Every finding on record at Pruitthealth - Fleming Island

Based on food service observations, staff interviews, and a review of facility policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, by failing to ensure food items were properly labeled and dated in both the main kitchen and nourishment rooms. This deficient practice prevents staff from determining appropriate use and increases the risk of pathogen exposure. This failure had the potential to affect all residents who consumed food items from the main kitchen and/or the facility's nourishment rooms.The findings include:On 4/13/2026 at 10:16 AM, an observation of the walk-in refrigerator revealed three Mountain Dew mini cans and one carton of yogurt stored in a bag on the top shelf with no labels or dates.On 4/13/2026 at 1:26 PM, another observation of the walk-in refrigerator revealed the same items with no label or date. An observation of the freezer at this time revealed one bag of cut squash opened and one box of sub roll dough opened with no labels or dates. (photographic evidence obtained)On 4/14/2026 at 11:54 AM, an observation of the walk-in refrigerator revealed two Mountain Dew cans and one personal thermal container stored with no labels or dates. (photographic evidence obtained)On 4/15/2026 at 12:25 PM, an observation of the nourishment room revealed one container of ice cream with no label or date.On 4/15/2026 at 12:36 PM, another observation revealed two bottles of coffee creamer and two cans of Coca-Cola with no labels or dates. During the same observation, one opened container of yogurt was dated 4/13/2026, but was not marked with a resident name. (photographic evidence obtained)On 4/15/2026 at 11:41 AM, during an interview with Dietary Aide/Cook C, he stated he had been employed by the facility for five years. He further stated it was the responsibility of the kitchen staff to label products with the date received and to label and date opened items prior to returning them to the refrigerator, freezer, or dry storage. Dietary Aide/Cook C stated kitchen staff were responsible for stocking and maintaining the nourishment rooms.On 4/15/2026 at 12:00 PM, an interview with Assistant Kitchen Manager B revealed that she had been employed by the facility for five years. She stated all opened items were to be labeled with an opened date and should only be kept for three days after that date.Reference: FDA Food Code 2022. https://www.fda.gov/media/184685/download?attachment; (Accessed on 4/21/2026) Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 555. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.A review of the facility's policy and procedure titled Receipt of Food Storage Supplies (dated 10/20/2025), revealed:Policy Statement: It is the policy of PruittHealth that all food and supplies will be checked in and stored immediately upon delivery to ensure food safety. Scope: This policy applies to all dietary partners employed by PruittHealth and others as assigned. Procedures:. 6. Supplies removed from shipping boxes should be placed on shelves or in proper bins/containers the day of delivery. All supplies should be labeled and dated with delivery date. 7. The first in, first out (FIFO) method must be used to ensure proper rotation of all food items to help prevent spoilage.

Based on facility documentation and staff interviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff consistent with their expected roles, by failing to provide consistent food service training and reliable documentation of in-service training to kitchen staff, as well as accurate training records to reflect staff training attendance. Unsafe kitchen practices can lead to widespread foodborne illness outbreaks. This affected all kitchen staff members due to the facility's inability to produce training records with dates and signatures verifying staff attendance. Training was also produced for a staff member with dates prior to his date of hire. The findings include:During a tour in the kitchen on 4/14/2026 at 11:45 AM, Certified Dietary Manager (CDM) A was asked to provide staff training documents for the last three months. A review of the training documents provided by CDM A revealed evidence of one training session titled Calibrating Thermometer and Holding Temperatures on Tray Line (dated 4/14/2026). CDM A was asked to provide training documents for the last six months. A review of the training binder provided by CDM A revealed training titled Food Allergies (dated 1/23/2026 with a handwritten notation of redone 3/26/26), but there were no corresponding participant signatures or date(s) to verify staff attendance. Further review revealed a training document titled Fire safety (dated 4/10/2024) that had participant signatures but no date to indicate when staff completed the training. It also included a handwritten notation of redone 1-15-2026 with no corresponding participant signatures or date to verify staff attendance. Training documents titled Three-Compartment Sink Procedures (dated 4/10/2026) revealed another handwritten notation of redone 2/5/2026 with no documentation to indicate which staff attended the original training versus the redone training. Lastly, training documents titled Outdated Product (dated 5/5/2023) again revealed a handwritten notation of redone 3-15-2026 without clear documentation of who was in attendance. The documentation provided indicated a gap in required in-service training for kitchen staff, with the last recorded session occurring on 8/13/2024, prior to the 1/23/2026 review date.On 4/15/2026 at 1:15 PM while reviewing the training binder, it was noted that Dietary Aide D's signature was documented for the following training sessions conducted prior to his date of hire: Pureed Foods dated 3/15/2024; Always Available Cart and Supplies dated 3/9/2023; Training Session with no title, dated 3/22/2022; Temperatures dated 5/5/2023; Floors dated 5/5/2023, and Allergies dated 5/24/2022.On 4/15/2026 at 1:25 PM, a review of the employee roster with hire dates revealed that Dietary Aide D's hire date was 7/8/2025. A review of the Florida Background Screening Clearinghouse verified Dietary Aide D's employment history and revealed no prior employment at the facility. (Photographic evidence obtained)On 4/15/2026 at 1:50 PM, a review of Dietary Aide D's personnel file revealed documentation including a new partner information form, partner handbook acknowledgement, and non-solicitation and confidentiality agreement, each containing Dietary Aide D's printed name and signature, dated 7/8/2025.On 4/14/2026 at 12:45 PM, an interview with CDM A revealed that in-service training for kitchen staff was conducted monthly depending on the topic, and additional training was provided as needed when issues arose.On 4/15/2026 at 11:41 AM, an interview with Dietary Aide/Cook C revealed that he had been employed by the facility for five years. He reported that kitchen staff received training as needed.On 4/15/2026 at 1:30 PM, an interview with CDM A revealed that Dietary Aide D worked at the facility for approximately six months and had not been employed with the facility prior to that time.On 4/15/2026 at 2:13 PM, an interview with the Administrator revealed that training for dietary staff was conducted as needed and was not based on a set schedule or calendar, as the facility utilized an online training program to meet training requirements. A staff training policy and procedure was requested during this interview, and the Administrator stated the facility had no written policy and procedure for training requirements.

Based on staff interviews, record review, a review of the facility's policy titled Abuse Prevention and Reporting, and a review of the Agency for Health Care Administration's Background Screening Clearinghouse website, the facility's administration failed to to administer the facility in a manner that enabled it to use its resources effectively and efficiently when it failed to immediately investigate the death of Resident #1 on [DATE]. The facility failed to ensure that measures were immediately put in place for resident safety, and thorough investigations were completed to identify system failures and facility needs. This placed the facility's 47 other residents identified as having a Full Code status at risk of suffering avoidable and untimely deaths. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:48 PM on [DATE]. On [DATE] at 11:40 PM, Immediate Jeopardy (IJ) began. On [DATE], at 7:00 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on [DATE]. The findings include: Cross reference F578 and F678. A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and expired in the facility on [DATE]. His diagnoses included arthritis due to other bacteria - right knee, urinary tract infection, unspecified severe protein - calorie malnutrition, acute on chronic systolic (congestive heart failure), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), a need for assistance with personal care, hypotension (low blood pressure), long term use of aspirin, and type 2 diabetes mellitus with diabetic chronic kidney disease. A review of the resident's physician's orders, dated [DATE], revealed Code Status: Full code. (Copy obtained) A nursing progress note dated [DATE] revealed that the Senior Care Partner, the Social Services Director (SSD), and Therapy Services met with Resident #1 and his daughter. The resident was alert and oriented times four. The discharge plan was to return home where the resident lived with his daughter. The care plan and all current medications were reviewed, and the daughter was provided with a copy of both documents and verbalized understanding. All other questions were answered and concerns were addressed. A nursing progress note, dated [DATE], and authored by Registered Nurse (RN) E/Acting Director of Health Services (DHS), revealed that Certified Nursing Assistant (CNA) A alerted Licensed Practical Nurse (LPN) B that Resident #1 was unresponsive. LPN B verified that the resident was without a pulse or respirations and had a Full Code status. Cardiopulmonary resuscitation (CPR) was initiated, and the resident's time of death was 11:56 PM. LPN B attempted to reach the provider's answering service at 11:56 PM. The resident's daughter was notified at 12:07 AM. The Acting DHS and the Administrator were notified of the resident's passing, and the acting DHS arrived in the facility to assist/support the resident's family upon notification. The Acting DHS contacted the provider and updates were provided. Postmortem care was rendered. A care plan for Advance Directives/Full Treatment was initiated on [DATE]. Resident #1's Advance Directives were in effect, and he wished them to be carried out going forward. The interventions revealed that all staff should be made aware of the resident's wishes. The Advance Directives were to be reviewed with the resident/family quarterly. Staff were to discuss the resident's Advance Directives with the resident and/or the appointed health care representative. (Copy obtained) In a telephone interview with LPN B on [DATE] at 1:32 PM, he stated he had been employed with the facility since 2019 and was assigned to Resident #1 on [DATE]. He said that was his first day working with this resident. At the start of the shift (7:00 PM) Resident #1 was alert and oriented times 1-2 (he knew who he was and where he was) with some confusion. He stated at approximately 11:30 PM, CNA A was passing ice water and found the resident unresponsive. She notified him and both employees went to the resident's room. He assessed the resident for a carotid (neck) pulse (no pulse noted), he verified the code status (Full Code), and he started compressions. He stated he could not recall the time he initiated CPR. After approximately five minutes of compressions, he noticed the compressions were not having any effect, so he stopped. He tried to contact the provider, but the provider did not answer the phone. At approximately 12:00 AM, he contacted the resident's family. He then proceeded to the other nurses' station and notified the other nurses. When he was asked if he notified the DHS, he said the DHS was on vacation and he did not have contact information for the Acting DHS. He stated RN C notified the Acting DHS. When he was asked to explain the facility's protocol for administration of CPR, he stated when a resident was unresponsive, he should assess the resident for a pulse and respirations, verify the code status, initiate CPR, call a Code Blue (a medical emergency, specifically a resident experiencing cardiac or respiratory arrest) and 911, then continue CPR until emergency medical services (EMS) took over. He confirmed that he did not call 911 or a Code Blue. He said, I don't know why I didn't call a code or 911 because I know what do; I might have just panicked. He stated he was assigned 24 residents on [DATE]. When asked if he provided a written statement for facility management regarding the event, he stated, no. He added that the DHS and the Administrator interviewed him after the incident. He confirmed that he worked three more days after the incident and was terminated on [DATE] for not following the facility's protocol. A review of the facility assignments from [DATE] through [DATE] revealed that LPN B was assigned to 18, 16, 16 and 14 residents who had Full Code status on those days respectively. (Copies obtained) In an interview on [DATE] at 4:25 PM, RN E stated she was the Acting Director of Health Services (DHS) from [DATE] through [DATE] and was familiar with Resident #1. She said she assisted with his admission. He was blind, alert and oriented times 3 - 4. She stated the resident's discharge goal was to return home with his daughter. When asked about the resident's death, she stated on [DATE] at 2:00 AM, she received a telephone call from RN C who stated Resident #1 had expired and no Code Blue was called. RN C stated she and RN D were notified of the event two hours after the incident occurred. RN C continued that LPN B pronounced the resident's death, and the funeral home was on their way. The resident's family was already in the facility. RN E stated after she got off the phone, she contacted the Administrator, notified her of the incident, and went to the facility. When she arrived at 2:20 AM, the resident's family was in the resident's room and postmortem care had already been completed. After offering condolences to the family, she went to interview LPN B who provided the timeline of the event. (Copy obtained) LPN B stated he attempted CPR for five minutes. It was not successful and after pronouncing the resident's death, he attempted to contact the provider, then contacted the family. RN E stated she contacted Resident #1's Advanced Practice Registered Nurse (APRN) at 2:38 AM. The APRN was concerned that LPN B had pronounced the resident's death and could not establish the correct time of death, because RN C was not notified until two hours later when the resident's family and the funeral home had already been contacted. The APRN stated she had to consult with the resident's physician. After approximately five minutes the APRN called back and stated the resident's physician agreed to use the time that the LPN pronounced the resident's death and emphasized that it was outside of LPN B's scope of practice to pronounce the resident's death. RN E stated the DHS, who had been on leave, arrived at the facility at 6:00 AM and took over the investigation. RN E provided the DHS with the timeline of the event. During a telephone interview on [DATE] 11:44 AM, CNA A stated she had been employed at the facility for one year. When asked about Resident #1 and the [DATE] event, she stated [DATE] was the first time she had worked with Resident #1. She said she reported to work around 10:45 PM on [DATE] and at approximately 11:00 PM, she went to Resident #1's room to conduct shift rounds and the resident was in bed. Approximately 30 minutes later, she was passing ice water, and the resident was not in bed. She thought the resident was in the bathroom, but as she approached the resident's bed, she saw the resident in a kneeling position on the floor with his head resting on the bed in a praying position. He was between the bed and the window. She asked him if he was praying and he didn't respond. She tapped his shoulder and again asked if he was praying and he still did not respond. She immediately notified LPN B. LPN B and CNA A went right to the resident's room. After assessing for a pulse and respirations, LPN B walked out of the room to verify the resident's code status. Upon returning to the room a minute or so later, LPN B asked her to help him get the resident off the floor and onto the bed. She stated they placed the resident on the floor first, placed a draw sheet under the resident, and put him back in bed. She stated there were no other instructions provided by LPN B. She left the room to assist another resident who was in the bathroom and left LPN B in Resident #1's room. She stated she was not sure if LPN B administered CPR. She stated Resident #1 was warm to touch when they placed him back in bed. When asked if she provided the facility's management with a witness statement, she replied that she was interviewed by the DHS and described the event the same way she had described it during this interview. She said she was not asked to write a witness statement that day; however, on [DATE] (the date of the survey), she was asked to provide a written statement. When asked if she received any training after the incident, she said, No, they might have provided the training during the day. During an interview on [DATE] at 3:30 PM, the Social Services Director (SSD) stated she had been employed by the facility for five years. She stated the details of the event were reviewed by the Director of Health Services (DHS), the Administrator, and the Regional Nurse Consultant to determine whether the event met reporting requirements. She confirmed that allegations of Abuse/Neglect/Misappropriation should be reported within two hours. She was asked to review the [DATE] event for Resident #1. She confirmed that the incident took place on [DATE]. She stated she was not present during the incident. She explained that she received the timeline of the incident from RN E who was the Acting DHS at the time of the incident. The SSD stated on [DATE] at 11:30 PM, CNA A found Resident #1 unresponsive and notified LPN B, who assessed the resident and initiated cardiopulmonary resuscitation (CPR) at 11:40 PM. LPN B administered CPR for approximately five minutes. Resident #1 was unable to be resuscitated by LPN B, who pronounced the resident's death at 11:56 PM, and at that time, he called the provider and the family. The SSD confirmed that the incident was reported to the appropriate agencies on [DATE], five days after the event. She explained that the Administrator had notified the corporate office about the incident and was made aware that it was not a reportable event. When asked if the corporate personnel provided the rationale, she stated LPN B reported that Resident #1 was already cold/expired when he found him. When asked for documentation from LPN B indicating that the resident was cold, she confirmed that there was no documentation, and no witness statement was obtained. She added that on [DATE] she was notified by the Administrator that a determination had been made by the corporate office that the incident was indeed reportable and that LPN B should be terminated. A joint interview was conducted on [DATE] at 9:45 AM with DHS and the Administrator. The DHS stated her responsibility was to ensure the company's policies, process and nursing requirements were followed. She stated she ensured that the staffing requirements were met. She explained that she utilized a checklist during morning clinical meetings to ensure that all clinical issues were addressed. During the meeting, issues such as change in condition, incidents, hospitalization and admissions were reviewed. If the team identified that anything had been missed during their review, a staff member was assigned to ensure the missed task/component was addressed. When they were asked when documentation should be completed after an incident occurred, the DHS stated documentation should be completed as soon as the incident occurred. She further stated the DHS should be contacted after all incidents. The Administrator stated she was responsible for oversight of facility's operation. She used different audit tools to ensure that measures were met. She stated she reported to the corporate team weekly. When she was asked to explain the facility's grievance/concerns process, she said the SSD was the grievance officer. The SSD reviewed grievances/concerns with the Administrator and the DHS. Incidents/grievances/concerns were also discussed during morning meetings and the team decided whether or not an incident met the reporting requirements. All reportable incidents were also reviewed by the corporate Senior Nurse Consultant and Risk Manager. When asked to review the incident involving Resident #1, the Administrator stated she was contacted by RN E on [DATE] at 2:05 AM. RN E explained that she had received a call from RN C informing her that Resident #1 had expired and there were concerns, as there was a delay in her being notified of the incident. RN E stated she was enroute to the facility to find out what happened and to meet with the family. The Administrator asked RN E to gather information and call her back. Approximately 30 minutes later, the Administrator contacted RN E and asked to speak to LPN B. LPN B stated at approximately 11:40 PM, CNA A called him to Resident #1's room. The resident was unresponsive. LPN B administered CPR for approximately five minutes, and when he was unsuccessful, he stopped. LPN B stated he could not reach the on-call provider but reached the family. The Administrator asked LPN B to write a statement and put it under the DHS' door. She also asked him not to leave the facility until DHS arrived. The Administrator contacted the DHS who had just returned from vacation and notified her of the incident. She instructed her to go to the facility and assist with the investigation. The DHS stated she arrived at the facility at approximately 5:30 AM on [DATE]. She met with RN E and was provided with a synopsis of the incident. RN E told her that she called the on-call physician who voiced concerns with the time RN C was notified of the resident's time of death (concerns determining the time of death). The DHS interviewed LPN B who confirmed the incident as it was documented by RN E. He also confirmed that he did not call a Code Blue per facility policy, he conducted CPR alone and pronounced the resident's death. The DHS provided LPN B with a written warning and education on the facility's policy. The DHS confirmed that she did not obtain written statements from staff. She stated she interviewed them verbally but asked for nothing in writing. She also confirmed that LPN B failed to write a progress note after Resident #1's incident and the RN on duty at the time of the incident was not notified by LPN B until [DATE] at 1:55 AM (more than two hours later). When the Administrator was asked why the incident was not reported, she replied that they felt the incident did not meet the requirement for reporting it was an education moment because LPN B did not follow the facility's policy. She added that LPN B stated Resident #1 was already dead. When she was asked if there were any progress notes about the incident, she said no. She added that she spoke with the Senior Nurse Consultant (SNC) about the incident and she stated the incident did not meet the reporting requirements. When asked if LPNs could pronounce a resident's death, the Administrator confirmed that LPN B acted out of his scope of practice, but he could not reach the physician. She was then asked why LPN B was not suspended pending investigation of the event, and she replied that staff were suspended only when an incident was determined to be reportable. During an employee personnel record review, LPN B's file revealed no evidence of a current eligible Level II background screening. A review of the Agency for Health Care Administration's Background Screening Clearinghouse website on [DATE] at 1:15 PM revealed that LPN B's status was Ineligible. His fingerprints expired on [DATE]. Facility records showed LPN B was hired on [DATE] and separated on [DATE]. LPN B was a full-time caregiver, providing direct care to residents from [DATE] through [DATE]. During an interview and employee record review with the Human Resources Manager on [DATE] at 12:15 PM, she stated LPN B was no longer listed on the facility's roster due to a recent termination, and she was unaware that LPN B's background screening status was ineligible. After reviewing the Agency for Health Care Administration's Background Screening Clearinghouse website, she confirmed that LPN B did not have a current Level II background screening, and the employee's fingerprints expired on [DATE]. On [DATE] at 2:03 PM, a telephone interview was conducted with the Medical Director, who confirmed that he was notified of the incident involving Resident #1 on [DATE]. A telephone interview was conducted on [DATE] at 2:14 PM with the Senior Nurse Consultant (SNC). She stated she had been in her role since [DATE]. She said she was contacted by the Administrator about the [DATE] incident early on the morning of [DATE]. She was told that LPN B initiated CPR and stopped when he was unsuccessful. He then pronounced the resident's death. The Administrator informed her that the investigation was ongoing, and she would update her in the morning. The following day she followed up with the Administrator and she was notified that the facility had initiated training on CPR response and started a CPR audit. She was informed by the Administrator that the team did not identify the incident as reportable because LPN B stated Resident #1 was already dead when he went to the resident's room with CNA A. Upon further investigation and after consulting with the Risk Manager, it was determined that the incident was reportable, and a report was submitted on [DATE]. When asked to explain the facility's policy and procedure for CPR, the SNC stated if a resident was a Full Code, the staff should initiate CPR; however, if there was enough evidence or rigor mortis was present, staff should not initiate CPR and should instead contact the provider. She confirmed that CPR should be initiated if there was evidence/likelihood of survival, and once CPR was initiated, staff should not stop until the provider asked them to or EMS arrived and took over. A review of the job description for LPN/Charge Nurse (modified 10/2016), revealed: Job Purpose: Directs nursing care for the patients and supervises the day-to-day nursing activities performed by assigned staff. Such supervision should be in accordance with federal, state, and local and regulations governing the nursing center. Also, as directed by the Administrator, the Medical Director, RN Charge Nurse and/or the Director of Health Services, to ensure the appropriate care for patients is provided. Key Responsibilities include: - Provide care ensuring patient/resident safety. - Supervises Certified Nurse Assistants, directs work and makes appropriate assignments. - Completes documentation procedures on patients (appropriate use of forms, timelines, and Medicare documentation, etc. - Knowledge of procedures and ability to determine Advance Directives status for patients. - Responsible for ensuring Tenet Time is presented and discussed with all partners prior to and following all shifts. A review of the job description for the Administrator (created 09/08, modified 12/16), revealed: Job Purpose: To direct the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area [NAME] President, to provide appropriate care for our patients/residents. Key Responsibilities included: - Current knowledge of state and federal laws governing the operation of nursing facilities. - Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long-term care and services, and environmental health and safety relevant to nursing facility operation. - Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to ensure that care provided meets established standards of quality. - Demonstrate knowledge of and respect for the right, dignity and individuality of each patient /resident in all interaction. Demonstrates competency in the protection and promotion of resident rights. Able to act as a role model for center and staff. A review of the facility's policy and procedure titled Abuse Prevention and Reporting (effective [DATE], revised [DATE]) revealed: Abuse: Any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Procedure: 1. Anyone witnessing, suspecting or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator. 3. In the event the Administrator has knowledge that the resident has been abused, neglected or exploited while residing in the home, he/she will immediately make a report by phone or in person to the Department of Community Health. In the event that an immediate report to the Department is not possible, the Administrator shall make the report to the appropriate law enforcement agency. 4. The initial report of actual or suspected abuse shall contain at least the following: - Name and address of person making the report. - Name and address of the resident or former resident. - Name and address of the facility. - Nature and extent of any injuries or condition resulting from the suspected abuse, neglect or exploitation. - The suspected cause of the incident. - Any other information that the reporter believes might be helpful in determining the cause of the resident's injuries or condition and determining the identity of person or persons responsible for the incident. 5. Within 24 hours of the initial report, the Administrator shall also make a written report, using the Incident Report Form, documenting all known and relevant information, the investigation results, and any corrective or protective actions taken. 6. The written Incident Report shall be faxed to the Department of Community Health, Health Facility Regulation Department, Complaint Division. 7. The fax confirmation sheet shall be attached to the Incident Report and maintained in the central Incident Report file. 8. If the alleged perpetrator is a staff member of the home, the Administrator will place them on administrative leave until a determination of the allegation is made. Confirmed allegations shall result in termination with notification to appropriate boards, registries and agencies and the police as appropriate. .

Based on staff interviews, record review, and the facility's policy and procedure titled Advance Directives, the facility failed to act in accordance with Resident #1's Advance Directives and Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to honor Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:48 PM on [DATE]. On [DATE] at 11:40 PM, Immediate Jeopardy (IJ) began. On [DATE], at 7:00 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on [DATE]. The findings include: Cross reference F678 and F835. A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and expired in the facility on [DATE]. His diagnoses included arthritis due to other bacteria - right knee, urinary tract infection, unspecified severe protein - calorie malnutrition, acute on chronic systolic (congestive heart failure), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), a need for assistance with personal care, hypotension (low blood pressure), long term use of aspirin, and type 2 diabetes mellitus with diabetic chronic kidney disease. A review of the resident's physician's orders, dated [DATE], revealed Code Status: Full code. (Copy obtained) A nursing progress note dated [DATE] revealed that the Senior Care Partner, Social Services Director and Therapy Services met with Resident #1 and his daughter. The resident was alert and oriented times four (person, place, time and event). The discharge plan was to return home where the resident lived with his daughter. The care plan and all current medications were reviewed, and the resident's daughter was provided with a copy of both documents and verbalized understanding of them. All other questions were answered, and concerns were addressed. A nursing progress note, dated [DATE], and authored by Registered Nurse (RN) E/Acting Director of Health Services (DHS), revealed that Certified Nursing Assistant (CNA) A alerted Licensed Practical Nurse (LPN) B that Resident #1 was unresponsive. LPN B verified that the resident was without a pulse or respirations and had a Full Code status. Cardiopulmonary resuscitation (CPR) was initiated, and the resident's time of death was 11:56 PM. LPN B attempted to reach the provider's answering service at 11:56 PM. The resident's daughter was notified at 12:07 AM. The Acting DHS and the Administrator were notified of the resident's passing, and the acting DHS arrived in the facility to assist/support the resident's family upon notification. The Acting DHS contacted the provider and updates were provided. Postmortem care was rendered. A care plan for Advance Directives/Full Treatment was initiated on [DATE]. Resident #1's Advance Directives were in effect, and he wished them to be carried out going forward. The interventions revealed that all staff should be made aware of the resident's wishes. The Advance Directives were to be reviewed with the resident/family quarterly. Staff were to discuss the resident's Advance Directives with the resident and/or the appointed health care representative. (Copy obtained) In a telephone interview with LPN B on [DATE] at 1:32 PM, he stated he had been employed with the facility since 2019 and was assigned to Resident #1 on [DATE]. He said that was his first day working with this resident. At the start of the shift (7:00 PM) Resident #1 was alert and oriented times 1-2 (he knew who he was and where he was) with some confusion. He stated at approximately 11:30 PM, CNA A was passing ice water and found the resident unresponsive. She notified him and both employees went to the resident's room. He assessed the resident for a carotid (neck) pulse (no pulse noted), he verified the code status (Full Code), and he started compressions. He stated he could not recall the time he initiated CPR. After approximately five minutes of compressions, he noticed the compressions were not having any effect, so he stopped. He tried to contact the provider, but the provider did not answer the phone. At approximately 12:00 AM, he contacted the resident's family. He then proceeded to the other nurses' station and notified the other nurses. When he was asked if he notified the DHS, he said the DHS was on vacation and he did not have contact information for the Acting DHS. He stated RN C notified the Acting DHS. When he was asked to explain the facility's protocol for administration of CPR, he stated when a resident was unresponsive, he should assess the resident for a pulse and respirations, verify the code status, initiate CPR, call a Code Blue (a medical emergency, specifically a resident experiencing cardiac or respiratory arrest) and 911, then continue CPR until emergency medical services (EMS) took over. He confirmed that he did not call 911 or a Code Blue. He said, I don't know why I didn't call a code or 911 because I know what do; I might have just panicked. He stated he was assigned 24 residents on [DATE]. When asked if he provided a written statement for facility management regarding the event, he stated, no. He added that the DHS and the Administrator interviewed him after the incident. He confirmed that he worked three more days after the incident and was terminated on [DATE] for not following the facility's protocol. A review of the facility assignments from [DATE] through [DATE] revealed that LPN B was assigned to 18, 16, 16 and 14 residents who had Full Code status on those days respectively. (Copies obtained) In an interview on [DATE] at 4:25 PM, RN E stated she was the Acting Director of Health Services (DHS) from [DATE] through [DATE] and was familiar with Resident #1. She said she assisted with his admission. He was blind, alert and oriented times 3 - 4. She stated the resident's discharge goal was to return home with his daughter. When asked about the resident's death, she stated on [DATE] at 2:00 AM, she received a telephone call from RN C who stated Resident #1 had expired and no Code Blue was called. RN C stated she and RN D were notified of the event two hours after the incident occurred. RN C continued that LPN B pronounced the resident's death, and the funeral home was on their way. The resident's family was already in the facility. RN E stated after she got off the phone, she contacted the Administrator, notified her of the incident, and went to the facility. When she arrived at 2:20 AM, the resident's family was in the resident's room and postmortem care had already been completed. After offering condolences to the family, she went to interview LPN B who provided the timeline of the event. (Copy obtained) LPN B stated he attempted CPR for five minutes. It was not successful and after pronouncing the resident's death, he attempted to contact the provider, then contacted the family. RN E stated she contacted Resident #1's Advanced Practice Registered Nurse (APRN) at 2:38 AM. The APRN was concerned that LPN B had pronounced the resident's death and could not establish the correct time of death, because RN C was not notified until two hours later when the resident's family and the funeral home had already been contacted. The APRN stated she had to consult with the resident's physician. After approximately five minutes the APRN called back and stated the resident's physician agreed to use the time that the LPN pronounced the resident's death and emphasized that it was outside of LPN B's scope of practice to pronounce the resident's death. RN E stated the DHS, who had been on leave, arrived at the facility at 6:00 AM and took over the investigation. RN E provided the DHS with the timeline of the event. During a telephone interview on [DATE] 11:44 AM, CNA A stated she had been employed at the facility for one year. When asked about Resident #1 and the [DATE] event, she stated [DATE] was the first time she had worked with Resident #1. She said she reported to work around 10:45 PM on [DATE] and at approximately 11:00 PM, she went to Resident #1's room to conduct shift rounds and the resident was in bed. Approximately 30 minutes later, she was passing ice water, and the resident was not in bed. She thought the resident was in the bathroom, but as she approached the resident's bed, she saw the resident in a kneeling position on the floor with his head resting on the bed in a praying position. He was between the bed and the window. She asked him if he was praying and he didn't respond. She tapped his shoulder and again asked if he was praying and he still did not respond. She immediately notified LPN B. LPN B and CNA A went right to the resident's room. After assessing for a pulse and respirations, LPN B walked out of the room to verify the resident's code status. Upon returning to the room a minute or so later, LPN B asked her to help him get the resident off the floor and onto the bed. She stated they placed the resident on the floor first, placed a draw sheet under the resident, and put him back in bed. She stated there were no other instructions provided by LPN B. She left the room to assist another resident who was in the bathroom and left LPN B in Resident #1's room. She stated she was not sure if LPN B administered CPR. She stated Resident #1 was warm to touch when they placed him back in bed. When asked if she provided the facility's management with a witness statement, she replied that she was interviewed by the DHS and described the event the same way she had described it during this interview. She said she was not asked to write a witness statement that day; however, on [DATE] (the date of the survey), she was asked to provide a written statement. When asked if she received any training after the incident, she said, No, they might have provided the training during the day. A joint interview was conducted on [DATE] at 9:45 AM with the DHS and the Administrator. The DHS stated her responsibility was to ensure that the company's policies, process and nursing requirements were followed. She added that she ensured that the staffing requirements were met. She explained that she utilized a checklist during the morning clinical meeting to ensure that all clinical issues were addressed thoroughly and completely. During that meeting, issues such as change in condition, incidents, hospitalization and admissions were reviewed. She stated if the team found that anything had been missed, a staff member was assigned to ensure it was completed. When they were asked to review the incident involving Resident #1, the Administrator stated she was contacted by RN E on [DATE] at 2:05 AM. RN E explained that she had received a call from RN C notifying her that Resident #1 had expired and she had concerns as there was a delay in notifying her of the incident. RN E stated she was enroute to the facility to find out what happened and meet with the family. The Administrator asked RN E to gather information and call her back. Approximately 30 minutes later, the Administrator contacted RN E and asked to speak to LPN B. LPN B stated at approximately 11:40 PM, CNA A called him to Resident #1's room. The resident was unresponsive, he performed CPR for approximately five minutes, and when he was unsuccessful, he stopped. LPN B stated he could not reach the on-call provider but reached the family. The Administrator asked LPN B to write a statement and put it under the DHS' door. She also asked him not to leave the facility until DHS arrived. The Administrator contacted the DHS who had just returned from vacation and notified her of the incident. She instructed her to go to the facility and assist with the investigation. The DHS stated she arrived at the facility at approximately 5:30 AM on [DATE]. She met with RN E and was provided with a synopsis of the incident. RN E told her that she called the on-call physician who voiced concerns with the time RN C was notified of the resident's time of death (concerns determining the time of death). The DHS interviewed LPN B who confirmed the incident as it was documented by RN E. He also confirmed that he did not call a Code Blue per facility policy and conducted CPR alone and pronounced the resident's death. When asked about the facility's protocol when staff find a resident who is unresponsive, the DHS outlined the following steps: Step 1: Assess for a pulse and respirations (apical pulse (the pulse felt at the apex (bottom) of the heart, on the left side of the chest) for one minute). Step 2: Find the code status. Step 3: If the resident is a Full Code, activate Code Blue (paging overhead) and initiate CPR. She stated if there were signs of death, CPR should not be initiated. If CPR was initiated, it should not be stopped until 911/EMS (Emergency Medical Services) took over. On [DATE] at 2:03 PM, a telephone interview was conducted with the Medical Director, who confirmed that he was notified of the incident involving Resident #1 on [DATE]. He stated his expectation was that when a resident who was a Full Code was found unresponsive, CPR should be performed, unless there were signs that rigor mortis had set in. At that point, an RN could pronounce a resident's death. He stated when CPR is initiated, staff should not stop until they are told to stop by a physician or EMS upon arrival. He said he was notified that LPN B was unable to reach the provider. He said, At the very least, he should have stopped and got the RN to pronounce the death because an LPN cannot pronounce death. A telephone interview was conducted on [DATE] at 2:14 PM with the Senior Nurse Consultant (SNC). She stated she had been in her role since [DATE]. She said she was contacted by the Administrator about the [DATE] incident early on the morning of [DATE]. She was told that LPN B initiated CPR and stopped when he was unsuccessful. He then pronounced the resident's death. When asked to explain the facility's policy and procedure for CPR, the SNC stated if a resident was a Full Code, the staff should initiate CPR; however, if there was enough evidence or rigor mortis was present, staff should not initiate CPR and should instead contact the provider. She confirmed that CPR should be initiated if there was evidence/likelihood of survival, and once CPR was initiated, staff should not stop until the provider asked them to or EMS arrived and took over. A review of the facility's policy titled Advance Directives: Florida (revised [DATE], reviewed [DATE]), revealed: Forms: Florida Living Will Form, Florida Healthcare Surrogate Form Policy Statement: This healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center. .

Based on staff interviews, record review, and a review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR), the facility failed to administer cardiopulmonary resuscitation (CPR) to one resident who had a Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to provide CPR according to Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired at the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:48 PM on [DATE]. On [DATE] at 11:40 PM, Immediate Jeopardy (IJ) began. On [DATE], at 7:00 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on [DATE]. The findings include: Cross reference F578 and F835. A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and expired in the facility on [DATE]. His diagnoses included arthritis due to other bacteria - right knee, urinary tract infection, unspecified severe protein - calorie malnutrition, acute on chronic systolic (congestive heart failure), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), a need for assistance with personal care, hypotension (low blood pressure), long term use of aspirin, and type 2 diabetes mellitus with diabetic chronic kidney disease. A review of the resident's physician's orders, dated [DATE], revealed Code Status: Full code. (Copy obtained) A nursing progress note dated [DATE] revealed that the Senior Care Partner met with the resident to review his admission and orient him to the unit and routine. The resident was alert and oriented times four (alert to himself, his location, the time, and the circumstances), and he was blind. The initial care conference was scheduled pending family availability. A nursing progress note dated [DATE] revealed that the resident was alert and oriented times three. He had no complaints and no distress was noted. His vital signs were within normal limits, and his medications were taken without difficulty. Therapy was completed at bedside and safety precautions were in place. A nursing progress note dated [DATE] revealed that the Senior Care Partner, the Social Services Director (SSD), and Therapy Services met with Resident #1 and his daughter. The resident was alert and oriented times four. The discharge plan was to return home where the resident lived with his daughter. The care plan and all current medications were reviewed, and the daughter was provided with a copy of both documents and verbalized understanding. All other questions were answered and concerns were addressed. A nursing progress note, dated [DATE], and authored by Registered Nurse (RN) E/Acting Director of Health Services (DHS), revealed that Certified Nursing Assistant (CNA) A alerted Licensed Practical Nurse (LPN) B that Resident #1 was unresponsive. LPN B verified that the resident was without a pulse or respirations and had a Full Code status. Cardiopulmonary resuscitation (CPR) was initiated, and the resident's time of death was 11:56 PM. LPN B attempted to reach the provider's answering service at 11:56 PM. The resident's daughter was notified at 12:07 AM. The Acting DHS and the Administrator were notified of the resident's passing, and the acting DHS arrived in the facility to assist/support the resident's family upon notification. The Acting DHS contacted the provider and updates were provided. Postmortem care was rendered. A care plan for Advance Directives/Full Treatment was initiated on [DATE]. Resident #1's Advance Directives were in effect, and he wished them to be carried out going forward. The interventions revealed that all staff should be made aware of the resident's wishes. The Advance Directives were to be reviewed with the resident/family quarterly. Staff were to discuss the resident's Advance Directives with the resident and/or the appointed health care representative. (Copy obtained) In a telephone interview with LPN B on [DATE] at 1:32 PM, he stated he had been employed with the facility since 2019 and was assigned to Resident #1 on [DATE]. He said that was his first day working with this resident. At the start of the shift (7:00 PM) Resident #1 was alert and oriented times 1-2 (he knew who he was and where he was) with some confusion. He stated at approximately 11:30 PM, CNA A was passing ice water and found the resident unresponsive. She notified him and both employees went to the resident's room. He assessed the resident for a carotid (neck) pulse (no pulse noted), he verified the code status (Full Code), and he started compressions. He stated he could not recall the time he initiated CPR. After approximately five minutes of compressions, he noticed the compressions were not having any effect, so he stopped. He tried to contact the provider, but the provider did not answer the phone. At approximately 12:00 AM, he contacted the resident's family. He then proceeded to the other nurses' station and notified the other nurses. When he was asked if he notified the DHS, he said the DHS was on vacation and he did not have contact information for the Acting DHS. He stated RN C notified the Acting DHS. When he was asked to explain the facility's protocol for administration of CPR, he stated when a resident was unresponsive, he should assess the resident for a pulse and respirations, verify the code status, initiate CPR, call a Code Blue (a medical emergency, specifically a resident experiencing cardiac or respiratory arrest) and 911, then continue CPR until emergency medical services (EMS) took over. He confirmed that he did not call 911 or a Code Blue. He said, I don't know why I didn't call a code or 911 because I know what do; I might have just panicked. He stated he was assigned 24 residents on [DATE]. When asked if he provided a written statement for facility management regarding the event, he stated, no. He added that the DHS and the Administrator interviewed him after the incident. He confirmed that he worked three more days after the incident and was terminated on [DATE] for not following the facility's protocol. A review of the facility assignments from [DATE] through [DATE] revealed that LPN B was assigned to 18, 16, 16 and 14 residents who had Full Code status on those days respectively. (Copies obtained) In an interview on [DATE] at 4:25 PM, RN E stated she was the Acting Director of Health Services (DHS) from [DATE] through [DATE] and was familiar with Resident #1. She said she assisted with his admission. He was blind, alert and oriented times 3 - 4. She stated the resident's discharge goal was to return home with his daughter. When asked about the resident's death, she stated on [DATE] at 2:00 AM, she received a telephone call from RN C who stated Resident #1 had expired and no Code Blue was called. RN C stated she and RN D were notified of the event two hours after the incident occurred. RN C continued that LPN B pronounced the resident's death, and the funeral home was on their way. The resident's family was already in the facility. RN E stated after she got off the phone, she contacted the Administrator, notified her of the incident, and went to the facility. When she arrived at 2:20 AM, the resident's family was in the resident's room and postmortem care had already been completed. After offering condolences to the family, she went to interview LPN B who provided the timeline of the event. (Copy obtained) LPN B stated he attempted CPR for five minutes. It was not successful and after pronouncing the resident's death, he attempted to contact the provider, then contacted the family. RN E stated she contacted Resident #1's Advanced Practice Registered Nurse (APRN) at 2:38 AM. The APRN was concerned that LPN B had pronounced the resident's death and could not establish the correct time of death, because RN C was not notified until two hours later when the resident's family and the funeral home had already been contacted. The APRN stated she had to consult with the resident's physician. After approximately five minutes the APRN called back and stated the resident's physician agreed to use the time that the LPN pronounced the resident's death and emphasized that it was outside of LPN B's scope of practice to pronounce the resident's death. RN E stated the DHS, who had been on leave, arrived at the facility at 6:00 AM and took over the investigation. RN E provided the DHS with the timeline of the event. During a telephone interview on [DATE] 11:44 AM, CNA A stated she had been employed at the facility for one year. When asked about Resident #1 and the [DATE] event, she stated [DATE] was the first time she had worked with Resident #1. She said she reported to work around 10:45 PM on [DATE] and at approximately 11:00 PM, she went to Resident #1's room to conduct shift rounds and the resident was in bed. Approximately 30 minutes later, she was passing ice water, and the resident was not in bed. She thought the resident was in the bathroom, but as she approached the resident's bed, she saw the resident in a kneeling position on the floor with his head resting on the bed in a praying position. He was between the bed and the window. She asked him if he was praying and he didn't respond. She tapped his shoulder and again asked if he was praying and he still did not respond. She immediately notified LPN B. LPN B and CNA A went right to the resident's room. After assessing for a pulse and respirations, LPN B walked out of the room to verify the resident's code status. Upon returning to the room a minute or so later, LPN B asked her to help him get the resident off the floor and onto the bed. She stated they placed the resident on the floor first, placed a draw sheet under the resident, and put him back in bed. She stated there were no other instructions provided by LPN B. She left the room to assist another resident who was in the bathroom and left LPN B in Resident #1's room. She stated she was not sure if LPN B administered CPR. She stated Resident #1 was warm to touch when they placed him back in bed. When asked if she provided the facility's management with a witness statement, she replied that she was interviewed by the DHS and described the event the same way she had described it during this interview. She said she was not asked to write a witness statement that day; however, on [DATE] (the date of the survey), she was asked to provide a written statement. When asked if she received any training after the incident, she said, No, they might have provided the training during the day. During an interview on [DATE] at 3:30 PM, the Social Services Director (SSD) stated she had been employed by the facility for five years. She was asked to review the [DATE] event for Resident #1. She confirmed that the incident took place on [DATE]. She stated she was not present during the incident. She explained that she received the timeline of the incident from RN E who was the Acting DHS at the time of the incident. The SSD stated on [DATE] at 11:30 PM, CNA A found Resident #1 unresponsive and notified LPN B, who assessed the resident and initiated cardiopulmonary resuscitation (CPR) at 11:40 PM. LPN B administered CPR for approximately five minutes. Resident #1 was unable to be resuscitated by LPN B, who pronounced the resident's death at 11:56 PM, and at that time, he called the provider and the family. A joint interview was conducted on [DATE] at 9:45 AM with the DHS and the Administrator. When they were asked to review the incident involving Resident #1, the Administrator stated she was contacted by RN E on [DATE] at 2:05 AM. RN E explained that she had received a call from RN C notifying her that Resident #1 had expired and she had concerns as there was a delay in notifying her of the incident. RN E stated she was enroute to the facility to find out what happened and meet with the family. The Administrator asked RN E to gather information and call her back. Approximately 30 minutes later, the Administrator contacted RN E and asked to speak to LPN B. LPN B stated at approximately 11:40 PM, CNA A called him to Resident #1's room. The resident was unresponsive, he performed CPR for approximately five minutes, and when he was unsuccessful, he stopped. LPN B stated he could not reach the on-call provider but reached the family. The Administrator asked LPN B to write a statement and put it under the DHS' door. She also asked him not to leave the facility until DHS arrived. The Administrator contacted the DHS who had just returned from vacation and notified her of the incident. She instructed her to go to the facility and assist with the investigation. The DHS stated she arrived at the facility at approximately 5:30 AM on [DATE]. She met with RN E and was provided with a synopsis of the incident. RN E told her that she called the on-call physician who voiced concerns with the time RN C was notified of the resident's time of death (concerns determining the time of death). The DHS interviewed LPN B who confirmed the incident as it was documented by RN E. He also confirmed that he did not call a Code Blue per facility policy and conducted CPR alone and pronounced the resident's death. When asked about the facility's protocol when staff find a resident who is unresponsive, the DHS outlined the following steps: Step 1: Assess for a pulse and respirations (apical pulse (the pulse felt at the apex (bottom) of the heart, on the left side of the chest) for one minute). Step 2: Find the code status. Step 3: If the resident is a Full Code, activate Code Blue (paging overhead) and initiate CPR. She stated if there were signs of death, CPR should not be initiated. If CPR was initiated, it should not be stopped until 911/EMS (Emergency Medical Services) took over. On [DATE] at 2:03 PM, a telephone interview was conducted with the Medical Director, who confirmed that he was notified of the incident involving Resident #1 on [DATE]. He stated his expectation was that when a resident who was a Full Code was found unresponsive, CPR should be performed, unless there were signs that rigor mortis had set in. At that point, an RN could pronounce a resident's death. He stated when CPR is initiated, staff should not stop until they are told to stop by a physician or EMS upon arrival. He said he was notified that LPN B was unable to reach the provider. He said, At the very least, he should have stopped and got the RN to pronounce the death because an LPN cannot pronounce death. A telephone interview was conducted on [DATE] at 2:14 PM with the Senior Nurse Consultant (SNC). She stated she had been in her role since [DATE]. She said she was contacted by the Administrator about the [DATE] incident early on the morning of [DATE]. She was told that LPN B initiated CPR and stopped when he was unsuccessful. He then pronounced the resident's death. When asked to explain the facility's policy and procedure for CPR, the SNC stated if a resident was a Full Code, the staff should initiate CPR; however, if there was enough evidence or rigor mortis was present, staff should not initiate CPR and should instead contact the provider. She confirmed that CPR should be initiated if there was evidence/likelihood of survival, and once CPR was initiated, staff should not stop until the provider asked them to or EMS arrived and took over. A review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR - effective [DATE], reviewed [DATE]), revealed: Policy Statement: Cardiopulmonary resuscitation (CPR) must be initiated on any patient/resident that has experienced cardiac arrest and does not have a Do Not Resuscitate (DNR) order. Further clarification for initiation of CPR is as follows: 1. When a patient/resident shows no signs of breathing and/or circulation. 2. The nurse will not initiate CPR, even in the absence of a DNR, if a patient/resident is obviously clinically and irretrievably dead and the death was not witnessed. Examples of signs that a patient/resident is clinically irretrievably dead include: no measurable vital signs, cool to the touch, and pupils that are fixed and dilated. 3. If there is no DNR order, and there is any question about whether or not the patient/resident is clinically and irretrievably dead, the nurse shall always initiate CPR. 4. If the death is witnessed and there is no DNR order, CPR will be initiated, even if the patient/resident is clinically and irretrievably dead. Definition: Cardiopulmonary Resuscitation is the administration of therapeutic resuscitative measures for cardiac or pulmonary arrest. These include closed chest cardiac massage and enhanced respiratory assistance. No CPR is a physician's written order not to apply or attempt resuscitation. All measures to provide therapeutic assistance and comfort will be continued. Attending Physician is the medical physician charged with ultimate responsibility for patient/resident's medical care. Procedure: When a Patient/Resident Experiences Cardiac or Respiratory Arrest and CPR is Medically Justified: 1. A licensed nurse certified in CPR will be available on all shifts. One-Rescuer or Two- Rescuer CPR will be initiated as appropriate. 2. If a patient/resident is found in cardiac or respiratory arrest, the appropriate personnel will be notified and the status of the DNR determined. 3. Designated staff will immediately call emergency services. 4. All staff members certified in CPR or licensed staff should immediately go to the identified room. A designated staff person will be responsible for responding immediately with the emergency equipment. 5. If the person is medically determined to need CPR and there are three certified staff, two will take turns performing CPR per American Heart Association guidelines and the third will provide direction to all other staff and document times and actions taken. If there are only two staff members, one will perform CPR per the American Heart Association guidelines and the other will provide direction to all other staff. 6. The Charge Nurse will call the patient/resident's physician or on-call physician to inform him that emergency service has been called and then follow the physician's orders. 7. The Charge Nurse is responsible for informing the patient/resident's legal representative, responsible party, or authorized person next (as defined in the HIM Manual). 8. The Administrator or Director of Health Services will be informed. Documentation: 1. After the crisis is over, the occurrence and related information will be documented in the 1. Nurse's Notes in detail of what actions were taken and what meds were given during the code. 2. For healthcare centers with electronic charting the note will be in the nurse department notes. .

Based on staff interviews, record review, and the facility's policy and procedure titled Abuse Preventing and Reporting, the facility failed to 1) Ensure that alleged violations involving resident neglect were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation resulted in serious bodily injury (death), to the State Survey Agency in accordance with State law for one (Resident #1) of three resident incident reports reviewed. The findings include: A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and expired in the facility on [DATE]. A review of the resident's physician's orders, dated [DATE], revealed Code Status: Full code. (Copy obtained) A nursing progress note, dated [DATE], and authored by Registered Nurse (RN) E/Acting Director of Health Services (DHS), revealed that Certified Nursing Assistant (CNA) A alerted Licensed Practical Nurse (LPN) B that Resident #1 was unresponsive. LPN B verified that the resident was without a pulse or respirations and had a Full Code status. Cardiopulmonary resuscitation (CPR) was initiated, and the resident's time of death was 11:56 PM. LPN B attempted to reach the provider's answering service at 11:56 PM. The resident's daughter was notified at 12:07 AM. The Acting DHS and the Administrator were notified of the resident's passing, and the acting DHS arrived in the facility to assist/support the resident's family upon notification. The Acting DHS contacted the provider and updates were provided. Postmortem care was rendered. A care plan for Advance Directives/Full Treatment was initiated on [DATE]. Resident #1's Advance Directives were in effect, and he wished them to be carried out going forward. In a telephone interview with LPN B on [DATE] at 1:32 PM, he stated he had been employed with the facility since 2019 and was assigned to Resident #1 on [DATE]. He said that was his first day working with this resident. At the start of the shift (7:00 PM) Resident #1 was alert and oriented times 1-2 (he knew who he was and where he was) with some confusion. He stated at approximately 11:30 PM, CNA A was passing ice water and found the resident unresponsive. She notified him and both employees went to the resident's room. He assessed the resident for a carotid (neck) pulse (no pulse noted), he verified the code status (Full Code), and he started compressions. He stated he could not recall the time he initiated CPR. After approximately five minutes of compressions, he noticed the compressions were not having any effect, so he stopped. He tried to contact the provider, but the provider did not answer the phone. At approximately 12:00 AM, he contacted the resident's family. He then proceeded to the other nurses' station and notified the other nurses. When he was asked if he notified the DHS, he said the DHS was on vacation and he did not have contact information for the Acting DHS. He stated RN C notified the Acting DHS. When he was asked to explain the facility's protocol for administration of CPR, he stated when a resident was unresponsive, he should assess the resident for a pulse and respirations, verify the code status, initiate CPR, call a Code Blue (a medical emergency, specifically a resident experiencing cardiac or respiratory arrest) and 911, then continue CPR until emergency medical services (EMS) took over. He confirmed that he did not call 911 or a Code Blue. He said, I don't know why I didn't call a code or 911 because I know what do; I might have just panicked. He stated he was assigned 24 residents on [DATE]. When asked if he provided a written statement for facility management regarding the event, he stated, no. He added that the DHS and the Administrator interviewed him after the incident. He confirmed that he worked three more days after the incident and was terminated on [DATE] for not following the facility's protocol. During an interview on [DATE] at 3:30 PM, the Social Services Director (SSD) stated she had been employed by the facility for five years. She stated the details of the event were reviewed by the Director of Health Services (DHS), the Administrator, and the Regional Nurse Consultant to determine whether the event met reporting requirements. She confirmed that allegations of Abuse/Neglect/Misappropriation should be reported within two hours. She was asked to review the [DATE] event for Resident #1. She confirmed that the incident took place on [DATE]. She stated she was not present during the incident. She explained that she received the timeline of the incident from RN E who was the Acting DHS at the time of the incident. The SSD stated on [DATE] at 11:30 PM, CNA A found Resident #1 unresponsive and notified LPN B, who assessed the resident and initiated cardiopulmonary resuscitation (CPR) at 11:40 PM. LPN B administered CPR for approximately five minutes. Resident #1 was unable to be resuscitated by LPN B, who pronounced the resident's death at 11:56 PM, and at that time, he called the provider and the family. The SSD confirmed that the incident was reported to the appropriate agencies on [DATE], five days after the event. She explained that the Administrator had notified the corporate office about the incident and was made aware that it was not a reportable event. When asked if the corporate personnel provided the rationale, she stated LPN B reported that Resident #1 was already cold/expired when he found him. When asked for documentation from LPN B indicating that the resident was cold, she confirmed that there was no documentation, and no witness statement was obtained. She added that on [DATE] she was notified by the Administrator that a determination had been made by the corporate office that the incident was indeed reportable and that LPN B should be terminated. In an interview on [DATE] at 4:25 PM, RN E stated she was the Acting Director of Health Services (DHS) from [DATE] through [DATE] and was familiar with Resident #1. She stated the resident's discharge goal was to return home with his daughter. When asked about the resident's death, she stated on [DATE] at 2:00 AM, she received a telephone call from RN C who stated Resident #1 had expired and no Code Blue was called. RN C stated she and RN D were notified of the event two hours after the incident occurred. RN C continued that LPN B pronounced the resident's death, and the funeral home was on their way. The resident's family was already in the facility. RN E stated after she got off the phone, she contacted the Administrator, notified her of the incident, and went to the facility. When she arrived at 2:20 AM, the resident's family was in the resident's room and postmortem care had already been completed. After offering condolences to the family, she went to interview LPN B who provided the timeline of the event. (Copy obtained) LPN B stated he attempted CPR for five minutes. It was not successful and after pronouncing the resident's death, he attempted to contact the provider, then contacted the family. RN E stated she contacted Resident #1's Advanced Practice Registered Nurse (APRN) at 2:38 AM. The APRN was concerned that LPN B had pronounced the resident's death and could not establish the correct time of death, because RN C was not notified until two hours later when the resident's family and the funeral home had already been contacted. The APRN stated she had to consult with the resident's physician. After approximately five minutes the APRN called back and stated the resident's physician agreed to use the time that the LPN pronounced the resident's death and emphasized that it was outside of LPN B's scope of practice to pronounce the resident's death. RN E stated the DHS, who had been on leave, arrived at the facility at 6:00 AM and took over the investigation. RN E provided the DHS with the timeline of the event. A joint interview was conducted on [DATE] at 9:45 AM with the DHS and the Administrator. The Administrator stated she was responsible for the oversight of the facility's operation. She stated she used different audit tools to ensure that measures were met. She added that she reported to the corporate team weekly. When asked to explain the facility's grievance/concerns process, she replied that the SSD was the grievance officer. The SSD reviewed grievances/concerns with the DHS and the Administrator. She added that incidents/grievances/concerns were also discussed during morning meetings, and the team decided whether or not an incident met the reporting requirements. All reportable incidents were also reviewed by the corporate Senior Nurse Consultant and Risk Manager. When asked to review the [DATE] incident involving Resident #1, the Administrator stated she was contacted by RN E on [DATE] at 2:05 AM and RN E explained that she had received a call from RN C informing her that Resident #1 had expired. There were concerns, as there was a delay in her having been notified of the event. RN E added that she was enroute to the facility to find out what happened and to meet with the family. The Administrator asked RN E to gather more information and call her back. Approximately 30 minutes later, the Administrator contacted RN E and asked to speak to LPN B. LPN B stated that at approximately 11:40 PM, CNA A called him to Resident #1's room. The resident was unresponsive. LPN B administered CPR for approximately five minutes, and when he was unsuccessful, he stopped. LPN B stated he could not reach the on-call provider but reached the family. When asked why the incident was not reported, the Administrator stated they felt the incident did not meet the requirement for reporting. She stated, It was an education moment because LPN B did not follow the facility's policy. She stated LPN B reported that Resident #1 was already dead. When asked if there were any progress notes documenting the incident, she replied, no. She added that she spoke to the Senior Nurse Consultant (SNC) about the incident and the SNC stated the incident did not meet reporting requirements. When asked if LPN B could pronounce a resident's death, she confirmed that LPN B acted out of his scope of practice but stated he could not reach the physician. She was then asked why LPN B was not suspended pending the investigation. She stated staff were suspended only when an incident was determined to be reportable. During a telephone interview on [DATE] 11:44 AM, CNA A stated she had been employed at the facility for one year. When asked about Resident #1 and the [DATE] event, she stated [DATE] was the first time she had worked with Resident #1. She said she reported to work around 10:45 PM on [DATE] and at approximately 11:00 PM, she went to Resident #1's room to conduct shift rounds and the resident was in bed. Approximately 30 minutes later, she was passing ice water, and the resident was not in bed. She thought the resident was in the bathroom, but as she approached the resident's bed, she saw the resident in a kneeling position on the floor with his head resting on the bed in a praying position. He was between the bed and the window. She asked him if he was praying and he didn't respond. She tapped his shoulder and again asked if he was praying and he still did not respond. She immediately notified LPN B. LPN B and CNA A went right to the resident's room. After assessing for a pulse and respirations, LPN B walked out of the room to verify the resident's code status. Upon returning to the room a minute or so later, LPN B asked her to help him get the resident off the floor and onto the bed. She stated they placed the resident on the floor first, placed a draw sheet under the resident, and put him back in bed. She stated there were no other instructions provided by LPN B. She left the room to assist another resident who was in the bathroom and left LPN B in Resident #1's room. She stated she was not sure if LPN B administered CPR. She stated Resident #1 was warm to touch when they placed him back in bed. When asked if she provided the facility's management with a witness statement, she replied that she was interviewed by the DHS and described the event the same way she had described it during this interview. She said she was not asked to write a witness statement that day; however, on [DATE] (the date of the survey), she was asked to provide a written statement. A review of the facility's policy and procedure titled Abuse Prevention and Reporting (effective [DATE], revised [DATE]) revealed: Abuse: Any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Procedure: 1. Anyone witnessing, suspecting or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator. 3. In the event the Administrator has knowledge that the resident has been abused, neglected or exploited while residing in the home, he/she will immediately make a report by phone or in person to the Department of Community Health. In the event that an immediate report to the Department is not possible, the Administrator shall make the report to the appropriate law enforcement agency. 4. The initial report of actual or suspected abuse shall contain at least the following: - Name and address of person making the report. - Name and address of the resident or former resident. - Name and address of the facility. - Nature and extent of any injuries or condition resulting from the suspected abuse, neglect or exploitation. - The suspected cause of the incident. - Any other information that the reporter believes might be helpful in determining the cause of the resident's injuries or condition and determining the identity of person or persons responsible for the incident. 5. Within 24 hours of the initial report, the Administrator shall also make a written report, using the Incident Report Form, documenting all known and relevant information, the investigation results, and any corrective or protective actions taken. 6. The written Incident Report shall be faxed to the Department of Community Health, Health Facility Regulation Department, Complaint Division. 7. The fax confirmation sheet shall be attached to the Incident Report and maintained in the central Incident Report file. 8. If the alleged perpetrator is a staff member of the home, the Administrator will place them on administrative leave until a determination of the allegation is made. Confirmed allegations shall result in termination with notification to appropriate boards, registries and agencies and the police as appropriate. .

Based on observations, record review, and interviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs), received necessary services to maintain good grooming and personal hygiene for one (Resident #294) of a total survey sample of 19 residents by not providing adequate fingernail care. The findings include: On 10/07/2024 at 10:59 AM, Resident #294 was observed in his room, sitting up in a wheelchair with elongated, jagged fingernails with brown matter underneath. (Photographic evidence obtained). The resident was asked how long it had been since his fingernails had been trimmed. He stated, It's been a while. On 10/08/2024 at 9:58 AM, the resident was observed lying in bed with elongated, jagged fingernails with brown matter underneath. (Photographic evidence obtained) The resident was asked if any staff had offered to trim or clean his fingernails and he stated, No. The resident was asked if he wanted his fingernails trimmed and he stated, Yes. The resident was asked if staff offered to trim his nails today would he allow it and he stated, Yes. A record review was conducted on 10/08/2024 at 11:40 AM which revealed that Resident #294 was admitted to the facility on [DATE] with diagnoses/needs including a need for assistance with personal care, cognitive/communication deficit and diabetes mellitus type II. A review of the resident's admission MDS (minimum data set) assessment, dated 9/29/2024, revealed that the assessment was incomplete (in progress). A review of the resident's care plan, dated 9/24/2024, revealed the following Focus Area: Resident has ADL decline related to status post amputation from gangrene infection to left foot, hyperlipidemia, diabetes mellitus type II, a history of stomach cancer, atrial fibrillation, and other comorbidities. Goal: The resident will receive assistance to be kept clean, dry, and comfortable through the next 30 days, and resident's ADL needs will be met and independence potential maximized within constraints of disease through next review. On 10/08/2024 at 1:26 PM, an interview was conducted with Certified Nursing Assistant (CNA) A. She was asked who was responsible for providing fingernail care to the residents. She stated, The CNAs. She was asked how often nail care was provided. She stated, As needed or whenever we see that it needs to be done. She was asked if she provided fingernail trimming for residents with diabetes. She stated, Yes, but we have to be careful at all times not to make the nails bleed. She was asked if she'd had training/education for abuse/neglect. She stated, Yes, when we do [web-based training] and we have different subjects every month. The CNA was accompanied to Resident #294's bedside to assess the status of his fingernails. She was asked if she thought the resident needed fingernail care. She stated, Yes. The resident's fingernails were elongated and jagged with brown matter underneath. On 10/08/2024 at 1:31 PM, an interview was conducted with Registered Nurse (RN) B who was asked who was responsible for providing fingernail care for the residents. She stated, The CNAs unless its a diabetic resident, then the nurses have to do it. She was asked when fingernail care was provided. She stated, I wanna say as needed. She was asked if she'd had training/education for abuse/neglect. She stated, Yes, recently. RN B was then accompanied to Resident #294's bedside to assess the status of his fingernails. She was asked if she thought the resident needed fingernail care. She stated, Yes, he needs it. The resident's fingernails were elongated and jagged with brown matter underneath. On 10/08/2024 at 3:58 PM, a policy and procedure for ADL care was requested from the Director of Nursing who reported that the facility did not have a policy and procedure for ADL care.

Based on observation, staff interview and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness for all but one of the residents in the facility. The dietary staff failed to follow the proper procedures for hand hygiene, disposable glove use, food storage, date marking and proper sanitation practices in the kitchen. Specific instruction and procedures on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: Observations made during the initial tour of the kitchen on 05/10/2021 at 11:10 AM, with Employee D, Dietary Manager, included the following: Debris from the cardboard boxes and containers was observed on floor of the walk-in freezer. The floors under and behind the ice machine, the food warming ovens and the deep fryers were observed to have a build-up of food debris and grime. The food warmer oven had crumbs of food debris on the ledge under the controls and caked on food that had run out under the top oven door. There was a build-up of stuck on grease between the two fryers. The stand mixer had encrusted food on the under carriage and the inside of the stand. The air vents throughout the kitchen had a black biological growth on them. A drain under the main prep table was covered with built up black grime. There was stuck on food and grime in the grout of the floor throughout the kitchen. A food scoop was observed on the rack with the clean utensils with dried on food stuck to it. (Photographic evidence obtained) In the walk-in cooler two plastic storage bags containing partially used deli meat were observed. One bag was date marked 04-27 with a black marker. One bag was marked Open 5-2 with a black marker. Another partially used bag of deli meat was observed with no date mark and the bag was not sealed. (Photographic evidence obtained) During a second tour of the kitchen on 05/12/2021 at 11:30 AM, Employee H was observed preparing chef salads. She had taken the bag of sliced deli meat with the date mark of 5-2, opened it, cut the meat into slices, and placed it on top of the prepared salads. During an interview on 05/12/2021 at 11:43 AM, Employee D was asked about the date marking of the deli meats that were observed on 05/10/2021 during the initial tour. Review of the date marking guide indicated that deli meat should be discarded 5 days after opening the original package if not used. He was informed of the deli meat, marked 5-2, being used by Employee H to make the chef salads. He immediately went to the prep table and looked at the date mark on the bag of the deli meat. He instructed Employee H to throw the salads and deli meat away, and to make new salads with fresh deli meat. Employee H stated she thought she was using a new package she had opened more recently. During the lunch meal observation in the kitchen on 05/12/2021 at 11:50 AM, Employee G, removed the pans of prepared food from the warmers, removed the plastic wrap covering them and placed them in the steam table. He dropped a crumpled wad of plastic wrap on the floor in front of the steam table and walked away. Employee F walked over, picked up the plastic wrap with her gloved hands and threw it in the garbage can under the handwashing sink near the tray line. She did not change her gloves and wash her hands. She proceeded to set up the trays, plate the food and place a dinner roll on each plate without changing her gloves and washing her hands. At 12:20 PM, Employee F was observed moving the food with her gloved hands to the place on the plate where she wanted the food. She did this on several plates and did not change gloves. She used a dry towel to wipe the gloves and continued to plate the food, touching various surfaces with the contaminated gloves. She plated 76 residents' food without changing her gloves or washing her hands. During an interview with the Employee D on 05/12/2021 at 1:42 PM, he stated that Employee H told him that she did not check the date on the deli meat, and she should have. He stated the dietary staff have been trained and they know to check the date mark on items in the cooler prior to using them. During an interview with Employee E, Certified Dietary Manager, on 05/13/2021 at 1:45 PM, she stated that the kitchen has not been deep cleaned for some time. The facility is having trouble filling all the dietary positions and because of that the deep cleaning has not been done. She stated, We know it needs to be done. She produced a cleaning schedule for the kitchen that was blank and stated, It isn't being done. (Copy obtained). Review of the facility policy and procedure entitled Bare Hand Contact with Food and Use of Plastic Gloves, effective 10/01/2017 and revised 10/18/2017, revealed it read: It is the policy of [Facility] plastic gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handler's hands to the food product being served. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose and discarded when damaged or soiled. Hands are to be washed before putting on the plastic gloves. Anytime a contaminated surface is touched the gloves must be changed including but not limited to the following: After handling garbage or garbage cans, after handling anything soiled, after picking up an item off of the floor, anytime you touch a contaminated surface. Wash hands when removing and/or changing gloves (Copy obtained). Review of the facility policy and procedure entitled Labeling, Dating and Storage, effective 06/01/2016 and revised 10/18/2017, revealed it read: It is the policy of [Facility] for all partners who assist in handling, preparing, serving and storing food items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. 1. Food items will be properly labeled with the name of the item and a use by date. 2. Food will be stored in their original container or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. 3. Prepared food items will be discarded according to the USDA Quick Reference Shelf Life List. 4. Those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with a use by date based on the USDA Quick Reference Shelf Life List (Copy obtained). Review of the facility policy and procedure entitled Receipt and Storage of Food & Supplies, effective 09/01/2001 and revised on 03/24/2016, revealed it read: 4. All storage areas will be clean, organized and ready to receive deliveries. 8. Floors must be swept and mopped daily (Copy obtained). Review of the facility policy and procedure entitled Quick Reference Shelf Life List, effective 11/22/2017 and revised on 02/23/2018, revealed it read: All opened refrigerator items must have a use by date. All items will be dated on date of arrival. Deli Meats: 5 days (Copy obtained).

Based on kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in a safe operating condition. The facility failed to ensure that the dietary staff were trained and knowledgeable about the proper procedures for the safe operation of the dish machine. Failing to sanitize the dishes may potentially lead to negative health outcomes for the residents. The findings include: During the initial tour of the kitchen on 05/10/2021 at 11:10 AM, Employee H was observed operating the dish machine. The machine was run through 5 cycles and the wash cycle temperature only reached 156' F to 158'F, and the rinse cycle only reached 178'F. Observation of the machine specifications posted on the side of the machine revealed it read: Wash cycle minimum temperature: 160'F. Rinse cycle minimum temperature: 180'F. (Photographic evidence obtained) Employee H stated the machine was a high temperature sanitization machine. She confirmed the water temperature was not high enough to sanitize the dishes, stating it needed to be minimally 160'F for the wash cycle and 180'F for the rinse cycle. A large plastic bucket of chlorine sanitizer was observed under the machine with a clear plastic hose running out through the lid of the bucket into the machine. During an interview on 05/10/2021 at 11:25 AM with Employee H she was asked about the use of small canister of chlorine test strips on top of the machine. When asked if she uses the chlorine test strips to test the sanitizer level, she stated yes. She took a chlorine test strip and tested the water when the machine finished another cycle. The test strip registered 0 parts per million (ppm). She then took a quaternary (quat) ammonium test strip from a shelf above the ware washing sinks on the other side of the dish room. She ran the machine again. The quat test strip registered 0 ppm. When asked to explain why she was testing for chemical sanitizer if it was a high temp machine, she stated that if the machine does not reach a high enough temperature, then the chemical sanitizer works. She was not able to explain how the machine worked. She did not know what type of chemical was used in the machine. She pointed to the dispenser on the wall and said, It's whatever they fill that with. The water temperatures for the wash cycle were still only reaching 158'F and the rinse cycle only 178'F. Employee H stated the chemical sanitizer should be automatically working since the temperatures are not high enough. During an interview with the Certified Dietary Manager (CDM) on 05/10/2021 at 11:30 AM, she was not certain how the machine switches from high temperature to chemical sanitation. She thought the chemical used in the dish machine is chlorine. She tested the sanitation with the chlorine test strips and the test strip registered 0 ppm. She could feel the chemical on her hands and was sure it was dispensing the chemical sanitizer during the rinse cycle. During an interview with the Dietary Manager (DM) on 05/10/2021 at 11:33 AM, he stated that the dish machine is a hybrid. It uses high temperature sanitation and chemical sanitation. He was not able to explain how the machine works. He knew that if the temperature did not rise to a high enough level, the chemical sanitizer is supposed to kick in. When informed about the test strips registering 0 ppm, he was not sure how the machine is set up to switch from high temp to chemical sanitation. He was informed that the temperature of the water was not high enough in the wash or rinse cycle. He ran the machine and observed the temperatures to be: Wash cycle = 158'F and the Rinse cycle = 178'F. He stated that sometimes it does not get to the right temperature and he has to call the contracted maintenance provider to come work on the machine. He thought the chemical sanitizer for the machine in the bucket was chlorine and since the machine was not reaching a high enough temperature, the chemical sanitizer should be working. He could not explain why the test strips registered 0 ppm. He was not able to determine when the machine had last been functioning properly. He stated he would use paper plates for the lunch meal service and rewash all of the dishes when the machine was fixed. During an interview on 05/10/2021 at 1:20 PM with the representative from the contracted maintenance provider for the dish machine, who was on site working on the dish machine, he confirmed that the water temperatures were not hot enough. He explained that he had to adjust the water heater booster and make some other adjustments to the machine. He explained the machine is a hybrid machine. When the water temperature does not reach 160'F during the wash cycle and 180'F during the rinse cycle, minimally, the machine is to be switched manually by the dietary staff member running the machine to chemical sanitation. He pointed to a control box on the wall above the dish machine and explained how the electrical wiring is to be plugged into a receptacle inside the box and then the chlorine in the bucket under the machine will start to dispense into the machine. He confirmed that the machine must be switched manually. It does not automatically change from high temp to chemical sanitization. The staff have to watch the temperature gauges to determine if and when the machine needs to be switched from high temp sanitation to chemical sanitation. Review of the facility policy and procedure entitled Dish Machine Rinse Additive Use revealed it read: When the temperature on the wash cycle goes below 160'F or the sanitizing cycle goes below 180'F, 3. Turn on the sanitizer manually (show the staff where and how).

Based on record review, observations, and interviews, the facility failed to provide prompt and appropriate care for a resident presenting with complaints of chest pain for one (Resident #65) of one resident reviewed from a sample of 26 residents. The findings include: A review of the Resident #65's medical record revealed an initial admitted [DATE]. Her primary medial diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also indicated the resident suffered a heart attack in 2009. A review of the most recent comprehensive assessment dated [DATE] indicated the resident's cognition was intact (BIMS 10/15) and she required extensive to total assistance with activities of daily living. On 5/11/21 at 10:20 AM, the resident was overheard yelling for help. Observation upon entering the room revealed she was lying in bed and was pale. When asked what her concerns were, the resident stated, Something is wrong with me. I feel like I might be having a heart attack or something. She explained that she was having pain and heaviness in her back, right chest, right shoulder, and right arm. She rated the pain a 10 out of 10 on a 0-10 verbal scale. The resident also complained of fatigue and stated it was difficult to perform simple movements like changing the channel on her television without becoming tired. On 5/11/21 at 10:21 AM, the resident's assigned nurse was notified of the resident's complaints. At 10:22 AM, the nurse responded to the resident's room. She asked the resident what was wrong. The resident reported pain in her back, chest, arm and shoulder and stated she felt fuzzy. The nurse asked whether the pain was new or chronic. The resident stated, No, this is something new. The nurse continued to assess the resident for neurological concerns, auscultated heart and lung sounds, and informed the resident that there was nothing to indicate the resident was having a stroke or heart attack. The resident again voiced complaints of pain and the nurse responded by saying, I've already given you everything I could for pain. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's history and physical dated 3/11/21 indicated a history of heart attack in 2009. On 05/11/21 at 11:27 AM an interview was conducted with the Unit Manager as she was exiting the resident's room. She explained the resident didn't feel any better, but did rate her pain an 8/10 which was previously 10/10, so she was going to take that as a good sign. The unit manager was asked what the facility's typical response would be if a resident with a history of a heart attack complained that she may be having a heart attack. She explained that a full set of vitals would be taken and the physician would be contacted. She went on to say, Because I know her, I feel like it is more of an anxiety issue. On 5/11/21 at 12:50 PM an interview was conducted with the resident. She confirmed that she had suffered a heart attack in the past and that the arm/shoulder pain she was experiencing felt just like this. The resident requested to be evaluated by a doctor. Regarding the symptom of being fuzzy, the resident explained that her vision was blurry and that she was extremely fatigued. She confirmed that these symptoms were new onset. The resident's request to be evaluated by a doctor was relayed to the resident's assigned nurse on 05/11/21 at 12:56 PM. On 05/11/21 at 12:56 PM an interview was conducted with Employee N, RN. She explained that she had notified the physician of the resident's concerns and that a chest x-ray, labs, and an electrocardiogram (ECG) were ordered. The nurse was asked whether the ECG had been ordered to be done as soon as possible. She replied that it would be done sometime today. On 05/11/21 at 03:16 PM, approximately approximately four and a half hours after the resident's initial complaint, the radiology technician arrived to the facility to perform the x-ray and ECG. On 05/12/21 at 01:12 PM an interview was conducted with the Director of Nursing (DON). She explained that for a resident who presented with signs and symptoms of a heart attack, the facility would notify 911. She went on to explain that because the facility knows the resident's behaviors and anxiety, 911 was not called. The DON was asked for the facility's policy regarding changes in condition and emergency response. She stated she didn't believe the facility had a policy for either topic. A policy was not produced during the survey. On 5/12/21 the results of the ECG indicated consider anteroseptal [CONDITION(S)] damage. (Photographic Evidence Obtained) On 05/13/21 at 11:23 AM an interview was conducted with the resident's attending physician. He explained that his expectation was that an EKG should be done now. He stated, there is no such thing as a routine EKG. According to Merck Manual https://www.merckmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/chest-pain (accessed 5/11/2021): A high index of suspicion is important when evaluating patients with chest pain. For adults with acute chest pain, immediate life threats must be ruled out. Most patients should initially have pulse oximetry, electrocardiogram (ECG), and a chest x-ray. Evaluation must be prompt so that patients with ST-elevation [CONDITION(S)] infarction or other criteria for intervention can be in the heart catheterization laboratory (or have thrombolysis) within the 90-minute standard.

Based on observations, interviews, and resident record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one out of 26 residents. (Resident #36) The findings include: On May 11, 2021 at 9:29 AM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup lid was dated Sunday, 5/9/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) Resident #36 was observed lying in bed with head of bed elevated, pleasant and conversant. She was asked if she used the straw that was in her cup to drink her water. She stated, Yes, I suppose so. On May 12, 2021 at 12:15 PM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup lid was dated Tuesday, 5/11/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) On May 13, 2021 at 9:05 AM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup was dated Wednesday, 5/12/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) On May 13, 2021 at 09:07 AM an interview was held with floor nurse, Employee C. She confirmed that she was caring for Resident #36 today. She did not know why Resident #36 has had a straw in her bedside water cup. When asked if she was aware the label on her water cup says no straws she stated, No, I'm not sure. When asked if Resident #36 is not supposed to use straws she said, No, I'm not sure. I'll have to ask the unit manager. On May 13, 2021 at 10:26 AM an interview was conducted with Employee B, Unit Manager. She confirmed Resident #36 had an order for no straws. Regarding the reason, Employee B replied, She has a history of aspiration. The speech therapist had seen her and determined she should not use straws. I just went around and did an in-service with all staff about following the orders for not using straws. On May 13, 2021 at 1:09 PM an interview was conducted with Employee A, Speech Therapist. Regarding Resident #36's status of no straws and the reason she stated, Typically an order for no straws is due to decreased lingual strength and the ability to control the liquid bolus, but the desire to continue on thin liquids. Resident #36 is at an aspiration risk, and for her, using a straw puts her at a higher risk for aspiration. A review of the current orders for Resident #36 revealed a diet order written on October 14, 2020 which read, NAS (no added salt) Special instructions: No straw. Side of gravy with meat. Upright for all intake. May require assistance with cutting food items into small bite size pieces. A review of Resident #36's care plan, dated April 4, 2020 and revised March 30, 2021 revealed the following focus, goal and interventions: Focus: Resident is at nutrition and/or hydration risk as evidenced b: consumes less than 75% of food and/or fluids at most meals, dementia, low pre-[MEDICATION(S)], requires oral supplements to meet nutritional needs, ride sided weakness, at risk for skin breakdown, requires assist with meat cut up into bite size portions and gravy on the side to increase mastication. Goal: Resident will remain adequately hydrated as evidenced by good skin turgor, pink and moist membranes, and sufficient fluid intake through next 30 days. Interventions: Monitor for skin breakdown. No straws for drinking. Nursing to cut up meat when needed. Provide house shakes at/between meals. May have fluctuating mental status, monitor at meal times and provide supervision/assistance as needed. Observe for s/s dehydration and report to nurse. A review of the Speech Therapy Progress and Discharge Summary for Resident #36, dated Start of Care 10/08/2020 and End of Care 10/14/2020 revealed precautions which specify aspiration precautions, regular/thin liquids, no straw.

Based on record review and interviews, the facility failed to adequately monitor for the use of antipsychotic medications for 1 of 7 residents reviewed for unnecessary medications from 26 sampled residents. (Resident #9) The findings include: Record review revealed Resident #9 was a [AGE] year old female admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the Quarterly Review of the Minimum Data Set (MDS) completed 4/22/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and a Mood Severity score of 07 indicating some depression. The medication orders included [MEDICATION(S)] 5 mg daily for depression, [MEDICATION(S)] HCI 300 mg daily for depression, [MEDICATION(S)] 3 mg daily for depression, and Vilbryd 40 mg daily for depression. The medical record did not reveal any orders for the monitoring of behaviors for the ordered medications. Review of the care plan revealed a focus area for the use of medications with a potential risk for adverse consequences related to antipsychotic medications. Interventions included to assess effectiveness of drug treatment, attempt GDR (gradual dose reduction) if not contraindicated, and monitor resident's behavior and response to medication. Review of the April and May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/21 at 1:36 PM an interview was conducted with the Director of Nursing (DON) who was asked if behavioral monitoring is conducted on residents receiving antipsychotic or antidepressant medications. The DON stated an order is put into the Electronic Medical Record (EMR), and the nurses document on the MAR/TAR their observations. The DON was asked if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the EMR and confirmed there was no order; therefore it did not appear on the MAR/TAR for the nurses to document their observations.

Based on records reviews and observations, the facility failed to ensure medication error rates were below five percent by failing to administer eye drops appropriately for one of eight (Resident #171) residents reviewed during observations of medication administration. The medication error rate was 6.25% with 2 errors out of a total of 32 opportunities for errors. The findings include: A review of the medical record for Resident #171 was conducted. She was admitted to the facility on [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plans for Resident #171 revealed a focus area for visual disturbances which indicated the resident required the use of [MEDICATION(S)] eye drops. A review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/21 at 4:26 PM an observation of medication administration for Resident #171 was conducted with Employee N, Registered Nurse (RN). She instilled one drop of the [MEDICATION(S)] ophthalmic solution to the resident's left eye. She then instilled one drop of the [MEDICATION(S)] ophthalmic solution to the resident's right eye. The nurse failed to apply pressure to either eye after administering the medication. The nurse also failed to instruct the patient to keep her eyes closed for 1-2 minutes to allow absorption of the medication into the eyes. A review of the facility's medication administration policy titled Medication Administration: Eye Drops was conducted. The policy was last revised on 1/30/20. The policy directed staff to instruct the patient/resident to close eyes slowly to allow proper distribution of drops over surface of the eye and to keep eyes closed for 1-2 minutes. According to Mayo Clinic, https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-ophthalmic-route/proper-use/drg- 320 (accessed on 5/13/21), keep the eye closed and apply pressure to the inner corner of the eye with a finger for 1 or 2 minutes to allow the medicine to be absorbed by the eye.

Based on observation of medication administration, reconciliation of the observed medication administration with the medical record, and staff interviews, the facility failed to ensure it was free of medication errors. Facility nursing staff crushed a time-released tablet that the manufacturer stated do not crush. The facility also failed to notify the physician promptly about the medication error. This affected one (Resident #2) of two residents observed during medication administration. The findings include: A review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During the medication pass observation on 3/22/21 at 10:40 a.m., Licensed Practical Nurse (LPN) A, was observed administering medication to Resident #2. Reconciliation of the administered medication with the resident's medical record, and a review of the facility document titled 'Medications That Should Not Be Crushed', revealed one medication error for Resident #2. A review of Resident #2's medical record, including physician's orders, revealed an active order for [MEDICATION(S)] extended release (ER) 10 milligrams (mg), one tablet by mouth daily given as a muscle relaxer and scheduled at 9:00 a.m. Employee A was observed crushing Resident #2's [MEDICATION(S)] 10 mg ER tablet and placing it in applesauce. On 3/22/21 at 10:45 a.m., LPN A was made aware of the medication error identified for Resident #2. She stated, I did not see the instruction for [MEDICATION(S)] XL. It should not be crushed. I crushed it by mistake. When asked about the next step going forward, she stated, I will make sure not to crush the medication. The nurse said nothing about notifying the physician about the medication error. On 3/22/21 at 12:00 p.m., Registered Nurse (RN/Staff Educator) B was made aware of the medication error identified for Resident #2 during the medication administration observation. She stated the expectation was to notify the physician promptly about the medication error. She stated she did not see in Resident #2's medical record that the physician had been notified. She stated she would speak with LPN A and ensure that the physician was notified. During an interview on 3/23/21 at 9:45 a.m., the Director of Nursing (DON) agreed that the medication [MEDICATION(S)] extended release (ER) was on the 'Do Not Crush' list because it was a slow-release medication. Crushing the medication was contraindicated. A review of the facility policy titled Medication Discrepancies and Adverse Reactions, revealed: In the event of a medication discrepancy or adverse medication reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare. The attending physician is notified promptly of the error or significant adverse medication reaction. A review of the progress note, dated 3/23/21 at 12:29 p.m., revealed LPN A noted, Writer crushed resident's [MEDICATION(S)] ([MEDICATION(S)]) 10 mg ER in error. Employee A notified the physician on 3/23/21 at 12:10 p.m. (after the staff educator was made aware of the error).