Every finding on record at Pruitthealth - Ocilla

Based on observation and staff interviews, the facility failed to ensure residents' living area was safe, clean, comfortable and homelike in two of 51 rooms (room [ROOM NUMBER], room [ROOM NUMBER]). Specifically, residents' rooms contained wheelchairs and a personal fan with dirt and debris build-up that had the potential to affect residents' safety and comfort. Findings include:Observations on 9/16/2025 at 9:40 am, 9/17/2025 at 8:30 am, and 9/18/2025 at 9:00 am revealed the wheelchairs in room [ROOM NUMBER]A and room [ROOM NUMBER] had dirt and dust accumulation on various parts of the equipment, including a brown substance on the seat of wheelchair in room [ROOM NUMBER]. Observation with concurrent interview on 9/18/2025 at 9:10 am with the Administrator, confirmed both wheelchairs in room [ROOM NUMBER]A and room [ROOM NUMBER] were soiled in dirt and dust, with brown substance in wheelchair seat of room [ROOM NUMBER]. The Administrator revealed wheelchairs are cleaned monthly. She stated that she was unsure if maintenance kept a log. The Administrator revealed she was going to get the chairs cleaned immediately. Interview on 9/18/2025 at 10:25 am with the Maintenance Director revealed that she keeps a maintenance log of when wheelchairs are cleaned which is monthly. She stated she does not have access to those records because of a computer glitch. The Surveyor reviewed photographs that were taken of the dirty equipment with the Maintenance Director. She confirmed they were soiled and stated her expectations were that residents have clean, safe, working wheelchairs. A policy related to environment/equipment was requested from the Administrator who revealed there was no environmental/equipment policy.

Based on observations, interviews, record review, and review of the facility's policy titled admission Comprehensive Plan of Care, the facility failed to develop and implement a comprehensive person-centered care plan for five of 33 sampled residents (R) (R60, R31, R28, R41, and R36). Specifically, the facility failed to develop and implement care plans related to nail care for R60, R31, R41, R28 and R36. In addition, the facility failed to implement a care plan related to providing oxygen as ordered for R28.Findings include: The facility policy titled admission Comprehensive Plan of Care with revision date of 7/27/2023 revealed, 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. 1. Record review of R60's Electronic Health Record (EHR) revealed the following diagnoses that included but not limited to paraplegia and traumatic brain injury. Review of the admission Minimum Data Set (MDS) assessment for R60 dated 5/25/2025 for Section C (Cognitive Patterns) revealed, a Brief Interview Mental Status Score (BIMS) score of 99 which indicated severe cognitive impairments. Section GG (Functional Abilities and Goals) revealed that the resident was totally dependent for all ADL services (including personal hygiene care). Observation on 9/16/2025 at 10:00 am and on 9/17/2025 at 11:00 am revealed R60 had long jagged broken nails coated with a dark substances under the nail and around the cuticles. Review of R60's physician order dated 9/27/2022 revealed, an order that read, Podiatry /dental/ophthalmic care as needed. Review of R60's care plan created on 9/27/2022 revealed, R60 was totally dependent for all ADL care RT (related to) traumatic brain injury RT MVA (motor vehicle accident). Intervention included but not limited to: shampoo/nail care as needed. Interview with the Minimum Data Set (MDS) Coordinator on 9/18/2025 at 10:01 am, revealed that her expectation was that the Certified Nursing Assistants (CNA) and nursing staff should follow the care plan. 2. Review of R31's Annual MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed, R31 was dependent for toileting and moderate assistance for personal hygiene and lower body dressing, shower/bathe. Review of the care plan for R31, dated 8/8/2025 revealed that R31 had a potential for ADL decline related to a history of cerebral infarction. Interventions included but not limited to: check nails, ensure they are clean, and provide assistance when needed. An observation on 9/16/2025 at 9:38 am revealed that R31 had long, brown finger nails. An observation and interview on 9/17/2025 at 8:06 am revealed, R31 had long, brown fingernails. R31 revealed that she did not want her nails that long. An interview with the Assistant Director of Health Services (ADHS) on 9/18/2025 at 10:09 am revealed that the expectation was that nurses and CNA's will follow the care plan. ADHS further revealed that the care plan could be found on the CNA's resident profile. An interview and observation with Director of Health Services (DHS) on 9/17/2025 at 2:10 pm revealed that long and dirty nails were not acceptable. She stated that the expectation was that CNA's and nurses will follow the care plan. The DHS verified that the care plans for residents could be found on the CNA's resident profile in the electronic medical record. 3. A review of R28's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed that R28 had a BIMS score of 11 which indicated moderate cognitive impairment. Section I (Active Diagnoses) revealed diagnoses that included but not limited to Alzheimer's disease, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. Section GG (Functional Abilities) revealed that the resident required moderate assistance with personal hygiene and upper body dressing and maximal assistance with showering/bathing, and lower body dressing. A review of the care plan for R28 dated 8/14/2025 revealed that R28 had a potential for ADL decline related to hip fracture. Interventions included but not limited to: setting up resident for ADLs. An observation and interview on 9/16/2025 at 9:50 am with R28 revealed that the resident had long fingernails. R28 revealed that she would like to have them cut. She revealed that the podiatrist cuts toenails, but no one cuts fingernails. She revealed that she had an ingrown toenail that had not been addressed. An observation and interview on 9/17/2025 at 9:19 am revealed R28 fingernails remained long and had not been addressed. R28 revealed that someone worked on her toenails last night. An interview and observation with the DHS on 9/17/2025 at 2:10 pm revealed R28's fingernails that were observed to be long and dirty nails was not acceptable. The DHS further revealed that residents should be receiving routine nail care on bath days and that all CNAs received education on nail care and trimming. The DHS revealed that the expectation was that CNA's and nurses will follow the care plan. An interview with MDS Coordinator on 9/18/2025 at 3:28 pm confirmed that R28 care plan reflected set up resident for ADL care and further explained that if the care plan stated set up resident for ADLs, it meant bathing, grooming, which includes nail care. The MDS Coordinator revealed that the expectation was for staff to follow the care plan and confirmed that CNA's have received education on nail care and if a resident refuses nail care, it should be documented in the chart and reported to the nurse. 4. A review of R28's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed that R28 had a BIMS score of 11 which indicated moderate cognitive impairment. Section I (Active Diagnoses) revealed diagnoses that included but not limited to Alzheimer's disease, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. Section GG (Functional Abilities) revealed that the resident required moderate assistance with personal hygiene and upper body dressing and maximal assistance with showering/bathing, and lower body dressing. A review of the care plan for R28, dated 8/14/2025 revealed that R28 used oxygen related to her diagnosis of chronic obstructive pulmonary disorder. Interventions included but not limited to: oxygen as ordered. A review of physician orders for R28 revealed an order for oxygen at 2 liters per minute (LPM) via nasal cannula continuous. An observation on 9/16/2025 at 9:50 am revealed that R28 was wearing her oxygen and the concentrator was set at two and half liters per minute. An observation on 9/17/2025 at 9:19 am revealed that R28 was wearing her oxygen and the concentrator was set between two and two and half liters per minute. An interview with Licensed Practical Nurse (LPN) CC on 9/17/2025 at 10:54 am confirmed that oxygen setting was on 2.5 LPM. LPN CC revealed that she was responsible for checking the oxygen levels to make sure that the residents were receiving oxygen as ordered. An interview with the ADHS on 9/18/2025 at 10:09 am revealed that the expectation was that staff follow the care plans. An interview and observation with the DHS on 9/17/2025 at 2:10 pm revealed that expectation was that nurses will follow the care plan. 5. A review of the EHR revealed that R41 was admitted to the facility with diagnoses that included but not limited to type 2 diabetes mellitus, generalized muscle weakness, and cognitive communication deficit. A review of the significant change MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of 11, which indicated moderate cognitive impairment, Section GG (Functional Abilities and Goals) revealed that the resident was dependent on staff for personal hygiene care. A review of the care plan dated 8/7/2025 revealed an intervention that included staff to set up resident for ADLs. Observation on 9/16/2025 at 10:49 am revealed R41's toenails were long, thick and yellow with a yellowish/brownish substance underneath them. Observation and interview with R41 on 9/17/2025 at 9:10 am revealed the resident's toenails long, thick, and yellow with a yellowish/brownish substance underneath them and not trimmed. R41 was asked about his toenails but did not appear to understand the question as he was not providing an answer to address the question. Observation of R41 on 9/18/2025 at 9:30 am revealed, R41 was lying in bed with his feet uncovered and his toenails were noted to be long, thick, yellow with a yellowish/brownish substance underneath and not trimmed. Observation and interview on 9/17/2025 at 2:10 pm with the DHS confirmed R41's toenails were long and dirty with a yellowish/brownish substance underneath them. She revealed that resident's nails should be trimmed by a CNA if they were not diabetic, otherwise they must be trimmed by a nurse. She revealed residents' nails should be cleaned and trimmed during bath or as needed. The DHS revealed that staff should document each time nail care was provided and also document refusals. She confirmed that all resident's should have ADL care plan as that was how staff know what interventions need to be implemented. DHS stated she was going to look for the resident's ADL care plan and get back to surveyor. When asked who completed care plans, DHS revealed that prior to coming to this facility she completed care plans so she has been updating them. Later when interviewed she confirmed that ADL care plans were present but older plans did not address specific ADL needs such as nail care and bathing but current plans do. Upon entering R41's room and observing the toenails, DHS stated that R41 may be receiving podiatry care for toenail trimming. DHS also confirmed that the resident's toenails were very long and discolored and should be receiving care to address the toenails. She confirmed that the care plan for R41 was not being implemented as there had been a failure to address nail care that was a part of personal hygiene. Interview with MDS coordinator on 9/18/2025 at 2:00 pm revealed that she was responsible for doing comprehensive MDS assessment and that the care plan was developed by the interdisciplinary team. She confirmed that Set up resident for ADLs on the care plan includes dressing, bathing, grooming, and meals. She also confirmed that nail care was included in grooming and that CNAs were expected to be knowledgeable of this through their training on those specific interventions that were included in the care area. The MDS coordinator revealed her expectation was that staff follow the care plan and provide appropriate ADL care including cleaning and trimming nails. 6. A review of the EMR revealed that R36 was admitted to the facility with diagnoses that included but not limited to major depressive disorder, recurrent, severe with psychotic symptoms and unspecified dementia, unspecified severity, with other behavioral disturbance, and generalized weakness. A review of the quarterly MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for personal hygiene care. A review of the care plan dated 9/4/2025 revealed an intervention that included but not limited to staff to set up resident for ADLs. Observation and interview on 9/16/2025 at 9:40 am with R36 revealed his fingernails were long with a brown and yellow substance underneath them. R36 revealed his fingernails needed to be trimmed and cleaned. Observation and interview on 9/17/2025 at 1:00 pm with R36 revealed his fingernails were long with a brown and yellow substance underneath them. R36 revealed he would like his fingernails to be trimmed and cleaned. Observation and interview on 9/17/2025 at 2:10 pm with the DHS confirmed the resident's nails were long and dirty with a yellow-brown substance. The DHS confirmed that all residents have an activity of daily living (ADL) care plan, as that was how staff know what interventions need to be implemented. She confirmed that the care plan for R36 was not being implemented by failure to address personal hygiene including nail care. Interview on 9/18/2025 at 1:33 pm with the MDS Coordinator revealed that she was responsible for doing comprehensive MDS assessments, and that care plans are developed as a team. She confirmed the resident was dependent on staff for personal hygiene. She confirmed that the resident's ADL care plan included an intervention set up resident for ADLs which includes dressing, bathing, nail care, grooming, and eating even though it does not specifically list those tasks. She confirmed that CNAs receive orientation and that nail care was discussed during orientation as part of ADL care. She further explained that staff were educated on following care plan interventions and that it was her expectation that staff follow the care plan and provide ADL care including cleaning and trimming nails. Cross Reference F677

Based on observations, interviews, record review, and review of the facility's policy titled Specialty Services: Dental Services, Vision, the facility failed to ensure that Activities of Daily Living (ADL) care services were provided for five of 33 sampled residents (R) R60, R31, R28, R41, and R36 related to nail care. Findings include: Review of the facility's policy titled Specialty Services :Dental Services, Vision, dated 9/5/2025 revealed, It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient /resident to ensure the highest well-being of the residents. The healthcare center has specialty service providers who provides consultation , participates in Inservice education , and is available in case of emergency. Specialty Services include, but not limited to: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health. 1. Review of R60's Electronic Health Record (EHR) revealed the following diagnoses that included but not limited to paraplegia and traumatic brain injury. Review of the admission Minimum Data Set (MDS) assessment for R60 dated 5/25/2025 for Section C (Cognitive Patterns) revealed, a Brief Interview Mental Status Score (BIMS) score of 99 which indicated severe cognitive impairments. Section GG (Functional Abilities and Goals) revealed that Review of R60's physician order dated 9/27/2022 revealed, an order that read, Podiatry /dental/ophthalmic care as needed. Observations on 9/16/2025 at 10:00 am and at 11:00 am revealed R60 lying in bed in a fetal position. R60's fingernails and toenails were extremely long, jagged, untrimmed and dirty with a brown substance under the nails and around the cuticles During an observation and interview on 9/16/2025 at 1:00 pm with Certified Nursing Assistant (CNA) GG and Wound Care Nurse Licensed Practical Nurse (LPN) GG, both confirmed that R60's nails were long, dirty, and required trimming. Both staff described the dark substances and discoloration as dirt. Review of R60's ADL care plan dated 9/27/2022 revealed a focus area intervention for nail care services. The intervention. stated shampoo/nail care as needed. Review of the Podiatrist onsite scheduled visit to the facility revealed the following onsite dates as 6/4/2025 and 7/10/2025 however there was no evidence that R60 received nail care services during on these visits. During an interview with the Director of Health Services (DHS) on 9/17/2025 at 4:09 am, the DHS confirmed that the podiatrist was in the building on the following dates. The DHS confirmed that R60 was not seen by the podiatrist by error. She reported that R60's nails should have been addressed during bathing. She reported that her expectations are for the certified nursing assistant to report any nail care needs. 2. Review of R31's Annual MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed, R31 was dependent for toileting and moderate assistance for personal hygiene and lower body dressing, shower/bathe. Review of the care plan for R31, dated 8/8/2025 revealed that R31 had a potential for ADL decline related to a history of cerebral infarction. Interventions included but not limited to: check nails, ensure they are clean, and provide assistance when needed. An observation on 9/16/2025 at 9:38 am revealed that R31 had long, brown finger nails. An observation and interview on 9/17/2025 at 8:06 am revealed, R31 had long, brown fingernails. R31 revealed that she did not want her nails that long. An observation and interview on 9/17/2025 at 1:50 pm with Certified Nursing Assistant (CNA) EE in room [ROOM NUMBER] revealed, she was trimming nails for the resident in bed B. She revealed that she just trimmed R31 nails (after the discovery). She further revealed that she was just given nail clippers and a list of residents that fingernails needed to be cut. The list included the two residents (R31 and her roommate). She denied knowing the policy around cutting fingernails nor had she received training from the facility and that the CNA's do not usually cut nails. CNA EE revealed that they would tell the nurse instead. CNA EE revealed that it had been months since the residents' nails were cut. 3. A review of R28's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed that R28 had a BIMS score of 11 which indicated moderate cognitive impairment. Section I (Active Diagnoses) revealed diagnoses that included but not limited to Alzheimer's disease, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. Section GG (Functional Abilities) revealed that the resident required moderate assistance with personal hygiene and upper body dressing and maximal assistance with showering/bathing, and lower body dressing. A review of the care plan for R28 dated 8/14/2025 revealed that R28 had a potential for ADL decline related to hip fracture. Interventions included but not limited to: setting up resident for ADLs. An observation and interview on 9/16/2025 at 9:50 am with R28 revealed that the resident had long fingernails. R28 revealed that she would like to have them cut. She revealed that the podiatrist cuts toenails, but no one cuts fingernails. She revealed that she had an ingrown toenail that had not been addressed. An observation and interview on 9/17/2025 at 9:19 am revealed R28 fingernails remained long and had not been addressed. R28 revealed that someone worked on her toenails last night. An interview and observation with the DHS on 9/17/2025 at 2:10 pm revealed R28's fingernails that were observed to be long and dirty nails was not acceptable. The DHS further revealed that residents should be receiving routine nail care on bath days and that all CNAs received education on nail care and trimming. The DHS revealed that the expectation was that CNA's and nurses will follow the care plan. An interview with Clinical Competency Coordinator (CCC) on 9/18/2025 at 11:16 am revealed that CNA's receive education at hire, annual competency, and monthly through a computer education program. The education includes nail care training, and it was a part of the CNA's school training program. The CCC expectation was that CNA's will provide nail care to residents. 4. A review of the EHR revealed that R41 was admitted to the facility with diagnoses that included but not limited to type 2 diabetes mellitus, generalized muscle weakness, and cognitive communication deficit. Review of podiatry visits documents revealed R41 was seen on 7/14/2024, 9/19/2024, 11/27/2024, and 4/24/2025. There was no documentation of any additional visits. A review of the significant change MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of 11, which indicated moderate cognitive impairment, Section GG (Functional Abilities and Goals) revealed that the resident was dependent on staff for personal hygiene care. Observation on 9/16/2025 at 10:49 am revealed R41's toenails were long, thick and yellow with a yellowish/brownish substance underneath them. Observation and interview with R41 on 9/17/2025 at 9:10 am revealed the resident's toenails long, thick, and yellow with a yellowish/brownish substance underneath them and not trimmed. R41 was asked about his toenails but did not appear to understand the question as he was not providing an answer to address the question. Observation of R41 on 9/18/2025 at 9:30 am revealed, R41 was lying in bed with his feet uncovered and his toenails were noted to be long, thick, yellow with a yellowish/brownish substance underneath and not trimmed. Observation and interview on 9/17/2025 at 2:10 pm with the DHS confirmed R41's toenails were long and dirty with a yellowish/brownish substance underneath them. She revealed that resident's nails should be trimmed by a CNA if they were not diabetic, otherwise they must be trimmed by a nurse. She revealed residents' nails should be cleaned and trimmed during bath or as needed. The DHS revealed that staff should document each time nail care was provided and also document refusals. She confirmed that all resident's should have ADL care plan as that was how staff know what interventions need to be implemented. DHS stated she was going to look for the resident's ADL care plan and get back to surveyor. When asked who completed care plans, DHS revealed that prior to coming to this facility she completed care plans so she has been updating them. Later when interviewed she confirmed that ADL care plans were present but older plans did not address specific ADL needs such as nail care and bathing but current plans do. Upon entering R41's room and observing the toenails, DHS stated that R41 may be receiving podiatry care for toenail trimming. DHS also confirmed that the resident's toenails were very long and discolored and should be receiving care to address the toenails. She confirmed that the care plan for R41 was not being implemented as there had been a failure to address nail care that was a part of personal hygiene. Interview with the DHS on 9/18/2025 at 10:10 am revealed that nail care was one of the competencies on the nursing staff orientation, so staff was aware that nail care is a required care area for each resident. The DHS provided a copy of the CNA's complete orientation check list and Partner Orientation Checklist which listed nail care. The DHS revealed, it is her expectation that nail care, cleaning of the nails and trimming if residents were not receiving podiatry care needs to be done on bath days or upon request from residents. 5. A review of the EMR revealed that R36 was admitted to the facility with diagnoses that included but not limited to major depressive disorder, recurrent, severe with psychotic symptoms and unspecified dementia, unspecified severity, with other behavioral disturbance, and generalized weakness. A review of the quarterly MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for personal hygiene care. A review of the care plan dated 9/4/2025 revealed an intervention that included but not limited to staff to set up resident for ADLs. Observation and interview on 9/16/2025 at 9:40 am with R36 revealed his fingernails were long with a brown and yellow substance underneath them. R36 revealed his fingernails needed to be trimmed and cleaned. Observation and interview on 9/17/2025 at 1:00 pm with R36 revealed his fingernails were long with a brown and yellow substance underneath them. R36 revealed he would like his fingernails to be trimmed and cleaned. Observation and interview on 9/17/2025 at 2:10 pm with the DHS confirmed the resident's nails were long and dirty with a yellow-brown substance. The DHS confirmed that all residents have an activity of daily living (ADL) care plan, as that was how staff know what interventions need to be implemented. She confirmed that the care plan for R36 was not being implemented by failure to address personal hygiene including nail care. Interview on 9/17/2025 at 2:15 pm with CNA BB revealed that he cleans nails when giving a resident a bath. CNA BB revealed, he would only trim a resident's nails if they were not diabetic and if resident allowed him to do so. He stated he doesn't normally care for R36 but that he was going to give the resident a bath and provide nail care since the resident's nails were soiled and long. Cross Reference F656

Based on observations, interviews, record review, and review of facility's policy titled Enteral Nutrition (Tube Feedings), the facility failed to follow physician orders and professional standards of care for one of four residents (R) R31 that received enteral feedings. This deficient practice had the potential to place R31 at increased risk of complications and adverse clinical outcomes. Findings include:Review of the facility policy titled Enteral Nutrition (Tube Feedings), with a review date of 9/12/2024 revealed: 2. The Physician will write orders prescribing formula, rate, route of administration, and flush orders for individual patient/residents. Review of the Annual Minimal Data Set (MDS) for R31, dated 8/8/2025 revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section I (Active Diagnoses) diagnoses included, but not limited to: type 2 diabetes, cerebral infarction, congenital stenosis and stricture of esophagus, gastrostomy tube, chronic nausea and vomiting, and dysphagia.Review of the care plan for R31, dated 8/8/2025 revealed, R31 needed tube feedings related to her diagnosis of congenital stenosis and stricture of esophagus. The goal was to maintain nutritional stability via enteral tube feeding. Interventions included: flush as ordered, follow enhanced barrier precautions, treatment as ordered by medical doctor, and tube feedings as ordered.Review of the Physician Orders for R31 dated 8/6/2024 revealed, gastrostomy tube (G-tube) residuals are checked before feeding and if residual is greater than 100 milliliters (ML) then hold the feeding and call the medical doctor for further orders every shift; check placement prior to med administration/flushes every shift; and formula [name] via G-tube bolus 237ML after meals and bedtime (four times a day.) Special instruction orders included: flush with 200ML water after each feeding, after every meal and at bedtime. Observation of R31 enteral feeding process on 9/17/2025 at 8:06 am revealed, Licensed Practical Nurse (LPN) CC dressed out in gown and gloves. LPN CC did not check placement or residual prior to connecting the large syringe used for bolus administration of formula. LPN CC flushed with cold water poured into a drinking cup from her medication cart water pitcher. She poured the water into the large syringe up to the 60ML measurement line on the side of the syringe and then poured the remaining water from the cup up to 50ML measurement line. LPN CC disconnected the syringe. R31 immediately vomited but declined nausea medication offered by the nurse.Interview with LPN CC on 9/18/2025 at 8:30 am confirmed, LPN CC did not check residuals or placement and did not measure the water. She also confirmed that she did not flush with 200ML of water as ordered by the physician. She states she has received an in-service on tube feedings. Interview with Assisted Director of Health Services (ADHS) on 9/18/2025 at 10:09 am revealed, the enteral tube feeding process includes the nurse gathering supplies, follows enhanced barrier precautions and sets up their supplies in a clean manner. The nurse checks residuals, administers the formula and flush per the physician orders.Interview with the Director of Health Services (DHS) on 9/18/2025 at 10:39 am revealed, the expectation is that nurses' follow policy. They are expected to complete the task as ordered by the physician. Nurses receive education and annual competency for enteral tube feedings.

Based on observations, staff interviews, record review and facility policy titled, Oxygen Administration, the facility failed to administer oxygen (O2) at the correct ordered setting for one of 15 residents (R) (R28) receiving O2 therapy. This deficient practice had the potential to place R28 at increased risk of respiratory complications and adverse clinical outcomes.Findings include:Review of the facility's policy titled Oxygen Administration revised 8/23/2023 revealed: It is the policy of the facility to provide oxygen safely and accurately to appropriate patients/residents. Procedure included: 4. Regulate liter flow to ordered/desired rate.Review of the Quarterly Minimum Data Set (MDS) for R28, dated 8/14/2025 revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section I (Active Diagnoses) diagnoses including, but not limited to: Alzheimer's Disease, chronic obstructive pulmonary disease (COPD), dysphagia, and muscle weakness.Review of the care plan dated 8/14/2025 revealed that R28 uses oxygen related to her diagnosis of COPD. The goal was to maximize oxygen saturation levels by administering oxygen as ordered by the physician. Review of the Physician Orders for R28 dated 7/26/2024 revealed, oxygen at two liters (LPM-liters per minute) via nasal cannula (NC) continuous every shift.Observation on 9/16/2025 at 9:50 am revealed, R28 was wearing her oxygen via NC and the O2 concentrator (machine that produces oxygen) was running at the setting of 2.5 LPM.Observation on 9/17/2025 at 9:19 am revealed, R28 was wearing her oxygen via NC and the O2 concentrator was running at the setting of 2.5 LPM.Interview with Licensed Practical Nurse (LPN) CC on 9/17/2025 at 10:54 am confirmed, the O2 concentrator setting was at 2.5LPM and should be set at 2LPM. She states that she is to check the O2 concentrator settings and make sure residents are on the setting that is ordered by the physician. Interview with the Assistant Director of Health Services (ADHS) on 9/18/2025 at 10:09 am confirmed, nurses should check the O2 concentrator settings every time they enter a room where O2 is in use.Interview with the Director of Health Services (DHS) on 9/18/2025 at 10:39 am confirmed, her expectation is for the nurses to observe the O2 settings on the concentrator and verify the settings match the physician's order.

Based on observation, staff interviews, and review of the facility's policy titled, Medication Storage in the Healthcare Centers, the facility failed to ensure a medication cart was locked or under direct supervision of authorized staff in an area where residents could access medications for one of three medication carts located on Unit One. In addition, the facility failed to ensure that one of three medication carts and one of one treatment carts located on Unit One were maintained in a sanitary manner. This deficient practice has the potential to place residents at risk of unauthorized and unsafe access to medications and risk of receiving medications from an unsanitary environment.Findings include: Review of the facility's policy titled Medication Storage in Healthcare Centers revised 6/20/2025 revealed, medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, Certified Medications, and pharmacy personnel. In addition, Procedure revealed, number 3: nursing staff and medication aids who administer medications are responsible for the cleaning and organization of medication carts and storage areas.Observation on 9/17/2025 at 7:01 am of Licensed Practical Nurse (LPN) CC revealed, medication cart on Unit One was left unlocked when LPN CC entered a resident room to administer medication. LPN CC was observed standing behind the curtain out of eyesight of the medication cart.Observation on 9/17/2025 at 7:23am and again at 7:58 am of LPN CC leaving the medication cart on Unit One unlocked and out of eyesight while in a resident's room administering medications during the routine med pass procedure. Interview with LPN CC on 9/17/2025 at 10:54 am confirmed, she left the medication cart unlocked and out of eyesight all three times during the medication pass observation. LPN CC confirmed there is a potential that a resident could enter the medication cart. She states the policy is that medication carts should remain locked at all times when out of eyesight of the nurse.Observation with concurrent interview on 9/17/2025 at 10:54 am with LPN CC revealed that the medication cart located on Unit One had dirt and a sticky substance on the bottom of the last drawer. LPN CC states the Unit Manager manages the medication carts and confirmed the medication cart was not clean.Observation and concurrent interview on 9/17/2025 at 10:28 am with the Wound Care Nurse (WCN) revealed a wet substance in the bottom of the third draw of the treatment cart. There were sterile dressings that were wet. The WCN states the wound cleanser spilled but did not observe wound cleanser in the cart. She confirmed that the cart should be clean and dry. The WCN states she was going to dispose of all the contaminated items.Interview with the Assistant Director of Health Services (ADHS) on 9/18/2025 at 10:09 am revealed that nurses are responsible for keeping the medication carts clean.Interview with the Pharmacy Consultant on 9/22/2025 at 9:00am revealed that she trains the nurses to keep the medication carts locked and within eyesight if the cart is unlocked.

Based on observations, staff interviews, and the facility's policy, Infection Control-Dining Services, the facility failed to ensure that staff used proper hand sanitation methods during one of two meal observations. This deficient practice had the potential to affect the 10 residents dining and contribute to the potential spread of infectious disease.Findings include:Review of the facility policy titled Infection Control-Dining Services with a review date of 11/30/2023 revealed, 2. All partners will wash their hands just before they start to work in the kitchen and when they have used their hand in an unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes or handling patients/residents.Observation on 9/17/2025 at 12:31 pm revealed, Certified Nursing Assistant (CNA) EE passing out food trays to 10 residents in the dining hall area. She passed out food trays without sanitizing her hands. She then assisted one resident by adjusting her positioning. CNA EE touched the resident's arms, shoulders, and her seat. CNA EE did not sanitize her hands before passing more additional food trays. Interview on 9/17/2025 at 12:35 with CNA EE confirmed, she did not sanitize her hands before passing food trays, between passing food trays, or after touching the resident with positioning assistance. CNA EE stated she is supposed to sanitize her hands before and between passing food trays and anytime she touches a resident.Interview on 9/18/2025 at 9:13 am with the Administrator revealed, all staff should be sanitizing their hands between passing food trays. They receive training on infection control at least monthly.Interview on 9/18/2025 at 2:05 pm with the Infection Preventionist revealed, it is her expectation that staff sanitize the hands of residents and their own hands before food trays are passed and between passing each food tray. She stated staff receive training monthly on infection control practices.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for one of one resident (Resident (R) R1) reviewed for accidents out of a total sample of 3. This failure caused actual harm on 06/26/25 when Certified Nursing Assistant (CNA) AA served R1 a hot soup on a Styrofoam bowl and left the room with R1 attempting to pull the bowl closer when the bowl fell on R1's sternum and R1 sustained a second degree burn on her chest and was hospitalized .Findings include:Review of R 1's admission Record, located in the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to muscle weakness (generalized), unspecified abnormalities of gait and mobility, other reduced mobility, Muscle weakness (generalized), and difficulty in walking.Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/2025 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. It was recorded that R1 under section GG-under Eating /Oral hygiene/ Upper body dressing requires Setup or clean-up assistance,Review of R1 Progress Note dated 6/26/2025 at 5:58 pm indicated Resident requested soup for dinner. CNA fixed her some chicken soup. Soup was placed on the bedside table by CNA which advised resident soup was hot. NursingFurther review of R1's Progress Note dated 6/26/2025 at 06:00 pm [Recorded as Late Entry on 6/27/2025 11:23 am] revealed CNA heard resident yell for help. When CNA entered the room, the soup bowl noted to be on floor. The resident states she pulled soup to her and started feeding herself. The soup fell off bedside table on to resident sternum/Abd area. NP notified new order given. Nursing Review of Progress Note dated 6/26/2025 at 6:35 pm revealed Emergency Medical Service (EMS) here to take the resident to the emergency room (ER). Review of Facility Wound Summary Report for R1 indicated a burn on 6/26/2025 at 6 pm located in the mid-chest area with an initial size of 5x5 centimeters (cm). Review of R1's entire clinical record failed to indicate an assessment to determine the resident's ability to handle hot liquids had been completed for the resident prior to 6/26/2025.Review of hospital record revealed R1 was admitted to the local hospital on 6/26/2025 due to second degree burn after spilling hot soup while she was drinking it.During an observation and interview on 7/2/2025 at 1:05 pm with R1, she revealed that she requested soup from Certified Nursing Assistant (CNA), CNA AA because she did not like what was on the dinner tray. R1 stated that CNA AA brought the soup in a Styrofoam bowl and sat the soup on a bedside table across the bed. R1 stated that she tried to move the soup, and the bowl fell on her chest and hands. R1 stated that she pushed the bowl off her chest to the floor and started screaming for help. She stated that the soup was very hot. R1 further stated that CNA AA responded within five minutes and reported that she could not do anything because she has to call the nurse, which she did.During an interview on 7/2/2025 at 1:28 pm with Licensed Practical Nurse (LPN) CC she revealed that she was on call on the night of the incident. She stated that she received a call from LPN BB that R1 sustained a burn. She stated that she notified the Administrator and informed her of the burn incident for R1.During an interview on 7/2/2025 at 2:48 pm LPN BB revealed that she was at the nursing station when the CNA AA informed her that R1's soup fell on her chest. She stated that she went to R1's room and R1 informed her that the soup was on her bedside table and as she tried to pull the soup closer to her the bowl fell and landed on her chest. LPN BB stated that she notified the physician and LPN CC who was the nurse on call, and the family was notified. She stated that the physician gave her orders for Silvadene and later an order to send R1 to the hospitalDuring a telephone interview on 7/2/2025 at 7:35 pm with CNA AA she revealed that she served R1 her dinner tray and she did not like what was on the tray. She stated that R1 requested soup. She stated that R1 was in bed Head of the Bed (HOB) elevated at 45-degree angle, and legs slightly elevated. She stated that she warmed the soup for a minute in a Styrofoam bowl in the microwave. CNA AA stated that the soup was not steaming because she held the bowl in her hand. It was further reported that she gave R1 some crackers per R1 request to soak them in the soup and placed the bowl on the bedside table with a towel across R1's chest. CNA AA stated that she then went to another resident's room across from R1's room to assist that resident. While in the other resident's room CNA AA reported that she heard R1 calling her name. Upon returning to R1's room CNA AA reported observing the bowl was on the floor and the towel was no longer on the R1's chest. She stated that R1 told her that she was burned, and that is when she called the nurse to the room to evaluate R1. During an interview on 7/3/2025 at 1:41 pm with Minimum Data Status (MDS) Coordinator who revealed the Interdisciplinary Team (IDT) discussed to ensure that all residents are assessed to handle utensils, liquids, and bowls. However, she did not specify if residents were assessed for hot liquidsDuring an interview on 7/3/2025 at 1:59 pm with the Dietary Manager revealed that she does not know if residents were assessed for hot liquids. She stated that assessment is completed as a team (IDT). The Dietary Manager stated that she cannot specifically say there was an in-service on hot liquids prior to the burn incident on 6/26/2025.During an interview on 7/3/2025 at 2:33 pm with the Administrator, who revealed that she expected staff to check food temperature before serving, and if the food needs to be reheated to follow the in-service procedure on 6/27/2025 in service provided. During an interview on 7/3/2025 at 2:40 pm with Director of Nursing (DON) regarding resident assessment. She revealed that residents are assessed upon admission by rehabilitation services and determination and recommendation is communicated to the nursing staff, and if a resident is declining that a referral is made. She stated that all residents are assessed for safety overall and ability.The facility implemented the following:1. SBAR (situation, background, appearance, review and notify) form was completed on 6/26/2025 indicating a burn to the lower part of sternum and top of abdomen.2. Skin assessment completed on 6/26/2025 with treatments identified as nutrition or hydration intervention, pressure-reducing device for chair, and pressure-reducing device for bed.3. Order received for silver sulfadiazine cream, as needed, for burn.4. Transferred to local hospital on 6/26/2025 for evaluation of burn.5. Care plan intervention updated on 6/27/2025 for Occupational Therapy (OT) to evaluate and treat. In addition, a care plan was developed related to the burn to the chest.6. Inservice on 6/27/2025 titled, Food Temperature safety and follow diet. Detailing that when food items should be logged when microwaved. Further stating that once heated to 165 degrees Fahrenheit the food must then be cooled to a reasonable eatable temperature for the resident to eat it.

Based on record review and staff interviews the facility failed to ensure that staff designated as the Dietary Manager was a Certified Dietary/Food Service Manager or had a similar food service management certification or degree. There were 51 of 53 Residents receiving an oral diet. Findings include: Review of the job description for Dietary Manager (DM) (created September 2008 and modified January 2016 revealed Minimum Licensure/Certification Required by Law: must be certified in an accredited course in Dietetic training approved by the Association of Nutrition and Foodservice Professionals and/or the Academy of Nutrition and Dietetics. Review of the new hire checklist revealed the start date of the DM as 5/17/2021. During an interview with the DM on 6/7/2021 at 11:13 a.m., revealed that she began working at the facility as DM in May 2021. The DM revealed that she is neither Serve Safe certified nor was she a Certified Dietary Manager (CDM). The DM explained she would be beginning her certification classes later this month. During an interview with the Administrator on 6/10/2021 at 3:32 p.m., revealed that the Administrator revealed that she was aware the current DM was not in compliance with the current regulations related to the requirements for the position of DM.

Based on observation, staff interviews, and review of facility policy titled, Glucometer Cleaning and Disinfecting the facility failed to provide effective infection control practices related to medication administration for one of seven residents (R#34) that received fingerstick blood sugar checks and for one of one resident (R#37) that received nasal spray. Findings include: 1. Review of the manufacturer's instructions for [MEDICATION(S)] nasal spray revealed 7. Wipe the nasal applicator with a clean tissue and replace the dust cap and the safety clip. Record review revealed Resident R#37 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration for R#37 with LPN AA on 6/9/2021 at 9:03 a.m. revealed that LPN AA was observed to remove the cap from the resident's [MEDICATION(S)] spray and administered one spray in each nostril without cleaning the nasal applicator before or after administration of the medication. During an interview on 6/9/2021 at 9:12 a.m. with LPN AA revealed that she should have cleaned the nasal applicator with a clean tissue prior to administering the medication and after administering the medication. During an interview with the Director of Health Services (DHS) on 6/9/2021 at 9:30 a.m. revealed that she expected the licensed nursing staff to clean nasal applicators prior to administering medication and after administering medication. DHS confirmed that LPN AA should have cleaned the nasal applicator. 2. Review of facility policy titled, Glucometer Cleaning and Disinfecting (revised 4/28/2021) documented 4. Clean and disinfect the meter by using approved Germicidal and Disinfectant wipes. Record review revealed R#34 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of a fingerstick blood sugar check for R#34 on 6/9/2021 at 11:38 a.m. with LPN BB revealed the glucometer (a device to check blood glucose levels) was cleaned with an alcohol prep pad before and after use. (This glucometer was not used for any additional residents). During an interview with LPN BB on 6/9/2021 at 11:41 a.m. revealed she should have cleaned the glucometer with the approved germicidal wipes and not with an alcohol swab. During an interview with Clinical Competency Coordinator (CCC) on 6/10/2021 at 9:28 a.m. the CCC stated it was her expectation for the licensed nursing staff to clean the glucometers with the approved germicidal wipes that are available on each nursing cart.

Based on interviews, medical record review, and review of the facility policy titled, Care Plans the facility failed to implement interventions for Cardiopulmonary Resuscitation (CPR) for two of four residents (R#1 and R#3). On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Nurse Consultant and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:22 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: 1. Record review revealed that R#1 experienced a change in condition on [DATE]. Staff stated R#1 had a change in her breathing at around 3:00 a.m. and then again around 5:00 a.m. when the Certified Nursing Assistant (CNA) reported to the nurse a decline in condition. Licensed Practical Nurse BB (LPN BB), assessed and obtained orders for a chest x-ray. The resident's symptoms included gurgling, labored breathing and fixated eyes with vital signs of ,[DATE], Blood Pressure (BP), pulse 55, and temperature 96.1. The nurse left the room to call Emergency Medical Services (EMS) and CNA AA remained in the room. Upon EMS arrival CNA AA exited the room to redirect EMS to the correct door and let them in the facility. When CNA AA returned to the resident room the resident was non-responsive, EMS placed EKG leads on the resident and instructed the nurse to call a nurse supervisor to pronounce, she was asystole (no electrical activity of the heart). Cardiopulmonary Resuscitation (CPR) was not initiated by the facility staff prior to the entrance of EMS even though during an interview with CNA AA she revealed to the surveyor that she witnessed the R#1 take her last breath. CNA AA confirmed that she did not initiate CPR because she thought that EMS would take over, she continued by stating that she felt like they could have saved her. 2. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] progress note that R#3's respirations were uneven and labored; unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. LPN FF stated upon arrival to the facility Hospice RN#2 was informed that R#3 had a full code status in the system. LPN FF stated, Hospice RN#2 showed her a Do Not Resuscitate (DNR) order for R#3. Record review of Visit Note Report dated [DATE] revealed Hospice RN#2 was at bedside when R#3 died , and CPR was not performed. Medical record review reflected R#3 was to be a Full Code. R#3 had a Physician Orders for Life-Sustaining Treatment (POLST) indicating a DNR status; however, the POLST was not signed by R#3's POA or Health Care Agent and a Full Code Status remained in place. LPN FF confirmed that she would have done CPR for R#3 if Hospice RN#2 had not shown her a DNR order. Immediate Jeopardy was identified on [DATE] and determined to existed on [DATE] in the areas of ; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.24 Quality of Life, F678 (S/S: J). A Removal Plan (Credible Allegation of Compliance) was received on [DATE] related to 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including cardiopulmonary resuscitation, Advance Directives and care plans. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and procedures governing when to provide cardiopulmonary resuscitation and what is required for fully implemented Advance Directives. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. Review of the facility policy titled, Care Plans reviewed [DATE] documented the following: It is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) manual and the patient/resident choice. The care plan will contain 4 main components: Problem, Goal, approaches, and Role or accountability. The goal is an expected outcome the patients/residents should achieve by implementing specific interventions. Record review revealed that R#1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of the medical record profile banner revealed that R#1 was a Full Code status and R#1's care plan status was listed as a full code. Record review revealed that R#1 had a care plan in place since [DATE] for Advanced Directives documenting that R#1 was a FULL CODE. The care plan goal documented that R#1 would receive life saving measures through the review period. Approaches were listed as Administer CPR in the event of a [MEDICAL CONDITION]. All staff to be made aware of R#1's wishes. Notify MD and RP of any changes. Review directives with R#1 every quarter or significant change. Record review revealed that R#1 experienced a change in condition on [DATE] and that CPR was not provided. During an interview on [DATE] at 10:08 a.m. with the Director of Health Services (DHS), she stated her expectations are that staff would follow the physician orders and care plans. She confirmed R#1 was a full code status. 2. Record review revealed that R#3 had a care plan in place since [DATE] for Advanced Directives documenting that R#3 was a FULL CODE with interventions that included, Administer CPR in the event of [MEDICAL CONDITION] and all staff to be made aware of resident's wishes. Notify MD and RP of any changes. Review directives with R#3's family every quarter or significant change. Review of R#3's medical record reflected that R#3 was to be a Full Code. R#3 had a Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] indicating a DNR status; however, the POLST was not signed by R#3's POA or Health Care Agent and a Full Code Status was in place. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] at 7:30 a.m. on a progress note that R#3 respirations were uneven and labored with shortness of breath (SOB) noted. R#3 was unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. During an interview on [DATE] at 1:00 p.m. with LPN FF confirmed that she would have initiated CPR on R#3 if Hospice RN#2 had not shown her a DNR order. During an interview on [DATE] at 9:30 a.m. with LPN CC stated that she is responsible for reviewing and revising care plans at the time MDS assessments are completed. LPN CC stated advance directive care plans are completed on admission as a part of baseline care plans. LPN CC stated if a resident's code status changed after admission, nurses are responsible for writing the order and the care plan revision to reflect any changes. During an Interview on [DATE] at 2:10 p.m. with Social Services (SS) stated when residents are admitted to the facility, POLST are completed by the Admission Director (AD) which is included with the admission packet. SSD stated, if for any reason the resident wanted to change or revoke their advance directives after admission, she would follow up with getting the appropriate signatures. SS stated once a POLST is signed, she would give it to the nurses to complete the order and update the care plans. During an interview on [DATE] at 11:15 a.m. with the Administrator, she stated her expectations of staff are to make sure care plans reflect physician orders and if a resident has orders for a full code then staff should initiate CPR; if not clear or there is not DNR in place, staff should automatically initiate CPR. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], Resident #1 was a full code. R #1 stopped breathing, but the facility staff nor the EMTs performed CPR. The facility failed to follow the care planned interventions for R #1. 2.On [DATE], Resident #3 was reflected as full code in the medical record. R #3 had a POLST indicating a DNR status; however, the POLST was not fully executed as the Responsible Party was not R #3's POA or Health Care Agent. R #3 stopped breathing, but no CPR was performed. The facility failed to follow the care planned interventions for R #3. 3.On [DATE], the MDS Coordinator completed 100% care plan audit on 52 of 52 in-house residents and 4 of 4 hospitalized residents to verify care plan matched the identified code status. Per the audit, 56 of 56 residents' care plan matched the code status that was noted in the physician orders and on the face sheet. 4.On [DATE], the DHS, ADHS, and Unit Manager started in-service for licensed nurses on review how to identify the resident's code status in the EMR and where to find, follow, and update the advanced directive care plan. 93.75% of the licensed nurses, which included 4 of 4 full-time RNs, 1 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator received the information. In-service was completed on [DATE]. 5. Any licensed nurse not receiving the care plan education due to scheduled time off or FMLA staff will be in-serviced prior to next scheduled shift. Education was added to new partner orientation. 6. During admission, readmission, significant change, per resident/authorized person's request, and quarterly care plan meetings, the Social Worker, DHS/ADHS, Unit Managers, and Case Mix (MDS) coordinator will review advanced directive care plan for any changes to the resident's advanced directive. If any changes to the resident's advanced directive, the MDS coordinator will update the advanced directive care plan after all DNR/POLST form are validated and received. 7.All corrective actions were completed on [DATE]. 8.The immediacy of the IJ was removed on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review revealed that on [DATE], Resident #1 was a full code. R #1 stopped breathing, but the facility staff nor the EMTs performed CPR. The facility failed to follow the care planned interventions for R #1. 2. Record review revealed that on [DATE], Resident #3 was reflected as full code in the medical record. R #3 had a POLST indicating a DNR status; however, the POLST was not fully executed as the Responsible Party was not R #3's POA or Health Care Agent. R #3 stopped breathing, but no CPR was performed. The facility failed to follow the care planned interventions for R #3. 3. Record review revealed on [DATE], the MDS Coordinator completed 100% care plan audit on 52 of 52 in-house residents and 4 of 4 hospitalized residents to verify care plan matched the identified code status. Per the audit, 56 of 56 residents' care plan matched the code status that was noted in the physician orders and on the face sheet. Interview on [DATE] with LPN CC MDS Coordinator at 4:00 p.m. confirmed that she was completed a 100% care plan audit was completed on 52 of 52 in-house residents and 4 of 4 hospitalized residents to verify care plan matched the identified code status. She reported 56 of 56 residents' care plan matched the code status that was noted in the physician orders and on the face sheet. Interviews conducted with 3 of 4 residents with a BIMS score 10 or higher to verify their code status preference: On [DATE] at 5:55 p.m. interview with R#12 stated staff spoke with her related to code status. R#12 stated she is a DNR by her own choice; Record review of Advance Directive and Code Status Report dated [DATE] revealed R#12 DNR status; Record review of Resident Progress Note dated [DATE] revealed staff discussed code status with R#12 and she wishes to remain a DNR. Review of Care plan, Physician order, and face sheet revealed they matched code status. On [DATE] at 6:00 p.m. interview with R#10 stated staff spoke with related to code status. R#10 stated he changed to a full code; Record review of Advance Directive and Code Status Report dated [DATE] revealed R#10 DNR status; 3.Record review of Resident Progress Note dated [DATE] revealed staff discussed code status with R#10 and his wishes to change code status to full code. Responsible party was made aware of decision. Review of Care plan, Physician order, and face sheet revealed they were updated and matched code status. On [DATE] at 6:10 p.m. interview with R#14stated staff spoke with related to code status. R#14 stated he did not want CPR. Record review of Advance Directive and Code Status Report dated [DATE] revealed R#14 DNR status; Record review of Resident Progress Note dated [DATE] revealed staff discussed code status with R#14 and his wishes to remain a DNR. Review of Care plan, Physician order, and face sheet revealed they matched code status. 4. Record review revealed on [DATE], the DHS, ADHS, and Unit Manager started in-service for licensed nurses on review how to identify the resident's code status in the EMR and where to find, follow, and update the advanced directive care plan. 93.75% of the licensed nurses, which included 4 of 4 full-time RNs, 1 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator received the information. In-service was completed on [DATE]. Interviews conducted on the following dates and times for licensed staff from every shift: on [DATE] at 10:37 a.m., with Wound Care; [DATE] at 1:00 p.m., with Unit Manager#2; [DATE] at 1:50 p.m., with LPN EE; [DATE] at 2:20 p.m., with LPN Unit Manager#1; [DATE] at 4:51 p.m., with LPN VV; [DATE] at 4:58 p.m., with LPN XX. Licensed staff were able to recognize when a resident needed Cardiopulmonary Resuscitation, by the profile sheets banner with code status, the physician's orders and the care plan. If a resident's wishes are a full code status CPR would be initiated by them, EMS would be notified and CPR would continue by staff until the arrival of EMS, EMS would take over and transport to the hospital. Interviews were conducted on the following dates and times for six licensed staff from every shift: on [DATE] at 10:37 a.m., with Wound Care; [DATE] at 1:00 p.m., with Unit Manager#2; [DATE] at 1:50 p.m., with LPN EE; [DATE] at 2:20 p.m., with LPN Unit Manager#1; [DATE] at 4:51 p.m., with LPN VV; [DATE] at 4:58 p.m., with LPN XX Licensed staff interviewed were able to recognize when a resident needed Cardiopulmonary Resuscitation, by the profile sheets banner with code status, the physician's orders and the care plan. If a resident's wishes are a full code status CPR would be initiated by them, EMS would be notified and CPR would continue by staff until the arrival of EMS, EMS would take over and transport to the hospital. 5. On [DATE] at 4:58 p.m. a phone interview with 7 pm- 7 am LPN VV stated she is not full time with PH Ocilla and works with Agency. LPN VV' stated she was in-serviced last week and every time she switch facilities. On [DATE] at 1:00 p.m. a phone interview with 7 pm- 7 am LPN FF stated she has been out on maternity leave and that staff called her and in-serviced her over care plans and cpr/advanced directives. On [DATE] at 4:58p.m. a phone interview with 7 pm- 7 am LPN VV stated she is not full time with PH Ocilla and works with Agency. LPN VV' stated she had not been educated on care plans at PH Ocilla prior to last week's in-service however, every time she switch facilities she receives in-services. 6. Interview with R#10 on [DATE] at 6:00 p.m. revealed that staff spoke with him related to his code status preference. R#10 stated that he told staff he wanted to change his code status from a DNR to a Full code status. Record review revealed that there were not any newly admitted residents. Record review of Resident Progress Note dated [DATE] revealed staff discussed code status with R#10 and his wishes to change code status to full code and the Responsible party was informed. Record Review of R#10's Care plan, Physician order, and face sheet revealed they were updated and matched code status. Interview on [DATE] with LPN CC MDS Coordinator at 4:00 p.m. stated she was educated by DHS on updating care plans to reflect code status change. She confirmed that if any changes to the resident's advanced directive, she will update the advanced directive care plan after all DNR/POLST form are validated and received. 7. All corrective actions were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE].

Based on record reviews, staff interviews, and review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), one-person the facility failed to provide CPR for two of four residents (R#1, R#3), failed to have Physician order [REDACTED].#3's Healthcare Agent for one of four residents (R#3), and the facility failed to ensure that two of 19 licensed nurses maintained a current CPR certification. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Nurse Consultant and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:22 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: 1. Record review revealed that R#1 experienced a change in condition on [DATE]. Staff stated R#1 had a change in her breathing at around 3:00 a.m. and then again around 5:00 a.m. when the Certified Nursing Assistant (CNA) reported to the nurse a decline in condition. Licensed Practical Nurse BB (LPN BB), assessed and obtained orders for a chest x-ray. The resident's symptoms included gurgling, labored breathing and fixated eyes with vital signs of ,[DATE], Blood Pressure (BP), pulse 55, and temperature 96.1. The nurse left the room to call Emergency Medical Services (EMS) and CNA AA remained in the room. Upon EMS arrival CNA AA exited the room to redirect EMS to the correct door and let them in the facility. When CNA AA returned to the resident room the resident was non-responsive, EMS placed EKG leads on the resident and instructed the nurse to call a nurse supervisor to pronounce, she was asystole (no electrical activity of the heart). Cardiopulmonary Resuscitation (CPR) was not initiated by the facility staff prior to the entrance of EMS even though during an interview with CNA AA she revealed to the surveyor that she witnessed the R#1 take her last breath. CNA AA confirmed that she did not initiate CPR because she thought that EMS would take over, she continued by stating that she felt like they could have saved her. 2. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] progress note that R#3's respirations were uneven and labored; unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. LPN FF stated upon arrival to the facility Hospice RN#2 was informed that R#3 had a full code status in the system. LPN FF stated, Hospice RN#2 showed her a Do Not Resuscitate (DNR) order for R#3. Record review of Visit Note Report dated [DATE] revealed Hospice RN#2 was at bedside when R#3 died , and CPR was not performed. Medical record review reflected R#3 was to be a Full Code. R#3 had a Physician order [REDACTED].#3's POA or Health Care Agent and a Full Code Status remained in place. LPN FF confirmed that she would have done CPR for R#3 if Hospice RN#2 had not shown her a DNR order. Immediate Jeopardy was identified on [DATE] and determined to existed on [DATE] in the areas of ; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.24 Quality of Life, F678 (S/S: J). A Removal Plan (Credible Allegation of Compliance) was received on [DATE] related to 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including cardiopulmonary resuscitation, Advance Directives and care plans. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and procedures governing when to provide cardiopulmonary resuscitation and what is required for fully implemented Advance Directives. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: The facility had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. 1. Record review revealed that R#1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of the medical record profile banner revealed that R#1 was a Full Code status and R#1's care plan status was listed as a full code. Record review of the nursing progress notes dated [DATE] at 2:26 a.m. written by LPN BB documented the following: R#1 had several episodes of green bile vomitus. No fever noted. Resident had diarrhea also. Will continue to observe. At 6:33 a.m., LPN BB documented that R#1 had noted wheezing and gurgling. A Chest x-ray was ordered by the Medical Doctor (MD). The documentation continued by describing the resident's skin as warm and dry vital signs are weak and thready, B/P was ,[DATE], P55 (Pulse), T96.1 (temperature). EMS was notified at 5:45. EMS arrived at 6 a.m. Upon arrival it was noted that the skin was warm. An EKG was taken, no activity noted. The Director of Health Services (DHS) was notified at that time. A record review of the EMS Patient Care Report dated [DATE] at 5:38 a.m. documented [MEDICAL CONDITION] prior to EMS arrival, [DATE] at 5:47 a.m. EKG asystole. Patient Description: Patient Dead at scene - No Resuscitation Attempted. EMS was received by LPN BB. Narrative: EMS called to unknown problem at nursing home upon arrival: PT (patient) with no signs of life DOA (Dead On Arrival). No resuscitation attempted asystole in two leads. A record review of the Electrocardiogram (EKG) strip dated [DATE] at 5:56 a.m. revealed no heart rhythm. During a record review of the nursing progress notes dated [DATE] at 6:45 a.m. a Nurse's Note written by the DHS stated that R#1's skin was grey and cold to touch, vital signs absent. Family member notified. Interview on [DATE] at 1:33 p.m. with a Family member of R#1 revealed that she knew the resident was legally a full code. She further stated that she had been contacted by the DHS of the facility and made aware that R#1 had died . During an interview on [DATE] at 4:00 p.m. CNA AA revealed that R#1 had vomited, described as bile, nausea and diarrhea starting at around 10:00 p.m. She continued by stating this was consistent all night. Around 12:30 a.m. R#1 was still vomiting and had diarrhea. Two hours later R#1 still had nausea and vomiting. She had a wet sound, not wheezing but her breathing had changed this was around 2:30 a.m. or 3:00 a.m. CNA AA further stated that R#1's breathing pattern changed again around 5:00 a.m. and the nurse called the ambulance. She further commented that I walked in the room and I guess I saw her take her last breath. We didn't initiate the CPR. I just stood back. I thought the EMT's would do it. During an interview on [DATE] at 5:18 p.m. with LPN BB she revealed that R#1 got sick and had nausea and vomiting, further stated the CNA's kept cleaning her up. At around 5:00 a.m. she checked on R#1 and her vital signs had dropped, EMS was called, and they got to the facility fast. When they got in the room, they wanted to do an Electrocardiogram (EKG) but there was no paper in the machine, by the time they got back she was staring at the ceiling. LPN BB confirmed that CNA BB was with R#1 and did not start CPR, she further stated that R#1 took her last breath as we were entering the room. LPN BB confirmed she was in the room and did not start CPR because EMS had arrived. During an interview on [DATE] at 11:00 a.m. with EMS#1, he revealed when they arrived at the ambulance entrance of the facility they were told by an unknown person inside the facility, to go around the facility to the entrance at the shelter. He stated they loaded their equipment back into the ambulance and went to the stated entrance and proceeded to the resident's room with an unknown staff person. He further stated when they got to the room no facility staff persons were performing CPR on the resident, so we ran a strip meaning an EKG strip and there were no viable vital signs. He confirmed that staff were not performing CPR and continued by stating that unless someone (staff) was actually doing CPR, we would not have initiated it. During an interview on [DATE] at 11:13 a.m. with EMS#2, he revealed the resident had already passed away when they entered the facility. EMS#2 stated there was some confusion about the ambulance entrance and they were told to go around to another entrance. We were escorted back to the resident's room by an unknown facility staff member and another facility staff member was in the room with the resident when we (EMS) arrived. EMS#2 confirmed that the staff person in the room with the resident was not performing CPR, he continued by stating we would do CPR until we were legally told otherwise, if they (facility staff) had been performing CPR we would have pushed them out of the way and continued it, but no one was. We ran an EKG strip on the resident, and she was asystole (no electrical activity of the heart). During an interview on [DATE] at 10:00 a.m. with the DHS, she revealed that R#1 had vomited and had diarrhea several times throughout the night, at around 5:00 a.m. she had a change in her breathing and a Chest X-Ray (CXR) was ordered after LPN BB contacted the physician. She further stated at 5:15 a.m. R#1's vital signs were thready and her Blood Pressure (BP) was ,[DATE]. At 5:35 a.m. her BP had dropped, Emergency Medical Services (EMS) arrived at the facility around 5:55 a.m. The DHS stated that LPN BB would not have started CPR at that time because R#1 was still breathing. She further stated that CNA AA and LPN BB did not start CPR when the R#1 stopped breathing because EMS was already at the facility. During an interview on [DATE] at 2:00 p.m. with LPN YY she revealed that LPN BB came over to her side of the facility and asked for help to gather paperwork to send R#1 to the hospital because her vital signs were really low and she had vomited twice. CNA AA was in the room with the resident while the nurse came over to ask for help. LPN YY confirmed that a code was not called for R#1. During an interview on [DATE] at 10:08 a.m. with the DHS, she stated her expectations of staff would be to follow physician orders [REDACTED].#1 was a full code status. During an interview on [DATE] at 1:13 p.m. with the Administrator, she revealed that she was informed by the DHS of the events surrounding R#1's death. She also recalled that the nurse, LPN BB and CNA AA stated to her that the resident was alive, and 911 was called and in the process of getting EMS in the facility she was no longer breathing. EMS ran strips and told the staff to call someone to pronounce her. She recalled that LPN BB and CNA AA were in the room at the time. The Administrator stated that LPN BB and CNA AA had been in and out of the room during the night with CNA AA reporting to LPN BB the condition of R#1. The Administrator further stated that CNA AA looked out the window of R#1's room and saw EMS, CNA AA then walked to the door to get their attention and told them to go to the back door of the facility. The Administrator revealed at that time R#1 was still alive and was not clinically dead until EMS arrived, she continued to state that it all happened in a matter of minutes while CNA AA remained in the room with R#1 and she was under the impression that when EMS arrived they would take over. The Administrator confirmed that LPN BB was aware of R#1's full code status but CNA AA wouldn't have known, the CNA's would call for help immediately in that situation because typically CNA's do not start CPR. She stated CNA's would call for a licensed nurse and if EMS were in the room they would take over. Administrator confirmed the staff did not initiate CPR, and in a matter of minutes of staff letting EMS inside, R#1 died . 2. Record review revealed that R#3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set ((MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) score 10. Review of R#3's admission packet dated [DATE] revealed: 1. No advance directives listing a durable Power of Attorney (POA) for healthcare or healthcare agent. 2. A form titled DNR dated [DATE] which documented that R#3's Do not resuscitate (DNR) order or Physician order [REDACTED]. 3. A form titled Admission Data dated [DATE] listed R#3 Responsible Party (RP). Review of the medical records for R#3 revealed a physician's orders [REDACTED]. Review of the care plan dated [DATE] revealed R#3 was a full code with interventions that included, administer CPR in the event of [MEDICAL CONDITION] and all staff to be made aware of resident's wishes. Review of a Hospice Visit note report dated [DATE] and completed by Hospice RN #1 documented: R#3 was admitted under Hospice services with primary hospice [DIAGNOSES REDACTED]. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] at 7:30 a.m. on a progress note that R#3's respirations were uneven and labored with shortness of breath noted. R#3 was unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. Hospice RN#2 stated she was on her way. Review of a Hospice Visit Note Report dated [DATE] revealed Hospice RN#2 visited the facility after LPN FF reported R#3 was actively dying. On arrival, Hospice RN#2 met with LPN FF. R#3 was lying in hospital bed, unresponsive to tactile stimulation, arms were flaccid, respirations were shallow and agonal with some periods of apnea noted. R#3's respirations continued to slow and then stopped. Cardiopulmonary Resuscitation (CPR) was not performed. Hospice RN#2 pronounced R#3 at 9:26 a.m. and notified R#3's Responsible Party. Review of the medical record reflected that R#3 was to be a Full Code. R#3 had a Physician order [REDACTED].#3's POA or Health Care Agent and a Full Code Status remained in place. Review of the Guidance for Completing the POLST Form #5 documented If the patient lacks decision making capacity, the POLST form may be signed by an authorized person, which includes, in the following priority: the agent named on the patients durable power of attorney for healthcare or a health care agent named on the patient's advance directive for healthcare, spouse, court-appointed guardian, son or daughter (age 18 or older), parent, brother or sister (age 18 or older). Review of R#3 history's and physical (H&P) from another Nursing Home facility dated [DATE] revealed R#3 was single with no children. During an interview on [DATE] at 10:10 a.m. with Hospice RN#1 revealed she admitted R#3 on hospice services on [DATE]. She reported prior to hospice admission, R#3 was a full code. Hospice RN#1 stated a POLST was completed and R#3's code status changed to a DNR. Hospice RN#1 stated after getting the POLST signed by R#3's Responsible Party and one doctor, she faxed it to the facility on the same day. Hospice RN#1 stated she leaves the admissions papers at the facility in the resident's chart and communicates any order changes verbally with the charge nurse. Hospice RN#1 confirmed Hospice RN#2 was at R#3's bedside when he passed with DNR orders in hand. (that was not signed by R#3's Healthcare Agent or two Physician signatures). During an interview on [DATE] at 10:08 a.m. with Director of Health Services (DHS) revealed if a resident was admitted to hospice and their code status changes, the hospice nurse would verbally communicate this with her. DHS stated that R#3's code status was never changed in his medical records from Full code to DNR because she never received a copy of the POLST indicating R#3 was a DNR. DHS stated she had called Hospice office several times requesting the POLST and was told R#3's Responsible Party would like a few days to review before he signed R#3 up with Hospice. DHS stated staff did not initiate CPR on R#3, who had a full code status in the system because Hospice RN#2 was at bedside with a DNR POLST (that was not signed by R#3's Healthcare Agent). DHS stated her expectations of staff would be to follow physician orders [REDACTED]. During an interview on [DATE] at 1:25 p.m. with the Admission Director (AD) stated the POLST was a legal signed document which included one physician signature and R#3's Responsible Party. AD stated that is how they have always done it. AD stated that R#3 did not have any children and that the Responsible Party admitted R#3 to the facility because R#3 was not able to sign is own admission paper because he was too out of it. AD confirmed that she was aware R#3's Responsible Party was not his POA. AD stated R#3's Responsible Party was in the process of getting POA over R#3, but he never got it completed before R#3 died . During an interview on [DATE] at 11:46 a.m. with LPN EE she stated that to find the code status for residents she would look at the patient's profile banner, and the care plan under the physician orders [REDACTED]. LPN EE confirmed that R#3's and R#1's medical record revealed that they all had a Full Code status on their profile banner, the physician's orders [REDACTED]. During an interview on [DATE] at 1:00 p.m. with LPN FF stated she was the Charge nurse assigned to R#3 on [DATE]. LPN FF stated upon arrival to the facility Hospice RN#2 was informed that R#3 had a full code status in the system. LPN FF stated, Hospice RN#2 showed her a Do not resuscitate (DNR) order for R#3. LPN FF stated Hospice RN# 2 was at R#3's bedside when R#3 passed. LPN FF identified where to locate resident's code statuses on face sheet, orders, banner, and the care plan. LPN FF confirmed that she would have initiated CPR on R#3 if Hospice RN#2 had not shown her a DNR order. During an interview on [DATE] at 10:45 a.m. the Administrator stated she did not recall anything significant about R#3 passing that would call for any significant message to be sent to her. Administrator stated R#3 passed on a Sunday and believe she was informed the following day. R#3 had a recent [DIAGNOSES REDACTED]. Administrator stated the facility always kept in contact with R#3's family, the Responsible Party and Aunt because he did not have any children and was single. Administrator stated R#3 Responsible Party was trying to get Power of Attorney (POA). Administrator confirmed R#3's Responsible party was the resident's nephew and that the resident had no children. Administrator stated the POLST uploaded in matrix was signed by R#3's Responsible Party (who was not R#3's Health Care Agent) and a physician on [DATE] with no second physician signature. Further review of the medical records for R#3 revealed the POLST for R#3 that included a second Physician signature was dated [DATE] which was 15 days after R#3's death and that the Responsible party was not R#3's Healthcare Agent. 3. During a review of the licensed nursing staff's CPR certifications, it was revealed that LPN BB, who was no longer employed at the facility, but was in charge of R#1 on [DATE] when R#1 died , had an expired CPR certification. Further review revealed that two additional licensed nurses did not maintain a current CPR certification. During an interview on [DATE] at 11:15 a.m. with the Administrator, she stated that the DHS was responsible for ensuring that licensed staff maintain a current CPR certification The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], Resident #1 was a full code. R #1 stopped breathing, but the facility staff nor the EMTs performed CPR. The facility failed to follow the care planned interventions for R #1. Resident #1 died on [DATE] and is no longer in PH Ocilla. 2. On [DATE], Resident #3 was reflected as full code in the medical record. R #3 had a POLST indicating a DNR status; however, the POLST was not fully executed as the Responsible Party was not R #3's POA or Health Care Agent. R #3 stopped breathing, but no CPR was performed. The facility failed to follow the care planned interventions for R #3. Resident #3 died on [DATE] and is no longer in PH Ocilla. 3. An immediate investigation was initiated by the Administrator and DHS on [DATE] to determine the root cause of Resident #1's incident involving staff interviews, a review of the resident #1's medical record, and EMTs' statement. 4. Resident #3's POLST was not received by the facility's staff until the day his death when the Hospice nurse presented the completed form to the facility name. The nurse did not give a reason for the delay. On [DATE], the facility's Director of Health Services (DHS) contacted the PH Hospice's Director of Health Services to discuss the delay in the receipt of the documentation and the requirements for authorized person on the DNR/POLST forms. 5. An investigation of the root causes were initiated and completed. The root causes focused on nurses' lack of knowledge regarding their responsibilities to residents during cardiac or respiratory arrest even if EMTs are present and the requirements for a valid DNR/POLST form. 6. On [DATE], the DHS started an in-service with licensed nurse that included, but not limited to the location of the crash cart, items included on the crash cart, reviewed code status, reviewed advanced directive care plans, and discussed MD/NP notification for change of status. The in-service was completed by [DATE] with 93.75% of the licensed nurses, which included 4 of 4 full-time RNs, 1 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator. 7. The Social Worker completed 100% advanced directive audit to verify code status of 52 of 52 in-house residents and 4 of 4 hospitalized residents. Per the audit, 17 of 56 residents had a DNR in place. There were 2 issues identified when the DNR forms were reviewed. Resident A's DNR was signed by responsible party that was not the Health Care Agent or POA. The Social Worker contacted the responsible party (niece) to educate her on the requirements of POA/Health care agent/authorized person. She verbalized understanding of Resident A's code status being changed from DNR to full code. Resident B's DNR was signed by his responsible party (aunt) on the DNR without decision making capability form. Resident B is a quadriplegic with a BIMS score of 15. The social worker discussed advanced directive and code status with Resident B. Resident B decided to return to full code status. The Director of Health Services notified the attending physician of both Residents A and B updated code status, obtained a Full code order, updated the advanced directive care plan, and completed a progress note. This review and update started on [DATE] and was completed on [DATE]. 8. On [DATE], the social worker interviewed 4 residents with BIMS greater than 10 with DNR status. 2 of the 4 revoked their DNR status and requested full code status and lifesaving efforts. The Director of Health Services notified the attending physician of both residents, updated the code status, obtained a Full code order, updated the advanced directive care plan, and completed a progress note. The Social Worker notified both residents' responsible party of the residents' request. 9. On [DATE], the Director of Health Services completed a CPR certification review on all current licensed staff. 4 of 4 RNs, 2 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator's CPR certifications. The nurse assigned to Resident #1 on [DATE] is no longer employed at PH Ocilla facility; her CPR certification had expired. Ongoing, Human Resource and Director of Health Services will obtain a current CPR certification card during the hiring process. 10. Nursing in-services included Lippincott procedures for Cardiopulmonary resuscitation (refresher CPR review: reviewed criteria for when to initiate CPR and when not to initiate CPR, i.e. obviously clinically and irretrievably dead and the death was not witnessed with include symptoms of no measurable vital signs, cool to touch, and pupils that are fixed and dilated), change in status with MD/NP notification, and Documentation (thorough, complete, and accurate). In the event of cardiopulmonary arrest, if the resident does not meet the irretrievably dead criteria, the licensed nurse(s) will immediately begin CPR, EMS will be notified, code status will be reported, and CPR continued until the EMTs take over in performing CPR. If the resident meets the criteria for irretrievably dead, the licensed nurse will not begin CPR, but will contact the MD to report findings and receive order to release the body and not notify EMS service. Licensed nurses were educated of notifying EMTs upon arrival of code status and what forms to present to EMTs upon arrival which includes the resident's code status. The Director of Health Services completed in person in-services to 2 of 4 full-time RNs, 2 of 2 agency RNs, 1 of 1 Case Mix (MDS) coordinator, and 5 of 14 LPNs. Assistant Director of Health Services and Unit Manager completed telephone in-services to 2 of 4 full-time RNs and 8 of 14 LPNs. 100% of the licensed nurses, which included 4 of 4 full-time RNs, 2 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator received the in-services. This in-service was started on [DATE] and completed on [DATE]. Ongoing, this will be included in new partner orientation. 11. The Director of Health Services educated 93.75% of the licensed nurses, which included 4 of 4 full-time RNs, 1 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator, on how to identify the resident's code status in the EMR, where to find the signed DNR form in MatrixCare, where to update the code status in the physician's orders [REDACTED]. This in-service was completed [DATE]. 12. Any licensed nurse not receiving the advanced director/code status education due to scheduled time off or FMLA staff will be in-serviced prior to next scheduled shift. 13. The Senior Nurse Consultant completed an in-service on the policy Advanced Directive: Georgia and POLST form with 1 of 1 Social Worker, 1 of 1 DHS, 1 of 1 Assistant Director of Health Services (ADHS), 1 of 1 Admissions Director, 2 of 2 Unit Managers, and 1 of 1 Administrator. The in-service include verifying the resident's BIMS score (if greater than 10, resident can sign own form), right form (determined by resident's capacity to understand and if POA/Health care agent appointed), right resident/representative's signature (verify correct person is signing form, i.e. authorized person/POA/Health care agent) and correct number of MD signatures (2 MD signatures needed if signed by authorized person, but not POA/Health care agent). This in-service was completed with 100% of clinical administrative staff members on [DATE]. i. Residents will remain a full code until a fully implemented DNR/POLST is received with all the appropriate signatures. ii. The social worker/administrator/DHS will follow up with authorized person after 24 hours from the initial conversation regarding changing to DNR status (to follow up on their decision regarding code status choice, answer any follow up questions or concerns, and/or check on the return of signed form, if indicated). Resident/authorized person will be notified that there status remain as a full code until all signatures, including MD(s) are received. iii. Once facility receives the DNR/POLST signed form from the authorized person/POA/Health care agent, facility will have 2 business days to secure the appropriate physician(s) signature. The social worker and/or DHS/ADHS will follow up each business day until form is signed by the appropriate MD(s). 14. Education on CPR certification and advanced directive will be added to new partner orientation. There were no newly hired staff. 15.The facility will not require certified nursing assistants to obtain CPR certification. Facility will continue to educate all departments, including the certified nursing assistants on the INTERACT (residents' change of condition and notification) program and notifying the nurse(s) immediately for acute changes of condition, including but not limited to residents with poor/reduced appetite, skin changes, abnormal vital signs, resident noted without respirations, etc. This INTERACT training for change of condition is completed upon hire and as needed. 16. The DHS and ADHS will performed a Mock code twice a month on different shifts to ensure the education and training is properly demonstrated. The Lippincott checklist for 2-person Cardiopulmonary Resuscitation will be used to document participation and evaluation. On [DATE], 2 mock respiratory code scenarios were held with the on-duty night shift and day shift staff. DHS, ADHS, Unit manager reviewed criteria for when to initiate CPR and when not to initiate CPR, i.e. obviously clinically and irretrievably dead and the death was not witnessed with include symptoms of no measurable vital signs, cool to touch, and pupils that are fixed and dilated). There were 100% participation from the scheduled licensed staff 6 of 6 RN and 3 of 3 LPN. 17.On [DATE], the Activities Director mailed an advanced directive informational packet to each of the 52 active residents' responsible party and hand delivered the packet to 20 of 52 in-house residents with a BIMS score 10 or greater. The advanced directive (TRUNCATED)

Based on record review and staff interviews the facility failed to ensure that the Administration provided oversight and monitoring of safety concerns with ensuring staff provided Cardiopulmonary Resuscitation (CPR) for two residents, failed to ensure that the required authorized signatures for paperwork related to Advanced Directives for residents was received prior to their death, and failed to ensure that licensed nursing staff maintained current CPR certification. The facility census was 58. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Nurse Consultant and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:22 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: 1. Record review revealed that R#1 experienced a change in condition on [DATE]. Staff stated R#1 had a change in her breathing at around 3:00 a.m. and then again around 5:00 a.m. when the Certified Nursing Assistant (CNA) reported to the nurse a decline in condition. Licensed Practical Nurse BB (LPN BB), assessed and obtained orders for a chest x-ray. The resident's symptoms included gurgling, labored breathing and fixated eyes with vital signs of ,[DATE], Blood Pressure (BP), pulse 55, and temperature 96.1. The nurse left the room to call Emergency Medical Services (EMS) and CNA AA remained in the room. Upon EMS arrival CNA AA exited the room to redirect EMS to the correct door and let them in the facility. When CNA AA returned to the resident room the resident was non-responsive, EMS placed EKG leads on the resident and instructed the nurse to call a nurse supervisor to pronounce, she was asystole (no electrical activity of the heart). Cardiopulmonary Resuscitation (CPR) was not initiated by the facility staff prior to the entrance of EMS even though during an interview with CNA AA she revealed to the surveyor that she witnessed the R#1 take her last breath. CNA AA confirmed that she did not initiate CPR because she thought that EMS would take over, she continued by stating that she felt like they could have saved her. 2. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] progress note that R#3's respirations were uneven and labored; unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. LPN FF stated upon arrival to the facility Hospice RN#2 was informed that R#3 had a full code status in the system. LPN FF stated, Hospice RN#2 showed her a Do Not Resuscitate (DNR) order for R#3. Record review of Visit Note Report dated [DATE] revealed Hospice RN#2 was at bedside when R#3 died , and CPR was not performed. Medical record review reflected R#3 was to be a Full Code. R#3 had a Physician order [REDACTED].#3's POA or Health Care Agent and a Full Code Status remained in place. LPN FF confirmed that she would have done CPR for R#3 if Hospice RN#2 had not shown her a DNR order. Immediate Jeopardy was identified on [DATE] and determined to existed on [DATE] in the areas of ; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.24 Quality of Life, F678 (S/S: J). A Removal Plan (Credible Allegation of Compliance) was received on [DATE] related to 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including cardiopulmonary resuscitation, Advance Directives and care plans. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and procedures governing when to provide cardiopulmonary resuscitation and what is required for fully implemented Advance Directives. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: The facility had a Position Description for the job title of Administrator. The description included that the job purpose for the Administrator was to direct the day-to-day functions of the nursing center in accordance with current Federal, State, and local regulations that govern long-term care centers and as may be directed by the Area Vice President, to provide appropriate care for our patients/residents. The position description also included a key responsibility of the ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. The facility had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. The facility had an Advance Directive: Georgia Georgia Advance Directive for Healthcare policy statement that documented this healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Administration failed to ensure that care plans were followed related to Cardiopulmonary Resuscitation (CPR) being provided for two of three residents (R#1 and R#3). Cross refer F656 Administration failed to ensure that Cardiopulmonary Resuscitation (CPR) was provided for two of three residents (R#1, R#3), failed to have Physician order [REDACTED].#3's Healthcare Agent for one of three residents (R#3), and failed to ensure that two of 19 licensed nurses maintained a current CPR certification,. Cross refer F678 During an interview on [DATE] at 10:00 a.m. with the DHS, confirmed that an audit of CPR certifications for licensed nursing staff had not been done as part of the investigation after R#1 died on [DATE]. During a phone interview on [DATE] at 1:13 pm with the Administrator confirmed the facility staff did not initiate CPR, and in a matter of minutes of staff letting EMS inside, R#1 died . During an interview on [DATE] at 10:45 a.m. with Administrator stated she had not laid eyes on R#3's paperwork but was made aware that it did not have two physician signatures on it. Administrator stated, if a resident was not able to sign for themselves and does not have a POA, the document would need two physicians' signatures. Administrator stated she was not aware of anything with R#3's paperwork until this investigation. Record review of the medical records for R#3 revealed the POLST for R#3 that included a second Physician signature was dated [DATE] which was 15 days after R#3's death and that the Responsible party was not R#3's Healthcare Agent. The facility implemented the following actions to remove the Immediate Jeopardy 1. The Senior Nurse Consultant completed an in-service on the policy Advanced Directive: Georgia and POLST form with 1 of 1 Social Worker, 1 of 1 DHS, 1 of 1 Assistant Director of Health Services (ADHS), 1 of 1 Admissions Director, 2 of 2 Unit Managers, and 1 of 1 Administrator. The in-service include verifying the resident's BIMS score (if greater than 10, resident can sign own form), right form (determined by resident's capacity to understand and if POA/Health care agent appointed), right resident/representative's signature (verify correct person is signing form, i.e. authorized person/POA/Health care agent) and correct number of MD signatures (2 MD signatures needed if signed by authorized person, but not POA/Health care agent). This in-service was completed with 100% of clinical administrative staff members on [DATE]. 2. Nursing in-services included Lippincott procedures for Cardiopulmonary resuscitation (refresher CPR review: reviewed criteria for when to initiate CPR and when not to initiate CPR, i.e. obviously clinically and irretrievably dead and the death was not witnessed with include symptoms of no measurable vital signs, cool to touch, and pupils that are fixed and dilated), change in status with MD/NP notification, and Documentation (thorough, complete, and accurate). In the event of cardiopulmonary arrest, if the resident does not meet the irretrievably dead criteria, the licensed nurse(s) will begin CPR, EMS will be notified, code status will be reported, and CPR continued until the EMTs take over in performing CPR. If the resident meets the criteria for irretrievably dead, the licensed nurse will not begin CPR, but will contact the MD to report findings and receive order to release the body and not notify EMS service. Licensed nurses were educated of notifying EMTs upon arrival of code status and what forms to present to EMTs upon arrival which includes the resident's code status. The Senior Nurse Consultant completed telephone in-service with the administrator on [DATE]. The Director of Health Services completed in person in-services with the Assistant Director of Health Services and Unit Managers. This in-service was started on [DATE] and completed on [DATE]. Ongoing, this will be included in new partner orientation. 3. The Administrator was also educated via telephone conference by the Senior Nurse Consultant on the following policies: a. QAPI on [DATE] which included: i. The administrator role in QAPI ii. Identifying issues iii. Conducting Root Cause Analysis (RCA) iv. Development action plans v. Bring back data from the actions plans for feedback from the team vi. Monthly meeting to discuss plan agendas b. Review of the identified FTAGS and the accompanying policies i. FTAG 656 Care Plans: Updating of care plan with admission, readmission, significant change, quarterly, and as needed. ii. FTAG 678 CPR: educated on the Lippincott procedures and Georgia advanced directive and DNR/POLST iii. FTAG 835 Administration: reviewed all deficiencies, RCA, and interventions iv. FTAG 867 QAPI: reviewed the administrator's role in QAPI, identifying root cause analysis, and developing action plans 4. The Area Vice President will have bi-weekly call with the administrator to review the deficiencies sited during the survey. a. Areas to be reviewed will be as followed: i. Audit tools review ii. Education follow up 5. The Administrator/DHS/ADHS will continue to complete weekly QAPI while survey tags are outstanding. Once tags are removed, the QAPI will return to monthly meetings with IDT team members and address any new areas of concerns with the appropriate PIP. The Area Vice President will monitor compliance and outcomes of the QAPI monthly. 6. Area Vice President and Senior Nurse Consultant will be available to the administrator as needed. 7. All corrective actions were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of an in-service Advanced Directive Policy and POLST form dated [DATE] revealed seven staff signatures including the Social Worker, DHS, Assistant Director of Health Services (ADHS), 1 Admissions Director, 2 Unit Managers, and the Administrator. Education included: right form, right signature (responsible party, POA, resident) and the right number of physician signatures. Interviews on [DATE] at 1:00 p.m. with LPN UM Unit Manager #2, [DATE] at 2:40 p.m. with Unit Manager #1 p.m. and with the Social Service Director at 3:00 p.m. revealed an understanding of who is an authorized person to sign Advanced Directives and residents with a Brief Interview for Mental Status (BIMS) of 10 or higher are to be interviewed for their Advanced Directive wishes. 2. Record review of the DNR/Full Code Inservice dated [DATE] and concluded on [DATE] revealed an in-service on DNR/Full Code, Lippincott CPR one & two person procedures care plan for code status. Lippincott 1. Change in status 2. Documentation, long term care. Nurses copy of procedure given to everyone. The in-service dated [DATE] revealed 4 RNs, 1 Agency RN, 14 LPNs, 1 MDS coordinator. Interviews with licensed nursing staff revealed they were educated that residents with a Full Code status will have CPR initiated and it will continue until EMS arrives. The following staff members were interviewed: on [DATE] at 10:37 a.m. with RN Wound Care; on [DATE] at 1:00 p.m. with LPN Unit Manager #2; on [DATE] at 1:50 p.m., with LPN EE; on [DATE] at 2:20 p.m., with LPN Unit Manager#1; on [DATE] at 4:51 p.m., with LPN VV; on [DATE] at 4:58 p.m., with LPN XX. Record review of a phone in-service dated [DATE] for the Administrator by the Regional Nurse Consultant revealed all FTAGS including 656,678,835, and 867 were reviewed and discussed. Advanced Directives for Health Care and QAPI importance's were stressed and discussed to review the areas of concern with appropriate follow up meetings and updates of Performance Improvement Plans (PIP). During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. During an interview on [DATE] at 5:09 p.m. the Administrator confirmed that she had received education on her roles and responsibilities to and for the facility. 3. Record review of a phone in-service dated [DATE] for the Administrator by the Regional Nurse Consultant revealed all FTAGS including 656,678,835, and 867 were reviewed and discussed. Advanced Directives for Health Care and QAPI importance's were stressed and discussed to review the areas of concern with appropriate follow up meetings and updates of Performance Improvement Plans (PIP). During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. During an interview on [DATE] at 5:09 p.m. the Administrator confirmed that she had received education on her roles and responsibilities to and policies for the facility. 4. The Area Vice President confirmed that she would be available as needed to support the Administrator. 5. During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. Education and support will be ongoing, QAPI meetings will be reviewed monthly and as needed. The Area Vice President confirmed that she would monitor for compliance. 6. Interview with the Area Vice President on [DATE] at 11:30 a.m. confirmed that she would be available as needed to support the Administrator. 7. All corrective actions were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE].

Based on observations, staff interviews, and review of the facility policy titled Quality Assurance- Performance Improvement it was determined that the facility staff failed to implement plans of action to correct identified quality deficiencies that were systematic, interdisciplinary, comprehensive and data-driven to improve safety and quality in the facility. The facility census was 58. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Nurse Consultant and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:22 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: 1. Record review revealed that R#1 experienced a change in condition on [DATE]. Staff stated R#1 had a change in her breathing at around 3:00 a.m. and then again around 5:00 a.m. when the Certified Nursing Assistant (CNA) reported to the nurse a decline in condition. Licensed Practical Nurse BB (LPN BB), assessed and obtained orders for a chest x-ray. The resident's symptoms included gurgling, labored breathing and fixated eyes with vital signs of ,[DATE], Blood Pressure (BP), pulse 55, and temperature 96.1. The nurse left the room to call Emergency Medical Services (EMS) and CNA AA remained in the room. Upon EMS arrival CNA AA exited the room to redirect EMS to the correct door and let them in the facility. When CNA AA returned to the resident room the resident was non-responsive, EMS placed EKG leads on the resident and instructed the nurse to call a nurse supervisor to pronounce, she was asystole (no electrical activity of the heart). Cardiopulmonary Resuscitation (CPR) was not initiated by the facility staff prior to the entrance of EMS even though during an interview with CNA AA she revealed to the surveyor that she witnessed the R#1 take her last breath. CNA AA confirmed that she did not initiate CPR because she thought that EMS would take over, she continued by stating that she felt like they could have saved her. 2. Record review revealed that R#3 experienced a change in condition on [DATE]. LPN FF documented on [DATE] progress note that R#3's respirations were uneven and labored; unresponsive to verbal and physical stimuli. LPN FF notified Hospice RN#2 of R#3 change of condition. LPN FF stated upon arrival to the facility Hospice RN#2 was informed that R#3 had a full code status in the system. LPN FF stated, Hospice RN#2 showed her a Do Not Resuscitate (DNR) order for R#3. Record review of Visit Note Report dated [DATE] revealed Hospice RN#2 was at bedside when R#3 died , and CPR was not performed. Medical record review reflected R#3 was to be a Full Code. R#3 had a Physician Orders for Life-Sustaining Treatment (POLST) indicating a DNR status; however, the POLST was not signed by R#3's POA or Health Care Agent and a Full Code Status remained in place. LPN FF confirmed that she would have done CPR for R#3 if Hospice RN#2 had not shown her a DNR order. Immediate Jeopardy was identified on [DATE] and determined to existed on [DATE] in the areas of ; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.24 Quality of Life, F678 (S/S: J). A Removal Plan (Credible Allegation of Compliance) was received on [DATE] related to 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.70 Administration, F835; 42 CFR 483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including cardiopulmonary resuscitation, Advance Directives and care plans. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and procedures governing when to provide cardiopulmonary resuscitation and what is required for fully implemented Advance Directives. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: A review of the Quality Assurance- Performance Improvement (QAPI) Plan (Facility name) [DATE] effective date: 12-May-2020 revealed the following: QAPI Purpose: The purpose of QAPI at (facility name) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patient, partners, and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Facility uses quality assurance and performance in improvement to make decisions and guide our day-to-day operation. (In establishing the system, we remain cognizant that QAPI is not a program; rather, it is the way we do our work.) QAPI includes all departments and all services. QAPI is comprehensive regarding systems of care, management practices, and business practices. Facility supports QAPI through the concept of team management and encouraging our partners to support each other and be accountable for their professional performance and practice. Direction of QAPI Activities: It is the expectation of the Governing Body that the center will follow the established QAPI process in order to guide and direct the operations of that location. The executive leadership of (facility name) sets the expectation and provides the resources for implementation. The center's QA&A committee (QAPI Committee) has overall responsibility to develop and modify their respective QAPI plan, review data, and set priorities for performance improvement projects (PIPs). Performance Improvement Projects (PIPs): PIPs will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements. The nursing center will conduct PIPS to examine and improve care or services in areas that the nursing center identifies as needing attention. Once opportunities are prioritized, focus areas are selected for the quarter. The QA&A Committee will appoint a subcommittee to develop a Performance Improvement Project Plan for each identified focus area. This includes development of Performance Improvement Project charter or scope of work, conducting root cause analysis, developing the performance improvement plan and monitoring the plan for success. Unexpected/unanticipated process failures or outcomes are evaluated to determine the root cause (RCA). RCA is a process for identifying the factors that cause variation in performance, in order to identify and implement the most effective solution. This process requires an in-depth look at processes and systems to determine: - What happened? - Why did it happen? - What can be done to prevent it from happening again? 1. R#1 was admitted to the facility on [DATE]. A review of the medical record profile banner revealed that R#1 was a Full Code status and R#1's care plan status is listed as a full code. However, facility staff witnessed R#1 take her last breath and did not initiate CPR. 2. R#3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the medical record reflected that R#3 was to be a Full Code. R#3 had a Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] indicating a DNR status; however, the POLST was not signed by R#3's POA or Health Care Agent and there were not two Physician signatures and a Full Code Status remained in place. A record review of the QAPI meeting dated [DATE] revealed no documentation of the incident surrounding R#1's death without CPR. During an interview on [DATE] at 11:15 a.m. with the Administrator, she revealed she was made aware of the incident with R#1 prior to her arrival at the facility on the morning of [DATE] and reported it to the proper authorities because they thought it was strange and it all happened in just a matter of minutes. She confirmed that a regularly scheduled QAPI meeting was conducted on the same day however, the incident surrounding R#1's death without CPR was not documented as part of the QAPI meeting minutes nor was a root cause (RCA) process initiated. (A Root Cause Analysis: is process requires an in-depth look at processes and systems to determine: - What happened? Why did it happen? What can be done to prevent it from happening again? The Administrator stated we would not have documented that because we were discussing July's events and we felt that EMS did not do what they could have or should have done. The Administrator confirmed that LPN BB did not initiate CPR. She also stated that R#1's care plan reflected that she was a full code status and she would have expected the staff to start CPR. The facility implemented the following actions to remove the Immediate Jeopardy: 1. ADHOC QAPI was held on [DATE]. In which the QAPI committee, the Administrator, Dietary manager, Social Worker, Activity Director, Unit Mangers, Admission Director, Director of Health Services, Assistant Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, C.N.A Medical Records, and financial Counselor met and reviewed the noncompliance with F 656 Care plans, F 678 CPR, F 835 Administration, and F 867 QAPI. The QAPI committee was led by the DHS root cause analysis and actions plans were created for each F tag the findings were as followed: a. F656 Care Plans: the RCA was determined to be the facility failed to update the update the care plan with current advance directive status. The action plan for the F Tag 656 included a 100% audit of all care plan to ensure accuracy of all current care plan with advance directive. The Director of Health Services educated the Case Mix Director on making sure care plans were updated. 93.75% of the licensed nurses were educated on updating care plans on admission with advance directives and with changes to advance directives. b.F 678 CPR: the RCA was determined to be the facility failed to start CPR for a full code resident #1 and EMS failed to start CPR for a full code resident. On resident #3, the authorized person did not sign the POLST form. The action plan is all licensed staff was audited to ensure CPR cards were current. The licensed staff was educated by the DHS and ADHS on when to perform CPR and when not to preform CPR. Residents' responsible party were educated on what an advanced directive is and who to contact for changes and questions, DNR, and CPR via informational packet that was mailed on [DATE]. Residents (20 of 52 in-house residents) with BIMS greater than 10 received the same informational packet and the nurses reviewed this with them. In the event of cardiopulmonary arrest, if the resident does not meet the irretrievably dead criteria, the licensed nurse(s) will begin CPR, EMS will be notified, code status will be reported, and CPR continued until the EMTs take over in performing CPR. If the resident meets the criteria for irretrievably dead, the licensed nurse will not begin CPR, but will contact the MD to report findings and receive order to release the body and not notify EMS service. Licensed nurses were educated of notifying EMTs upon arrival of code status and what forms to present to EMTs upon arrival which includes the resident's code status. Facility will perform mock codes to ensure facility understands what to do in a code situation. On [DATE], the facility's Director of Health Services (DHS) contacted the PH Hospice's Director of Health Services to discuss the delay in the receipt of the documentation and the requirements for authorized person on the DNR/POLST forms. Ongoing, when a resident is placed on hospice services, the Director of Health Services and/or Social Worker will follow up with hospice to review advanced directive and any changes that were made from their current code status. c. 835 Administration: the RCA was determined to be the administrator is new to Pruitthealth. The action plan for F 835 included education from the Senior Nurse Consultant on Advance Directives policy, POLST form, and QAPI guidelines. The Administrator will be monitored by the Area Vice President Bi-Weekly to review audits from the plan of correction, QAPI minutes and to mentor the administer. d.F 867 QAPI: the RCA was determined to be the facility failed to identify the issues that were cited. The action plan for F 867 included education for the QAPI team. The region team will review the monthly notes and will attend either in person for via virtual monthly meeting to ensure the process is maintained per policy. Interviews held on [DATE] with the QAPI members confirmed they were in attendance and verbalized understanding related to the topics covered: at 10:37 a.m., with Wound Care; at 1:00 p.m., with Unit Manager#2; at 1:50 p.m., with LPN EE; at 2:20 p.m., with LPN Unit Manager#1; at 11:27 a.m., with Hskpng LL; at 12:00 p.m., with Dietary Aide OO; at 3:00 p.m., with Social Service; at 3:34 p.m., with Medical Records/Central Supply; at 3:55 p.m., with Housekeeping Supervisor; at 3:00 p.m., with Mnt Director; at 4:26 p.m., with the Activity Director; at 4:15 p.m., with the Dietary Manager; at 4:05 p.m., with the Financial Counselor; and at 3:00 p.m., with Social Service; 2. Education regarding QAPI, on [DATE] the Administrator and the Department Managers to include the following staff but not limited to: Dietary manager, Social Worker, Activity Director, Unit Mangers, Admission Director, Director of Health Services, Assistant Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, C.N.A Medical Records, and financial Counselor, and were in-serviced by the Senior Nurse Consultant on QAPI requirements. The education focused but not limited to: Identifying issues Conducting Root Cause Analysis (RCA) Development action plans Bring back data from the actions plans for feedback from the team Monthly meeting to discuss plan agendas 3.The QAPI committee will continue to meet weekly while survey tags are outstanding. 4. All Corrective actions were completed on [DATE]. 5. The Immediacy of the IJ was removed on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1.Record Review revealed ADHOC QAPI was held on [DATE]. In which the QAPI committee, the Administrator, Dietary manager, Social Worker, Activity Director, Unit Mangers, Admission Director, Director of Health Services, Assistant Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, C.N.A Medical Records, and financial Counselor met and reviewed the noncompliance with F 656 Care plans, F 678 CPR, F 835 Administration, and F 867 QAPI. The QAPI committee was led by the DHS root cause analysis and actions plans were created for each F tag F656, F678, F835, and F867. a. Record Review of F656 Care Plans RCA determined that the facility failed to update the care plan with current advance directive status. The action plan for the F Tag 656 included a 100% audit of all care plan to ensure accuracy of all current care plan with advance directive. 93.75% of the licensed nurses were educated on updating care plans on admission with advance directives and with changes to advance directives. Record Review of Inservice Program Attendance Record Form dated [DATE] and Interviews with staff on [DATE] on every shift revealed CPR and care plan in-services were provided by the DHS/ Unit Managers to all licensed staff. Record review of form titled, PH Ocilla Advance Directive Code Status Audit dated for the month of [DATE] revealed new admission and readmitted residents audit was completed and appropriate follow up to ensure accuracy of documentation. Interview on [DATE] with LPN CC MDS Coordinator at 4:00 p.m. stated she was educated by DHS on updating care plans to reflect code status change. She confirmed that if any changes to the resident's advanced directive, she will update the advanced directive care plan after all DNR/POLST form are validated and received. b. Record Review revealed F 678 CPR RCA determined the facility failed to start CPR for a full code resident #1 and EMS failed to start CPR for a full code resident. On resident #3, the authorized person did not sign the POLST form. The facility action plan was reviewed and validated with the following: During the survey process there were no new nursing staff hires. A record review revealed an audit tool for (Facility name) Monthly CPR Certification audit including attaching a copy of licensed nurses' roster and their CPR certification expiration date. 4 of 4 RNs, 2 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator's CPR certifications audited to ensure CPR cards were current. A plan for follow for any certification that will expire within the next 60 days and a weekly check until an updated CPR card is received. The form includes the names of licensed nurses, CPR expiration date if within 60 days of the audit date, a follow up date with any identified nurse, the new CPR card received date and the expiration date. A record review revealed a copy of mailed letters to families including a letter of communication to inform them that the facility has the correct information to make informed decisions concerning advanced directive status while residing at the facility. Interviews with residents R#10, R#12, and R#14 with a BIMS greater than 10 (intact cognitive response) revealed that facility staff had spoken to them directly about their wishes for Advanced Directives. (see F656) An interview on [DATE] at 3:00 p.m. with the Social Service Director revealed an understanding of who is an authorized person to sign Advanced Directives and residents with a Brief Interview for Mental Status (BIMS) of 10 or higher are to be interviewed for their Advanced Directive wishes. A record review of the sign in sheet for in-services The Director of Health Services completed in person in-services to 2 of 4 full-time RNs, 2 of 2 agency RNs, 1 of 1 Case Mix (MDS) coordinator, and 5 of 14 LPNs on [DATE]-[DATE]. Assistant Director of Health Services and Unit Manager completed telephone in-services to 2 of 4 full-time RNs and 8 of 14 LPNs on [DATE]. 100% of the licensed nurses, which included 4 of 4 full-time RNs, 2 of 2 agency RNs, 14 of 14 LPNs, and 1 of 1 Case Mix (MDS) coordinator received the in-services. Staff were educated on DNR and Full code status. In addition those staff were educated on where to look for the code status, how to identify a full code status, how to identify a DNR status and how to run a DNR/Full code report from the Electronic Health Record (EHR). Further review revealed staff were educated on notification to the DHS if a resident has a change in condition to include but not limited to significant changes in vital signs, if a resident continues to have nausea, vomiting, diarrhea, chest pain, shortness of breath. Staff are to complete a Situation-Background-Assessment-Recommendation (SBAR) form, the physician and residents responsible party are to be notified as well as further actions needed. Further education provided to staff were the locations of the crash carts including items in the crash cart and documentation required during CPR including but not limited to a CPR flowsheet for start times, vitals signs, compressions and respirations given and confirmed by Interviews conducted on the following dates and times for licensed staff from every shift:[DATE] at 10:37 a.m., with Wound Care;[DATE] at 1:00 p.m., with Unit Manager#2;[DATE] at 1:50 p.m., with LPN EE;[DATE] at 2:20 p.m., with LPN Unit Manager#1;[DATE] at 4:51 p.m., with LPN VV;[DATE] at 4:58 p.m., with LPN XX. Record review revealed a form for Mock Codes with required attachments of licensed nurses Lippincott's CPR Checklist for each participant. The form requires two Mock Codes per month to be completed by the DHS or Assistant Director of Health Services (ADHS), name of all participants and any areas of improvement to be noted. Record review revealed a Mock Code dated [DATE] nine nursing staff attended. A skills checklist including demonstrations with evaluations. The DHS stated her interview with PH Hospice Director on [DATE] revealed the reason in the delay of paperwork being given to the facility was that the second physicians signature was missing. An interview with the PH Hospice nurse on [DATE] at 10:10 a.m. revealed that they did not need a second physicians' signature. Although the facility had the family listed as a nephew, PH Hospice had them listed as a son. c. Record Review of F 835 Administration RCA was determined to be the administrator is new to Pruitthealth. The action plan for F 835 included education from the Senior Nurse Consultant on Advance Directives policy, POLST form, and QAPI guidelines. The Administrator will be monitored by the Area Vice President Bi-Weekly to review audits from the plan of correction, QAPI minutes and to mentor the administer. Record Review of Inservice Program Attendance Record form on [DATE] at 6:30 p.m revealed. a telephone in-service with the Administrator by RN Nurse Consultant, revealed topics discussed were Advance Directives policy, POLST form, and QAPI guidelines. During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. Education and support will be ongoing, QAPI meetings will be reviewed monthly and as needed. d. Record Review of F 867 QAPI RCA determined the facility failed to identify the issues that were cited. The action plan for F 867 included education for the QAPI team. The region team will review the monthly notes and will attend either in person for via virtual monthly meeting to ensure the process is maintained per policy. During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. Education and support will be ongoing, QAPI meetings will be reviewed monthly and as needed. 2. Record Review Inservice Education regarding QAPI, on [DATE] with the Administrator and the Department Managers to include the following staff but not limited to: Dietary manager, Social Worker, Activity Director, Unit Mangers, Admission Director, Director of Health Services, Assistant Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, C.N.A Medical Records, and financial Counselor, and were in-serviced by the Senior Nurse Consultant on QAPI requirements revealed the education discussed: Change in status; Documentation; LTC; CPR guidelines; Discussed intervention; POLST and signature requirements; DNR and Advance Directive policy; Change in status; Documentation; LTC; CPR guidelines; Discussed intervention; POLST and signature requirements; DNR and Advance Directive policy Ftags, plans initiated, Advanced QAPI, stressed/discussed the importance of Advance QAPI to view areas of concerns with appropriate follow up meetings and updates in PIPs. Interviews held on [DATE] with the QAPI members confirmed they were in attendance and verbalized understanding related to the topics covered: at 10:37 a.m., with Wound Care; at 1:00 p.m., with Unit Manager#2; at 1:50 p.m., with LPN EE; at 2:20 p.m., with LPN Unit Manager#1; at 11:27 a.m., with Hskpng LL; at 12:00 p.m., with Dietary Aide OO; at 3:00 p.m., with Social Service; at 3:34 p.m., with Medical Records/Central Supply; at 3:55 p.m., with Housekeeping Supervisor; at 3:00 p.m., with Mnt Director; at 4:26 p.m., with the Activity Director; at 4:15 p.m., with the Dietary Manager; at 4:05 p.m., with the Financial Counselor; and at 3:00 p.m., with Social Service; Record Review of Last QAPI held [DATE]. Immediate Jeopardy was lifted on [DATE]. Next QAPI due by [DATE]. During an interview on [DATE] at 4:13 p.m. with the Regional Nurse Consultant, she confirmed that education was provided to the facility Administrator. Education and support will be ongoing, QAPI meetings will be reviewed monthly and as needed. 4. All Corrective actions were completed on [DATE]. 5. The Immediacy of the IJ was removed on [DATE].

Based on observations, interview and Policy titled Medication Administration: Oral Medications, the facility failed to prevent possible contamination of medication during medication administration with one of three licensed nurses. Sample size 31. Findings include; During an observation of medication adminsitration on 8/21/18 at 8:50 a.m. Nurse AA tore open a multi-dose cellophane packet. A pink pill fell out onto the Medication Administration Record [REDACTED]. The nurse then poured the pills into a medication cup. Medication was then administered. On 8/23/18 at 9:38 a.m. an telephone interview with Nurse AA was attempted. No answer and no return call. On 8/23/18 at 10:04 a.m. during an interview with Licensed Practical Nurse (LPN) BB, when asked what would be the process if a pill fell out of the cellophane multi-dose package onto the MAR, Nurse BB stated I was educated that if the pill touched any surface other than the pill cup, it is considered contaminated and the pill would need to be discarded. If there was another in the emergency stock, the pharmacy would give us the code to access it; then we would have it replaced. If not then we have to call the pharmacist to order more medicaton. On 8/23/18 at 10:10 a.m. an interview with the Director of Nursing (DON) indicated it would be her expectation that a pill that touched any other surface other than the pill cup, would be discarded. On 8/23/18 at 10:15 a.m. further interview with the DON revealed she spoke with other nurses and they all stated that the pill should be discarded and reordered from the pharmacy. Review of policy titled Medication Administration: Oral Medication reviewed 4/25/18, states Never touch any of the medication with fingers.

Based on observation, staff interview and policy review, the facility failed to ensure opened food items were labeled and dated before storage in two (2) of three (3) refrigerators, one (1) of 1 freezer, and dry storage area, and failed to demonstrate the proper technique for sanitizing dishware in the three (3) compartment sink to prevent the potential for a food borne illness. This deficient practice had the potential to effect all fifty-seven (57) residents receiving an oral diet. Findings include: 1. The facility's Leftover policy documented that the containers will be labeled with the food items, prepared/open date, and discard date. The policy also documented that non-perishable leftovers need to be stored in a dry cool area, dated and labeled, and discarded within 72 hours after being opened. However, during an observation on 5/9/16 at 11:20 a.m. of the 2-door reach-in refrigerator, closest to the door, there was a twenty (20) ounce plastic bottle of Pepsi on the top shelf that was opened with no label or date, and there was a clear resealable plastic bag with a red food substance the size of a golf ball that did not have a label or a date. There was also a white plastic bin containing raw bacon with no date on the container of when the bacon was taken out the original box and placed in the plastic bin. On 5/9/16 at 11:30 a.m., in the 2-door reach-in refrigerator, closest to a rack in the dry storage area, there was an opened four (4) pound, eight (8) ounce clear plastic container of maraschino cherries with no date and a one gallon plastic container of Buttermilk Ranch dressing that had a sticker that documented the open date was 1/21/16. There was also a partially used stalk of celery laying on top of a case of shredded cabbage, the celery stalk was not wrapped or dated after usage. On 5/9/16 at 11:40 a.m. in the upright freezer, there was a Cold Storage Chart secured to the front of the door. The chart documented to discard mayonnaise, Dressings, and Condiments one month after opening. On 5/9/16 at 11:45 a. m. in the dry storage area, there was an opened thirty-two (32) ounce bag of raisin bran cereal in a clear plastic bin with no open date. During an interview on 5/9/16 at 11:55 a.m., the Dietary Manager (DM) confirmed the previously listed findings and was not able to identify the red food substance in the clear resealable bag with no label and date. She stated she expected staff to label, date and securely wrap all opened food items before storage, and date food items once removed from original packaging and placed in a different container. She also expected staff to follow the cold storage chart secured to the upright freezer and discard food items according to the chart. A review of facility inservices revealed that an in-service was conducted in October 2015 regarding how to store foods in coolers. 2. The facility's Pot/Pan Washing and Sanitation policy documented that Quaternary concentration items need to be immersed for sixty (60) seconds in the solution. On 5/11/16 at 11:30 a.m. dietary cook AA, was washing a blender bowl in the 3 compartment sink. The dietary cook washed the blender bowl in soapy water, rinsed in clean water, then swirled the bowl in the sanitizing solution for 2 seconds and placed it back on the blender stand. Continued observation of the 3 compartment sink revealed that the facility used EcoLab Quaternary solution for sanitizing. There was an EcoLab poster above the 3 compartment sink that documented to immerse items in the sanitizing solution one minute or longer. During an interview on 5/11/16 at 11:30 a.m. dietary cook AA, stated she had attended an in-service by the DM on the usage of the 3 compartment sink. However, when she was asked about the sanitizing solution and how long items needed to be in the solution, the dietary cook did not verbally respond to the question. On 5/11/16 at 11:32 a.m., the DM stated that she had conducted in-services regarding the use of the 3 compartment sink and expected dietary staff to wash dishware using the proper method. The DM stated that items should be submerged in the sanitizing solution for thirty (30) seconds. The DM did not respond when surveyor indicated the poster above the 3 compartment sink documented to immerse items for one minute or longer. A review of inservice documentation revealed a dietary in-service was conducted on sanitizer readings in April 2014 and January 2016.

Base on observations and interview, the facility failed to provide an environment free from stained and soiled privacy curtains, rust, missing paint, missing tile, nonfunctioning window latches, and peeling and stained caulking in eighteen (18) of fifty-one (51) occupied resident rooms. Findings Include: The following observations were made on Wing One (1) which consisted of three (3) halls and Wing Two (2) which consisted of three halls: 1. On 5/9/16 at 3:24 p.m., in room 14, the privacy curtain had two large red beverage stains. 2. On 5/10/16 at 2:33 p.m., room 6, there was paint missing on the left wall near Bed A and at the head of the bed. In the bathroom, the toilet had caulking peeling away from the base and was discolored. 3. On 5/10/16 at 2:38 p.m., in room 10, there were food particles on the privacy curtain. 4. On 5/10/16 at 2:40 p.m., in room 12, there were food particles on the privacy curtain. 5. On 5/10/16 at 2:41 p.m., in room 14, there were food particles on the privacy curtain near bed B, and the lower portion of the door frame to the bathroom was rusty. 6. On 5/10/16 at 2:43 p.m., in room 19, the closet door was missing a knob on the front panel. 7. On 5/10/16 at 2:51 p.m., in room 26, there were multiple areas with food particles on the privacy curtain. 8. On 5/10/16 at 2:53 p.m., in room 30, the lower portion of the door frame to the bathroom was rusty. 9. On 5/10/16 at 2:55 p.m., in room 34, there was missing floor tile near the bathroom entrance, and the lower portion of the door frame to the bathroom was rusty. 10. On 5/10/16 at 3:01 p.m., in room 36, there was missing floor tile in the bathroom, and the caulking around the toilet base was brown and peeling away. The lower portion of the door frame to the bathroom was rusty. 11. On 5/10/16 at 3:04 p.m., in the bathroom of room 37, there were missing floor tiles near the sink and near the bathroom entrance. 12. On 5/10/16 at 3:07 p.m., in the bathroom of room 5, the toilet, when flushed, leaked water from the rear left base of the toilet. 13. On 5/10/16 at 3:10 p.m., in room 41, there was a black substance on three cinder blocks on the wall near the entrance door, the privacy curtain was dirty, and in the bathroom, the lower door frame was rusty. On 5/11/16 at 8:50 a.m. the two window latches were not working. 14. On 5/10/16 at 3:13 p.m., in room 43, the privacy curtains were dirty. In the bathroom the toilet caulking was discolored and peeling away from the toilet base. On 5/11/16 at 8:31 a.m. one of two window latches was not working. 15. On 5/10/16 at 4:30 p.m., in room 40, two of four window latches did not work. 16. On 5/11/16 at 8:25 a.m., in room 52, one window latch did not work. 17. On 5/11/16 at 8:27 a.m., in room 51, one window latch did not work. 18. On 5/11/16 at 8:29 a.m., in room 47, one window latch did not work. During an interview on 5/10/16 at 3:17 p.m., the Housekeeping Supervisor stated the privacy curtains would be taken down and washed. She also stated she could not provide a cleaning log because the log was computerized and was too many pages to print. During an interview on 5/11/16 at 9:05 a.m., the Administrator confirmed that the previously listed window latches did not work.

Based on observation, staff interview and record review, the facility failed to follow the plan of care to utilize a bed alarm for three (3) residents (#73, #44, and #23) and obtain laboratory tests for one (1) resident (#20) from a total sample of thirty-six (36) residents. Findings include: 1. Resident #73 had a Care Plan, dated 6/19/15, for being at risk for falls related to impaired mobility. The care plan was updated on 12/14/15 with an intervention for a bed pressure alarm. However, on 5/10/16 at 5:00 p.m the resident was observed to be in bed with the bed alarm switched in the off position on the alarm box. During an interview on 5/10/16 at 5:03 p.m, Certified Nursing Assistant (CNA), JJ confirmed the resident's bed alarm was in the off position and not blinking to indicate it was in use and stated the alarm box should be blinking. Cross reference to F323 2. Resident #44 had a Care Plan, dated 2/5/16, for being at risk for falls related to unsteady gait, [MEDICAL CONDITION] and other co-morbidities . Documentation on the Care Plan revealed the resident experienced falls without injury on 4/4/16 and 4/21/16. An intervention was added to the Care Pan on 4/21/16 for a bed pressure alarm. However, the resident was observed in the bed with the bed alarm in the off position on the alarm box and not blinking to indicate it was in use on 5/10/16 at 3:15 p.m., 4:05 p.m., 4:45 p.m. and 4:48 p.m. During an interview on 5/10/16 at 4:48 p.m., CNA II confirmed the bed alarm was not on. Cross reference to F323 3. Resident #23 had a Care Plan for being at risk for falls related to impaired mobility and impaired vision. The care plan included Interventions for the use of a body alarm when up in a wheelchair and a pressure sensor while in the bed However, on 5/10/16 at 5:01 p.m., the resident was observed lying in bed but the bed alarm was not turned on. Cross reference to F323 4. Resident #20 had a Care Plan, dated 9/22/14, for being at an increased risk for bleeding related to anticoagulant therapy. The care plan included an intervention for licensed nursing staff to obtain [MEDICATION NAME] (PT) and International Normalized Ratio (INR) laboratory tests as ordered. On 1/20/16 the physician ordered PT and INR laboratory tests to be obtained once a week for three weeks. The first PT and INR was obtained on 1/21/16. The next laboratory test would have been due on 1/28/16. However, a PT and INR was not obtained again until twelve days later, on 2/8/16. Cross reference to F502

Based on observations, staff interview, and record review, the facility failed to maintain safe water temperatures on one (1) of six (6) halls, and utilize bed alarms for four (4) residents (#18, #44, #73 and #23) of ten (10) sampled residents reviewed for falls, from a total sample of thirty-six (36) residents. Findings include: 1. During observations on 5/10/16 from 11:17 a.m. to 11:27 a.m., with the facility's Maintenance Director, there were unsafe hot water temperatures in the following rooms: Room 52: 123 degrees Fahrenheit (F) at 11:17 a.m. Room 50: 121 degrees F at 11:20 a.m. Wing 1, Hall 3 shower room sink: 122 degrees F at 11:25 a.m. Room 53: 122 degrees F at 11:27 a.m. During an interview on 5/10/16 at 11:30 a.m., the Administrator implemented an immediate plan. The plan include that the hot water was turned off for the effected area, hand sanitizing wipes were placed in the residents' rooms, body audits were completed on residents with no adverse findings, and a plumber was notified and on-site on 5/10/16. The water heater was reset and drained and repairs were completed. Temperatures would be checked every thirty (30) minutes for twenty-four (24) hours, then twice daily for five (5) days, and if there were no further problems, daily random temperatures checks would be obtained thereafter. Review of the recorded temperatures revealed that temperatures remained below 120 degrees F throughout the monitoring. Review of the water temperature logs from 1/1/16 through 5/3/16 revealed no evidence of temperatures greater than 120 degrees F. 2. Resident #73 had [DIAGNOSES REDACTED]. Resident #73 had a Care Plan, dated 6/19/15, for being at risk for falls related to impaired mobility. On 11/26/15 the resident sustained [REDACTED]. The care plan was updated again on 12/14/15 with an intervention for a bed pressure alarm. However, on 5/10/16 at 5:00 p.m., the resident was observed to be in bed with the bed alarm switched in the off position on the alarm box. During an interview on 5/10/16 at 5:03 p.m, Certified Nursing Assistant (CNA), JJ confirmed the resident's bed alarm was in the off position and was not blinking to indicate it was in use and stated the alarm box should be blinking. During an interview on 5/10/16 at 5:05 p.m., CNA II, stated she forgot to check the resident's alarm when she was in the room at the beginning of the shift and had not checked the alarm since her shift started at 3:00 p.m. During an interview on 5/11/16 at 3:55 p.m, the Director of Nursing (DON) stated the alarm should have been on for this resident during observation on 5/10/16 and at all times the resident is in bed. The DON stated that the CNA's should be checking the alarm when providing care to ensure the alarm is on and functioning. During an interview on 5/11/16 at 5:32 p.m., the Unit 2 Nurse Manager stated that she added the pressure alarm intervention to the resident's care plan on 12/14/15 because the resident was confused at times and attempted to get up without assistance. The Unit Manager revealed the resident no longer tried to get up without assistance but the decision was made to continue to use the bed alarm. 3. Resident #44 had [DIAGNOSES REDACTED]. The resident had a Care Plan in place, dated 2/5/16, for being at risk for falls related to unsteady gait, Chronic Obstructive Pulmonary Disease (COPD) and other co-morbidities . Documentation on the Care Plan revealed the resident experienced falls without injury on 4/4/16 and 4/21/16. An intervention to wear non-skid socks was added to the care plan on 4/4/16 and an intervention for a pressure alarm was added on 4/21/16. However, the resident was observed in the bed with the bed alarm in the off position on the alarm box and not blinking to indicate it was in use on 5/10/16 at 3:15 p.m., 4:05 p.m., 4:45 p.m. and 4:48 p.m. During an interview on 5/10/16 at 4:48 p.m., CNA II stated that the resident was a fall risk and tried to get out of bed without assistance and that is why he had a bed alarm. CNA II, confirmed the bed alarm was in the off position and not blinking to indicate it was in use. The CNA turned the alarm on after she confirmed the alarm box was turned off. CNA, II further stated she did not check the alarm when she checked on the resident at the beginning of the shift and had not checked the alarm since her shift started at 3:00 p.m. During an interview on 5/11/16 at 3:55 p.m., the DON stated the resident's bed alarm should have been on during the observation on 5/10/16 and at all times the resident is in bed due to his fall history. 4. Resident # 23 has [DIAGNOSES REDACTED]. The resident had a Care Plan for being at risk for falls related to impaired mobility and impaired vision. The care plan included Interventions for the use of a body alarm when up in a wheelchair and a pressure sensor while in the bed. However, on 5/10/16 at 5:01 p.m., the resident was observed lying in bed, but the bed alarm was not turned on. During an interview on 5/12/16 at 1:26 p.m., Unit Manager GG stated that bed alarms should be on at all times if residents are in bed for their safety. She also stated that chair alarms should be on at all times if the resident is in the chair for their safety. 5. Resident #18 had [DIAGNOSES REDACTED]. Resident #18 was observed on 5/10/16 at 5:15 p.m. in bed, with a bed alarm in place. However, the bed alarm was turned off. Licensed Practical Nurse (LPN) BB confirmed the bed alarm was in the off position. LPN BB turned the bed alarm to the on position at that time. There was a Care Plan in place since 8/18/14, that documented the resident was at risk for falls related to a history of falls, poor safety awareness, Dementia and impaired mobility. However, the interventions listed with the Care Plan did not include the use of a bed alarm. During an interview on 5/12/16 at 12:40 p.m., the Assistant Director of Nursing (ADON) stated it was the responsibility of the nursing staff to update the care plan, including any devices present, such as the alarms for the bed and chair. The ADON stated her expectations of the nursing staff was to ensure these devices were in place and in the on position, functioning properly.

Based on observation and staff interview, the facility failed to ensure personal care items for residents were labeled and stored in a sanitary manner in one (1) resident room and nine (9) shared bathrooms of fifty-one (51) occupied resident rooms. Findings Include: 1. During an observation on 5/9/16 at 11:30 a.m. and 2:34 p.m., in the shared bathroom for room [ROOM NUMBER], there was an unlabeled, unbagged urinal hat stored on the floor near the left side of toilet. On 5/10/16 at 7:41 a.m. and 2:29 p.m. there was an unlabeled toothbrush and tube of toothpaste laying on the window ledge. On 5/10/16 at 8:20 a.m and 2:30 p.m., in room [ROOM NUMBER], there was an unlabeled, unbagged wash basin stored on the floor under Bed A. 2. On 5/10/16 at 2:43 p.m., in the shared bathroom of room [ROOM NUMBER], there was an unlabeled toothbrush and toothpaste stored on the right side of the sink. 3. On 5/10/16 at 2:49 p.m., in the shared bathroom of room [ROOM NUMBER], there was an unlabeled denture cup stored on the right side of the sink. 4. On 5/10/16 at 2:55 p.m., in the shared bathroom of room [ROOM NUMBER], there was an unlabeled blue toothbrush and a bar of soap stored on the window ledge. 5. On 5/10/16 at 2:59 p.m. and on 5/12/16 at 8:15 a.m., in the shared bathroom of room [ROOM NUMBER], there was an unlabeled, unbagged wash basin stored on the floor and a bar of soap and unlabeled toothbrush stored on the window ledge. 6. On 5/10/16 at 3:01 p.m., in the shared bathroom of room [ROOM NUMBER], there was an unlabeled, unbagged urine hat stored on the floor. 8. On 5/12/16 at 8:17 a.m. in the shared bathroom of room [ROOM NUMBER], there was an unlabeled, unbagged urine hat stored on the left hand rail. 9. On 5/9/16 at 11:38 a.m. and on 5/10/16 at 7:38 a.m., in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] there was an unlabeled, unbagged basin and bedpan stored on the bathroom floor. During an interview on 5/12/16 at 9:37 a.m., the Administrator confirmed that she expected personal items to be bagged and stored in the residents' cabinets.