). Photographic evidence obtained. Findings include: (1) During an observation on 2/20/23 at 9:45 AM, Resident #406 had a peripheral intravenous (IV) catheter site to the left wrist. There was tape and clear dressing over the site, but no date noted. During an interview on 2/20/23 at 9:45 AM, Resident #406 stated, This [peripheral intravenous (IV) catheter] was put in by a paramedic before I came here. During an interview on 2/20/23 at 3:20 PM, the Assistant Director of Nursing (ADON)/ Infection Preventionist confirmed there was no date on the bandage and stated, I would expect an IV site to have a date on the bandage. The intravenous site bandage should be changed every three days. I cannot tell when this was last changed. Review of the admission record documented Resident #406 was readmitted to the facility on [DATE]. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #406 from February 15, 2023 through February 20, 2023 revealed no record of care for the intravenous site. Review of the physician's orders for Resident #406 from February 15, 2023 through February 20, 2023, revealed no orders for an intravenous site or intravenous site care. Review of the Readmission Nursing Assessment for Resident #406 dated 2/16/22 read, . Section 10 Integrity. A. Is the resident being admitted with impaired skin integrity? IF yes, please identify all areas below: Site: Other, left wrist. Type: IV/Sub q/Implanted Port [subcutaneous with implanted port]. Review of the policy titled Peripheral IV [Intravenous] Dressing Changes, last reviewed 1/18/23, read, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings . General Guidelines . 2. Change the dressing at the time of catheter site rotation (every 72 to 96 hours) or immediately upon observing that the integrity of the dressing has been compromised. Steps in the Procedure. 7. Label dressing with date, time, and initials. (2) During an observation on 2/20/23 at 2:00 PM, Resident #413 had a Peripherally Inserted Central Catheter (PICC) Line dressing on the left arm dated 2/8/23. During an interview on 2/20/23 at 3:30 PM, the ADON stated, The dressing is dated 2/8/23. PICC line dressings should be changed every seven days. This one has not been changed as it should. Review of the care plan for Resident #413 read, Concern: I have a peripherally inserted central catheter for medication administration. Goal: I will remain free of complications from intravenous therapy. Interventions: . My PICC line dressing will be changed per physician orders. Review of the physician's orders for Resident #413 dated 2/13/23 read, Change PICC line dressing every day shift every Thursday and as needed. Review of the MAR and TAR for February 2023 for Resident #413 read, Change PICC line dressing every day shift every Thursday. Start Date 2/16/23. There was no documentation for Thursday, February 16, 2023. Review of the policy and procedure titled PICC/Midline Dressing Changes, last reviewed 1/18/23, read, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines: 1. Change catheter dressing every 5-7 days, or if it is wet, dirty, not intact or compromised in any way.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Resident #117, Resident #122) reviewed for gastrostomy tubes. Findings include: 1. During an observation on 2/22/2023 at 9:18 AM with Staff F, License Practical Nurse (LPN), Resident #117 was lying in bed with a gastrotomy tube observed on the left side of abdomen with dressing dated 2/22/2023. Review of Resident #117's Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section K, Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 02/03/2023. Review of Resident #117's MDS Medicare-5 Day assessment dated [DATE], Section K Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 01/10/2023. Review of Resident #117 physician's order dated 1/11/2023 reads, Enteral Feed Order five times a day Isosource 1.5 Cal @ [at] 1 can (250ml). Minimum volume to be infused 500 ml/d [milliliters per day] with flush of free water of 100ml [milliliters] before and after each bolus feeding via feeding tube. 2. During an interview on 2/22/2023 at 10:40 AM, Staff G, License Practical Nurse (LPN), confirmed Resident #122 had a gastrostomy tube on his left side of abdomen. Review of Resident #122's MDS Quarterly assessment dated [DATE], Section K Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 01/12/2023. Review of Resident #122's MDS discharged - Return Anticipated assessment dated [DATE], Section K Swallowing / Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 11/18/2022. Review of Resident #122's physician order dated 11/30/2022 reads, Enteral Feed Order two times a day Isosource 1.5 Cal @ 60 ml/hr x 12 hrs/d from 1800-0600 [60 milliliters per hour times 12 hours per day from 6:00 PM - 6:00 AM]. Volume to be infused 720. During an interview on 2/22/2022 at 12:45 PM with Staff E, MDS Coordinator, stated, [Resident #117 name] and [Resident #122 name] definitely have gastrostomy tubes. I will get together with the MDS Director, I know they have to be corrected. Review of the policy titled MDS 3.0 Completion last reviewed on 1/18/2023 reads, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5%. Thirty-eight medication administration opportunities were observed, and two errors were identified for 2 (Resident #78 and Resident #209) of 5 residents reviewed for medication administration. The medication error rate was 5.26%. Findings include: During an observation of medication administration on 2/22/23 at 8:50 AM, Staff C, Registered Nurse (RN), injected the Peripherally Inserted Central Catheter (PICC) line of Resident #78 with contents of a syringe labeled Heparin Lock Flush Solution and then immediately injected contents of second syringe labeled Saline Flush NaCl [Sodium Chloride]. Staff C did not aspirate for blood return. Staff C then connected tubing, which had been primed with medication. During an interview on 2/22/23 at approximately 8:55 AM, Staff C, RN, stated, I injected the Heparin lock and then the Saline before the antibiotic. That is how you do this. When asked if there was an order for Heparin, she stated, Yes, there is an order for the Heparin. During an interview on 2/22/23 at 6:00 PM, the Director of Nursing (DON) stated, I would expect the nurse to flush with saline before and after the medication administration. You would not use heparin unless it was specifically ordered for the patient. Review of the physician's orders for February 2023 for Resident #78 revealed no order for Heparin. Review of the policy titled 005-J Flushing Midline and Central Line IV Catheters, last reviewed on 1/18/23 read, Flushing when giving medication with SASH (saline, administer medications, saline, heparin) method for open ended (non-valved) catheters . 3. Connect 10 mL (milliliter) syringe containing preservative free .9% normal saline (amount as ordered or per facility protocol) to catheter via needleless connection device. 4. Aspirate slowly for blood return to ensure patency of catheter. 5. Flush with preservative free .9% normal saline (amount established by pharmacy or facility protocol) using push-pause method . 8. Administer medication. 9. Disconnect medication from needleless connection device . 11. Connect another 10 mL syringe containing normal saline (amount as ordered or per facility protocol) to catheter via needleless connection device. 12. Flush with preservative free .9% normal saline (amount established by pharmacy or facility protocol) . 16. Connect 10 mL syringe containing heparin (amount and/or concentration as ordered or per facility protocol) to catheter via injection or needleless connection device. 2. During an observation of medication administration on 2/22/23 at 8:25 AM, Staff C, RN, poured Polyethylene Glycol powder into a plastic drinking cup. The cup did not contain any markings for measuring the solution. Staff C, RN mixed water with the powder and administered it to Resident #209. During an interview on 2/22/23 at 8:25 AM following medication administration, Staff C, RN, stated, I do not need to use the lid to measure the medication. I can tell by looking in the drinking cup how much is in there. During an interview on 2/23/23 at 9:10 AM, the DON stated, We expect the nurse to measure liquid or other medications that are not pre-measured in the appropriate container, that might be a medicine cup or a syringe. For MiraLax [Polyethylene Glycol], the inside of the lid has the marking for the appropriate dose. I would expect the nurse to use that lid to measure the correct amount.

Based on observation, interview, and record review, the facility failed to ensure food was stored in the kitchen and 2 of 4 nourishment rooms in accordance with professional standards for food service safety and maintain food preparation equipment in a clean, sanitary manner (Photographic evidence obtained). Findings include: An initial tour of the kitchen was conducted on 2/20/2023 at 9:15 AM with the Certified Dietary Manager (CDM). The walk-in cooler had a full size sheet pan with 2 large raw pork roasts with no label or date, one raw pork roast hanging off the pan above a bag of raw chicken, the bag of raw chicken was sitting in a large amount of blood that had no date or label and the bag was hanging over the edge of the pan, two bags of soup that were unlabeled and undated, three cases of thawed health shakes without a pulled from freezer or use by date, a box of approximately 56 raw shell eggs stored on the top shelf directly over 6 assorted cases of individual juices. There was a buildup of ice observed throughout the walk-in freezer on the walls, floor, shelves, and on the various boxes of food. The walk-in freezer had several open boxes that exposed food to the elements and potential freezer burn and compromising the integrity of the foods from the buildup of ice collected on the open food boxes. During an interview on 2/20/23 at 9:30 AM, the Certified Dietary Manager (CDM) verified raw meats should be placed on an appropriate sized pan or container without the raw product hanging over edge of the pan/container, that foods should be labeled and dated in the coolers, that all products should be labeled and dated for storage, pulled dates placed on health shakes when pulled from the freezer to thaw and that raw shell eggs should have been stored on the bottom shelf in the cooler and not over other food products. A follow up tour of the kitchen was conducted on 2/21/23 at 6:20 AM with the CDM. Six hood lights over the stove were not working, the microwave had a buildup of food particles on the back and top of the microwave, and the test strips had an expiration date of March 2021. During an interview on 2/21/23 at 6:20 AM, the CDM verified that six lights were not working under the stove hood, the test strips had an expiration date of March, 2021 and no other test strips were available for the pot and pan sink. A tour of the nourishment rooms was conducted with the CDM on 2/22/23 beginning at 8:30 AM. The F-unit nourishment room had an opened container of thickened nectar tea that was not labeled with an opened date. The A-unit nourishment room had 2 open containers of thickened cranberry juice stored in the refrigerator without an open date labeled on the containers. During an interview on 2/22/23 at 8:45 AM, the CDM confirmed F-unit nourishment room had an opened container of thickened nectar tea that was not labeled with an opened date and the A-unit nourishment room had 2 open containers of thickened cranberry juice stored in the refrigerator without an open date labeled on the containers. Review of the policy titled Floor Stock, last reviewed on 1/18/23 read, Procedure . 2. c. Rotate stock and remove outdated items. Review of the policy titled Food Storage,, last reviewed on 1/18/23, read, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Foods will be stored at appropriate temperatures and by methods designed to prevent cross contamination or cross contamination. Review of the policy titled General Food Preparation and Handling, last reviewed on 1/18/23, read, Procedure. 3. Food Preparation. a. Meats, fish and poultry will be defrosted using safe thawing practices: in the refrigerator in a drip proof container, and in a manner that prevents cross contamination. Review of the policy titled General HACCP [Hazard, Analysis, Critical, Control, Points] Guidelines for Food Safety, last reviewed on 1/18/23, read, Procedure . 6. Safe Thawing Practices. a. Thaw meat, fish and/or poultry in a refrigerator in a drip proof container and in a way that prevents cross contamination (on a lower shelf with nothing underneath or near it). 11. Receiving. b. Label and date foods and put away promptly.

Based on observation, interview, and record review, the facility failed to ensure resident care equipment was kept in a clean and sanitary manner for 1 of 6 residents (Resident #39) reviewed for tube feeding equipment. Findings include: An observation of tube feeding on 2/20/2023 at 10:11 AM showed residue on the Intravenous (IV) pole for Resident #39. An observation of tube feeding on 2/21/2023 at 6:27 AM showed residue on the IV pole for Resident #39. An observation of tube feeding on 2/22/2023 at 1:31 PM showed residue on the IV pole for Resident #39. During an interview on 2/24/2023 at 2:10 PM, Staff A, Licensed Practical Nurse (LPN), confirmed the IV pole was dirty from tube feeding spills and the pole should be cleaned and wiped down when the tube feeding was changed out or when spills were noticed. During an interview on 2/24/2023 at 2:30 PM, the Infection Preventionist (IP) stated, Housekeeping cleans the equipment if not in use and nursing cleans equipment while in use. Review of the policy titled Cleaning and Disinfection of Environmental Surfaces, last review 1/18/23, read, Policy Statement. Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation. 3. Devices that are used by staff but not in direct contact with residents, shall be cleaned and disinfected regularly by the environmental services staff and as needed by the nursing staff. 9. Housekeeping surfaces will be cleaned on a regular basis when spills occur and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled.

Based on interview and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards of practice for 1 of 3 residents (Resident #203) reviewed for discharge. Findings include: Review of the admission record for Resident #203 documented the resident was admitted to the facility on [DATE]. Review of the electronic census record for Resident #203 showed stop billing date of 2/9/23. Review of the electronic medical record did not contain a transfer form or a discharge summary documenting the transfer/discharge to the hospital for Resident #203. During an interview on 2/22/23 at 12:47 PM, the Administrator stated, There was no transfer/discharge form completed for Resident #203. Review of the policy titled Transfer and Discharge (including AMA), last review 1/18/23, read, 10. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All other information necessary to meet the resident's needs .11. Non-Emergency Transfers or Discharges. A. Document the reasons for the transfer or discharge in the resident's medical record .12. Emergency Transfers/Discharges. 12. Emergency Transfers/Discharges. d. The original copies of the transfer form and Advance Directives accompany the resident. Copies are retained in the medical record. f. Document assessment findings and other relevant information regarding the transfer in the medical record.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 7 medication carts (B Villa Cart #1 and A Villa Cart #1) and failed to ensure medications were secured (photographic evidence obtained). Findings include: During an observation on 2/20/2023 at 9:41 AM of B Villa Medication Cart #1 with Staff B, License Practical Nurse (LPN), there was one open Lispro insulin pen without the original pharmacy package and one opened Wixela inhalation device with no open date or original pharmacy packaging. During an interview on 2/20/2023 at 9:47 AM, Staff B, LPN, stated, Medication should be dated when opened and kept in the original pharmacy package. During an observation on 2/20/2023 at 9:48 AM of A Villa Medication Cart #1 with Staff C, Registered Nurse (RN), there was one opened bottle of Dorzolamide eye drops with no opened date, two open bottles of Timolol Maleate Ophthalmic Solution with no open date, and one Latanoprost Ophthalmic Solution 0.005% with no open date. During an interview on 2/20/2023 at 9:55 AM, Staff C, RN, stated, Eye drops should be labeled with the date they are opened. During an observation on 2/20/2023 at 10:21 AM, Resident #18 was lying in bed. On the bedside table, there was an opened tube of zinc oxide ointment. During an observation on 2/20/2023 at 10:43 AM, Resident #118 was lying in bed. On the bedside table, there was a Spiriva Respimat inhalation spray next to the television remote control. During an interview on 2/20/2023 at 10:48 AM, Staff D, LPN, stated, [Resident #118's name] should not have medication in his room. During an interview on 2/21/2023 at 2:00 PM, the Director of Nursing stated, The staff should properly label and store all medications in their individual packaging. All medication that requires an opened date should be dated upon opening. The only way a resident can have medication in their room is if the resident has a self-administration order. The nurse must educate the resident and return demonstration from the resident on how and when to use medication should be performed. Review of the facility policy titled Labeling of Medication Containers, last reviewed on 1/18/2023, reads, Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number; f. The date the medication was dispensed; g. appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use. Review of the policy titled Medication Storage, last reviewed on 1/18/2023 reads, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 46573 2. During an observation on 2/21/2023 at 11:12 AM, Resident #103 had a medication cup containing three pills on the bedside table. During an interview on 2/21/2023 at 11:12 AM, Resident #103 stated, I'm sorry. I fell asleep and didn't take them. During an interview on 2/21/2023 at 11:17 AM, Staff A, Licensed Practical Nurse (LPN) stated, She [Resident #103] started taking them and I said I would come back and check on her, but I didn't. It was my fault. I should have stayed until she took them all. During a medication administration observation on 2/21/2023 at 5:23 PM, Staff H, LPN, placed Amiodarone Tablet 200 milligram (mg), Apixaban Tablet 5 mg, and Carvedilol Tablet 6.25 mg in a medication cup and placed the cup on top the medication cart. Staff H then left the cart unattended, walked around the corner of the hall to obtain a resident's blood pressure measurement. The medication cart was not in Staff H's line of vision. During an interview on 2/21/2023 at 5:23 PM, when Staff H, LPN, returned to the cart, she stated, I should not have left the medication on the cart. I would usually take the medicine with me or lock it in the cart, but I didn't. During a medication administration observation on 2/22/2023 at 8:50 AM, Staff C, Registered Nurse (RN), obtained an intravenous solution bag labeled Daptomycin Intravenous (IV) Solution and placed it on top of the medication cart. Staff C left the hall to gather supplies leaving Daptomycin solution on top of the cart. The medication cart was not in Staff C's line of vision. During an interview on 2/22/2023 at 8:50 AM, when Staff C, RN, returned to the cart, she stated, It is ok to leave it on the cart because I was going to use it right away. During an interview on 2/22/2023 at 6:00 PM, the Director of Nursing stated, Medications, whether pills or IV solutions, should not be left unattended. We expect our nurses will not leave medications unattended at the bedside or on top of the medication cart.

Based on interview and record review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. This has the potential to affect the current 149 residents who reside in the facility if their advance directive wishes are not verified. Findings include: Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Department of Health State of Florida Do Not Resuscitate Order documented the advanced directive was signed by the Resident #1's representative and the physician dated [DATE]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . read DNR [Do Not Resuscitate]. Review of the progress note dated [DATE] at 8:53 PM written by Staff A, LPN (Licensed Practical Nurse) on [DATE] at 10:57 AM reads, Resident was found unresponsive by staff in room. Resident's upper half of body was on bed, lower half on floor. Upon arrival, confirmed that the resident was not breathing and did not have a pulse. CPR [cardiopulmonary resuscitation] was initiated and EMS [Emergency Medical Services] notified and had arrived. Upon confirmation of DNR status, CPR was stopped. MD [Medical Director], Risk Manager, and family notified. Review of Resident #1's care plan dated [DATE] reads, I have formulated the following Advanced Directive: DNR with a goal, I will have my advanced directives honored and followed during my stay. During an interview on [DATE] at 11:40 AM the Director of Nursing (DON) stated he was made aware of an incident involving one of the Licensed Practical Nurses at the facility initiating CPR on a resident on [DATE] when the LPN called him and notified him. He stated the LPN admitted to referring to the nurses' information sheet [a paper used by nurses to help them keep track of their patients. It is started at the beginning of the nurses shift while getting report from the leaving nurse] for his information as to code status instead of looking at the computer and/or looking for a Do Not Resuscitate [DNR] in the chart. The LPN did not follow the facility protocol and started CPR prior to verifying Resident #1's code status. During an interview on [DATE] at 1:01 PM with the Assistant Administrator and the Director of Nursing (DON), the DON stated he had a meeting with the unit managers, and nursing leadership personnel regarding the incident in which a resident received CPR with a code status of DNR. He stated he spoke with the LPN who had initiated the CPR and informed him to document accurately what occurred during the incident. He stated he notified the nurse to verify code status prior to any CPR. The DON stated he spoke with the nursing staff and tried to gather information to figure out a root cause analysis to assure the incident did not occur again. The cause was determined is staff was depending on report sheets/report, not verifying the code status in the record. An in-service with staff was conducted to correct the issue. During an interview on [DATE] at 10:20 AM Staff A, LPN stated, I was the nurse for Resident #1 on [DATE]. One of the CNAs [Certified Nursing Assistant] came and told me the resident was on the floor. I went to the room and found the resident unresponsive. The supervisor came into the room as well. We repositioned the resident on the floor and called out for someone to find out code status on the resident. One of the nurses checked the patient's report sheet and said to start CPR. CPR was initiated. EMS arrived in the room and took over the CPR which had already been started. [Staff A's name] stated EMS wanted verification of DNR status, so the chart was searched for code status. The DNR was found and brought to the room. EMS called one of their doctors who told them to stop CPR and call the time of death. During an interview on [DATE] at 10:15 AM Staff C, LPN stated, I was working on B-Villa on [DATE] when I heard a call that a resident was in distress. I went over to assist. CPR had been initiated on [Resident #1's name]. I called a Code Blue overhead and called 911. I then went in to assist with chest compressions. EMS arrived and took over the CPR. Someone, I don't remember who, was printing the resident's chart and found a copy of the DNR. She presented it to the team. EMS called a doctor, I don't know which one, and the doctor on the phone said to stop CPR and call time of death. CPR was stopped. During an interview on [DATE] at 3:29 PM Staff B, LPN, Unit Manager stated, I knew to look for code status prior to starting CPR, but I was in the room assisting with the resident, so I requested another nurse to find out what the resident's code status was. The other nurse came back and stated, start CPR. I assumed she found the code status, so we initiated CPR. I was the nurse that notified the family of the death of Resident #1. I gave no personal details of the death. I did not tell the family and/or POA [Power of Attorney] that CPR was performed. During an interview on [DATE] at 11:06 AM the Medical Director stated, I was informed by the DON about CPR being conducted on one of my patients on [DATE] after the incident. During my conversation with the DON, I stated there should be an in-service conducted with all the staff on CPR and checking code status. If CPR is performed on a patient several outcomes can occur. Unsuccessful CPR will not bring the patient back to life but may cause physical harm to the body. If the patient is frail, damage to the ribcage, and/or vital organs can occur. Successful CPR will bring the patient's heart back to beating but the patient can be in an [CONDITION(S)] hit/[CONDITION(S)] [caused by a complete lack of oxygen to the brain which results in the death of brain cells/damage that affects the brain]. The patient may not be neurologically intact with meaningful life. The other direction could be that the patient comes back to life and maintains their previous status. In that incident the patient is going to start asking why CPR was conducted and they will be angry. Review of the policy and procedure titled, Emergency Procedure - Cardiopulmonary Resuscitation revised February 2018 reads: General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Cardiopulmonary Resuscitation/Basic Life Support] shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual.

Based on interview and record review the facility administration failed to conduct a thorough investigation of an identified concern to determine a root caused analysis, failed to bring the incident to the QAPI (Quality Assurance Performance Improvement) committee, provided limited staff training and did not effectively and efficiently attain and maintain the highest practicable physical well-being of each resident by not honoring resident's right for advance directive of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. Findings include: Review of the Job Description for Job Title Executive Director, revised [DATE], reads Position Purpose: Operates the facility in accordance with Company vision, mission, and values. Develops and implements strategies to safely meet the healthcare needs of residents and the community in compliance with federal, state, and local requirements, in a financially sound manner. Maintains and enhances the facility's brand and reputation in the community. Essential Job Functions - Principal Accountabilities: Oversees all facility operations, ensuring residents' needs are met in a safe, cost-effective, manner, in compliance with federal, state, and local regulations. Maintains a well-qualified, engaged, and productive workforce to meet the needs of residents and the community. Directs or implements policies, objectives, or activities of facility departments to ensure continuing operations, to maximize returns on investment, or to increase productivity. Review of the Job Description for Director of Nursing, revised [DATE], reads Position Purpose: Within the framework of the objectives and policies established by the Executive Director, the Director of Nursing will plan and coordinate nursing services with those of the medical and administrative systems. The Director of Nursing will participate as a member of the facility management team in planning, policy formulation, and administrative decision making with attention to the role, functions, and operations of the facility's nursing services. The position is responsible for resident care, management, resource management, and fiscal management. Essential Job Functions - Principal Accountabilities: Responsible for managing, directing, and supervising all nursing functions. Responsible for staff performance, staff recruitment, staff retention, and staff development. Defines and maintains the standards of nursing practice in the facility. Assesses the quality of care rendered. Review of Job Description for Assistant Director of Nursing, revised [DATE], reads Position Purpose: Assists the Director of Nursing in planning and delivering nursing services for the facility. Participates as a member of the facility management team in planning, policy formulation, and administrative decision making with attention to the role, functions, and operations of the facility's nursing services. May be responsible for specific specialty areas within the department, such as Risk Management, Staff Development, etc. Essential Job Functions - Principal Accountabilities: Responsible for managing, directing, and supervising assigned nursing functions. Responsible for staff performance, staff recruitment, staff retention, and staff development. Maintains the standards of nursing practice in the facility. Assesses the quality of care rendered. Review of the Job Description for Job Title Unit Supervisor, revised [DATE], reads Position Purpose: The purpose of this position is to administer and coordinate the activities of the assigned unit to ensure responsive medical support for residents in accordance with company and corporate policies and procedures. Essential Job Functions - Principal Accountabilities: Oversees the daily workflow of the unit. Observes residents, charting and reporting changes in conditions such as adverse reactions to medications or treatment and takes necessary actions. Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Department of Health State of Florida Do Not Resuscitate Order documented the advanced directive was signed by the Resident #1's representative and the physician dated [DATE]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . read DNR [Do Not Resuscitate]. Review of the progress note dated [DATE] at 8:53 PM written by Staff A, LPN (Licensed Practical Nurse) on [DATE] at 10:57 AM reads, Resident was found unresponsive by staff in room. Resident's upper half of body was on bed, lower half on floor. Upon arrival, confirmed that the resident was not breathing and did not have a pulse. CPR [cardiopulmonary resuscitation] was initiated and EMS [Emergency Medical Services] notified and had arrived. Upon confirmation of DNR status, CPR was stopped. MD [Medical Director], Risk Manager, and family notified. Review of Resident #1's care plan dated [DATE] read I have formulated the following Advanced Directive: DNR with a goal I will have my advanced directives honored and followed during my stay. During an interview on [DATE] at 11:40 AM the Director of Nursing (DON) stated he was made aware of an incident involving one of the LPN's at the facility initiating CPR on a resident on [DATE] when the LPN called him and notified him. He stated the LPN admitted to referring to the nurses' information sheet [a paper used by nurses to help them keep track of their patients. It is started at the beginning of the nurses shift while getting report from the leaving nurse] for his information as to code status instead of looking at the computer and/or looking for a Do Not Resuscitate [DNR] in the chart. The LPN did not follow the facility protocol and started CPR prior to verifying Resident #1's code status. During an interveiw on [DATE] at 1:01 PM with the Assistant Administrator and the Director of Nursing (DON), the DON stated he had a meeting with the unit managers, and nursing leadership personnel regarding the incident in which a resident received CPR with a code status of DNR. He stated he spoke with the LPN who had initiated the CPR and informed him to document accurately what occurred during the incident. He stated he notified the nurse to verify code status prior to any CPR. The DON stated he spoke with the nursing staff and tried to gather information to figure out a root cause analysis to assure the incident did not occur again. The cause was determined is staff was depending on report sheets/report, not verifying the code status in the record. An in-service with staff was conducted to correct the issue. He stated he did not bring the incident to QAPI due to the fact that it was an isolated incident, and he did not find it necessary. Documentation of the investigation, training, root cause analysis, and attending nurses' statements were requested. The Assistant Administrator and the DON stated none of the actions taken were documented. Facility administrative staff did provide limited staff training documentation. During an interview on [DATE] at 10:20 AM Staff A, LPN stated, I was the nurse for Resident #1 on [DATE]. One of the CNAs [Certified Nursing Assistant] came and told me the resident was on the floor. I went to the room and found the resident unresponsive. The supervisor came into the room as well. We repositioned the resident on the floor and called out for someone to find out code status on the resident. One of the nurses checked the patient's report sheet and said to start CPR. CPR was initiated. EMS arrived in the room and took over the CPR which had already been started. [Staff A's name] stated EMS wanted verification of DNR status, so the chart was searched for code status. The DNR was found and brought to the room. EMS called one of their doctors who told them to stop CPR and call the time of death. During an interview on [DATE] at 3:29 PM Staff B, LPN, Unit Manager stated, I knew to look for code status prior to starting CPR, but I was in the room assisting with the resident, so I requested another nurse to find out what the resident's code status was. The other nurse came back and stated, start CPR. I assumed she found the code status, so we initiated CPR. I was the nurse that notified the family of the death of Resident #1. I gave no personal details of the death. I did not tell the family and/or POA [Power of Attorney] that CPR was performed. During an interview on [DATE] at 11:06 AM the Medical Director stated, I was informed by the DON about CPR being conducted on one of my patients on [DATE] after the incident. During my conversation with the DON, I stated there should be an in-service conducted with all the staff on CPR and checking code status. If CPR is performed on a patient several outcomes can occur. Unsuccessful CPR will not bring the patient back to life but may cause physical harm to the body. If the patient is frail, damage to the ribcage, and/or vital organs can occur. Successful CPR will bring the patient's heart back to beating but the patient can be in an [CONDITION(S)] hit/[CONDITION(S)] [caused by a complete lack of oxygen to the brain which results in the death of brain cells/damage that affects the brain]. The patient may not be neurologically intact with meaningful life. The other direction could be that the patient comes back to life and maintains their previous status. In that incident the patient is going to start asking why CPR was conducted and they will be angry. During an interview on [DATE] at 12:00 PM, the Director of Nursing (DON) stated he is responsible for oversight of the nursing department at the facility. Review of the policy and procedure titled, Emergency Procedure - Cardiopulmonary Resuscitation revised February 2018 reads: General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Cardiopulmonary Resuscitation/Basic Life Support] shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual.

Based on interview, and record review, the quality assessment and assurance committee failed to identify, develop, and implement appropriate plans of action to correct the quality deficiencies to honor the resident's wishes of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. This has the potential to affect the current 149 residents who reside in the facility if their advance directive wishes are not verified. Findings include: Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Department of Health State of Florida Do Not Resuscitate Order documented the advanced directive was signed by the Resident #1's representative and the physician dated [DATE]. Review of the physician's order dated [DATE] at 8:45 PM. read DNR [Do Not Resuscitate]. Review of the progress note dated [DATE] at 8:53 PM written by Staff A, LPN (Licensed Practical Nurse) on [DATE] at 10:57 AM reads, Resident was found unresponsive by staff in room. Resident's upper half of body was on bed, lower half on floor. Upon arrival, confirmed that the resident was not breathing and did not have a pulse. CPR [cardiopulmonary resuscitation] was initiated and EMS [Emergency Medical Services] notified and had arrived. Upon confirmation of DNR status, CPR was stopped. MD [Medical Director], Risk Manager, and family notified. Review of Resident #1's care plan dated [DATE] read I have formulated the following Advanced Directive: DNR with a goal I will have my advanced directives honored and followed during my stay. During an interview on [DATE] at 11:40 AM the Director of Nursing (DON) stated he was made aware of an incident involving one of the Licensed Practical Nurses at the facility initiating CPR on a resident on [DATE] when the LPN called him and notified him. He stated the LPN admitted to referring to the nurses' information sheet [a paper used by nurses to help them keep track of their patients. It is started at the beginning of the nurses shift while getting report from the leaving nurse] for his information as to code status instead of looking at the computer and/or looking for a Do Not Resuscitate (DNR) in the chart. The LPN did not follow the facility protocol and started CPR prior to verifying Resident #1's code status. The DON stated he did not bring the matter to QAPI because it was an isolated incident, and he did not feel it would be required. The DON stated he did complete CPR training with the COVID Unit training on ,d+[DATE]-,d+[DATE]. He stated he did not complete training with all staff or all nursing staff as this was not a required training for staff. Review of the Facility In-service dated [DATE] - [DATE] titled, DNR status and COVID Unit documented 24 CNAs (Certified Nursing Assistant), 11 LPNs, 2 Unit assistants, and 6 PCAs (Personal Care Attendant) sign as having attended the in-service. No RNs (Registered Nurse) signed as having attended the in-service. Review of the current staffing list documents the facility employs 140 CNAs, 55 LPNs, and 13 RNs. Information was requested regarding the number of PCAs employed by the facility, no documentation was provided. During an interview on [DATE] at 1:01 PM with the Assistant Administrator and the Director of Nursing (DON), the DON stated he had a meeting with the unit managers, and nursing leadership personnel regarding the incident in which a resident received CPR with a code status of DNR. He stated he spoke with the LPN who had initiated the CPR and informed him to document accurately what occurred during the incident. He stated he notified the nurse to verify code status prior to any CPR. The DON stated he spoke with the nursing staff and tried to gather information to figure out a root cause analysis to assure the incident did not occur again. The cause was determined is staff was depending on report sheets/report, not verifying the code status in the record. An in-service with staff was conducted to correct the issue. He stated he did not bring the incident to QAPI due to the fact that it was an isolated incident, and he did not find it necessary. Documentation of the investigation, training, root cause analysis, and attending nurses' statements were requested. The Assistant Administrator and the DON stated none of the actions taken were documented. Facility administrative staff did provide limited staff training documentation. Facility administrative staff did provide limited staff training documentation. During an interview on [DATE] at 10:20 AM Staff A, LPN stated, I was the nurse for Resident #1 on [DATE]. One of the CNAs [Certified Nursing Assistant] came and told me the resident was on the floor. I went to the room and found the resident unresponsive. The supervisor came into the room as well. We repositioned the resident on the floor and called out for someone to find out code status on the resident. One of the nurses checked the patient's report sheet and said to start CPR. CPR was initiated. EMS arrived in the room and took over the CPR which had already been started. [Staff A's name] stated EMS wanted verification of DNR status, so the chart was searched for code status. The DNR was found and brought to the room. EMS called one of their doctors who told them to stop CPR and call the time of death. During an interview on [DATE] at 10:15 AM Staff C, LPN stated, I was working on B-Villa on [DATE] when I heard a call that a resident was in distress. I went over to assist. CPR had been initiated on [Resident #1's name]. I called a Code Blue overhead and called 911. I then went in to assist with chest compressions. EMS arrived and took over the CPR. Someone, I don't remember who, was printing the resident's chart and found a copy of the DNR. She presented it to the team. EMS called a doctor, I don't know which one, and the doctor on the phone said to stop CPR and call time of death. CPR was stopped. During an interview on [DATE] at 11:06 AM the Medical Director stated, I was informed by the DON about CPR being conducted on one of my patients on [DATE] after the incident. During my conversation with the DON, I stated there should be an in-service conducted with all the staff on CPR and checking code status. If CPR is performed on a patient several outcomes can occur. Unsuccessful CPR will not bring the patient back to life but may cause physical harm to the body. If the patient is frail, damage to the ribcage, and/or vital organs can occur. Successful CPR will bring the patient's heart back to beating but the patient can be in an [CONDITION(S)] hit/[CONDITION(S)] [caused by a complete lack of oxygen to the brain which results in the death of brain cells/damage that affects the brain]. The patient may not be neurologically intact with meaningful life. The other direction could be that the patient comes back to life and maintains their previous status. In that incident the patient is going to start asking why CPR was conducted and they will be angry. He stated he did not bring the incident to QAPI. He stated this is an isolated incident. During an interview on [DATE] at 12:00 PM the Director of Nursing (DON) stated something is brought to QAPI if it is out of the normal. Falls, chronic concerns, not following physician orders, not following policies, are all examples of out of the normal. The DON stated performing CPR on a resident with a DNR would be brought to QAPI. He stated they did not have a formal meeting concerning the incident, but verbally spoke with everyone involved. No documentation can be provided, as it was all verbal. He stated he did not know which EMS arrived at their facility on [DATE] and assisted with CPR of their resident. During an interview on [DATE] at 12:00 PM the Assistant Administrator stated anything with a negative outcome to a resident would go to QAPI. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), revised ,d+[DATE], reads, Policy. It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Definitions: Adverse Event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. Performance Improvement (PI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. Policy Explanation and Compliance Guidelines. 2. The QAA Committee shall be interdisciplinary and shall: b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. c. Develop and implement appropriate plans of action to correct identified quality deficiencies. Program Development Guidelines: 2. Governance and Leadership a. The governing body and/or executive leadership is responsible and accountable for the QAPI program. b. v. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to resident based on performance indicator data, and resident and staff input, and other information.

Based on interview and record review the facility failed to ensure medical records on each resident are maintained in accordance with accepted professional standards and practices for complete and accurate records for 1 of 3 residents, Resident #1. Findings include: Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Department of Health State of Florida Do Not Resuscitate Order documented the advanced directive was signed by the Resident #1's representative and the physician dated [DATE]. Review of the physician's order dated [DATE] at 8:45 PM. read DNR [Do Not Resuscitate]. Review of the progress note dated [DATE] at 8:53 PM written by Staff A, LPN (Licensed Practical Nurse) on [DATE] at 10:57 AM reads, Resident was found unresponsive by staff in room. Resident's upper half of body was on bed, lower half on floor. Upon arrival, confirmed that the resident was not breathing and did not have a pulse. CPR [cardiopulmonary resuscitation] was initiated and EMS [Emergency Medical Services] notified and had arrived. Upon confirmation of DNR status, CPR was stopped. MD [Medical Director], Risk Manager, and family notified. During an interview on [DATE] at 1:01 PM with the Assistant Administrator and the Director of Nursing (DON), the DON stated he had a meeting with the unit managers, and nursing leadership personnel regarding the incident in which a resident received CPR with a code status of DNR. He stated he spoke with the LPN who had initiated the CPR and informed him to document accurately what occurred during the incident. He stated he notified the nurse to verify code status prior to any CPR. The DON stated he spoke with the nursing staff and tried to gather information to figure out a root cause analysis to assure the incident did not occur again. The cause was determined is staff was depending on report sheets/report, not verifying the code status in the record. An in-service with staff was conducted to correct the issue. He stated he did not bring the incident to QAPI due to the fact that it was an isolated incident, and he did not find it necessary. Documentation of the investigation, training, root cause analysis, and attending nurses' statements were requested. The Assistant Administrator and the DON stated none of the actions taken were documented. During an interview on [DATE] at 10:15 AM Staff C, LPN stated, I was working on B-Villa on [DATE] when I heard a call that a resident was in distress. I went over to assist. CPR had been initiated on [Resident #1's name]. I called a Code Blue overhead and called 911. I then went in to assist with chest compressions. EMS arrived and took over the CPR. Someone, I don't remember who, was printing the resident's chart and found a copy of the DNR. She presented it to the team. EMS called a doctor, I don't know which one, and the doctor on the phone said to stop CPR and call time of death. CPR was stopped. During an interview on [DATE] at 10:20 AM Staff A, LPN stated, I was the nurse for Resident #1 on [DATE]. One of the CNAs [Certified Nursing Assistant] came and told me the resident was on the floor. I went to the room and found the resident unresponsive. The supervisor came into the room as well. We repositioned the resident on the floor and called out for someone to find out code status on the resident. One of the nurses checked the patient's report sheet and said to start CPR. CPR was initiated. EMS arrived in the room and took over the CPR which had already been started. [Staff A's name] stated EMS wanted verification of DNR status, so the chart was searched for code status. The DNR was found and brought to the room. EMS called one of their doctors who told them to stop CPR and call the time of death. During an interview on [DATE] at 12:30 PM the Director of Nursing (DON) stated that he was not aware of which EMS service arrived, he did not have the names of the EMS staff that came to the facility, he did not have the time documented when EMS arrived, when they began to assist with CPR, and when CPR was stopped. The DON stated there was no documentation when CPR was initiated and when it was stopped. There is no documentation for the time of death of Resident #1. It is his expectation that staff would document all activities that are conducted with a resident and any care they receive. During an interview on [DATE] at 12:30 PM the Assistant Administrator stated it was his expectation that the staff follow facility policy with all documentation. Review of the facility policy titled Charting and Documentation dated [DATE] reads Policy Statement. Services provided to the resident, or any changes in resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation. 1. Observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided. b. The name and title of the individual (s) who provided the care. c. The evaluation data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician, or other staff, if indicated. g. The signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to ensure that the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and included the expiration date when applicable in 6 of 6 medication carts and 2 of 3 medication rooms reviewed. Findings: On 8/23/2021 at 9:05 AM an observation of medication cart #1 with Staff F, Licensed Practical Nurse (LPN), showed two opened [MEDICATION(S)] 0.05% eye drops with no opened or expiration dates, and one opened [MEDICATION(S)] insulin with no opened or expiration dates. During an interview on 8/23/2021 at 9:10 AM, Staff F, LPN, stated, All medications should have the date they are opened and when they expire. On 8/23/2021 at 9:20 AM, an observation of medication cart #2 with Staff G, LPN, showed two opened [MEDICATION(S)] eye drops with no resident identifiers and no opened or expiration dates, and one refresh eye drops with no resident identifier and no opened or expiration dates. During an interview on 8/23/2021 at 9:40 AM, Staff G, LPN, stated, All medications should have the resident they are for, the date they were opened or when they expire. On 8/23/2021 at 9:50 AM, an observation of medication cart #3 with Staff H, LPN, showed two medication cups in the top drawer of the medication cart. The first medication cup contained seven medications with no resident identifier and the second medication cup contained seven medications with no resident identifier. There were one opened [MEDICATION(S)] eye drops with an opened date of 7/2/2021, one opened [MEDICATION(S)] Flex pen with no opened date, and one unopened [MEDICATION(S)] Flex pen, not refrigerated per pharmacy recommendations. During an interview on 8/23/2021 at 10:00 AM, Staff H, LPN, stated, I should not have pre poured medications in the cart. The residents were not in their rooms when I poured them, so I put them in the drawer. I should not have. All insulins should be refrigerated if they are not opened. All insulins should be dated. The eye drops are expired and should not be on the medication cart anymore. On 8/23/2021 at 10:10 AM, an observation of medication cart #4 with Staff D, LPN, showed three cups of medications on top of the medication cart. The first medication cup contained nine medications with no resident identifier, the second cup contained three medications with no resident identifier, and the third cup contained six medications with no resident identifier. There was one opened bottle of [MEDICATION(S)] eye drops with no opened or expiration dates. During an interview on 8/23/2021 at 10:27 AM, Staff D, LPN, stated, We should not have pre poured medications and if eye drops are opened, they should have the date they are opened and the expiration date. On 8/23/2021 at 10:32 AM, an observation of medication cart #5 with Staff I, LPN, showed one unopened [MEDICATION(S)] insulin flex pen, not refrigerated per pharmacy recommendation and one opened [MEDICATION(S)] insulin with no opened or expiration dates. During an interview on 8/23/2021 at 10:40 AM, Staff I, LPN, stated, All Insulin should be refrigerated when in a pharmacy package that states refrigerate and all insulins should be dated with the date opened and the expiration date. On 8/23/2021 at 11:00 AM, an observation of medication cart #6 with Staff J, LPN, showed one medication cup in the top drawer of the medication cart with nine medications with no resident identifier, one opened bottle of [MEDICATION(S)] eye drops with no opened or expiration dates, and one opened [MEDICATION(S)] Insulin Flex pen with an opened date of 7/3/2021, with pharmacy instructions to discard after 42 days. During an interview on 8/23/2021 at 11:10 AM, Staff J, LPN, stated, I should not have pre poured medications and made sure the resident was available to take them. All eye drops should have the date opened or expired and the insulin should have been discarded because it expired. On 8/24/2021 at 3:35 PM, an observation of the automated medication dispensing machine #1 with the Director of Nursing (DON) for outdated medications showed eight [MEDICATION(S)] 150 mg (milligram) capsules with an expiration date of 8/3/2021, four [MEDICATION(S)] 1 mg tablets with an expiration date of 8/3/2021, seven [MEDICATION(S)] 5 mg tablets with an expiration date of 8/3/2021, eight [MEDICATION(S)] Monotrate ER (Extended Release) 30 mg tablets with an expiration date of 8/2/2021, ten [MEDICATION(S)] 250 mg tablets with an expiration date of 8/2/2021, eight [MEDICATION(S)] 10 mg tablets with an expiration date of 8/3/2021, five [MEDICATION(S)] 25 mg capsules with an expiration date of 8/11/2021, eight [MEDICATION(S)] 50 mg capsules with an expiration date of 8/5/2021, five [MEDICATION(S)] 1 mg tablets with an expiration date of 8/5/2021, nine Tamsulosin 0.4 mg capsules with an expiration date of 8/5/2021, nine [MEDICATION(S)] 5 mg tablets with an expiration date of 8/5/2021, six [MEDICATION(S)] 10 mg tablets with an expiration date of 8/3/2021, and six [MEDICATION(S)] 15 mg tablets with an expiration date of 8/5/2021. On 8/24/2021 at 3:55 PM, an observation of the automated medication dispensing machine #2 with the Director of Nursing for outdated medications showed two [MEDICATION(S)] 0.3 mg/3 ml (milliliter) pens with an expiration date of 3/31/2021, and four [MEDICATION(S)] 15 mg tablets with an expiration date of 8/5/2021. During an interview on 8/24/2021 at 4:10 PM, the Director of Nursing stated, I was not aware that these machines had expired medications in them. They should not be available for staff to use. I am not sure how this happened. Review of the facility policy and procedure titled Storage of Medications, with an approval date of 6/28/2021, reads, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each residents' medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several people. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secure location. Medications must be stored separately from food and must be labeled accordingly. Review of the facility policy and procedure titled Labeling of Medication Containers, with an approval date of 6/28/2021, reads, Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Policy Interpretation and Implementation: . 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name, . h. The expiration date when applicable . 4. Labels for each floor's stock medications shall include all necessary information such as: . c. The expiration date when applicable.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent elopement of two of 10 sampled residents. The facility failed to follow its Elopement policy. These failures resulted in Residents #1 and #2, who the facility assessed as at risk for elopement, exiting the facility without staff knowledge or supervision. The residents successfully walked out of the building, crossed a busy 4-to-6 lane highway and walked approximately a mile, passing through an interchange where vehicles enter and exit the interstate on both sides of the highway. The facility's failure to provide adequate supervision resulted in the elopement of two cognitively-impaired residents from the secure memory unit placing the residents in a situation likely to cause serious injury, harm, impairment or death to the residents. Findings: A review of a video provided by the Administrator on 06/17/2016 showed on 06/11/2016 at 5:58 PM two residents wearing Wander Guard alarms exiting the memory care unit through an exterior door. Further review showed a staff member (staff S) disarming the alarm at 6:18 PM without checking for the residents. The residents successfully walked out of the building, at some point crossed a busy highway and walked approximately a mile, passing through an interchange where vehicles enter and exit the interstate on both sides of the highway. At approximately 6:45 PM an employee (staff F) driving on Archer Rd. recognized the residents and called his supervisor (staff R) to report seeing them. The facility dispatched staff R and staff D at 6:45 PM to pick the residents up and return them to the facility at 6:55 PM. On 06/13/2016 at 2:20 PM an interview with the DON (Director of Nursing) revealed she became aware of the elopement of two residents about 6:45 PM on June 11, 2016 when she was notified by Staff L, Licensed Practical Nurse (LPN). Staff L discovered the residents missing and the House Supervisor, and Assistant Maintenance Director started looking for them. The house supervisor found them and brought them back. She reported that staff had located them in the parking lot of a restaurant. She said the two residents left through a door in memory care unit to the garbage area outside. A telephone interview was conducted with the Assistant Maintenance Director on 6/13/16 at 6:15 PM. He stated he was working at the facility the evening of 6/11/16 when he received a phone call from Staff F, Maintenance Worker. Staff F reported seeing residents #1 and #2 at the bank parking lot on Archer Road. The Assistant Maintenance Director then reported the sighting of the two residents to the memory unit. The Assistant Maintenance Director stated that based on Staff L ' s reaction, his impression was that the LPN did not know the residents had eloped. A telephone interview was conducted with Staff F at 7:36 PM on 6/13/16. He stated he was in his personal vehicle transporting items from the old facility to the new location when he happened to see residents #1 and #2 in the bank parking lot. He was not a part of an organized search. Staff F called his supervisor, the Assistant Maintenance Director, and informed him. No staff member or anyone else was with the two residents. They were on the south side of Archer Road. He stayed with them until facility resident care staff were dispatched and returned the residents to the facility. Medical record review revealed the facility admitted Resident #1 on 07/31/2015 with multiple [DIAGNOSES REDACTED]. The facility assessed the resident as unable to accurately recall events. Review of the quarterly MDS (minimum data set) Brief Interview for Mental Status (BIM) score dated 05/09/2016 for Resident #1 showed a 0 indicating severely impaired cognition. Resident #1 was identified at high risk for elopement and wandering related to the resident ' s impaired cognition and a history of wandering and pacing on the Elopement Assessment form dated 06/11/2016. The facility developed a care plan dated 11/13/2015 and last updated 05/13/2016 for risk for elopement secondary to exit seeking behavior. 1. Determine resident ' s reason for exit seeking. 2. Photograph resident and place on a protected list for at risk residents 3. Initiate wander alert system 4. Check Wander Guard for placement and function QS (every shift) and PRN (as needed) 5. Allow for safe wandering 6. Redirect resident as needed 7. Provide emotional support as needed 8. Encourage family/representative to visit as much as possible as needed. Medical record review revealed the facility admitted Resident #2 on 01/11/2016 with multiple [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] BIM (brief interview for mental status) showed a score of 10 indicating moderately impaired. The Elopement Assessment form dated 06/11/2016 revealed the facility assessed the resident as a high risk for elopement and wandering related to the resident expressing anger about nursing home placement, a habit of pacing, verbalizations of I ' m going home , dementia, and being upset with her son. The facility developed a care plan dated 01/15/2016 and last updated 04/15/2016 for Hospice services and risk for elopement secondary to exit seeking behavior. 1. Determine resident ' s reason for exit seeking. 2. Photograph resident and place on a protected list for at risk residents 3. Initiate wander alert system 4. Check Wander Guard for placement and function QS (every shift) and PRN (as needed) 5. Allow for safe wandering 6. Redirect resident as needed 7. Provide emotional support as needed 8. Encourage family/representative to visit as much as possible as needed. She was also care planned for risk for falls related to lack of coordination, muscle weakness, impaired vision Review on 6/13/16 of the Elopement policy (revised 04/07/2016) revealed: .b. Those residents that are assessed to be At Risk for elopement will be furnished with a Wander Guard transmitter. c. All effort will be made by the facility to place all or most residents at risk for elopement on the memory unit.e. Wander Guard checklists will be done daily and monitored by nursing. Wander guards will be checked to ensure operative devices (transmitters) are working properly and transmitter ID and expiration date will be documented.g. Staffing on the memory care unit will be increased as needed to accommodate the residents ' safety.l. Residents on the memory unit who have been identified as an elopement risk will be supervised by staff when leaving the floor. The facility provided an acceptable credible allegation of compliance on 06/17/2016. Immediate Jeopardy was verified as removed prior to exit on 06/17/2016 with remaining non-compliance at 42 CFR 483.25 Quality of Care, scope and severity of a D. The facility ' s Focused Elopement Quality Improvement Team will meet weekly for 8 weeks to monitor monitor. Maintenance and nursing will check doors and Wander Guard alarms daily to verify continued functioning and implement interventions promptly including notification of the DON and/or Administrator. Cameras were installed at the nurses ' station for monitoring exits and will be were reviewed daily by Unit Managers to identify if there were elopements or elopement risks. Elopement education for all staff will be completed, staff will be at the exit doors until all staff complete the elopement/alarm training, a sign is to be posted advising visitors not to escort residents outside without permission, and elopement drills are to be completed on each nursing station rotating shifts for at least 30 days. On 06/13/2016 at 2:20 PM an interview with the DON revealed on June 11,2016 the Maintenance Director was immediately called in to address the alarms, all doors were manned by staff, family was notified, the ARNP (Advanced Registered Nurse Practitioner) was notified, and staff was educated about the incident. Once the residents were returned to the facility a head-to-toes assessment was done on Residents #1 and #2. On 6/13/16, starting at 3:30 PM a tour of the memory unit with the maintenance director showed all seven exterior doors were supervised by facility staff members sitting near each exit. An interview was conducted on 6/17/2016 at 5:38 PM with Staff Education Coordinator. She stated she trained facility staff on elopement, door alarms, call bells, frequent rounding, and Wander Guards. The staff education is ongoing at this time and all shifts are being trained. The facility managers assist with the training. An interview was conducted on 6/17/2016 at 6:15 PM with Staff A, LPN, assigned to the memory care unit. She stated residents were assessed for elopement within 72 hours of admission. They received a Wander Guard on admission. They are care planned on admission if assessed as elopement risk or having exit seeking behavior, they will receive a Wander Guard. An interview was conducted on 6/17/2016 at 6:30 PM with Staff M, LPN. She said she had elopement/alarm training on Monday. An interview was conducted on 6/17/2016 at 6:35 PM with Staff N, C.N.A. She stated she had elopement/alarm training today. An interview was conducted on 6/17/2016 at 6:38 PM with Staff C, C.N.A. She related she had elopement/alarm training on Monday following the incident of elopement on Saturday. An interview was conducted on 6/17/2016 at 6:43 PM Staff O, LPN, on B wing. She had the elopement/alarm training earlier this week, but could not remember which day. She also had training again today. An interview on 6/17/2016 at 6:46 PM with Staff P, LPN, revealed he was in an in-service training this week on elopement/alarm. An interview on 6/17/2016 at 6:50 PM with Staff J, LPN, revealed she was trained on elopement/alarms yesterday. She normally works memory care. Observations on 06/11/2016 through 06/17/2016 showed staff monitoring doors and making rounds on residents. Review of the facility's policy and procedure entitled Abuse & Neglect revised 07/24/2013 defines neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. III Prevention 2. Supervisors and managers have responsibility for training and supervision of staff as well as monitoring residents or resident care areas. 4. the facility staff shall observe and supervise residents in an effort to identify: a. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility. Training logs provided by the Administrator showed the staff had been trained on Neglect and provided the material for training.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent elopement of two of 10 sampled residents. The facility failed to follow its Elopement policy. These failures resulted in Residents #1 and #2, who the facility assessed as at risk for elopement, exiting the facility without staff knowledge or supervision. The residents successfully walked out of the building, crossed a busy 4-to-6 lane highway and walked approximately a mile, passing through an interchange where vehicles enter and exit the interstate on both sides of the highway. The facility's failure to provide adequate supervision resulted in the elopement of two cognitively-impaired residents from the secure memory unit placing the residents in a situation likely to cause serious injury, harm, impairment or death to the residents. Findings: A review of a video provided by the Administrator on 06/17/2016 showed on 06/11/2016 at 5:58 PM residents # 1 and #2 wearing Wander Guard alarms exiting the memory care unit through an exterior door. Further review showed a staff S disarming the alarm at 6:18 PM without checking for the residents. The residents successfully walked out of the building, at some point crossed a busy highway and walked approximately a mile, passing through an interchange where vehicles enter and exit the interstate on both sides of the highway. At approximately 6:45 PM an staff f driving on Archer Rd. recognized the residents and called his supervisor (staff R) to report seeing them. The facility dispatched staff R and staff D at 6:45 PM to pick the residents up and return them to the facility at 6:55 PM. On 06/13/2016 at 2:20 PM an interview with the DON (Director of Nursing) revealed she became aware of the elopement of two residents about 6:45 PM on June 11, 2016 when she was notified by Staff L, LPN. Staff L discovered the residents missing and the House Supervisor, and Assistant Maintenance Director started looking for them. The house supervisor found them and brought them back. She reported that staff had located them in the parking lot of a restaurant. She said the two residents left through a door in memory care unit to the garbage area outside. A telephone interview was conducted with the Assistant Maintenance Director on 6/13/16 at 6:15 PM. He stated he was working at the facility the evening of 6/11/16 when he received a phone call from Staff F, Maintenance Worker. Staff F reported seeing residents #1 and #2 at the bank parking lot on Archer Road. The Assistant Maintenance Director then reported the sighting of the two residents to the memory unit. The Assistant Maintenance Director stated that based on Staff L ' s reaction, his impression was that the LPN did not know the residents had eloped. A telephone interview was conducted with Staff F at 7:36 PM on 6/13/16. He stated he was in his personal vehicle transporting items from the old facility to the new location when he happened to see residents #1 and #2 in the bank parking lot. He was not a part of an organized search. Staff F called his supervisor, the Assistant Maintenance Director, and informed him. No staff member or anyone else was with the two residents. They were on the south side of Archer Road. He stayed with them until facility resident care staff were dispatched and returned the residents to the facility. Medical record review revealed the facility admitted Resident #1 on 07/31/2015 with multiple [DIAGNOSES REDACTED]. The facility assessed the resident as unable to accurately recall events. The Brief Interview for Mental Status (BIM) score for Resident #1 showed a 0 indicating severely impaired cognition on the Quarterly MDS dated [DATE]. Resident #1 was identified at high risk for elopement and wandering related to the resident ' s impaired cognition and a history of wandering and pacing on the Elopement Assessment form dated 06/11/2016. The facility developed a care plan dated 11/13/2015 and last updated 05/13/2016 for risk for elopement secondary to exit seeking behavior. 1. Determine resident ' s reason for exit seeking. 2. Photograph resident and place on a protected list for at risk residents 3. Initiate wander alert system 4. Check Wander Guard for placement and function QS (every shift) and PRN (as needed) 5. Allow for safe wandering 6. Redirect resident as needed 7. Provide emotional support as needed 8. Encourage family/representative to visit as much as possible as needed. Medical record review revealed the facility admitted Resident #2 on 01/11/2016 with multiple [DIAGNOSES REDACTED]. The MDS initial assessment dated [DATE] indicated a BIM score of 10 indicating moderately impaired. The Elopement Assessment form dated 06/11/2016 revealed the facility assessed the resident as a high risk for elopement and wandering related to the resident expressing anger about nursing home placement, a habit of pacing, verbalizations of I ' m going home , dementia, and being upset with her son. The facility developed a care plan dated 01/15/2016 and last updated 04/15/2016 for Hospice services and risk for elopement secondary to exit seeking behavior. 1. Determine resident ' s reason for exit seeking. 2. Photograph resident and place on a protected list for at risk residents 3. Initiate wander alert system 4. Check Wander Guard for placement and function QS (every shift) and PRN (as needed) 5. Allow for safe wandering 6. Redirect resident as needed 7. Provide emotional support as needed 8. Encourage family/representative to visit as much as possible as needed. She was also care planned for risk for falls related to lack of coordination, muscle weakness, impaired vision Review on 6/13/16 of the Elopement policy (revised 04/07/2016) revealed: .b. Those residents that are assessed to be At Risk for elopement will be furnished with a Wander Guard transmitter. c. All effort will be made by the facility to place all or most residents at risk for elopement on the memory unit.e. Wander Guard checklists will be done daily and monitored by nursing. Wander guards will be checked to ensure operative devices (transmitters) are working properly and transmitter ID and expiration date will be documented.g. Staffing on the memory care unit will be increased as needed to accommodate the residents ' safety.l. Residents on the memory unit who have been identified as an elopement risk will be supervised by staff when leaving the floor. The facility provided an acceptable credible allegation of compliance on 06/17/2016. Immediate Jeopardy was verified as removed prior to exit on 06/17/2016 with remaining non-compliance at 42 CFR 483.25 Quality of Care, scope and severity of a D. The facility ' s Focused Elopement Quality Improvement Team will meet at least weekly for at least 8 weeks to monitor. Maintenance and/or nursing will check doors and Wander Guard alarms daily to verify continued functioning. Cameras were installed at the nurses ' station for monitoring exit. Cameras will be reviewed daily by Unit Managers to identify if there were elopements or elopement risks. Elopement education for all staff will be completed, staff will be at the exit doors until all staff complete the elopement/alarm training, a sign is to be posted advising visitors not to escort residents outside without permission, and elopement drills are to be completed on each nursing station rotating shifts for at least 30 days. On 06/13/2016 at 2:20 PM an interview with the DON revealed on June 11,2016 the Maintenance Director was immediately called in to address the alarms, all doors were manned by staff, family was notified, the ARNP (Advanced Registered Nurse Practitioner) was notified, and staff was educated about the incident. Once the residents were returned to the facility a head-to-toe assessment was done on the residents. On 6/13/16, starting at 3:30 PM a tour of the memory unit with the maintenance director showed all seven exterior doors were supervised by facility staff members sitting near each exit. An interview was conducted on 6/17/2016 at 5:38 PM with Staff Education Coordinator. She stated she trained facility staff on elopement, door alarms, call bells, frequent rounding, and Wander Guards. The staff education is ongoing at this time and all shifts are being trained. The facility managers assist with the training. An interview was conducted on 6/17/2016 at 6:15 PM with Staff A, L.P.N, assigned to the memory care unit. She stated residents were assessed for elopement within 72 hours of admission. They received a Wander Guard on admission. They are care planned on admission if assessed as an elopement risk or having exit seeking behavior, they will receive a Wander Guard. An interview was conducted on 6/17/2016 at 6:30 PM with Staff M, LPN. She said she had elopement/alarm training on Monday. An interview was conducted on 6/17/2016 at 6:35 PM with Staff N, C.N.A. She stated she had elopement/alarm training today. An interview was conducted on 6/17/2016 at 6:38 PM with Staff C, C.N.A. She related she had elopement/alarm training on Monday following the incident of elopement on Saturday. An interview was conducted on 6/17/2016 at 6:43 PM Staff O, LPN, on B wing. She had the elopement/alarm training earlier this week, but could not remember which day. She also had training again today. An interview on 6/17/2016 at 6:46 PM with Staff P, LPN, revealed he was in an in-service training this week on elopement/alarm. An interview on 6/17/2016 at 6:50 PM with Staff J, LPN, revealed she was trained on elopement/alarms yesterday. She normally works memory care. Observations on 06/11/2016 through 06/17/2016 showed staff monitoring doors and making rounds on residents.

Base on medical record review, observations, resident interview and staff interviews facility failed to insure an environment free of hazards for 1 of 13 patients that have the potential of utilizing the wheelchair lift on the facility's transport van. Findings: Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The resident was scheduled to have outpatient dialysis three days a week. The resident was to be transported to and from the dialysis center by the van owned and operated by the facility, (Gainesville Healthcare Center). Review of the medical record for resident #1 revealed a nursing note dated 11/22/2013 written on the 3-11 shifts " Resident was sent to NFRMC for evaluation from dialysis center. Resident ' s daughter notified, DON and ARNP " . Review of the medical record for resident #1 revealed a Discharge Summary from Shands at UF dated 11.28.2013 that revealed " [AGE] year old female s/p fall during a transfer at dialysis and suffered a R frontal Inter-cranial Hemorrhage, Rib fractures right 4-6, Right displaced distal clavicle fracture. " Interview on 12/10/13 at 9:37 AM and again at 11:45 AM with the Sam Bell, the Van driver on duty revealed that he was not the driver on day of the incident involving resident #1 on 11/22/13. He stated that lift on the van would stick or stop intermittently. He stated that if you bounce up and down if may release the lift and if that did not work you could use the hydraulic pump to manually move the lift. He stated that about two years ago a person ran over the ramp with their care and that is when the intermittent problems started. He stated that the maintenance director was notified. Interview with Sam Ewald the van driver involved in the incident of 11/22/2013 revealed that he was at the dialysis center picking up resident #1 to return her to the nursing home He stated that both he and she were on the lift when the lift stopped moving up. He stated that he tried to put one foot under the lift to make it start moving again but lost his balance. He stated that he was holding on resident #1 ' s wheelchair and they both fell off the lift. He stated that a dialysis nurse was present and called 911. He stated that the resident was taken to the hospital for evaluation of her injuries. Review of the medical record for resident #1 revealed a Nursing Note written on 11/23/2013 " Resident post fall. Upon investigation resident was sent to ER after fall. Resident being loaded on lift, lift was not operating properly and resident and driver fell off lift. Resident transported to hospital from dialysis. Educated driver on proper lifting and safety and transfers. Fall assessment and care plan updated " . Review of the medical record for resident #1 revealed a care plan started on 11/21/13 and updated problem of fall with injury on 11/22/13 after the fall. The new approaches added on 11/22/13 were " Sent to ER " and " Educated driver on proper lifting and safety and transfers " . Review of Estimate of costs from Gator Custom Mobility to repair the lift dated 11/25/2013 revealed a total cost of $1,638.25 to repair the lift. Interview with Chris Fletcher, Director of Maintenance on 12/10/2013 at 1:13 PM revealed that he had received the Estimate to repair the lift but did not know if or when the lift will be repaired. Review of facility documentation revealed that the wheelchair ramp was repaired on December 23, 2013 and a quality monitor was developed and implemented to evaluate the correct and safe operation of the lift. Review of the Quick Reference Installation Sheet for the Braum Millennium Series lift revealed in the Maintenance and Lubrication Schedule section "Discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any signs of wear, damage or improper operation. " Interview with resident #3 on 21/10/2013 at 12:00 Noon revealed that he receives dialysis 3 days a week and is transported to dialysis by the facility ' s van. The resident stated that he has observed the lift get stuck and the van driver has to hand crank for inside the van to get the resident in. He stated that it has been happening for some time. Several observations at 8:35 AM, 9:37 AM, and 11:45 AM revealed of residents being loaded on and off the van with the lift being utilized.

Base on medical record review, observations, resident interview and staff interviews facility failed to insure the safety of 1 of 13 patients that have the potential of utilizing the wheelchair lift on the facility's transport van. Findings: Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The resident was scheduled to have outpatient [MEDICAL TREATMENT] three days a week. The resident was to be transported to and from the [MEDICAL TREATMENT] center by the van owned and operated by the facility, (Gainesville Healthcare Center). Review of the medical record for resident #1 revealed a nursing note dated 11/22/2013 written on the 3-11 shifts " Resident was sent to NFRMC for evaluation from [MEDICAL TREATMENT] center. Resident ' s daughter notified, DON and ARNP " . Review of the medical record for resident #1 revealed a Discharge Summary from Shands at UF dated 11.28.2013 that revealed " [AGE] year old female s/p fall during a transfer at [MEDICAL TREATMENT] and suffered a R frontal Inter-cranial Hemorrhage, Rib fractures right 4-6, Right displaced distal clavicle fracture. " Interview on 12/10/13 at 9:37 AM and again at 11:45 AM with the Sam Bell, the Van driver on duty revealed that he was not the driver on day of the incident involving resident #1 on 11/22/13. He stated that lift on the van would stick or stop intermittently. He stated that if you bounce up and down if may release the lift and if that did not work you could use the hydraulic pump to manually move the lift. He stated that about two years ago a person ran over the ramp with their care and that is when the intermittent problems started. He stated that the maintenance director was notified. Interview with Sam Ewald the van driver involved in the incident of 11/22/2013 revealed that he was at the [MEDICAL TREATMENT] center picking up resident #1 to return her to the nursing home He stated that both he and she were on the lift when the lift stopped moving up. He stated that he tried to put one foot under the lift to make it start moving again but lost his balance. He stated that he was holding on resident #1 ' s wheelchair and they both fell off the lift. He stated that a [MEDICAL TREATMENT] nurse was present and called 911. He stated that the resident was taken to the hospital for evaluation of her injuries. Review of the medical record for resident #1 revealed a Nursing Note written on 11/23/2013 " Resident post fall. Upon investigation resident was sent to ER after fall. Resident being loaded on lift, lift was not operating properly and resident and driver fell off lift. Resident transported to hospital from [MEDICAL TREATMENT]. Educated driver on proper lifting and safety and transfers. Fall assessment and care plan updated " . Review of the medical record for resident #1 revealed a care plan started on 11/21/13 and updated problem of fall with injury on 11/22/13 after the fall. The new approaches added on 11/22/13 were " Sent to ER " and " Educated driver on proper lifting and safety and transfers " . Review of Estimate of costs from Gator Custom Mobility to repair the lift dated 11/25/2013 revealed a total cost of $1,638.25 to repair the lift. Interview with Chris Fletcher, Director of Maintenance on 12/10/2013 at 1:13 PM revealed that he had received the Estimate to repair the lift but did not know if or when the lift will be repaired. Review of facility documentation revealed that the wheelchair ramp was repaired on December 23, 2013 and a quality monitor was developed and implemented to evaluate the correct and safe operation of the lift. Review of the Quick Reference Installation Sheet for the Braum Millennium Series lift revealed in the Maintenance and Lubrication Schedule section "Discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any signs of wear, damage or improper operation. " Interview with resident #3 on 21/10/2013 at 12:00 Noon revealed that he receives [MEDICAL TREATMENT] 3 days a week and is transported to [MEDICAL TREATMENT] by the facility ' s van. The resident stated that he has observed the lift get stuck and the van driver has to hand crank for inside the van to get the resident in. He stated that it has been happening for some time. Several observations at 8:35 AM, 9:37 AM, and 11:45 AM revealed of residents being loaded on and off the van with the lift being utilized.

Base on medical record review, observations, resident interview and staff interviews facility failed to maintain the wheelchair lift on the resident transport van in a safe operating condition. Findings: Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The resident was scheduled to have outpatient [MEDICAL TREATMENT] three days a week. The resident was to be transported to and from the [MEDICAL TREATMENT] center by the van owned and operated by the facility, (Gainesville Healthcare Center). Review of the medical record for resident #1 revealed a nursing note dated 11/22/2013 written on the 3-11 shifts " Resident was sent to NFRMC for evaluation from [MEDICAL TREATMENT] center. Resident ' s daughter notified, DON and ARNP " . Review of the medical record for resident #1 revealed a Discharge Summary from Shands at UF dated 11.28.2013 that revealed " [AGE] year old female s/p fall during a transfer at [MEDICAL TREATMENT] and suffered a R frontal Inter-cranial Hemorrhage, Rib fractures right 4-6, Right displaced distal clavicle fracture. " Interview on 12/10/13 at 9:37 AM and again at 11:45 AM with Van Driver #1, the Van driver on duty revealed that he was not the driver on day of the incident involving resident #1 on 11/22/13. He stated that lift on the van would stick or stop intermittently. He stated that if you bounce up and down if may release the lift and if that did not work you could use the hydraulic pump to manually move the lift. He stated that about two years ago a person ran over the ramp with their care and that is when the intermittent problems started. He stated that the maintenance director was notified. Interview with Van Driver #2 involved in the incident of 11/22/2013 revealed that he was at the [MEDICAL TREATMENT] center picking up resident #1 to return her to the nursing home He stated that both he and she were on the lift when the lift stopped moving up. He stated that he tried to put one foot under the lift to make it start moving again but lost his balance. He stated that he was holding on resident #1 ' s wheelchair and they both fell off the lift. He stated that a [MEDICAL TREATMENT] nurse was present and called 911. He stated that the resident was taken to the hospital for evaluation of her injuries. Review of the medical record for resident #1 revealed a Nursing Note written on 11/23/2013 " Resident post fall. Upon investigation resident was sent to ER after fall. Resident being loaded on lift, lift was not operating properly and resident and driver fell off lift. Resident transported to hospital from [MEDICAL TREATMENT]. Educated driver on proper lifting and safety and transfers. Fall assessment and care plan updated " . Review of the medical record for resident #1 revealed a care plan started on 11/21/13 and updated problem of fall with injury on 11/22/13 after the fall. The new approaches added on 11/22/13 were " Sent to ER " and " Educated driver on proper lifting and safety and transfers " . Review of Estimate of costs from Gator Custom Mobility to repair the lift dated 11/25/2013 revealed a total cost of $1,638.25 to repair the lift. Interview with the Director of Maintenance on 12/10/2013 at 1:13 PM revealed that he had received the Estimate to repair the lift but did not know if or when the lift will be repaired. Review of the Quick Reference Installation Sheet for the Braum Millennium Series lift revealed in the Maintenance and Lubrication Schedule section "Discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any signs of wear, damage or improper operation. " Interview with resident #3 on 21/10/2013 at 12:00 Noon revealed that he receives [MEDICAL TREATMENT] 3 days a week and is transported to [MEDICAL TREATMENT] by the facility ' s van. The resident stated that he has observed the lift get stuck and the van driver has to hand crank for inside the van to get the resident in. He stated that it has been happening for some time. Several observations at 8:35 AM, 9:37 AM, and 11:45 AM revealed of residents being loaded on and off the van with the lift being utilized.

Based on observation, record review, interview, the facility failed to maintain an environment free of accident hazards by failing to initially provide an appropriately sized mattress that fit the bed frame, and promptly provide adequate supervision and assistive devices after the resident was found with her upper torso off the bed and head on the floor for one of five sampled residents, resident #1. The facility failure to initially provide an appropriately sized mattress, then monitor the resident while a new bed was obtained and utilize assistive devices after a partial fall from the bed lead to the resident sustaining a fall from the bed onto the floor face first. The resident sustained [REDACTED]. The resident was transported to the emergency department. Findings: Record review of resident #1's history and physical revealed a [AGE] year old resident who weighs over 200 pounds admitted to the facility on [DATE] from the hospital. Interview on 1/28/11 at 2:45 PM with CNA (Certified Nursing Assistant) #1 who was assigned to resident #1 on 1/26/11 revealed that upon arriving for her shift at 3:00 PM she did rounds and noted that the resident was sleeping. At 4:00 PM, she again checked on the resident whose daughter was at the bedside. Between 5:15-5:30 PM, CNA #1 stated that she parked the dinner cart and heard coughing coming from room 416. She went into 416 to find Resident #1 half on and half off the bed. CNA #1 stated that the resident was on a " low air mattress " on a bed frame that did not contain side rails. She repositioned resident #1 and notified the evening Registered Nurse (RN) supervisor that the resident needed a new bed due to finding the resident half on and half off the bed. The RN supervisor stated to that she would call housekeeping. CNA #1 states that 20-30 minutes later she was feeding the resident across the hall when she heard moaning sounds coming from outside the room. She was accompanied by CNA #2 who was also feeding a resident in the same room. They went into room 416 and found resident #1 face down on the floor. Interview with the RN, 3-11 shift supervisor, on 1/28/11 at 4:20 PM revealed that at 6:45 PM on 1/24/11 she received a call that resident #1 had fallen out of bed in room 416. The RN arrived in the room to find the resident face down on the floor bleeding from her face. Emergency Medical Services (EMS) was called. The RN recalled that at 5:50 PM on 01/24/11 a CNA (Certified Nursing Assistant) told her that resident #1 needed a new bed. At that time, RN #1 stated she paged housekeeping and asked that a new bed be delivered to the fourth floor. She stated that housekeeping responded quickly, but that the resident fell out of bed before the bed change could be made. Interview with housekeeping employee #1 on 1/28/11 at 5:00PM confirmed that the RN Supervisor did call to have a new bed with side rails brought up to resident #1. The housekeeping employee stated that after the call another bed was immediately located and prepared to be taken to the 4th floor. Upon arriving on the 4th floor with the bed, they were told that the resident had just fallen. Record review of the hospital emergency room record revealed that resident #1 sustained a hematoma on the left side of her forehead and a small laceration to her lower lip. On 1/28/11 at 6:15 PM observation and measurement of the Microcare by Invacare " low air mattress which is rented and does not belong to the facility, revealed that the mattress measured 38.5 inches across. The bed frame measured 35 inches across. No side rails were on the bed frame that the resident was on. The administrator confirmed that the bed frame and low air mattress that were measured were in use by resident #1 at the time of the fall. The Invacare low air mattress is made of a synthetic parachute type fabric. The bed frame was metal.