Every finding on record at Regents Park of Jacksonville

Based on record review, interviews, and facility policy and procedure review, the facility failed to develop a care plan for infection and/or antibiotics for Resident #85, and failed to implement a care plan related to use of bed rails for Resident #1, from a total survey sample of 43 residents. Failure to develop and implement a care plan placed residents at risk for missed care, increased risks, and potentially a decline in quality of life. The findings include: 1. A review of the clinical record revealed that Resident #85 was admitted on [DATE] with a re-entry on 10/20/24. His diagnoses included quadriplegia, pressure ulcer of the left buttock stage 4, chronic pain syndrome, osteomyelitis, spinal stenosis, acute kidney failure, and retention of urine. A review of the quarterly minimum data set (MDS) with an assessment reference date (ARD) of 5/4/25 revealed that Resident #85 had a brief interview for mental status (BIMS) score of 15/15, indicating he was cognitively intact. He was noted to have a venous/arterial ulcer and was on antibiotics therapy. A review of Resident #85's physician orders dated 4/22/25 revealed Amoxicillin-Pot Clavulanate Oral Tablet 875-125 milligrams (mg) every 12 hours for heel. Osteomyelitis for 42 Days. Minocycline HCl Oral Tablet 100 MG every 12 hours for Heel. Osteomyelitis for 42 Days. The stop date was noted as 6/3/25 for both medications. Further record review of an infection note dated 5/29/25 indicated that Resident #85 had a right heel wound for over three months. The resident had been on antibiotics before, but the wound was not healing. An infectious disease consultation was requested due to concerns about the right heel wound. An X-ray noted osseous erosions, which was concerning for possible osteomyelitis. Plan: Continue Augmentin 875-125 mg every 12 hours and Minocycline 100 mg every 12 hours for a total of six weeks of therapy, with an end of therapy date of June 3rd, 2025. MRI of the right foot to assess the extent of the infection with osteomyelitis date 5/27 results pending. Refer to podiatry and the orthopedic clinic for an appointment. A review of the care plan revised on 5/22/25 for Resident #85 revealed that antibiotic use and/or wound infection had not been care-planned. (Copy obtained) On 5/30/25 at 1:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that Resident #85 was on antibiotics therapy until 6/3/25 for right heel osteomyelitis. She explained that when residents are on antibiotics nurses should be monitoring the side effects and effectiveness of the medication. She stated that the Minimum Data Set (MDS) nurse was responsible for updating residents' care plans. On 5/30/25 at 1:29 PM, an interview was conducted with Registered Nurse (RN) D, MDS Coordinator. She stated care plan focus areas information is obtained from MDS assessment, nursing assessments, physician orders and tasks. She explained that this information is generated through reports and/or communication during clinical meetings. When asked about the care plan for Resident #85, she confirmed that the care plan for use of antibiotics and/or infection was not initiated. 2. During and interview with Resident #1 on 5/27/25 at 2:40 PM, he stated that his wife had requested side rails be placed on his bed to help him with mobility and positioning in bed. He stated his wife spoke with the unit nurse approximately 3 weeks ago, but did not know which one. He explained that no one had notified him of the status of the rails and they had not been placed on his bed. A review of the clinical record revealed that Resident #1 was admitted on [DATE]. His diagnoses included unspecified dislocation of left shoulder joint, subsequent encounter; muscle weakness (generalized); muscle wasting and atrophy not elsewhere classified, erosive (osteo)arthritis; age-related osteoporosis without current pathological fracture. A review of quarterly MDS with and ARD of 3/15/25 revealed that the resident had a BIMS score of 14/15, indicating cognitively intact. He was assessed to have functional impairment of upper extremity on one side, and required maximum assistance of personal hygiene, bed mobility and bed to chair transfer. A review of Resident #1's physician's orders revealed an order for side rails - half bilaterally for bed mobility (order dated 4/29/25). On 12/31/24- weight bearing to shoulder as tolerated. A review of the care plan revised on 1/25/25 revealed that the resident had activities of daily living (ADL) self-care performance deficit related to left shoulder dislocation, muscle wasting/atrophy/weakness, osteoporosis, osteoarthritis. Interventions included half side rail to right side of bed for bed mobility. (Copy obtained) Review of a nursing interdisciplinary team (IDT) note dated 4/29/25 indicated that the resident was educated on the risks versus benefits such as safety, security, mobility assistance and potential risks and negative outcomes that relate to use of bed rails. The use of bed rail(s) can present a hazard or involve potential risks to certain individuals, particularly those residents with physical limitations or altered mental status, such as delirium or dementia. Potential risks may include getting caught within the rail, getting caught between mattress and rail, strangulation, suffocation, bruising and/or skin tears caused by hitting against rail(s), crawling over the rail(s) and falling from greater heights increasing risk for serious injury or death. Other potential negative outcomes may include, but are not limited to, decline in muscle functioning, skin integrity issues, may alter resident's self-esteem, induces agitation or anxiety, feelings of isolation, decline in other areas of activities of daily living and reduced physical mobility. (Copy obtained) In an interview on 5/30/25 at 2:05 PM, the Certified Nursing Assistant (CNA) B stated that she was assigned to Resident #1. She explained that the resident required moderate assistance with bed positioning and used to be more mobile (requiring minimum assistance) with getting out of his bed when his side rail was in place. She stated she believed his rail was removed around three weeks ago, but was not totally sure of the exact date. During the interview on 5/30/25 at 2:13 PM, RN C Unit Manager stated that she was not aware that resident's side rail was missing, but was made aware by therapy services on 5/28/25. She stated that she spoke with other unit staff who stated that there was an issue with the resident's bed and his new bed would not accommodate the rails currently in maintenance stock. She stated that maintenance was to order new rails for the resident's current bed. She was unsure of the status of the order and could not produce written documentation related to the order when requested. A review of the facility's policy and procedures titled Comprehensive care plans revised on 1/2025 was conducted. The policy read, It is the policy of this facility to develop and implement a comprehensive person-centered care plan of each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 52728

Based on observation, interview and record review, the facility failed to administer oxygen at the ordered flow rate for one (Resident #155) of two residents reviewed for respiratory care, from a total of 43 sampled residents. The findings include: On 05/27/25 at 2:15 PM, Resident #155 was observed resting in bed with eyes closed and with respirations. Observation of the flow rate meter ball revealed it was between 2.5 and 3 liters. (Photographic evidence obtained) On 05/28/25 at 12:05 PM, Resident #155 was observed resting in bed with eyes closed and with respirations. Observation of the flow rate meter ball revealed it was was between 2.5 and 3 liters. (Photographic evidence obtained) On 05/30/25 at 9:33 AM, Resident #155 was observed resting in bed with eyes closed and with respirations. Observation of the flow rate meter ball revealed it was between 2.5 and 3 liters. (Photographic evidence obtained) A review of the clinical record revealed Resident #155 was an [AGE] year old male admitted on [DATE] with diagnoses including dependence on supplemental oxygen, chronic ischemic heart disease, unspecified, and heart disease, unspecified. A review of Resident #155's current physician's orders revealed the resident was prescribed oxygen (O2) at 2 liters/per minute (min.) via nasal cannula for diagnosis of shortness of breath (SOB), every shift for SOB. A review of the baseline care plan for Resident #155, dated 05/21/25, documented the resident was not oriented to person, place, time or situation. Additional review of Resident #155's baseline care plan documented a focus of: the resident is at risk for respiratory complications. The baseline care plan goal noted that the resident will have a minimized risk of respiratory distress through review date. Interventions included: administer oxygen as ordered (Refer to medication administration record for current order). Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects. Report to MD as indicated. Observe for signs or symptoms of respiratory complication. Notify MD of abnormal findings. Observe O2 saturation levels via pulse oximetry as ordered and report as needed. On 05/30/25 at 9:37 AM, an interview was conducted with Employee A, LPN, who reported she has worked at the facility for 3 1/2 years. Observation of Resident #155's room at that time with Employee A revealed that the oxygen (O2) flow rate was set at 3 liters (L) per minute (min). Employee A reviewed the resident's oxygen order in Point Click Care (PCC) and stated that Resident #155's oxygen order was written on 05/27/25, and the order was 2L/min. She explained that she checks resident oxygen flow rates throughout her shift. The process for ensuring residents receive the correct amount of oxygen includes making sure the O2 concentrator is set at the correct liter flow rate, make sure the nasal cannula (NC) is properly placed, and take resident oxygen saturation levels. She explained that she began her shift today at 7:00 AM, and checked Resident #155's oxygen this morning and thought that the order for the resident's oxygen was 3 L/min. Review of the facility's policy titled Oxygen Administration, Date Implemented: 11/2020, Date Reviewed/Revised: 01/2025 and Reviewed/Revised: Clinical Services, documented Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy, page 1 of 2.

Based on food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to maintain sanitary conditions in the main kitchen by following proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Unsafe food handling practices represent a potential source of pathogen exposure. Failure to maintain sanitary food preparation can potentially put the residents at risk for foodborne illness. The findings include: During observations of the kitchen and lunch meal service on 11/07/23 from 10:35 am to 12:55 pm, the following was observed: Employee H was observed on the clean side of the dish machine emptying trays of clean dishes as they came out of the dish machine, she had no gloves on. The dish machine was observed to be a low temperature dish machine with chlorine bleach as the sanitizing agent. From 10:35 am to 11:00 am, Employee H went back and forth between the clean and dirty side of the dish room loading and unloading the trays without washing her hands. As the dishes were cleaned and came out of the machine on the conveyor belt, she took the trays and emptied them, stacking the dishes up on a shelf. The dishes were not allowed to air dry. The stainless steel-utensils used by the residents were not allowed to air dry. They were dumped into another tray and taken to the kitchen. At 11:45 am, the registered dietician and dietary staff were observed wrapping the wet utensils in napkins and placing them on food trays for service. At 11:00 am, the Staffing Coordinator, Employee K, was observed working in the dish room loading dirty dishes onto dish machine trays. Employee H was observed going to the dirty side of the dish room and putting dirty dishes on a tray. She then returned to the clean side of the room and continued unloading dishes without washing her hands. At 11:10 am, Employee H was asked to test the sanitizer level in the dish machine. She stated she needed to get the test strips and left the dish room. She returned and tested the water on a cup that had just been washed. The test strip remained white indicating 0 parts per million (ppm) of bleach in the water. She took another test strip and tried again by placing the test strip on the back of an insulated dome cover. The test strip remained white indicating 0 ppm. (Photographic evidence obtained) She stated she did not understand why the test strip did not turn blue. She tested the machine this morning when she came to work. Employee H referred to the log on a clip board hanging on the wall. The log read 50 ppm for the date 11/07/23. She then asked the other dietary aide, Employee G, for assistance. Employee G came over to the dish machine and took the bucket of chlorine bleach out from under the machine and stated that the bucket was empty. Employee H went and got another bucket and Employee G inserted the hose into the new bucket and showed Employee H how to do it. She placed the new bucket of chlorine bleach under the machine and went back to her task. Employee H continued to run the machine. At 11:22 am, she was asked to test the machine again. She tested it using a test strip and the test strip remained white. When asked what she was trained to do, she stated she was going to inform the CDM and left the dish room. At 11:25 am, the DM entered the dish room and tested the water with a test strip. The test strip remained white. (Photographic evidence obtained) He then primed the machine at the top of the machine where the hose from the bucket of chlorine bleach enters the machine and ran a load of dishes. He tested the water and the test strip indicated 200+ ppm. The DM stated that the test strip was very dark and there was a lot of bleach in the water now. It was probably due to having just primed it. He confirmed that 200+ ppm was a toxic level of bleach, and he would keep an eye on it. At 11:40 am, black biological growth was observed on the interior surfaces of the ice machine. Black biological growth and dust debris was observed on the air vents over the food preparation table and the smoke alarm in the center of the ceiling in the kitchen. Black biological growth was observed on the gaskets and interior of the milk cooler. Food debris was observed on the inside of the cooler and the bottom of the milk cooler was wet with slimy black liquid with a spoon lying in it. (Photographic evidence obtained) Three large cardboard boxes containing Styrofoam cups and hinged containers with lids were observed sitting directly on the floor of the kitchen. The staff later used the products to serve the lunch meal service to the residents. (Photographic evidence obtained) The drawers of the service tables were observed to have food debris in the bottoms. Utensils in the drawers were not clean and had food debris stuck on them. Missing and broken floor tiles were in front of the prep sink, at the entry way of the kitchen, and throughout the kitchen. The tray carts were dirty clean with food debris stuck on them. The floors under the equipment and in the corners of the kitchen were not clean with a buildup of food and grease debris. The sides and back of the steam table had dried up food debris and liquid that had run down the side. The storage and food preparation table had food debris on the them. Plates stacked in the plate warmer had food debris stuck to them. Large stainless steel baking pans were observed to be wet and stacked in such a way that did not allow for air drying. The tile wall of the kitchen near the steam table and entrance had brown food and dust debris stuck-on it. (Photographic evidence obtained) A ceiling tile was hanging down above the walk-in cooler. Two large chopping knives and a long-serrated knife were observed lying on the window sill at the back of the kitchen. The chopping knives were lying on top of cooking gloves and the serrated knife was lying on the sill itself. At 11:50 am, the DM went to the sill and took serrated knife down. He took it to the prep table and proceeded to use it. He did not clean it prior to use. (Photographic evidence obtained) At 11:52 am, when asked why the knives were stored in such a manner, the DM shrugged his shoulders, shook his head and stated, I don't know. The Assistant Dietary Manager (ADM), Employee F, was observed opening a cardboard container of mashed potato flakes with her bare hands. She then pour the food into a pot of water on the stove. The ADM closed the container and put it away for future use, she did not mark a date on the box. At 11:55 am, broken floor tiles were observed in the walk-in freezer. The shelves and the floor of the freezer were not clean and had discarded food containers under the shelves. (Photographic evidence obtained) The shelves in the walk-in cooler had a buildup of food debris and the cooler walls had black biological growth on them. Under the shelves there were discarded cardboard food wrappers and food debris. A large sleeve of sliced cheese was uncovered, open to the air with no date mark on it. (Photographic evidence obtained) At 12:00 pm, the ADM was observed to don a pair of disposable gloves without washing her hands and started to plate the food for the lunch. Shortly thereafter, she left the steam table and walked 20 feet over to the oven, opened the door, and with hot pads took a pan out of the oven. The ADM took the pan to the steam table and put it in. She did not change the contaminated gloves or wash her hands and don new gloves. At 12:40 pm, the DM stated he did not have enough staff to do the deep cleaning that needed to be done in the kitchen. He confirmed that the ADM should doff disposable gloves after contaminating them and then wash her hands with soap and water prior to donning a pair of new gloves. The DM stated he would provide an in-service for the staff who operate the dish machine to make sure they are monitoring the level of sanitizer and that the machine is functioning properly. During an interview with the Administrator on 11/07/2023 at 2:00 pm, she produced the Quality Assurance Committee Performance Improvement Plan (PIP) from the prior recertification survey when the facility had been cited for deficiencies in the kitchen. The Administrator stated that the PIP was still ongoing even though the plan was only for the three months after the survey to ensure the deficiencies were corrected. She acknowledged that the ice machine was not clean, and the plan had not been followed. She explained that the facility contracts for maintenance of the ice machine and the vendor last cleaned the machine on 09/14/2023. The Administrator stated the dietary staff clean the machine once a month, but she was unable to produce a log showing the cleaning had been done. None of the other findings during this survey were identified during the recertification survey. A review of the invoice from the vendor providing maintenance and cleaning services of the ice machine dated 09/21/2023 revealed it read: Cleaned ice machine in the kitchen. Chemically cleaned the evap and all the tube. Scrubbed the inside of the bin and reservoir. Replace water filter. Technician recommended a new machine multiple times to the client due to how old it is. Checked operation (Copy obtained) Review of the Quality Assurance Committee PIP developed after the last recertification survey conducted on 07/27/2023, revealed the facility implemented monitoring of the cleanliness of the kitchen by developing a Food and Physical Safety Auditing tool that included cleaning schedules weekly for equipment and areas of the kitchen. Floors, walls, doors, baseboards cleaned. All dishes allowed to air dry (not stacked wet), pots, pans, dishware, utensils store to prevent contamination. All cooling units clean and in good condition. All food stored properly, and date marked. All equipment clean and in good working order. The tools had been marked off as being complete as of 10/26/2023. (Copies obtained) An infection control audit tool had been developed dated 10/12/2023 that read: 4. Staff washes hands when changing tasks, including before placing gloves on hands. 7. Proper dish washing procedures are followed. Sanitizer solutions at proper PPM and temperatures within desired range and recorded. Staff can verbalize how to check PPM's and appropriate dish machine temperature. Review of the facility policy and procedure entitled Ice Machine, effective 01/2021 revealed it read: The ice machine, scoop and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. (Copy obtained) Review of the facility policy and procedure entitled Personal Hygiene, effective 09/2020 read: To ensure proper personal hygiene practices to prevent contamination of food. Procedure: 2. Wash hands after the following activities, including, but not limited to: After touching anything that may contaminate hands, such as dirty dishes, un-sanitized equipment, work surfaces or wash cloths. Review of the facility policy and procedure entitled Hand Washing and Glove Use, effective 9/2020 read: hand washing is a vital role in infection control reducing the surface microorganisms on our hands. Gloves are used to provide a barrier between potential microorganisms and ready - to- eat food items being prepared and/or portioned by staff. Procedure: 1. Hands must be washed after contact with unsanitary surfaces and before wearing gloves. 5. Gloves should be changed frequently, single use task. Review of the facility policy and procedure entitled Cleaning Schedules, effective 01/2021 read: Food and Nutrition Service Staff shall maintain the sanitation of the Department through compliance with written, comprehensive cleaning schedules developed for the facility by the Food Service Manager. 5. The Food Service Manager will complete random audits to ensure personnel are compliant with cleaning and sanitizing of equipment and completion of the cleaning log. Review of the Daily/Weekly Kitchen Sanitation Checklist revised 11/04/2020 revealed it read: Main Kitchen: All reach-in and walk-in cooler clean all items covered, labeled and dated. Freezer - nothing on the floor, floor clean. Walk-ins- nothing on floor, floor clean, all food labeled and dated. Ice machine clean regular as scheduled. All food delivery carts clean in and out including wheels. Cooking area- make sure all equipment is clean and in good working order. Tray-line wiped down and sanitized under shelving clean. Kitchen floors cleaned including behind and under all equipment. Dish Room: Dish machine clean and in good working order. All utensils, pots and pans clean and stacked on rack properly to prevent wet nesting. Review of the facility policy and procedure entitled Sanitation, effective 09/2021 read: The facility strives to promote good sanitation practices to protect its residents and employees from foodborne illness. The facility sanitation process will ensure a clean, safe environment for it residents and staff. The Food and Nutrition Services staff identifies the potentially hazardous foods, which bacteria can grow most easily. The team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceilings and equipment and utensils are clean and/or sanitized and in good working order. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instruction procedures and Nutrition Services Cleaning Schedule. References: Ice machines/ice bins/dispensing nozzles and lines/cooking oil storage/water vending: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned:(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. https://www.fda.gov/food/fda-food-code/food-code-2022 Reference: United States Food and Drug Administration Food Code 2017. 3. PUBLIC HEALTH AND CONSUMER EXPECTATIONS. Clean environment. Page 10. https://www.fda.gov Reference: United States Food and Drug Administration Food Code 2017. Sections. 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. https://www.fda.gov

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to complete the temperature log for the three-compartment sink; properly clean and sanitize the kitchen ice machine, upper-level of convection oven, can opener, and oven tray lines; date mark several open packages of bread on the bread rack, and in the refrigerator. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 7/23/2023 at 11:15 a.m. During the tour, the July 2023 Sanitizer Solution Log for the three-compartment sink was incomplete; only 7/1/2023 was logged. No date markings were observed in the refrigerator on one open, wrapped bag of greens, one box of red potatoes, one box of melons, one plastic container of cottage cheese, or on one bag of onions. The bread rack next to the shelf in the dry storage room had several open bundles of bread with no date markings. The same observations of the red potatoes, melons, and bread were made again on 7/25/2023 at 1:43 p.m. One open box of strawberries was also observed on the shelf in the refrigerator. During the same time, the Certified Dietary Manager (CDM) was notified that one package of buns was taken off the shelf and discarded by this surveyor due to observation of mold on the buns. (Photographic evidence and copies obtained) A follow-up tour of the kitchen was conducted on 7/26/2023 at 11:19 a.m. The can opener pixel holder was greasy and filled with food debris. The oven tray was filled with food debris and a liquid substance, another oven tray was filled with food debris. The left side of the convection oven was filled with grease buildup. The convection oven bottom right and left door and inside floor of the oven were covered with a grime. The inside of the drink dispenser spigot was covered with grime and was observed hanging off the counter, and a black substance was observed on and around the internal shoot of the ice machine. (Photographic evidence obtained) An interview was conducted on 07/27/23 at 10:06 a.m. with Dietary Aide D. She stated temperature logs were completed daily by staff assigned to the area. Dietary Aides were responsible for the dish machine and the Cooks were responsible for the three-compartment sink. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, she stated, Opened food is labeled with the date opened and expiration date. When asked what happened when bread was opened, used, and placed back on the bread rack, she replied, Leftover bread should be discarded. The Cook was responsible for cleaning the oven and oven trays. Dietary Aides were responsible for cleaning the drink machine. When there was a problem with broken kitchen equipment, the manager would report items to maintenance. She was not sure how often the ice machine was cleaned. An interview was conducted on 07/27/23 at 10:24 a.m. with Cook E, who stated sanitation temperatures were documented by the staff assigned on the temperature log daily. The Cook and Dietary Aide stored food in the refrigerator and freezer. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, she stated, Open food is wrapped and labeled with the date opened and discarded in 3-7 days. Open bread was labeled with the date opened and the date to be discarded. All staff were responsible for cleaning the ice machine. The Cook was responsible for cleaning the kitchen ovens weekly. Cook E was not sure how cleaning was logged. When asked who was responsible for reporting broken equipment, she stated, All staff can complete a work order for maintenance. An interview was conducted on 07/27/23 at 10:50 a.m. with the Certified Dietary Manager (CDM), who confirmed that sanitation temperatures were documented on the temperature log daily by the staff assigned to the task. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, the CDM replied, Open food is sealed and labeled with the date opened and the date to be discarded. Open bread was labeled and dated. The Cook was responsible for cleaning the ovens and the Dietary Aide was responsible for cleaning the drink machine. The oven was cleaned every two weeks. The CDM reported broken kitchen equipment to maintenance. When asked how long the oven had not worked, she replied, I think forever. The CDM stated she and Cook/Assist Manager F were responsible for wiping the inside of the ice machine every two weeks. She confirmed there was no log to show evidence of the cleaning. A review of the facility's policy and procedure titled Pot and Test Strip Log, dated January 2021, revealed: Monitor the three-compartment sink wash temperature and chemical saturation (parts per million {PPM} at each pot and pan washing in order to assure proper cleaning and sanitizing of dishes. Procedure: 3. Test the third sink well for proper parts per million (PPM) per chemical directions. 4. Record chemical saturation level by indicating PPM using the appropriate litmus paper .Forms: Sanitizer Log. (Copy Obtained) A review of the facility's policy and procedure titled Sanitation, dated September 2021, revealed: The facility strives to promote good sanitation practices to protect its residents and employees from foodborne illness. The facility sanitation process will ensure a clean, safe environment for its residents and staff. Procedure: . The food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceilings and equipment and utensils are clean and/or sanitized and in good, working order. the Centers for Disease Control (CDC) Food handling guideline is used for specific hand washing procedure. 5. Ensure food and chemical containers are labeled with name and date received. 20. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instruction procedures and Nutrition Services Cleaning Schedule. (Copy Obtained) A review of the facility's policy and procedure titled Ice Machine, dated January 2021, revealed: The ice machine, scoop and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. (Copy Obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 3, Page 93 and Chapter 4, Page 127, 131, and 165. https://www.fda.gov (Accessed on 07/30/2023. 3-501.17, Commercially processed food, open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, Ready -to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Equipment. 4.501.11. Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Sanitization of Equipment and Utensils. 4-701.10 Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be sanitized.

Based on resident observation and interview, record review, staff interviews, and a review of the facility's policy and procedure, the facility failed to honor food preferences and alert kitchen and facility staff of major food allergies for one (Resident # 3) of fourteen residents observed for dining, from a total sample of 19 residents. Resident #3 is allergic to seafood, peanut butter and jelly. This was not listed on her dietary meal tray slip to alert staff to these food allergens when serving her meals and providing substitutions to pre-selected meal choices. Failure to identify and respect resident food allergens/intolerances could result in mild to acute, and potentially life-threatening allergic responses. The findings include: An interview was conducted with Resident #3 on 7/23/2023 at 1:29 PM, while she was observed eating lunch in her bed in an upright seated position. When asked how her lunch was, she reported her food preferences were not being met and the facility staff were not using the menus. She reported being allergic to seafood, fish, and shellfish, but had been given fish before because the facility did not honor her food requests. She further stated she was sent to the hospital after eating a peanut butter and jelly sandwich a while back, that resulted in her tongue and throat swelling. Resident #3 provided her food tray ticket, pointing out that her food choices for that meal were not what she was served. She further stated none of the foods she was allergic to were listed on the dietary meal tray slip. (Photographic evidence obtained) A record review for Resident #3 found she was admitted to the facility on [DATE], with a primary diagnosis of metabolic encephalopathy. She had a quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 5/14/2023, that noted she had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating she was cognitively intact and able to make daily decisions independently. She was coded as requiring supervision with eating after set-up assistance. Her primary medical diagnoses included metabolic encephalopathy, cerebral infarction, diabetes mellitus, dysphagia, heart failure, and multiple sclerosis. Resident #3 was care planned on 10/10/2022 for having a nutritional problem related to food allergies seafood, peanut butter, and jelly with the goal to maintain nutritional intake. Interventions included diet as ordered (Check POS (Physician's Order Sheets) for current order) and observe and document: tolerance to diet/fluids, refusing to eat, and when she appears concerned during mealtimes. On 1/24/2023, a care plan was created for allergies to include peanut butter and jelly, with the goal to remain allergic free until the next review date. Interventions included checking any food allergies when offering meals or snacks. (Photographic evidence obtained) A review of nursing progress notes revealed that on 1/20/2023, Resident #3 was noted with tongue swelling after eating a peanut butter and jelly sandwich. On 1/23/2023, a nursing note documented Resident #3 returned from the hospital with an allergy to peanut butter added to her chart, and dietary having been made aware. Another observation on 7/24/2023 at 1:19 PM, was made of Resident #3 where she was noted to be in her room, in a seated, upright position in bed eating lunch. She reported that again, they had served her the wrong meal. No food allergies were documented on her food tray slip alerting staff to her peanut butter, jelly, and seafood allergies. (Photographic evidence obtained) An interview was conducted with the Certified Dietary Manager (CDM) on 7/27/2023 at 9:51 AM, who reported that the Registered Dietician (RD) was responsible for gathering the food preferences, but she, the CDM, collected them if needed. The CDM confirmed that if there were updates or changes to a resident's diet, the RD made those updates to the dietary meal tray ticket through the Meal Tracker system. The CDM further stated that both food allergies and food preferences were identified on the dietary meal tray ticket printed from the Meal Tracker system and used by the dietary staff when preparing meals. On 7/27/2023 at 10:01 AM, an interview was conducted with the Registered Dietician (RD), who reported that she met with all new residents within 24-hours of admission to review preferences and complete a weight loss and malnutrition screening. New residents were given menus to fill out with preferences identified, that were collected and given to the dietary department for the day or week. She then made updates utilizing the Meal Tracking system. When asked about Resident #3, she reported that Resident # 3 was picky about her food, was on select menus where she could select her own food and preferences and wasn't nutritionally at risk. When asked how food allergies were identified, the RD stated the Meal Tracker system identified food allergies that were printed on the meal tray ticket. The RD was asked to pull up Resident #3 in the system and confirm that her food allergies were listed to print on her meal tray ticket. The RD stated she found a glitch in the system and confirmed that Resident #3's food allergies were not being pulled through the Meal Tracker system or being printed out on the meal tray ticket and stated, that's a problem. She further stated the Regional RD would be contacted for assistance and for the time being, she would be printing a list of all the residents with food allergies, placing a note about their food allergies in the Meal Tracking system so the residents' meal tray tickets would now have their food allergies printed on the ticket. A review of the facility's policy and procedure for Food Preferences (dated January 2023), revealed under procedure: Food preferences will be updated as needed on an ongoing basis and Food preferences may be kept on file or in the meal tray card system. (Photographic evidence obtained)

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings include: On 10/18/21 at 1:30 p.m., an observation of the low-temperature dishwasher machine was made. The dishwasher temperature log was observed with no area to record sanitizer strength on it. The Certified Dietary Manager (CDM) was asked about the log at this time, and he stated he had just started working here three weeks ago. He never noticed that the log had no area to document the sanitation of the dishwasher. An observation of lunch service was made on 10/18/21. Meal plates had plastic and metal covers that were not sitting directly on the plates. The plate coverings had slipped off the plates during transport from the kitchen to the resident rooms while in the food cart. At this time, it was also observed that not all residents had an insulated dome plate cover. Some residents' plates had metal plate covers, while others had no plastic bottom or metal pellet and only had an insulated dome covering the plate. On 10/18/21 at 1:40 p.m., the CDM was interviewed about the insulated plastic dome covers, and he stated more had been ordered but were backordered. He could not produce the original order from the previous CDM that he stated were backordered. At this time, the CDM produced a copy of the order for insulated dome plate coverings, which was dated 10/18/21, the same day the interview was conducted. When asked about the date on the order, he stated he had placed a new order because he could not find the original order. On 10/19/21 at 4:03 p.m., the CDM was asked to show the cooked temperatures and the trayline temperatures for the chicken served at lunch. The CDM showed the temperature log book, which had only one temperature recorded for chicken cooked at lunch, which was 155°F (Fahrenheit). The CDM stated the hold and cooking temperatures were the same. He reported the chicken should get to 165°F and that it was baked for about an hour. On 10/20/21 at 11:31 a.m., an observation was made in the kitchen to watch lunch service. The Assistant Food Service Manager (AFSM) was asked how the lunch food was cooked, and he confirmed he had cooked the foods for lunch. The lunch recipes were reviewed with the AFSM. At this time, the AFSM was interviewed, and he reported he had prepared and cooked the fresh zucchini, and reported he followed the recipes. He was asked if he added the salt in the recipe. He stated no, just garlic seasoning. He stated he didn't add salt because some residents were on a no added salt diet. The AFSM was asked if he liked the food. He stated, It doesn't matter what I like, I have to go by what the residents' needs are. The Director of Food Services was interviewed on 10/20/21 and confirmed the recipes should be followed, and salt should be added to the recipes when stated on the recipes. She confirmed all recipes were for all residents. The CDM reported that Dietary conducted weekly and daily audits. He produced no weekly audit forms. The Quality Assessment tool dated 1/14/21, had no additional dates or follow-up assessments on the form. (Copy obtained) A copy of another Quality Assessment and Performance Improvement Plan, dated 8/14/2021, with a completion date of 9/14/2021, was provided for review. Both of these Quality Improvement plans had no plan to improve food temperatures despite multiple grievances about cold food in grievance logs for the past six months. The CDM was interviewed on 10/20/21 at 12:20 p.m. He confirmed that the insulated bottoms and dome plate covers did not fit properly together with the metal base pellet, and reported they were purchased separately. A test tray at lunch on 10/20/21 at 1:09 p.m., revealed the vegetable quiche and zucchini were bland. At this lunch service, the kitchen ran out of knives and several residents were not given knives on their lunch trays. An additional interview was conducted with the CDM on 10/21/21 at 2:26 p.m. He reported he had just gotten a delivery of knives today. The box was unopened. The knives had not been cleaned or prepared for the next meal service yet. A review of the facility's policy on Cooking revealed, Cook food to a proper internal temperature to prevent foodborne illness. Facility procedures in this policy also read, Follow recipes for proper cooking times and temperatures.

Based on observations and interviews, the facility failed to ensure each resident was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Residents #45 and #136) of 31 sample residents. Specifically, the facility failed to properly assist Resident #45 through the facility in her Geri chair or ensure call lights were answered timely for Resident #136. The findings include: 1. A review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/2/2021 Minimum Data Set (MDS) assessment, Resident #45 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. According to a 9/27/2021 progress note, the resident was alert and oriented x 2 to 3. On 10/20/2021 at 11:40 a.m., Resident #45 was observed exiting the therapy room with Physical Therapist (PT) I. PT I was observed pushing the resident in her Geri chair, and with the second hand pushing the resident's tube feeding pole. He wheeled the resident in her Geri chair backwards out of the therapy room, and down three hallways towards the beauty salon. The Corporate Risk Management Specialist (CRMS) was observed assisting PT I pull the resident backwards into the beauty salon. On 10/20/2021 at 11:45 a.m., an interview was conducted with PT I. He stated he could have pushed Resident #45 forward in her Geri chair, but with his hands full pulling the tube feeding pole, it was easier to pull the resident backwards through the facility. He was not aware of the dignity aspect of pulling a resident backwards. He did not recall being educated on the concern. An interview was conducted with the CRMS on 10/20/2021 at 11:48 a.m. He stated he assisted PT I with helping Resident #45 into the beauty salon, because PT I had his hands full. The CRMS stated he thought it would be helpful to assist PT I. He further stated it could be difficult to push a resident forward in a Geri chair with a second device attached (tube feeding pole). He said pushing a resident backwards could be disorienting and could be a potential dignity concern. He was not sure if there had been training for the staff on resident dignity, but he would make sure it was addressed. A review of the facility's policy on Resident Rights (effective February 2021 without revision), revealed: The facility strives to assure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. 2. A record review for Resident #136 revealed a [AGE] year-old female admitted on [DATE] with a [CONDITION(S)], respiratory distress, diabetes and depression. She was alert and oriented with a BIMS score of 13 out of a possible 15 points, indicating intact cognition. She required extensive assistance with transfers, bathing, toileting and dressing, and was independent with eating. She was incontinent of bowel and bladder. She was able to speak with the [CONDITION(S)] in place and could make her needs known. On 10/18/2021 at 11:30 a.m., upon entering her room, her call light was on. She was very upset because it took so long for someone to answer call light. She said she was wet and needed to be changed. She stated she had put her light on prior to this surveyor's arrival. She stated a certified nursing assistant (CNA) came in said she would be back, then turned off the light and left. She said that was 15 minutes ago. A second staff person came in and asked what she wanted, and said she would get someone. During the interview at 12:05 p.m., the Director of Nursing (DON) entered the room. Resident #136 was asked if she knew who he was, and she replied no. The DON listened to her concerns and told her he would send someone in to assist her and write up a grievance. At 12:15 p.m., no staff had arrived. At 12:20 p.m., CNA E entered the room and asked what the resident needed. Resident #136 explained she needed to be changed and CNA E stated she would help her. A review of the staffing on the 200 Unit on 10/18/2021, revealed there were 33 residents on the unit. There were two nurses and two CNAs. During an interview with CNA E on 10/18/2021 at 1:30 p.m., she was asked how many CNAs were on the unit. She said only two, there were suppose to be three, but one was taken off to care for a resident needing 1:1 monitoring. Call light response was observed on the 200 hallway on 10/18/2021 between 11:30 a.m. and 1:45 p.m. The response time was 30-45 minutes. During an interview with Resident #136 on 10/20/2021 at 12:30 p.m., she was asked about call light response today. She said she put her light on this morning at 7:30 a.m. to get changed. CNA F came in and Resident #136 told her she was wet and needed to be changed. The CNA said she would come back, but when she came back at 8:30 a.m., the resident had already been served her breakfast and was eating, so she said the CNA should come back later. She did not like the fact she had to eat when she was wet. She was asked if she had reported these occurrences to anyone, and she replied that she had, but nothing had been done about it. During an interview with Resident #136 on 10/20/2021 at 11:05 a.m., she reported that she couldn't get help during the night to get changed. She said when she put her light on, someone must have been turning it off from outside the room, as the light would go off at the wall. She said, You have to keep putting the light on and hope someone will come. Finally someone came in at 3:30 a.m. An interview was conducted with the Unit Manager G on 10/18/2021 at 2:10 p.m. She was asked if she had been made aware by the residents of the long wait time for call lights. She said she was new to the position but the facility was working on it. A review of the grievance logs for the past six months found multiple complaints regarding call light response. The resolution was more in-service training. During an interview with the Social Worker on 10/21/2021 at 10:15 a.m., she was asked about the numerous complaints about long wait times for call light response. She said she was new to the facility and was not at the facility at the time. She said the facility was in the process of hiring new staff. A review of the Resident Council notes, dated 10/12/21, revealed call light response and long wait times were ongoing issues. An interview was conducted with the Director of Nursing (DON) on 10/21/2021 at 11:10 a.m. He was asked whether he was aware of the issue with long wait times for call lights and that staff were turning off the call lights and not returning to the residents' rooms. He said he had been in the position for only a few weeks and was evaluating what was going on in the facility. He was in the process of hiring more staff.

Based on record reviews, observations, and staff and resident interviews, the facility failed to ensure enteral feeding orders were followed per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. A record review for Resident # 78 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was alert and oriented with a Brife Interview for Mental Status (BIMS) score of 14 out of a possible 15 points. She required extensive assistance with transfers, dressing , bathing, and toileting, and she was dependent for meals/nutrition due to use of a feeding tube. A review of the October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Total volume of 1210 ml infused in 22 hours. May turn off for care. Start at 8pm, verify infusing every shift. Clear pump when total volume infused. Water flush 100 ml every 4 hours. During an observation on 10/18/2021 at 11:30 a.m., the tube feeding pump was not running. There was a container of Glucerna 1.2 tube feeding hanging on the IV (intravenous) pole. The container label was blank, there was no date or time the product was hung, the resident's name was not written on the product, nor was the flow rate ordered. An interview was conducted with Licensed Practical Nurse (LPN) D on 10/18/2021 at 11:45 a.m. She was asked why the tube feeding for Resident #78 was not running. She said the resident stated she felt full and complained of nausea. When asked how long the feeding had been off, she said since about 8:00 a.m. When asked if the physician had been notified she said no. She was asked when the tube feeding would be restarted, and she said she would ask the resident how she felt and then would turn it back on. Observation of the tube feeding pump on 10/18/2021 at 2:05 p.m., found it was running. LPN D was asked if Resident #78 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing of the orders, she said no. An interview was conducted with Resident #78 on 10/18/2021 at 12:05 p.m. She was asked if she had asked that the tube feeding be stopped this morning. She said she did. Her stomach felt very full and she had nausea. She was asked if she had had this issue before, and she replied yes, for awhile now. When asked if she was given any medication for the nausea, she said not that she knew of. An observation on 10/19/2021 at 9:10 a.m., found the tube feeding pump was not running. There was a full bottle of Glucerna 1.2 hanging with no date or time, flow rate or resident name. During an interview with Resident #78 on 10/19/2021 at 9:15 a.m., she was asked why the tube feeding was off. She said she had nausea again and requested it be stopped. The tube feeding pump was observed on 10/19/2021 at 4:10 p.m. It was turned on and indicated 343 ml had infused. The time started was not noted. An order was found on 10/19/21 at 2:30 p.m. to stop the tube feeding for three hours per resident request. A review of the nursing notes revealed on 10/11/21 she complained of nausea and requested the tube feeding be disconnected. On 9/27/2021, the resident requested the tube feeding be disconnected due to feeling full. Dietary consult to adjust feeding volume. There was no documentation the physician was notified, nor dietary consulted. An interview was conducted with the Registered Dietitian (RD) on 10/20/2021 at 9:35 a.m. She was asked when the last time was that she had reviewed the tube feeding orders for Resident #78. She said her last review was on 10/12/2021. The order included: Glucerna 1.2 at 55 ml/hour for 22 hours. She said the resident complained of feeling full and she decreased the water flush from 125 ml to 100 ml every 4 hours. She was asked if she was aware that Resident #78 had been complaining of nausea and fullness, and the tube feeding was being held during the day. She stated she was not told, but would follow up today. An observation of the tube feeding pump on 10/20/2021 at 11:05 a.m., found the tube feeding pump was off. An interview was conducted on 10/20/2021 at 11:15 a.m. with Agency LPN C. She was asked if the tube feeding was running for Resident #78 when she came in today. She said it was running and she shut it off at 10:30 a.m., as the pump read she had received 1210 ml. When asked what the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said because the resident sometimes requested the feeding be stopped, the schedule did not remain the same. When asked when the pump would be turned on, she replied 2:00 p.m. She was asked how she determined what time to restart the feeding. She replied that she gave the resident's stomach time to rest. When asked if the physician was aware that she was not receiving the tube feeding as ordered, she said she didn't know. An interview was conducted 10/21/2021 at 9:15 a.m. with the RD. She reported that she had spoken with the nurse and resident about the tube feeding schedule and the issue with the resident's nausea. The nurse told her that the feeding was not being given for 14 hours because the resident had been complaining about fullness and nausea. There was no indication of how much feeding she was receiving or when it was turned on or off. She said she spoke to the resident about the tube feeding schedule, and the resident wanted to have her tube feeding on during meal times so she could get up out of bed. She wanted to go to therapy. She did not want to be hooked up to the pump while out of bed. She told the RD that she wanted to be able to eat again. Speech therapy was in to see her today and conduct a swallow study and trial feeding. The RD stated there was an interdisplinary team meeting to discuss the issue with tube feeding, the pump being off, complaints of fullness and nausea, and the resident's request to be able to eat and have therapy. Orders had been obtained for [MEDICATION(S)] (nausea medication) and speech therapy. 2. A review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/2/2021 Minimum Data Set (MDS) assessment, Resident #45 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. According to a 9/27/2021 progress note, the resident was alert and oriented times 2 to 3. Resident observations: -10/18/2021 at 1:05 p.m. the tube feeding pump was infusing at 70 ml (milliliters)/hour -10/19/2021 at 8:25 a.m. the tube feeding pump was infusing at 70 ml/hour -10/19/2021 at 2:10 p.m. the tube feeding pump was infusing at 70 ml/hour -10/19/2021 at 3:10 p.m. the tube feeding pump was infusing at 70 ml/hour -10/21/2021 at 9:45 a.m. the tube feeding pump was infusing at 70 ml/hour A record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Total volume of 1560 ml infused in 24 H (hours). May turn off for care/services. Start at 2:00 p.m. Verify infusing Q (every) shift. Clear pump when total volume has infused. A record review revealed the last interdisciplinary team (IDT) progress note was written on 10/13/2021. It documented that the resident was on an enteral feeding, [MEDICATION(S)] 1.5 via feeding tube. The tube was patent and intact. The RD (registered dietitian) reviewed and adjusted the rate. A care plan, initiated on 8/10/2021 without revision, stated the resident was receiving enteral nutrition because of dysphagia. Interventions included to administer enteral nutrition as ordered (refer to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Registered Nurse (RN) G on 10/21/2021 at 9:54 a.m. She said that residents on a feeding tube would be monitored by the nurse on duty, the IDT and the RD. She said they had a nutritional at risk meeting each Friday to discuss residents identified with dietary concerns, including all of those on tube feedings. She said only the nurses would handle the pumps, and would be responsible for making sure the pumps were infusing correctly, according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN G observed the resident's feeding tube pump infusing at 70cc, changed it to 65 cc, and said it should not be at 70 cc. She said the unit manager should also be checking on the pump infusions to be sure the right order was in place. An interview was conducted with LPN D on 10/21/2021 at 9:59 a.m. She said she had noticed the other day that Resident #45's pump was infusing at 70 ml/hour, so she had to adjust it manually back to 65 ml/hour. She said that when she replaced the daily tube feeding bag of [MEDICATION(S)] 1.5 Cal (calorie) for a new one, and turned it on, the machine pump would reset itself back to the last programmed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she documented daily what her flush volume had been, but there was no place on the electronic medication or treatment administration record to document the resident's daily volume of enteral feeding. An interview was conducted with the Director of Nursing (DON) on 10/21/2021 at 10:10 a.m. He said the interdisciplinary team met each week for a nutritional at risk meeting, which would include residents with tube feeding orders. He said the RD would also attend. He said the residents reviewed each week were also triggered as at risk due to the documented weight levels. He said the IDT would make a progress note in the resident's chart regarding what the team had decided or assessed for those residents' dietary needs. He said that the nurses did not document a resident's daily total volume of enteral feed, but instead relied on the weights. An interview was conducted with the Registered Dietitian (RD) on 10/21/2021 at 10:17 a.m. She confirmed that the facility did not document a resident's total volume from the tube feeding. Instead, she reviewed weights and attended the nutritional at risk meeting. She said she had changed Resident #45's tube feeding order on 10/12/2021 to 65 ml/hour instead of 70 ml/hour. She said she was not aware that the resident was not receiving her enteral feeding according to the order. An interview was conducted with the DON and the RD on 10/21/2021 at 10:20 a.m. Neither staff member was aware the resident was receiving her tube feeding at 70 ml/hour instead of the current order of 65 ml/hour. Neither staff member was aware that the tube feeding pump was resetting itself to a prior order. The DON said he would look into the potential programming issue of the pump infuser in order to correct the concern.

Based on observation, interview and record review, the facility failed to provide appropriate oxygen therapy to one (Resident #34) of 33 residents sampled, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A review of the medical record revealed that Resident #34 was admitted into the facility on [DATE]. Her last readmission was on 11/13/2017. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/2021, revealed that Resident #34 scored 14 out of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating her cognition was intact. She required total assistance with transfers, and extensive assistance with bed mobility, locomotion on/off the unit, dressing, toilet use and personal hygiene. She required supervision with meals/eating. Based on the MDS assessment, Resident #34 did not receive oxygen prior to nor while residing in the facility. On 10/18/2021 at 2:15 p.m., Resident #34 was observed receiving oxygen via nasal cannula from a portable oxygen tank. The resident was unsure of the proper setting and could not explain why she was receiving oxygen. The flow rate could not be read, and the electronic medical record review rendered no orders for the resident to receive oxygen. On 10/19/2021 at 10:42 a.m., a record review for Resident #34 revealed there were no orders for oxygen. The latest written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/19/2021 at 10:50 a.m., Resident #34 was observed resting in bed with a nasal cannula present. The oxygen concentrator in her room was set at a flow rate of 4 LPM (liters per minute). A review of the most recent Care Plan for Resident#34 annotated oxygen as ordered and referred to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/2021 at 11:18 a.m., a record review of the MARs, TARs and orders from November 2019 through present failed to reveal an active order for oxygen for Resident #34. On 10/20/2021 at 11:04 a.m., Resident #34 was observed lying in bed. She was receiving oxygen via nasal cannula. Her oxygen concentrator was set at 4LPM. During an interview on 10/20/2021 at 11:07 a.m. with Agency Licensed Practical Nurse (LPN) D, she stated she was familiar with the resident and that she received continuous oxygen. When asked about the oxygen order, she consulted the online medical record then responded that she could not find an order and would have to consult the Assistant Director of Nursing (ADON) for additional assistance. She also stated per professional nursing standards, the oxygen tubing was to be changed weekly. On 10/20/2021 at 12:17 p.m., the ADON presented a copy of a verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the order was dated for the current date and a previous order was not found. During an interview on 10/21/2021 at 2:48 p.m., the Director of Nursing (DON) provided additional documentation confirming the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He could not provide an explanation as to why the oxygen was being administered prior to the order. .

Based on observation and staff and resident interviews, the facility failed to serve food that was palatable and at an appetizing temperature for three (Residents #67, #71 and #136) of 33 sampled residents. The findings include: During an interview with Resident #67 on 10/18/21 at 11:43 a.m., she said, The food here leaves much to be desired, has no taste, there is no seasoning in the food at all, and no condiments or salt and pepper are on the trays. She further stated the food was always served cold and there was no way to get it warmed up. She stated part of the problem was that the trays sat in the food carts for long periods of time before the staff started giving them out. The metal lids that covered the plates didn't fit and were usually half of the plate, so the food was cold before you received it. During an observation of the lunch meal on 10/18/21 at 12:45 p.m., the food cart arrived at 12:50 p.m., however no staff was present at the time. At 1:00 p.m., the first staff arrived and pushed the cart down the hall. When the certified nursing assistant (CNA) opened the food cart, the metal covers over the plates were tipped over and were no longer covering the food on the plates. In an interview with CNA E at 1:05 p.m., she was asked about the lids not covering the plates. She said the covers weren't the right ones. They don't fit these plates and will not stay in place. When asked if the residents had concerns regarding cold food, she said all the time. Also, there was one glass of water or juice on the trays and no other fluids were offered. CNA E was asked if other staff were available to assist with serving the trays. She said the other CNA was on her way. She said there were two CNAs on today for 33 residents. There had been three CNAs but one was taken off their assignment to provide one to one (1:1) supervision for a resident with behaviors. During an observation of the lunch meal on 10/19/21 at 12:50 p.m., a meal cart arrived on the floor, but no staff were present to start serving. One CNA started at 12:55 p.m. When she opened the cart, the metal covers over the plates were observed tipped over and not covering the plates. The trays were observed with one glass of fluid and they were only half full. There was no serving cart with coffee or other fluid choices. An interview was conducted with Resident #71 on 10/19/21 at 1:05 p.m. She was asked if she had eaten lunch. She said not yet but was hoping it was something decent. She said the food had no taste and it was always served cold. She was asked if she had asked for an alternate meal. She said they don't offer anything else. She stated she was diabetic and went to [CONDITION(S)] three times a week. On the days she went to [CONDITION(S)], she had to remind them she was back or she didn't get dinner. It is not good if I miss dinner, because we don't get snacks in the evenings. We use to get snacks at night, but its been months since that happened. If you ask for something to eat at night, you are told they don't have anything not even crackers. In an interview with Resident # 67 on 10/19/21 at 1:15 p.m., she was asked about her lunch meal. She said the meal ticket stated barbequed ribs and beans. It had no taste and it was as usual, served cold. I am grateful my daughter sends in food for me. During an interview with Resident #136 on 10/19/21 at 12:37 p.m., she stated, The food is horrible with absolutely no taste, and it is always served cold. The green beans and peas are served frozen barely warmed. There are no choices given. If food is cold, they will not heat it up. She was upset about the meal served last night for dinner. She said she had peas, corn, mashed potatoes and some kind of ground meat. None of the food was seasoned. It was worse than bland. Nothing is put on the tray like condiments, salt, pepper or sauces. During an interview with the Registered Dietitian (RD) on 10/20/21 at 9:30 a.m., she was asked if she had any complaints of cold food. She said there were complaints at the Resident Council meeting last week. She was asked what had been done to improve services. She said they would be doing a QAPI (Quality Assurance and Performance Improvement) plan. She was asked how often she was in the facility, and she said she worked full time. When asked if she was aware that the metal lid domes did not fit on the plates and when observed in the cart, all lids were on their sides and staff had to put the covers back over the plates. She was asked if she observed the staff when serving meals and if alternates were offered. When asked if she was aware of the meal trays were not served when the food carts went to the units, she said no but would be monitoring. She was asked if she was aware residents had multiple complaints about unseasoned, tasteless food, and she said she was told by the cook that no salt or seasonings were added to the food and they were not following the recipes. On 10/20/21 at 12:50 p.m., staff were observed serving the meal trays. The only fluids served on the trays were water or orange juice. There was no serving cart with coffee or other fluid choices. After all trays were distributed, the CNA was asked if there was coffee or other fluids available. She said she did not know. Another CNA said it is in the pantry. At 1:10 p.m., the CNA retrieved the cart from the pantry and placed it next to the empty food cart. The CNA was asked if someone would go down the halls and ask residents if they wanted coffee, ice tea or water. The CNA took the cart and went down the hall. During an interview with Resident #71 on 10/20/21 at 2:30 p.m., when she returned from [CONDITION(S)], she was asked if the facility sent her to [CONDITION(S)] with a lunch. She said they did but it was just a sandwich. She said she hopes there is something decent to eat for supper because she was hungry. She was asked if she had reported her concerns. She said she had, but staff come and go so fast, nothing changes.

Based on record review, observation, and staff and resident interviews, the facility failed to provide rehabilitative services to maintain/restore the highest level of physical, mental, functional and psychosocial well-being for one (Resident #78) of two residents sampled for rehabilitative services, from a total of 31 sampled residents. The findings include: A record review for Resident #78 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was alert and oriented and able to make her needs known. She had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. A review of the Minimum Data Set (MDS) assessment, dated 6/27/21, revealed she required extensive assistance of one person with bed mobility, transfers, bathing, dressing and toileting. She was not steady and only able to stabilize herself with staff assistance. She was totally dependent with eating related to her tube feeding. During an interview with Resident #78 on 10/18/21 at 11:30 a.m., she was asked if she got up out of bed. She said not often. She was asked the reason, and she replied, They don't get me up and I am hooked up to the tube feeding. She was asked if she was receiving therapy services, and she said no, but she wanted to have therapy so she could walk and eat again. Her roommate stated she could walk and they use to get her up. She didn't understand why they stopped. The roommate said she had been encouraging her everyday to get up. An interview was conducted with Unit Manager G on 10/18/21 at 1:30 p.m. She was asked how often Resident #78 got out of bed. She said they do ask her, but she didn't know how often she actually got up. She said she had only been in the position for a few weeks. Observations of Resident #78 on 10/19/21 at 10:30 a.m. and 3:45 p.m., found she was in bed. During an interview at 3:45 p.m., she was asked if she had been out of bed today, and she said no. When asked if the staff had offered to get her up, she said no. When asked if she had a wheelchair, she said there was one in the room, and it was not her roommate's; she could walk independently. An interview was conducted with Certified Nursing Assistant (CNA) F on 10/19/21 at 10:30 a.m. She was asked if Resident #78 got up out of bed, and she said she was fairly new and didn't know. CNA E stated she had seen Resident #78 up in a wheelchair but not for awhile. She said Resident #78 used to be able to walk to the nursing station with therapy, but that was when she came back in in June. An interview was conducted with the Occupational Therapist (OT) on 10/20/21 at 10:10 a.m. She was asked if Resident #78 was receiving therapy services. She said the facility could not provide therapy because she had no payor source. She was asked if she was receiving restorative nursing. The OT said the facility had no restorative program. An interview was conducted with the Rehabilitation Director (RD) on 10/20/21 at 10:20 a.m. She was asked if Resident #78 was receiving therapy. She said, No, she did have Occupational Therapy and Speech Therapy for one week from 7/29-8/5/21. She was asked if the resident was screened by Physical therapy (PT) or OT for the use of a wheelchair, and she said she would check and if not would have her screened by PT. The RD was asked if she was aware that when OT was asked if Resident #78 was receiving therapy, she stated the facility could not provide therapy because she had no payor source. She said if any resident needed therapy, even if there was no insurance, she went to the Administrator and got approval. She said there must have been some miscommunication with the staff, and she would conduct an in-service. She was asked if Resident #78 had been screened by Speech therapy (ST), as the resident was having issues with her tube feeding and was anxious to be able to eat again. The RD said she would have ST screen her today. During an interview with Resident #78 on 10/20/21 at 10:30 a.m., she was made aware that therapy had been consulted and that PT, OT and ST would be coming to evaluate her needs and obtain orders from the physician for therapy. She was very pleased and was hopeful that she could eat food again. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Speech Therapist on 10/21/21 at 3:20 p.m. She was asked if she had evaluated Resident #78. She said she saw her yesterday. She said she did a trial with pureed food and nectar thick liquid, and the resident did very well. She ordered a Modified [MEDICATION(S)] Swallow (MBS) to ensure there was no aspiration. She said she was a good candidate for an oral diet. She said the resident complained she had been having nausea lately with her tube feeding, and had asked for it to be turned off at times. She said an interdisplinary meeting (IDT) meeting was held today, and the nausea was brought up and an order was obtained for [MEDICATION(S)] (nausea medication).

Based on interviews and record reviews, the facility failed to ensure Agency clinical staff appropriately provided basic life support, including cardiopulmonary resuscitation (CPR) to a resident (#1) requiring such emergency care, out of three residents reviewed, by failing to 1) Verify the resident's code status prior to initiating CPR, 2) Call emergency medical services (EMS), and 3) Follow the facility's policy and procedure for CPR: Code Status Orders and Response. On [DATE] at 3:16 AM, Certified Nursing Assistant (CNA) B found Resident #1 unresponsive in bed. The resident was not breathing but was warm with secretions coming from his mouth. CNA B immediately summoned Agency Licensed Practical Nurse (LPN) C, who summoned Agency LPN A (the resident's assigned nurse) to the resident's room. CPR was initiated by these two nurses without first checking the resident's code status. At 3:30 a.m., Agency LPN A left the room to check the resident's code status while Agency LPN C continued CPR. Resident #1 was a full code status. Registered Nurse (RN) D was summoned and was met by Agency LPN A at the nurses' station at 3:36 a.m. Without assessing Resident #1, RN D instructed Agency LPN A to check Resident #1's chart, start CPR, and call the physician and family. She further stated if Agency LPNs A and C could not obtain a pulse, the resident was dead and there was no need to call EMS. RN D did not assist with CPR or call EMS herself. EMS was never called. At 3:37 a.m., Agency LPN A notified the on-call Advanced Practice Registered Nurse (APRN) that CPR had been stopped and Resident #1 expired. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 12:24 p.m. on [DATE]. On [DATE] at 3:16 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 4:45 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed upon survey exit on [DATE], effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. On [DATE], the facility's census was 91. Any residents whose Advance Directives indicated a Full Code Status were at risk. There were 61 residents who had a Full Code status at that time. The findings include: Cross reference F726 A review of Resident #1's medical record revealed an admission on [DATE] and a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's discharge was noted as [DATE], and his [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required extensive assistance with bed mobility and toilet use, limited assistance with transfers, and was independent with set-up for meals. His care plan for Advance Directives indicated the resident's wish to be a Full Code should he become unresponsive. An interview was conducted with the Regional Director of Risk Management on [DATE] at 11:05 a.m. regarding the resident's discharge. She confirmed that there was no documentation about his discharge, therefore information was obtained from the facility's investigation of the [DATE] event. She provided the following timeline: On [DATE] during routine rounding at 3:16 a.m., CNA B observed Resident #1 in his bed with is eyes closed and secretions coming out of his mouth. He was not breathing and his overall color was different. Previous rounding conducted at 1:55 a.m. revealed the resident was still warm to the touch. CNA B summoned for a nurse and Agency LPN C came to the room. While donning personal protective equipment (PPE) to get into the COVID-19 unit, she contacted Agency LPN A (primary nurse assigned to Resident #1), who was on break, to come to the unit. Upon entering the resident's room at 3:17 a.m., Agency LPN A assessed Resident #1. After determining that the resident had no pulse, she initiated CPR. Agency LPN C then asked CNA B to get linen to clean the resident. At around 3:18 a.m., Agency LPN A (primary nurse), entered the room and assisted Agency LPN C with compressions. After five minutes, Agency LPN C took over compressions again and asked Agency LPN A to check the resident's chart and confirm the code status. As Agency LPN C continued with compressions, she contacted Registered Nurse (RN Supervisor) D over her personal phone via [NAME] (voice-activated personal assistant that is part of Apple Inc.'s iOS, iPadOS, watchOS, macOS, and tvOS operating systems) to come to the unit, as there was an incident. RN D, who was on lunch break, was not provided with any details about which unit or room number Agency LPN C was referring to. When RN D arrived on the unit at approximately 3:25 a.m., she did not find anyone at the nurses' station and proceeded to care for her assigned resident. At 3:30 a.m., Agency LPN A went to the nurses station to verify Resident #1's code status. She noted that Resident#1 was a Full Code. She did not call EMS or overhead page Code Blue per the facility's policy and procedure. She notified Agency LPN C that Resident #1 was a Full Code and to continue CPR. At 3:36 a.m., RN D returned to the nurses' station from her assigned resident's room and found Agency LPN A there. Agency LPN A notified RN D that Resident #1 was unresponsive. RN D asked Agency LPN A to note the resident's time of death and contact the family and physician. RN D stated there was no need to contact EMS, as the resident had died . In a telephone interview on [DATE] at 12:40 p.m, CNA B stated Resident #1 was on the COVID unit. When she went to check his vital signs, she noted that he was not himself and had secretions coming from his mouth. He was warm to the touch. She summoned for the nurse on the non-COVID unit (LPN C), as she could not locate the nurse on the COVID unit (Agency LPN A). Agency LPN C responded. While donning PPE to enter the COVID unit, Agency LPN C contacted Agency LPN A, the nurse assigned to the COVID unit. Moments after that, Agency LPN C assessed the resident and initiated CPR. She then asked CNA B to get supplies to clean the resident's oral secretions. CNA B left the room to get supplies. She stated she had to get the linen from a different nursing unit. CNA B added that she did not even know the resident was a full code, as the nurses were slow to act and did not announce Code Blue on the overhead paging system. She said when she returned to the COVID unit, the nurses had already stopped CPR and she cleaned the resident. CNA B could not recall the time she returned to the unit. In a telephone interview on [DATE] at 12:44 p.m., Agency LPN A stated she could not remember the incident exactly. She mentioned that she provided the facility with a statement about the incident and stated that a copy could be obtained. (Copy obtained) Agency LPN A confirmed that she did not call EMS per the protocol. She stated RN D told her there was no need to call EMS if the resident was dead. When Agency LPN A was asked whether RN D assessed Resident #1 in order to make this determination, Agency LPN A stated no. At that time, Agency LPN A abruptly ended the interview. On [DATE] at 1:30 p.m., the Regional Director of Risk Management was interviewed. She stated she helped conduct the facility's investigation, and the nurses involved did not follow the facility's policy for Code Response. She added that in the event a resident was found unresponsive, the staff were expected to page Code Blue overhead with a room number, and designate one person to oversee the process, including calling EMS while others performed compressions. She confirmed the staff did not do any of the above. RN D/RN Supervisor, did not help the nurses with the CPR or assess the resident. She added that the facility had enough staff working that night, but they were not aware of the incident, as Agency LPNs A and C did not page Code Blue overhead or call EMS. They also failed to document the event. During a telephone interview with the APRN on [DATE] at 2:10 p.m., she stated she was on call the night of [DATE]. Facility staff paged her stating [Resident #1] had expired. She stated she called right back to acknowledge she had received the page. Staff did not ask her whether they should stop CPR. She was not familiar with the resident, and was not aware that the resident was a full code, so she told the staff she would relay the information to the attending physician. In a telephone interview on [DATE] at 3:30 p.m., the Medical Director (the resident's physician) stated he was notified of the incident the following morning by the on-call APRN. The APRN told him that staff notified her the resident had expired, but she was not informed that the resident was a full code. When asked his expectations on such a scenario, he stated he was not sure why the staff did not call EMS to honor the resident's wishes. He added that [Resident #1] was his patient, and it was a shock to hear of his demise. A review of the facility's policy and procedure titled CPR: Code status Orders and Response (Effective February 2021) revealed: Policy - The facility provides Basic Life Support (BLS) CPR only. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Advance Directives will be honored. On admission Staff will verify the presence of Advanced Directives documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered a full code unless the resident/representative wishes to change their decision. 1. Obtain advanced directives decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring a copies to the facility as soon as possible. 2. Discuss Code preference with the resident/resident representative. 3. Document resident/resident representative preferences in the medical record if the resident's wishes are different than the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Notify physician if the resident/resident representative preferences change, and obtain order. In the event that the physician is not available, the Medical Director may be contacted for the order. 5. While awaiting the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident or resident representative verbalizes the wish not to receive CPR, two staff members will witness and document this request. The conversation of the request will be printed and placed as the first document of the medical record. a. While the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly/ PRN 1. Review and discuss code status with the resident/resident representative and confirm code status is unchanged. Document wishes are unchanged in the medical records. 2. If resident or resident representative wishes to change status, document in the record and notify physician to obtain the order. 6. Social Services and/or nursing should discuss Advance Directive decision with the resident/resident representative to ascertain that the resident/resident representative understands the decision. 7. Notify attending MD of the resident/resident representative request for DNR or Full Code status. Residents' wishes will be honored. Staffing Staff members trained and/or certified to perform CPR for Health Care Providers will be present to provide CPR for those residents electing a full code status. These certified team members shall provide CPR until ordered to cease by an authorized, licensed physician, EMS arrives to assume care, or the resident's pulse and respirations are assessed as present. CPR certification staffing will be reviewed as indicated. Procedure for initiating CPR 1. Upon identification that the resident is unresponsive, the person making the identification will check for pulse and respirations, and immediately call for help; loudly calling Code Blue and Room (#). 2. Staff will respond to room with medical record and emergency cart. 3. Chart will be checked for code status and if resident is a full code CPR will be initiated. Once CPR is started, CPR will continue until: Relieved by EMS Relieved by another staff member who will take over CPR or Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident Pulse and respirations are palpable/observable 4. One person will assign task: a. Bring emergency cart and chart b. Provide CPR c. Call 911 d. Designate a scribe May use the code blue worksheet to notate timeline and activity, transcribe notes from worksheet to medical record upon resolution of event. e. Notify physician and resident representative f. Prepare paperwork for transfer to hospital g. Await EMS and escort to the resident 5. Assist with transfer of resident to gurney for transport 6. Complete paperwork to include but may not be limited to 24-hour and nurses' notes. 7. Notify the NHA and DON. 8. Replenish emergency cart. According to American heart association, https://cpr.heart.org/en/resources/what-is-cpr The 6 links in the adult out-of-hospital Chain of Survival (accessed on [DATE] at 2:30 p.m.): 1. Recognition of [CONDITION(S)] and activation of the emergency response system (calling [DATE] in the US) 2. Early CPR with an emphasis on chest compressions 3. Rapid defibrillation 4. Advanced resuscitation by Emergency Medical Services and other healthcare providers 5. Post-[CONDITION(S)] care 6. Recovery (including additional treatment, observation, rehabilitation, and psychological support) A strong Chain of Survival can improve chances of survival and recovery for victims of [CONDITION(S)] Top 10 Take-Home Messages for Adult Cardiovascular Life Support 1. On recognition of a [CONDITION(S)] event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). The facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor on [DATE] as follows: * The Administrator ensured the staff involved in the event were suspended on [DATE] pending investigation and outcome. The facility employees were terminated and the Agency staff were not permitted back in the facility effective [DATE]. * Agency and Facility staff must complete education prior to working. This began on [DATE]. The Staff Development Coordinator (SDC) to conduct the education and the Nurse Supervisor to conduct education during off hours and weekends. Education packet to be provided to the Administrator daily for review. The Administrator to maintain a tracking log for Agency staff to ensure orientation is completed. Agency staff education began on [DATE] on the following : Advanced Directives (post-test) Commitment to honoring advanced directive attestation Notification of change Abuse neglect exploitation mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Code status orders and response Nurse supervision responsibilities 100% compliance achieved by [DATE] * NHA education on job description was provided by the Regional Nurse Consultant by [DATE]. * On [DATE] the Regional Nurse Consultant completed the nurses' license verification and verified accuracy of the employee roster for the involved parties. * The Regional Nurse Consultant validated CPR certification status for all nurses on [DATE] with no concerns identified. * The Regional Nurse Consultant validated the Advance Directives attestation for all licensed staff with 100% compliance achieved by [DATE]. * Code Blue drills with all staff including new and temporary staff were conducted at the beginning of their shifts on [DATE]. Drills continued daily for one week and then two times weekly for four weeks to confirm all clinical staff understood the required process and response to honor Advance Directives. * Following the incident, the facility had two actual Code Blues and no concerns were identified. * An ad hoc quality assurance meeting was held to discuss QAPI (Quality Assurance and Performance Improvement) on [DATE]. Corrective actions related to this incident will be discussed in QAPI meetings until total compliance is achieved.

Based on interviews and record reviews, the facility failed to ensure Agency and facility clinical staff had competencies and skills sets for appropriately providing basic life support, including cardiopulmonary resuscitation (CPR) to a Resident (#1) requiring such emergency care, out of three residents reviewed. The facility failed to ensure Agency and facility staff knew to 1) Verify the resident's code status prior to initiating CPR, 2) Call emergency medical services (EMS), and 3) Follow the facility's policy and procedure for CPR: Code Status Orders and Response. On [DATE] at 3:16 AM, Certified Nursing Assistant (CNA) B found Resident #1 unresponsive in bed. The resident was not breathing but was warm with secretions coming from his mouth. CNA B immediately summoned Agency Licensed Practical Nurse (LPN) C, who summoned Agency LPN A (the resident's assigned nurse) to the resident's room. CPR was initiated by these two nurses without first checking the resident's code status. At 3:30 a.m., Agency LPN A left the room to check the resident's code status while Agency LPN C continued CPR. Resident #1 was a full code status. Registered Nurse (RN) D was summoned and was met by Agency LPN A at the nurses' station at 3:36 a.m. Without assessing Resident #1, RN D instructed Agency LPN A to check Resident #1's chart, start CPR, and call the physician and family. She further stated if Agency LPNs A and C could not obtain a pulse, the resident was dead and there was no need to call EMS. RN D did not assist with CPR or call EMS herself. EMS was never called. At 3:37 a.m., Agency LPN A notified the on-call Advanced Practice Registered Nurse (APRN) that CPR had been stopped and Resident #1 expired. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 12:24 p.m. on [DATE]. On [DATE] at 3:16 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 4:45 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed upon survey exit on [DATE], effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. On [DATE], the facility's census was 91. Any residents whose Advance Directives indicated a Full Code Status were at risk. There were 61 residents who had a Full Code status at that time. The findings include: Cross reference F678 A review of Resident #1's medical record revealed an admission on [DATE] and a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's discharge was noted as [DATE], and his [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required extensive assistance with bed mobility and toilet use, limited assistance with transfers, and was independent with set-up for meals. His care plan for Advance Directives indicated the resident's wish to be a Full Code should he become unresponsive. An interview was conducted with the Regional Director of Risk Management on [DATE] at 11:05 a.m. regarding the resident's discharge. She confirmed that there was no documentation about his discharge, therefore information was obtained from the facility's investigation of the [DATE] event. She provided the following timeline: On [DATE] during routine rounding at 3:16 a.m., CNA B observed Resident #1 in his bed with is eyes closed and secretions coming out of his mouth. He was not breathing, and his overall color was different. Previous rounding conducted at 1:55 a.m. revealed the resident was still warm to the touch. CNA B summoned for a nurse and Agency LPN C came to the room. While donning personal protective equipment (PPE) to get into the COVID-19 unit, she contacted Agency LPN A (primary nurse assigned to Resident #1), who was on break, to come to the unit. Upon entering the resident's room at 3:17 a.m., Agency LPN A assessed Resident #1. After determining that the resident had no pulse, she initiated CPR. Agency LPN C then asked CNA B to get linen to clean the resident. At around 3:18 a.m., Agency LPN A (primary nurse), entered the room and assisted Agency LPN C with compressions. After five minutes, Agency LPN C took over compressions again and asked Agency LPN A to check the resident's chart and confirm the code status. As Agency LPN C continued with compressions, she contacted Registered Nurse (RN Supervisor) D over her personal phone via [NAME] to come to the unit, as there was an incident. RN D, who was on lunch break, was not provided with any details about which unit or room number Agency LPN C was referring to. When RN D arrived on the unit at approximately 3:25 a.m., she did not find anyone at the nurses' station and proceeded to care for her assigned resident. At 3:30 a.m., Agency LPN A went to the nurses' station to verify Resident #1's code status. She noted that Resident#1 was a Full Code. She did not call EMS or overhead page Code Blue per the facility's policy and procedure. She notified Agency LPN C that Resident #1 was a Full Code and to continue CPR. At 3:36 a.m., RN D returned to the nurses' station from her assigned resident's room and found Agency LPN A there. Agency LPN A notified RN D that Resident #1 was unresponsive. RN D asked Agency LPN A to note the resident's time of death and contact the family and physician. RN D stated there was no need to contact EMS, as the resident had died . In a telephone interview on [DATE] at 12:44 p.m., Agency LPN A stated she could not remember the incident exactly. She mentioned that she provided the facility with a statement about the incident and stated that a copy could be obtained. (Copy obtained) Agency LPN A confirmed that she did not call EMS per the protocol. She stated RN D told her there was no need to call EMS if the resident was dead. When Agency LPN A was asked whether RN D assessed Resident #1 in order to make this determination, Agency LPN A stated no. At that time, Agency LPN A abruptly ended the interview. On [DATE] at 1:30 p.m., the Regional Director of Risk Management was interviewed. She stated she helped conduct the facility's investigation, and the nurses involved did not follow the facility's policy for Code Response. She added that in the event a resident was found unresponsive, the staff were expected to page Code Blue overhead with a room number, and designate one person to oversee the process, including calling EMS while others performed compressions. She confirmed the staff did not do any of the above. RN D/RN Supervisor, did not help the nurses with the CPR or assess the resident. She added that the facility had enough staff working that night, but they were not aware of the incident, as Agency LPNs A and C did not page Code Blue overhead or call EMS. They also failed to document the event. When asked about Agency staff orientation, she stated each Agency staff member was supposed to receive an orientation packet before the beginning of their first shift. She confirmed that the facility did not check the Agency staff for competency prior to their providing care for the facility's residents. In an interview on [DATE] at 9:35 a.m., the Administrator confirmed that prior to the incident on [DATE], the facility did not have a plan in place for ensuring that Agency staff completed the orientation packet training prior to the start of their first shift. She stated the Staff Development Coordinator (SDC) was responsible for the staff training, but the facility has had no SDC since [DATE]. The Director of Nursing (DON) was covering the position in the interim, but was on leave. When asked about the training provided to the Agency staff, the Administrator stated they were provided with a package containing different training topics and post-tests. She confirmed that the facility did not provide competency check offs for the Agency staff. During an interview on [DATE] at 11:31 a.m., Agency Licensed Practical Nurse (LPN) E stated her onboarding process in [DATE] included completing an orientation packet. She stated the packet was provided to her to complete and return after completion. She stated it was not mandatory to complete the training, and she could not remember whether she ever returned that packet to the facility. However, on [DATE], she was required to complete another packet and submit it to the SDC. When asked if she had completed any competencies prior to working with the residents at the facility, she answered, No. On [DATE] at 4:30 p.m., Agency CNA F stated she began working at the facility on and off since [DATE]. She denied being given an orientation packet with training to complete upon hire. She stated she had not completed an orientation competency check either. She added that the facility notified her on [DATE], that she had to complete mandatory training which included facility policies and procedures as well as abuse/neglect training. A review of the facility's policy and procedure titled CPR: Code status Orders and Response (Effective February 2021) revealed: Policy - The facility provides Basic Life Support (BLS) CPR only. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Advance Directives will be honored. On admission Staff will verify the presence of Advanced Directives documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered a full code unless the resident/representative wishes to change their decision. 1. Obtain advanced directives decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring a copy to the facility as soon as possible. 2. Discuss Code preference with the resident/resident representative. 3. Document resident/resident representative preferences in the medical record if the resident's wishes are different than the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Notify physician if the resident/resident representative preferences change, and obtain order. In the event that the physician is not available, the Medical Director may be contacted for the order. 5. While awaiting the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident or resident representative verbalizes the wish not to receive CPR, two staff members will witness and document this request. The conversation of the request will be printed and placed as the first document of the medical record. a. While the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly/ PRN 1. Review and discuss code status with the resident/resident representative and confirm code status is unchanged. Document wishes are unchanged in the medical records. 2. If resident or resident representative wishes to change status, document in the record and notify physician to obtain the order. 6. Social Services and/or nursing should discuss Advance Directive decision with the resident/resident representative to ascertain that the resident/resident representative understands the decision. 7. Notify attending MD of the resident/resident representative request for DNR or Full Code status. Residents' wishes will be honored. Staffing Staff members trained and/or certified to perform CPR for Health Care Providers will be present to provide CPR for those residents electing a full code status. These certified team members shall provide CPR until ordered to cease by an authorized, licensed physician, EMS arrives to assume care, or the resident's pulse and respirations are assessed as present. CPR certification staffing will be reviewed as indicated. Procedure for initiating CPR 1. Upon identification that the resident is unresponsive, the person making the identification will check for pulse and respirations, and immediately call for help; loudly calling Code Blue and Room (#). 2. Staff will respond to room with medical record and emergency cart. 3. Chart will be checked for code status and if resident is a full code CPR will be initiated. Once CPR is started, CPR will continue until: Relieved by EMS Relieved by another staff member who will take over CPR or Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident Pulse and respirations are palpable/observable 4. One person will assign task: a. Bring emergency cart and chart b. Provide CPR c. Call 911 d. Designate a scribe May use the code blue worksheet to notate timeline and activity, transcribe notes from worksheet to medical record upon resolution of event. e. Notify physician and resident representative f. Prepare paperwork for transfer to hospital g. Await EMS and escort to the resident 5. Assist with transfer of resident to gurney for transport 6. Complete paperwork to include but may not be limited to 24-hour and nurses' notes. 7. Notify the NHA and DON. 8. Replenish emergency cart. A review the Registered Nurse Job Description revealed: Direct Care/Patient Responsibilities Assess, plans, directs and evaluates total nursing care as determined by the resident's /patient 's age related physical, psychological, and cultural needs in accordance with established standards, policies and procedures and residents/patients care plan. Handles emergency situations in a prompt, precise and professional manner. Performs CPR as required. Demonstrates an ability to remain calm, perform effectively and professionally during peak periods of activity and emergency situation. Maintains accurate, detailed reports and records. Reports all changes in residents' /patients' condition to the supervisor timely. A review the Licensed Practical Nurse Job Description revealed: Direct Care/Patient Responsibilities Supervises C.N.A staff as required Assess, plans, directs and evaluates total nursing care as determined by the resident's /patient 's age related physical, psychological, and cultural needs in accordance with established standards, policies and procedures and residents/patients care plan. Handles emergency situations in a prompt, precise and professional manner. Performs CPR as required. Demonstrates an ability to remain calm, perform effectively and professionally during peak periods of activity and emergency situation. Maintain accurate detailed reports and records. Reports all changes in resident 's /patient's condition to the supervisor timely. A review the Staff Development Coordinator Job Description revealed: Summary of postion: The Staff Development Coordinator plans, organizes and coordinates all aspects of the program within the faclity. In addition, the Staff Develoment Coordinator plans, directs or coordinates the training and development activities for the staff at the faclity. Essential Duties and Responsibilities: Staff Development Analyzing training needs to develop new training or modify and improve existing programs. Conducts or arranges for ongoing technical training and personal development classes for staff members. Conduct orientation sessions and arrange on-the-job training for new hires. Coordinate established courses with the technical and professional courses provided by community schools and desigante training procedures. The facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor on [DATE] as follows: * The Administrator ensured the staff involved in the event were suspended on [DATE] pending investigation and outcome. The facility employees were terminated and the Agency staff were not permitted back in the facility effective [DATE]. * Agency and Facility staff must complete education prior to working. This began on [DATE]. The Staff Development Coordinator (SDC) to conduct the education and the Nurse Supervisor to conduct education during off hours and weekends. Education packet to be provided to the Administrator daily for review. The Administrator to maintain a tracking log for Agency staff to ensure orientation is completed. Agency staff education began on [DATE] on the following : Advanced Directives (post-test) Commitment to honoring advanced directive attestation Notification of change Abuse neglect exploitation mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Code status orders and response Nurse supervision responsibilities 100% compliance achieved by [DATE] * NHA education on job description was provided by the Regional Nurse Consultant by [DATE]. * On [DATE] the Regional Nurse Consultant completed the nurses' license verification and verified accuracy of the employee roster for the involved parties. * The Regional Nurse Consultant validated CPR certification status for all nurses on [DATE] with no concerns identified. * The Regional Nurse Consultant validated the Advance Directives attestation for all licensed staff with 100% compliance achieved by [DATE]. * Code Blue drills with all staff including new and temporary staff were conducted at the beginning of their shifts on [DATE]. Drills continued daily for one week and then two times weekly for four weeks to confirm all clinical staff understood the required process and response to honor Advance Directives. * Following the incident, the facility had two actual Code Blues and no concerns were identified. * An ad hoc quality assurance meeting was held to discuss QAPI (Quality Assurance and Performance Improvement) on [DATE]. Corrective actions related to this incident will be discussed in QAPI meetings until total compliance is achieved.

Based on interview and record review, the facility failed to ensure it provided requested showers for 1 (Resident #10) of 10 sampled residents who was dependent on staff to meet his Activities of Daily Living (ADLs) needs. The findings include: An interview conducted with Resident #10 on 02/03/2021 at 4:50 PM, revealed he had not had a shower in the past month and would like a shower. Employee A, Registered Nurse (RN), who was conducting a medication pass at the time of the interview stated she was going to address his concern. An interview conducted with Resident #10 on 02/04/2021 at 1:30 PM, revealed he had not received a shower or refused one. During a 2/4/2021 interview at 3:54 PM with Employee B, the Certified Nursing Assistant (CNA) assigned to Resident #10, she stated she could not recall the last time Resident #10 took a shower. During an interview with the Director of Nursing (DON) on 02/4/2021 at 4:00 PM, she reviewed ADL documentation for Resident #10 and confirmed he had not received the care as documented by Employee B, CNA. A review of Resident #10's medical record revealed, Residents scheduled shower day is every Monday, Wednesday, Friday to be given on 3 PM - 11 PM evening shift. A review of Resident #10's January and February 2021 bathing/shower documentation revealed the following: Bed baths were given on 1/15, 1/22, 1/25, 1/27, 1/29 and 2/3/21 by Employee B, CNA Partial baths were given on 1/1 and 2/1/21 No bathing documentation was found for 1/8/21 and 1/20/21 No shower documentation was found A review of Resident #10's care plan revealed a [MEDICAL CONDITIONS] resulting in left-sided [MEDICAL CONDITION]. The documented intervention was to Monitor/document resident's abilities for Activity of Daily Living (ADL) and assist resident as needed. Encourage resident to do what he is capable of doing for self. Resident #10 had documented ADL self-care performance deficit, could not complete ADL tasks independently and required individualized interventions to improve function. A review of Employee B, CNA's job description, revealed it was signed on 7/26/2016 and stated, Ensures that each resident's personal care needs are being met in accordance with the resident's wishes.

Based on observation, interview with facility staff and medical record review, the facility failed to ensure medications were properly labeled for 4 (Resident #6, #7, #8 and #9) of 6 residents who were selected for medication pass observation. This placed the resident at risk for a medication error related to unsafe medication administration. The findings include: An observation of medication administration with Employee A, Registered Nurse (RN) on 02/03/2021 at 4:41 PM revealed her placing 28 medication cups on top of the medication cart. Four of the medication cups had only room numbers marked on them with multiple white tablets. (photographic evidence obtained) During an interview with Employee A, (RN) on 02/03/2021 at 4:41 PM, she confirmed two medications in each of the four cups were Tylenol and/or [MEDICATION NAME] for Resident #6, Resident #7, Resident #8 and Resident #9. Employee A, (RN) asked if something was wrong and stated that was how she was taught to complete medication pass because she had 29 residents to get medications for. A review of Resident #6's Medication Administration Record [REDACTED]. The MAR for Resident #7 was reviewed and documented for [MEDICATION NAME] tablet give 650 milligrams by mouth every 4 hours as needed for mild pain. Resident #8 had a documented order for [MEDICATION NAME] 325 milligrams give 2 tablets by mouth every six hours as needed for pain. The MAR for Resident #9 revealed [MEDICATION NAME] 3 milligrams give 2 tablets by mouth at bedtime for [MEDICAL CONDITION] administer at hour of sleep. Documented initials on the MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on 02/04/2021 at 10:47 AM, she confirmed that there should be no pre-pouring. The DON provided a page from the facility pharmacy services which indicated that Medication Pass Review included Do not pre-pour. (photographic evidence obtained)

Based on observations of medication administration, interview, a review of policies and procedures and a review of Medication Administration Records (MARs), the facility failed to ensure it provided accurately documented MARs for one (Residents #5) of six residents sampled. The findings include: An observation of Employee C, Licensed Practical Nurse (LPN) on 02/04/2021 at 8:05 AM revealed she had medications for Resident #5 in a medication cup. A review of Resident #5's MAR showed the medications observed in the medication cup were already documented as given. (photographic evidence obtained) During an interview with Employee C, (LPN) on 02/04/2021 at 8:09 AM, she confirmed she had documented Resident # 5's medication as given in the MAR and she had not given them to him yet. Employee C, (LPN) also stated that she was aware she was not supposed to document before she administered the medication. A review of Resident #5's MAR was conducted and revealed the following medications were documented as administered: Multivital-M, [MEDICATION NAME] 10 milligrams [MEDICATION NAME] tablet 5 milligrams [MEDICATION NAME] tablet 10 milligrams [MEDICATION NAME] 5 milligrams Vitamin C 500 milligrams [MEDICATION NAME] 5 milligrams tablet [MEDICATION NAME] capsule 300 milligrams [MEDICATION NAME] Tablet 325 milligrams [MEDICATION NAME] tablet 5 milligrams. Each medication reviewed revealed Employee C's, (LPN) signature on the MAR documenting she had administered the medication for Resident #5 before he took the medication. A review of the facility provided medication 7.1 General Guidelines was conducted and under the subtitle documentation at line 1 revealed, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on record reviews and staff interviews, the facility failed to meet professional standards of quality for one (Resident #1) of three sampled residents who experienced an acute change in condition, by failing to appropriately assess the resident's condition and transfer them to a higher level of care as ordered by the physician for one (Resident #1) of three sampled residents who experienced an acute change in condition. The facility staff delayed Resident #1's hospital transfer for six hours, until she went into [MEDICAL CONDITION]. After attempted resuscitation and hospital transfer, she later died . This also placed the facility's 103 other current residents at risk of not receiving appropriate care following an acute change in condition. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as, The performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences, which shall include but is not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. The practice of practical nursing is the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 3:00 p.m. on [DATE]. On [DATE] at 3:30 p.m., the Immediate Jeopardy (IJ) began. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team. On [DATE] at 6:50 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed at the time of survey exit on [DATE] at 7:00 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference to F684. A review of Resident #1's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The resident had documented wishes to be resuscitated in the event of a [MEDICAL CONDITION] (full code). A review of the resident's most recent Minimum Data Set (MDS) assessment (quarterly), with an assessment reference date of [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 possible points, indicating severe cognitive impairment. The resident required extensive assistance of one staff member with most activities of daily living (ADLs), except for meals, for which she only required supervision. Further review of the clinical record revealed that from the date of admission on [DATE] through [DATE], the resident had not experienced any [MEDICAL CONDITION]-type activity. A review of Resident #1's respiratory record history from [DATE] through [DATE], revealed her average respiratory rate (RR) was ,[DATE] breaths per minute. A review of the [DATE] physician's orders [REDACTED]. A review of the resident's lab work showed that on [DATE], blood was drawn for a therapeutic level of [MEDICATION NAME], revealing suboptimal concentrations of the medication and a [MEDICATION NAME] level of 6.7 ug/ml (micrograms per milliliter). The normal range was noted as ,[DATE] ug/ml. This left Resident #1 more susceptible to [MEDICAL CONDITION] activity, and the resident's physician increased her [MEDICATION NAME] dosage from 100 mg twice daily to 300 mg at bedtime on [DATE]. In LPN A's nursing progress note dated [DATE] at 4:44 PM, she documented that she went to assess the resident with the two other nurses (RN B and RN C), and the resident's oxygen saturation dropped to 89% on room air with a RR of 26. The resident was rechecked and had a temperature of 99.2 degrees Fahrenheit (F) and RR 26 with slight twitching from head to toe. She noted that Resident #1 was placed on oxygen via face mask at 10 liters per minute and the oxygen saturation came up to 99%. A review of Resident #1's current physician's orders [REDACTED]. In LPN A's nursing progress note dated [DATE] at 4:54 PM, she documented that a telephone order was received from the physician instructing staff to, Send resident to ER for [MEDICAL CONDITION]/uncontrolled [MEDICATION NAME] levels. Based on a review of the resident's clinical record and a review of the facility's investigation documentation, on [DATE], Employee A, Licensed Practical Nurse (LPN), was working the day shift (7AM - 3PM) providing care on the unit where Resident #1 lived. Employee B, Registered Nurse (RN), was also working on that shift, and at 3:00 PM, Employee C, RN, came on duty to work the evening shift (3PM - 11PM) and to care for Resident #1. In a written statement, dated [DATE] at 3:30 PM, RN C wrote that during change of shift rounds, he found Resident #1 with a respiratory rate (RR) of 26, twitching activity, and she was not responding to painful stimulation. He documented that oxygen was started at 2 liters per minute. He called LPN A and RN B to assess the resident and documented that an order was received from the physician to send the resident to the emergency room (ER) for evaluation. In a written statement, dated [DATE], RN B recorded that she had been called to Resident #1's room to take a look at the resident, but at no time did she put a stethoscope to the resident or a blood pressure cuff. She documented that she observed the other nurses (LPN A and RN C) and the resident. She documented she saw Resident #1 twitching and verified through conversations with the nurses (A and C) that Resident #1 had a history of [REDACTED].#1's record to confirm a history of [MEDICAL CONDITION]. After confirming the [MEDICAL CONDITION] history, she reminded LPN A and RN C to call the physician, then she went to her office, leaving the other two nurses to continue assessing the resident. RN B stated that once she reached her office, she called the Medical Director's Clinical Nurse Liaison (CNL) about another matter. While she was speaking with the CNL, she called out to LPN A and RN C, asking whether the physician had been called. They had not called Resident #1's physician, so RN B mentioned the resident's condition to the CNL during the call. The CNL stated, She should go ahead and go out. She will probably need an IV (intravenous administration) of [MEDICATION NAME]. If the resident is having [MEDICAL CONDITION] it would be a risk to give her anything by mouth. A photograph of a text message sent by Employee B to the CNL on [DATE] at 3:54 PM revealed, Hey, (Resident #1) isn't responding to painful stimuli, she's lethargic and (Nurses A and C) are still assessing her. I am in here now. The CNL replied, If she is unresponsive, send her out. RN B messaged, (Resident #1) is not unresponsive, just lethargic, but staff are in there now. As part of the facility's investigation, a [DATE] facility-initiated interview (time unrecorded) was conducted with RN B. She was asked how she assessed Resident #1. She replied that she just visualized her. In the same interview it was recorded that RN B stated she thought Resident #1 was stable, and she asked Nurses A and C if the resident would be sent out emergently via 911. Nurses A and C replied, No, the resident was stable, so RN B returned to her office. As she was preparing to leave the facility for the day, RN B overheard LPN A tell RN C, If transport does not arrive in an hour, call 911. RN B then left the facility. During a [DATE] interview with RN B at 10:50 AM, she was asked how she determined that Resident #1 was stable on [DATE] before she left for the day. She replied that she visualized her. When asked whether a respiratory rate of ,[DATE] was normal or stable, RN B did not answer. In a written, signed statement dated [DATE], LPN A documented that at 4:00 PM on [DATE], she was called to Resident #1's room by RN C. There she found Resident #1 with an elevated temperature and not responding to a rigorous sternal rub (Using the knuckles of a closed fist to rub the center chest of a patient who is not alert and does not respond to verbal stimuli. Source - EMS1.com at www.ems1.com, accessed on [DATE] at 11:56 AM ). LPN A also described the resident as twitching with abnormal vital signs including a BP ,[DATE] (blood pressure, mmHg), P63 (pulse), RR26 (respiratory rate), Temp 99 degrees Fahrenheit (F), Oxygen Saturation (O2sats) of 89% and mouth breathing. In an undated and untimed statement made during the facility's investigation, LPN A documented that she informed the resident's relative of possible [MEDICAL CONDITION] and non-therapeutic [MEDICATION NAME] levels. A call was placed to a non-emergency transport company, but they were unavailable, so a second call was placed to another non-emergency transport company, who informed LPN A that there would be a one-hour wait. LPN A then left the facility. RN C recorded in his written statement, dated [DATE], a timeline of events and actions that were taken by him on [DATE] as follows: On [DATE] at 4:00 PM - (Resident #1's) respirations were 26. She was receiving oxygen at 2 liters per minute via nasal cannula. On [DATE] at 5:00 PM - Rechecked resident, no signs of pain or distress noted, RR25, oxygen at 2 liters per minute, resident stable, will continue to monitor. On [DATE] at 5:30 PM - No twitching, but RR25 and resident continues on oxygen at 2 liters to keep her sats (blood oxygen saturation) at 97%. Resident stable, will continue to monitor. On [DATE] at 6:00 PM - Temp 99.3 F, RR26, continues on oxygen at 2 liters per minute to keep her oxygen saturation at 97%. Resident stable, will continue to monitor. On [DATE] at 6:30 PM - No twitching, RR25, resident continues on oxygen at 2 liters per minute to help maintain her saturation of 97%. Resident stable, continue to monitor closely. On [DATE] at 7:00 PM - No twitching, RR25, continues on oxygen at 2 liters per minute. Stable, will continue to monitor closely. On [DATE] at 7:30 PM - No twitching, RR25, continues on oxygen at 2 liters per minute. Stable, will continue to monitor closely. On [DATE] at 8:00 PM - No twitching, RR25, continues on oxygen at 2 liters per minute to maintain her saturation at 97%. Called the non-emergency transport company again and they stated they would be available in 2 hours. Will continue to monitor closely. On [DATE] at 8:30 PM - Respiratory rate increased to RR26, (Resident#1} still requires oxygen at 2 liters per minute to maintain oxygen sats of 97%. Resident stable, continue to monitor. On [DATE] at 9:00 PM - RR26 breaths per minute. Continues to require oxygen at 2 liters per minute to maintain her sats at 97%. Stable, continue to monitor. On [DATE] at 9:30 PM - RR27 breaths per minute, oxygen saturation 94 %. Stable, will continue to monitor closely. On [DATE] at 10:00 PM - Called non-emergency transport, and they reported they would probably arrive at midnight or 1:00 AM. Went to the resident's room to recheck (Resident #1) and found the resident using accessory muscles to breathe. Asked another nurse (not identified in his note) to call 911. Monitored the resident at her bedside and at 10:14 PM, he documented that Resident #1 had a respiratory arrest and a code blue was called. A review of the facility's Code Blue worksheet revealed that on [DATE] at 10:14 PM, Resident #1 became unconscious. Cardiopulmonary resuscitation (CPR) was started at 10:14 PM. Emergency Medical Services arrived at 10:20 PM, took over CPR and transported the resident to the ER at 10:30 PM. Resident #1 did not survive. A review of the facility's policy for addressing a change in a resident's condition, revealed no instructions prioritizing or utilizing 911 in emergency situations, or when a resident experienced an acute change in condition, rather than non-emergency transportation. A review was conducted of the policy titled: Standard Notification of Resident/Patient Change in Condition (effective February 2020) from the clinical guidelines manual 5.1.1 page 1 of 1: Procedure - 1. Notify physician, resident/resident representative and case management when indicated, if there is a significant change in condition, regardless of the time of day. M. If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the call, another nurse will place the call. A review was conducted of the Policy and Procedure titled: Topic Significant Change in Resident Status ([DATE]) Manual 5.3.1, page 1 of 1: 1.Staff will monitor for significant change in the resident's status and notify resident physician. Procedure - 1. Significant change is one of the following: a. Deterioration in 2 or more activities of daily living b. Change in the ability to walk or transfer c. Change in the ability to use one's hands or grasp small objects d. Deterioration in behavior or mood to the point where daily problems arise or relationships become problematic e. Deterioration in health status that is permanent f. No response by the resident to the treatment for [REDACTED].>g. Initial onset of unplanned weight loss or gain of 5% body weight with a 30-day period h. Threat to life such as stroke, heart condition or [MEDICAL CONDITION] i. A new [DIAGNOSES REDACTED]. j. Improved behavior, mood or functional health status to the extent that the established plan of care no longer matches what is needed. k. New onset of impaired decision making l. Continence to incontinence or indwelling catheter m. Use of a restraint when it was never used before. During a [DATE] interview with the Director of Nursing (DON) at 2:42 PM, she was asked to clarify what no response to pain stimulation meant. She stated it meant the resident was not responsive. When asked what the significance of a respiratory rate of 25 - 27 was, she replied it meant the resident was in distress. When asked for her expectation of the nursing staff on [DATE] between 3:30 PM and 10:14 PM regarding Resident #1, she stated, They should have just sent her out 911. When the resident's care plan for [MEDICAL CONDITION] activity was reviewed with the DON, noting that during [MEDICAL CONDITION] activity the staff should document the [MEDICAL CONDITION] location, activity and level of consciousness after [MEDICAL CONDITION] activity, the DON confirmed that no documentation was available verifying this was done for Resident #1 on [DATE]. During a [DATE] interview with CNL at 11:02 AM, she verified that RN B called her on [DATE] (time not remembered) and reported that Resident #1 was not herself, respirations were up, the resident was twitching and staff were unable to get an oxygen saturation reading, because the resident's hands were twitching and jerking. She stated she asked RN B about the resident's [MEDICAL CONDITION] medication and whether she had received it the night before ([DATE]). RN B stated the resident had not received the correct dosage. The CNL stated she advised RN B that the resident would need to go to the hospital. She reached out to the resident's physician who also said, Send her to the hospital. She stated the expectation was that the facility would summons emergency transport for any respirations over 20, as this would be considered respiratory distress, especially for this resident with a typical RR of ,[DATE] per minute. When asked for her expectation of what would happen to a resident in respiratory distress for an extended period of time, she replied, I would expect them to die. During a [DATE] interview with the resident's physician at 11:36 AM, he was asked to recount what he recalled of the events of [DATE] related to Resident #1. He reported he remembered that Resident #1 had problems with her [MEDICATION NAME] level being low, so he increased her medication. When he learned that the resident was having a [MEDICAL CONDITION], he said he stated, This is not something we're going to mess with, especially in a nursing home where bad things do happen. He stated he asked that the resident be sent to the hospital and then, When I say to send the resident to the hospital, I mean go now. When asked about Resident #1's RR of ,[DATE] and the expected result of a prolonged period of respiratory distress, he stated, Bad stuff happens when someone is in distress. Sometimes someone can hang in there for a while, but they need a higher level of care, so they need to be sent to the ER immediately. In a [DATE] interview with the DON at 2:04 PM, she stated that RN C did not use the best clinical judgement. She further stated that respirations of ,[DATE] were not normal for any resident and required emergency intervention. She added that she could not understand why RN C did not call her for guidance. During a [DATE] interview with the Administrator at 5:00 PM, he was asked how the facility confirmed the resident's cause of death. He stated, Anytime a resident has a hospitalization or death, the very next day we call the hospital to determine the circumstances and to request a death certificate. He stated the facility called the hospital on [DATE] at 8:00 AM and they were notified that the resident died from cardiac failure. They requested a death certificate for Resident #1, and were told the hospital thought the physician had it. He would ask the physician to send it to the facility. No death certificate was provided for review. The administrator stated that the delay in provision of care and transportation to a higher level of care should never have happened. A review of an article titled: Help for [MEDICAL CONDITION] at the website www.dignityhealth.org revealed: Call 911 or seek emergency medical help for [MEDICAL CONDITION] if: Someone experiences a [MEDICAL CONDITION] for the first time. A person sustains an injury or experiences other serious symptoms such as trouble breathing. According to www.nursingcenter.com: Lippincott Nursing Center: Guide to Care for Patients: Managing [MEDICAL CONDITION], Source: The Nurse Practitioner (May2007 - Volume:32, Number5, Page,[DATE]: Basic First Aid for [MEDICAL CONDITION]: Call Emergency Medical Services (911) if the person has difficulty breathing or is not breathing or has a known heart condition. Monitor and note information about the [MEDICAL CONDITION], including the time the [MEDICAL CONDITION] began, stopped and body movements during the [MEDICAL CONDITION]. According to www.timeofcare.com: Time of Care Online Medicine Notebook. Respiratory Distress, Failure, Arrest: Respiratory distress is a condition of abnormal respiratory rate or effort . Respiratory distress includes increased work of breathing Respiratory distress leads to [MEDICAL CONDITION]. According to www.acls.com: Managing respiratory arrest: Respiratory arrest is usually the end point of respiratory distress that leads to [MEDICAL CONDITION]. Respiratory distress and failure may have multiple causes, all of which left untreated, can deteriorate into respiratory arrest. Regardless of the cause, respiratory arrest is a life-threatening situation that requires immediate management. According to www.verywellhealth.com: Differences between respiratory arrest and [MEDICAL CONDITION] by Rod Brouhard EMT-P (updated February 8, 2020): Respiratory arrest leads to [MEDICAL CONDITION]. These two conditions are absolutely linked. Respiratory arrest will always lead to [MEDICAL CONDITION] if nothing is done to treat it. According to www.healthline.com: What is Acute [MEDICAL CONDITION]? Written by Brindles Lee Macon and Winnie Yu (updated on [DATE]): [MEDICAL CONDITION] happens when the capillary or tiny blood vessels surrounding the lung air sacs cannot properly exchange carbon [MEDICATION NAME] for oxygen. With acute [MEDICAL CONDITION] you experience immediate symptoms from not having enough oxygen in the body. In most cases this failure may lead to death if it's not treated quickly. According to www.merckmanuals.com: Overview of Respiratory Arrest by Vanessa Moll, MD, DESA, Emory University School of Medicine (last review [DATE]): Respiratory arrest and [MEDICAL CONDITION] are distinct, but inevitably, if untreated, one leads to the other. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team as follows: On [DATE], the facility suspended LPN A, RN B and RN C pending investigation. On [DATE], the Regional Director of Risk Management initiated an investigation, interviewing and collecting written statements from Nurses A, B and C. On [DATE], the DON and the Staff Development Coordinator (SDC) assessed all residents in the facility for any change of condition. On [DATE], the facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting which included the Medical Director. A training and education plan for the facility was developed and approved by the committee. On the same day, the facility submitted a five-day federal report for abuse and neglect. On [DATE], the DON completed an audit of all residents receiving [MEDICAL CONDITION] medication for change in condition/[MEDICAL CONDITION] activity, and ensured that those residents had routine and physician-reviewed laboratory testing for medication levels. On [DATE], the SDC and the DON initiated abuse, neglect and exploitation training for all staff and change-in-condition training for all nurses. As of [DATE], 97% (two nurses were still out on sick leave, one was on family leave and two nurses were suspended) of nurses were re-educated by the DON on the protocol for change of condition. Education included: * Utilize 911 EMS service following MD orders to transfer to hospital due to change in condition. * Complete change of condition E-Interact form for identified change of condition. * Understand the need for immediate intervention when residents present with: Change in level of consciousness to include residents who are typically difficult to arouse and who are now unarousable. Elevated respiration rate that does not quickly resolve due to risk for [MEDICAL CONDITION]/fatigue. On [DATE], RN C was terminated and on [DATE], he was reported to the Florida Board of Nursing. On [DATE] and [DATE], the facility performed a 14-day look-back audit for all residents sent to the hospital to validate the timeliness of intervention and transfer. This was confirmed through review of the audits. Ten residents were reviewed, and no concerns were identified related to the timelines of intervention and transfer to hospital. On [DATE] at 9:30 AM, a review of the facility's education records confirmed that 28 nurses (97%) received the in-service training. On [DATE] at 3:30 PM, nurses E, F, G, H, I and J were interviewed by the survey team about the training received. They were each able to recall the training and appropriately answer questions about how they should respond in a similar situation. During a [DATE] interview with the Administrator at 2:30 PM, he stated the facility would continue to conduct on-going audits three times weekly for four weeks then as indicated by the QA&A compliance committee.

Based on record reviews and staff interviews, the facility failed to provide treatment and care based on the comprehensive assessment of a resident and in accordance with professional standards of practice, by failing to appropriately assess the resident's condition and transfer them to a higher level of care as ordered by the physician for one (Resident #1) of three sampled residents who experienced an acute change in condition. The facility staff delayed Resident #1's hospital transfer for six hours, until she went into [MEDICAL CONDITION]. After attempted resuscitation and hospital transfer, she later died . This also placed the facility's 103 other current residents at risk of not receiving appropriate care following an acute change in condition. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 3:00 p.m. on [DATE]. On [DATE] at 3:30 p.m., the Immediate Jeopardy (IJ) began. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team. On [DATE] at 6:50 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed at the time of survey exit on [DATE] at 7:00 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference to F658. A review of Resident #1's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The resident had documented wishes to be resuscitated in the event of a [MEDICAL CONDITION] (full code). A review of the resident's most recent Minimum Data Set (MDS) assessment (quarterly), with an assessment reference date of [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 possible points, indicating severe cognitive impairment. The resident required extensive assistance of one staff member with most activities of daily living (ADLs), except for meals, for which she only required supervision. Further review of the clinical record revealed that from the date of admission on [DATE] through [DATE], the resident had not experienced any [MEDICAL CONDITION]-type activity. A review of Resident #1's respiratory record history from [DATE] through [DATE], revealed her average respiratory rate (RR) was ,[DATE] breaths per minute. A review of the [DATE] physician's orders [REDACTED]. A review of the resident's lab work showed that on [DATE], blood was drawn for a therapeutic level of [MEDICATION NAME], revealing suboptimal concentrations of the medication and a [MEDICATION NAME] level of 6.7 ug/ml (micrograms per milliliter). The normal range was noted as ,[DATE] ug/ml. This left Resident #1 more susceptible to [MEDICAL CONDITION] activity, and the resident's physician increased her [MEDICATION NAME] dosage from 100 mg twice daily to 300 mg at bedtime on [DATE]. In LPN A's nursing progress note dated [DATE] at 4:44 PM, she documented that she went to assess the resident with the two other nurses (RN B and RN C), and the resident's oxygen saturation dropped to 89% on room air with a RR of 26. The resident was rechecked and had a temperature of 99.2 degrees Fahrenheit (F) and RR 26 with slight twitching from head to toe. She noted that Resident #1 was placed on oxygen via face mask at 10 liters per minute and the oxygen saturation came up to 99%. A review of Resident #1's current physician's orders [REDACTED]. In LPN A's nursing progress note dated [DATE] at 4:54 PM, she documented that a telephone order was received from the physician instructing staff to, Send resident to ER for [MEDICAL CONDITION]/uncontrolled [MEDICATION NAME] levels. Based on a review of the resident's clinical record and a review of the facility's investigation documentation, on [DATE], Employee A, Licensed Practical Nurse (LPN), was working the day shift (7AM - 3PM) providing care on the unit where Resident #1 lived. Employee B, Registered Nurse (RN), was also working on that shift, and at 3:00 PM, Employee C, RN, came on duty to work the evening shift (3PM - 11PM) and to care for Resident #1. In a written statement, dated [DATE] at 3:30 PM, RN C wrote that during change of shift rounds, he found Resident #1 with a respiratory rate (RR) of 26, twitching activity, and she was not responding to painful stimulation. He documented that oxygen was started at 2 liters per minute. He called LPN A and RN B to assess the resident and documented that an order was received from the physician to send the resident to the emergency room (ER) for evaluation. In a written statement, dated [DATE], RN B recorded that she had been called to Resident #1's room to take a look at the resident, but at no time did she put a stethoscope to the resident or a blood pressure cuff. She documented that she observed the other nurses (LPN A and RN C) and the resident. She documented she saw Resident #1 twitching and verified through conversations with the nurses (A and C) that Resident #1 had a history of [REDACTED].#1's record to confirm a history of [MEDICAL CONDITION]. After confirming the [MEDICAL CONDITION] history, she reminded LPN A and RN C to call the physician, then she went to her office, leaving the other two nurses to continue assessing the resident. RN B stated that once she reached her office, she called the Medical Director's Clinical Nurse Liaison (CNL) about another matter. While she was speaking with the CNL, she called out to LPN A and RN C, asking whether the physician had been called. They had not called Resident #1's physician, so RN B mentioned the resident's condition to the CNL during the call. The CNL stated, She should go ahead and go out. She will probably need an IV (intravenous administration) of [MEDICATION NAME]. If the resident is having [MEDICAL CONDITION] it would be a risk to give her anything by mouth. A photograph of a text message sent by Employee B to the CNL on [DATE] at 3:54 PM revealed, Hey, (Resident #1) isn't responding to painful stimuli, she's lethargic and (Nurses A and C) are still assessing her. I am in here now. The CNL replied, If she is unresponsive, send her out. RN B messaged, (Resident #1) is not unresponsive, just lethargic, but staff are in there now. As part of the facility's investigation, a [DATE] facility-initiated interview (time unrecorded) was conducted with RN B. She was asked how she assessed Resident #1. She replied that she just visualized her. In the same interview it was recorded that RN B stated she thought Resident #1 was stable, and she asked Nurses A and C if the resident would be sent out emergently via 911. Nurses A and C replied, No, the resident was stable, so RN B returned to her office. As she was preparing to leave the facility for the day, RN B overheard LPN A tell RN C, If transport does not arrive in an hour, call 911. RN B then left the facility. During a [DATE] interview with RN B at 10:50 AM, she was asked how she determined that Resident #1 was stable on [DATE] before she left for the day. She replied that she visualized her. When asked whether a respiratory rate of ,[DATE] was normal or stable, RN B did not answer. In a written, signed statement dated [DATE], LPN A documented that at 4:00 PM on [DATE], she was called to Resident #1's room by RN C. There she found Resident #1 with an elevated temperature and not responding to a rigorous sternal rub (Using the knuckles of a closed fist to rub the center chest of a patient who is not alert and does not respond to verbal stimuli. Source - EMS1.com at www.ems1.com, accessed on [DATE] at 11:56 AM ). LPN A also described the resident as twitching with abnormal vital signs including a BP ,[DATE] (blood pressure, mmHg), P63 (pulse), RR26 (respiratory rate), Temp 99 degrees Fahrenheit (F), Oxygen Saturation (O2sats) of 89% and mouth breathing. In an undated and untimed statement made during the facility's investigation, LPN A documented that she informed the resident's relative of possible [MEDICAL CONDITION] and non-therapeutic [MEDICATION NAME] levels. A call was placed to a non-emergency transport company, but they were unavailable, so a second call was placed to another non-emergency transport company, who informed LPN A that there would be a one-hour wait. LPN A then left the facility. RN C recorded in his written statement, dated [DATE], a timeline of events and actions that were taken by him on [DATE] as follows: On [DATE] at 4:00 PM - (Resident #1's) respirations were 26. She was receiving oxygen at 2 liters per minute via nasal cannula. On [DATE] at 5:00 PM - Rechecked resident, no signs of pain or distress noted, RR25, oxygen at 2 liters per minute, resident stable, will continue to monitor. On [DATE] at 5:30 PM - No twitching, but RR25 and resident continues on oxygen at 2 liters to keep her sats (blood oxygen saturation) at 97%. Resident stable, will continue to monitor. On [DATE] at 6:00 PM - Temp 99.3 F, RR26, continues on oxygen at 2 liters per minute to keep her oxygen saturation at 97%. Resident stable, will continue to monitor. On [DATE] at 6:30 PM - No twitching, RR25, resident continues on oxygen at 2 liters per minute to help maintain her saturation of 97%. Resident stable, continue to monitor closely. On [DATE] at 7:00 PM - No twitching, RR25, continues on oxygen at 2 liters per minute. Stable, will continue to monitor closely. On [DATE] at 7:30 PM - No twitching, RR25, continues on oxygen at 2 liters per minute. Stable, will continue to monitor closely. On [DATE] at 8:00 PM - No twitching, RR25, continues on oxygen at 2 liters per minute to maintain her saturation at 97%. Called the non-emergency transport company again and they stated they would be available in 2 hours. Will continue to monitor closely. On [DATE] at 8:30 PM - Respiratory rate increased to RR26, (Resident#1} still requires oxygen at 2 liters per minute to maintain oxygen sats of 97%. Resident stable, continue to monitor. On [DATE] at 9:00 PM - RR26 breaths per minute. Continues to require oxygen at 2 liters per minute to maintain her sats at 97%. Stable, continue to monitor. On [DATE] at 9:30 PM - RR27 breaths per minute, oxygen saturation 94 %. Stable, will continue to monitor closely. On [DATE] at 10:00 PM - Called non-emergency transport, and they reported they would probably arrive at midnight or 1:00 AM. Went to the resident's room to recheck (Resident #1) and found the resident using accessory muscles to breathe. Asked another nurse (not identified in his note) to call 911. Monitored the resident at her bedside and at 10:14 PM, he documented that Resident #1 had a respiratory arrest and a code blue was called. A review of the facility's Code Blue worksheet revealed that on [DATE] at 10:14 PM, Resident #1 became unconscious. Cardiopulmonary resuscitation (CPR) was started at 10:14 PM. Emergency Medical Services arrived at 10:20 PM, took over CPR and transported the resident to the ER at 10:30 PM. Resident #1 did not survive. A review of the facility's policy for addressing a change in a resident's condition, revealed no instructions prioritizing or utilizing 911 in emergency situations, or when a resident experienced an acute change in condition, rather than non-emergency transportation. A review was conducted of the policy titled: Standard Notification of Resident/Patient Change in Condition (effective February 2020) from the clinical guidelines manual 5.1.1 page 1 of 1: Procedure - 1. Notify physician, resident/resident representative and case management when indicated, if there is a significant change in condition, regardless of the time of day. M. If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the call, another nurse will place the call. A review was conducted of the Policy and Procedure titled: Topic Significant Change in Resident Status ([DATE]) Manual 5.3.1, page 1 of 1: 1.Staff will monitor for significant change in the resident's status and notify resident physician. Procedure - 1. Significant change is one of the following: a. Deterioration in 2 or more activities of daily living b. Change in the ability to walk or transfer c. Change in the ability to use one's hands or grasp small objects d. Deterioration in behavior or mood to the point where daily problems arise or relationships become problematic e. Deterioration in health status that is permanent f. No response by the resident to the treatment for [REDACTED].>g. Initial onset of unplanned weight loss or gain of 5% body weight with a 30-day period h. Threat to life such as stroke, heart condition or [MEDICAL CONDITION] i. A new [DIAGNOSES REDACTED]. j. Improved behavior, mood or functional health status to the extent that the established plan of care no longer matches what is needed. k. New onset of impaired decision making l. Continence to incontinence or indwelling catheter m. Use of a restraint when it was never used before. During a [DATE] interview with the Director of Nursing (DON) at 2:42 PM, she was asked to clarify what no response to pain stimulation meant. She stated it meant the resident was not responsive. When asked what the significance of a respiratory rate of 25 - 27 was, she replied it meant the resident was in distress. When asked for her expectation of the nursing staff on [DATE] between 3:30 PM and 10:14 PM regarding Resident #1, she stated, They should have just sent her out 911. When the resident's care plan for [MEDICAL CONDITION] activity was reviewed with the DON, noting that during [MEDICAL CONDITION] activity the staff should document the [MEDICAL CONDITION] location, activity and level of consciousness after [MEDICAL CONDITION] activity, the DON confirmed that no documentation was available verifying this was done for Resident #1 on [DATE]. During a [DATE] interview with CNL at 11:02 AM, she verified that RN B called her on [DATE] (time not remembered) and reported that Resident #1 was not herself, respirations were up, the resident was twitching and staff were unable to get an oxygen saturation reading, because the resident's hands were twitching and jerking. She stated she asked RN B about the resident's [MEDICAL CONDITION] medication and whether she had received it the night before ([DATE]). RN B stated the resident had not received the correct dosage. The CNL stated she advised RN B that the resident would need to go to the hospital. She reached out to the resident's physician who also said, Send her to the hospital. She stated the expectation was that the facility would summons emergency transport for any respirations over 20, as this would be considered respiratory distress, especially for this resident with a typical RR of ,[DATE] per minute. When asked for her expectation of what would happen to a resident in respiratory distress for an extended period of time, she replied, I would expect them to die. During a [DATE] interview with the resident's physician at 11:36 AM, he was asked to recount what he recalled of the events of [DATE] related to Resident #1. He reported he remembered that Resident #1 had problems with her [MEDICATION NAME] level being low, so he increased her medication. When he learned that the resident was having a [MEDICAL CONDITION], he said he stated, This is not something we're going to mess with, especially in a nursing home where bad things do happen. He stated he asked that the resident be sent to the hospital and then, When I say to send the resident to the hospital, I mean go now. When asked about Resident #1's RR of ,[DATE] and the expected result of a prolonged period of respiratory distress, he stated, Bad stuff happens when someone is in distress. Sometimes someone can hang in there for a while, but they need a higher level of care, so they need to be sent to the ER immediately. In a [DATE] interview with the DON at 2:04 PM, she stated that RN C did not use the best clinical judgement. She further stated that respirations of ,[DATE] were not normal for any resident and required emergency intervention. She added that she could not understand why RN C did not call her for guidance. During a [DATE] interview with the Administrator at 5:00 PM, he was asked how the facility confirmed the resident's cause of death. He stated, Anytime a resident has a hospitalization or death, the very next day we call the hospital to determine the circumstances and to request a death certificate. He stated the facility called the hospital on [DATE] at 8:00 AM and they were notified that the resident died from cardiac failure. They requested a death certificate for Resident #1, and were told the hospital thought the physician had it. He would ask the physician to send it to the facility. No death certificate was provided for review. The administrator stated that the delay in provision of care and transportation to a higher level of care should never have happened. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team as follows: On [DATE], the facility suspended LPN A, RN B and RN C pending investigation. On [DATE], the Regional Director of Risk Management initiated an investigation, interviewing and collecting written statements from Nurses A, B and C. On [DATE], the DON and the Staff Development Coordinator (SDC) assessed all residents in the facility for any change of condition. On [DATE], the facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting which included the Medical Director. A training and education plan for the facility was developed and approved by the committee. On the same day, the facility submitted a five-day federal report for abuse and neglect. On [DATE], the DON completed an audit of all residents receiving [MEDICAL CONDITION] medication for change in condition/[MEDICAL CONDITION] activity, and ensured that those residents had routine and physician-reviewed laboratory testing for medication levels. On [DATE], the SDC and the DON initiated abuse, neglect and exploitation training for all staff and change-in-condition training for all nurses. As of [DATE], 97% (two nurses were still out on sick leave, one was on family leave and two nurses were suspended) of nurses were re-educated by the DON on the protocol for change of condition. Education included: * Utilize 911 EMS service following MD orders to transfer to hospital due to change in condition. * Complete change of condition E-Interact form for identified change of condition. * Understand the need for immediate intervention when residents present with: Change in level of consciousness to include residents who are typically difficult to arouse and who are now unarousable. Elevated respiration rate that does not quickly resolve due to risk for [MEDICAL CONDITION]/fatigue. On [DATE], RN C was terminated and on [DATE], he was reported to the Florida Board of Nursing. On [DATE] and [DATE], the facility performed a 14-day look-back audit for all residents sent to the hospital to validate the timeliness of intervention and transfer. This was confirmed through review of the audits. Ten residents were reviewed, and no concerns were identified related to the timelines of intervention and transfer to hospital. On [DATE] at 9:30 AM, a review of the facility's education records confirmed that 28 nurses (97%) received the in-service training. On [DATE] at 3:30 PM, nurses E, F, G, H, I and J were interviewed by the survey team about the training received. They were each able to recall the training and appropriately answer questions about how they should respond in a similar situation. During a [DATE] interview with the Administrator at 2:30 PM, he stated the facility would continue to conduct on-going audits three times weekly for four weeks then as indicated by the QA&A compliance committee.

Based on record review and staff interview, the facility failed to ensure proper notice was provided to 2 of 3 sampled residents, of service changes related to their Medicare plan. (Residents #247 and #64) The findings include: The facility provided the SNF Beneficiary Protection Notification review form documenting Residents #247 and #64 discharged from Medicare Part A Services when benefit days were not exhausted and both residents received a Notice of Medicare Non-Coverage. Yes or No was not checked to each resident receiving the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage. Review of the notice provided for Resident #247 revealed her representative received the Notice of Medicare Non-Coverage by phone on 10/14/2019 for skilled services ending on 10/17/2019. Further record review for Resident #247 found she remained in the facility until she was discharged to the hospital on [DATE]. Record review for Resident #64 revealed she was admitted to the facility on [DATE] and had remained in the facility. Review of the SNF Beneficiary Protection Notification Review form completed by the Business Office Manager revealed her Medicare Part A Skilled Services started on 9/5/2019 and ended on 10/11/2019. Review of the Notice of Medicare Non-Coverage form provided to Resident #64 revealed her representative was given the notice by telephone on 10/7/2019 for skilled nursing services ending 10/10/2019. During an interview on 11/15/2019 at 10:14 AM with the Business Office Manager (BOM), she was asked if the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) Form CMS- was given to Resident #247 and Resident #64. She stated she would need to check with the Social Service Director (SSD) as she gives out the forms. During an interview on 11/15/2019 at 10:22 AM with the SSD, she was asked if she did the Skilled (SNFABN) Form CMS- for Resident #247 and Resident #64. She stated she would need to check the facility policy before she could answer the question. During further interview with the Business Office Manager on 11/15/19 10:52 AM, she stated she was on vacation that week and the Nursing Facility Advanced Beneficiary Notice of Non-Coverage notices did not get done.

Based on observation, interview, and record review, the facility failed to provide respiratory care according to the physician orders [REDACTED]. (Resident #86) The findings include: On 11/12/2019 at 11:08 AM, Resident #86 was observed lying in bed. She was using oxygen out of a concentrator located between her bed and the wall. The concentrator was set at 5 liters. A second observation was made in Resident #86's room on 11/12/2019 at 3:00 PM. Resident #86 was lying in bed awake and using oxygen. The oxygen concentrator was set at 5 liters. An interview was held with Resident #86 at the time of the second observation. She was asked what the concentrator setting should be, and she thought it was 3 liters. She was informed it was currently set at 5 liters. Resident #86 stated it may have changed because she was recently in the hospital. On 11/13/2019 at 10:15 AM, Resident #86 was observed in bed. The oxygen concentrator was set at 2 liters. A second interview with the resident at that time revealed she had informed the head nurse that her oxygehad been set at 5 liters, and it was changed. During an interview with the Director of Nursing (DON) and B Wing Unit Manager on 11/13/2019 at 10:22 AM, the B Wing Unit Manager stated the afternoon nurse on 11/12/2019 had changed the level of oxygen. She could not recall if he told her the setting was off or that it was at 5 liters. During an interview on 11/13/2019 at 10:28 AM, with the nurse who worked with Resident #86 during the 7:00 AM to 3:00 PM shift on 11/12/2019, the nurse (Employee B) stated she checked Resident #86's oxygen around 9:00 AM. She stated it was 2 liters at the time and she did not check the oxygen again during her shift. Review of the physician orders [REDACTED]. Review of the care plan for Resident #86 for shortness of breath revealed one of the approaches listed was for oxygen to be at 2 liters continuously due to the [DIAGNOSES REDACTED]. Review of the 10/27/2019 5-day minimum data set (MDS) revealed Resident #86 scored 15 out of 15 on her brief interview mental status score, indicating intact cognitive ability. Interview with Resident #86's certified nursing assistant (CNA), Employee A, on 11/14/2019 at 2:00 PM, revealed the CNAs make sure the oxygen is on. They check the setting and it should be at 2 liters. She stated she would notify the nurse if it was not set correctly. She was asked if she had worked with Resident #86 on 11/12/2019. She stated that 11/14/2019 was the first day she worked with Resident #86 for the current week.

Based on staff interview, clinical record review, and facility policy review, the facility failed to protect the rights for 1 (Resident #2) of 3 sampled resident receiving Hospice or Palliative Care, according to the resident census as of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation (CPR) in a timely manner when the resident was found unresponsive, with no pulse or respirations. The facility staff did not initiate CPR and did not call 911 for medical aid in accordance with their policy and procedure "Code Status Orders and Response effective [DATE], revised [DATE] and revised [DATE]. The findings include: A clinical record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with a readmission date of [DATE]. The resident's admission [DIAGNOSES REDACTED]. A review of the resident's advanced directives revealed the resident had a power of attorney dated [DATE] and a certificate of incapacity dated [DATE]. The resident had a physician's order dated [DATE] to discontinue the Do Not Resuscitate (DNR) order per the resident and daughter's wishes. The order also including discontinuing the Florida DNR for Emergency Medical Service (EMS), and the order indicated that the resident was a full code. A Nurses' Note dated [DATE] at 8:20 PM revealed per the resident and daughter, the resident was a full code. The note indicated that per a phone conversation with the resident's daughter, the DNR order was to be revoked immediately and the physician was made aware. A review of the Resident #2's care plan dated [DATE] revealed the resident had an advance directive on record including a power of attorney for health care and financial decisions. The resident was determined not to be capable of making informed healthcare decisions and there was a certificate of incapacity dated [DATE]. The resident was noted to be on Hospice. The goal was the advance directive was in effect and the wishes and directions would be carried out in accordance. Interventions included the appointed health care representative would make all health care decisions if the resident was incapacitated. Allow the resident, if able to discuss feelings regarding their advance directives, an advance directive could be revoked or changed if the resident and/or appointed health care representative changed their mind about the health care they wanted delivered. Arrange visits with the social worker or clergy as needed. Advise the resident and/or appointed health care representative to provide copies to the facility of any updated advanced directives. A review of the significant change in status Minimum Data Set (MDS) assessment for Resident #2 dated [DATE] revealed the resident was coded as receiving Hospice services. A review of the computerized Physician Order Sheet (POS) dated [DATE] revealed the resident was coded as a full resuscitate. A review of the Nurses' Note dated [DATE] at 1:30 PM revealed the nurse indicated the daughter was called and notified of the resident's condition of not opening her eyes, pale skin that remained warm to the touch. At 1:57 PM the resident's vital signs could not be obtained, the CNA had seen the resident's breathing cease and the nurse came and was unable to feel a carotid pulse. The resident's hands and feet were mottled and a code blue was announced. At 2:13 PM CPR was initiated. At 2:21 PM the 911 team arrived and CPR continued and the resident was taken via stretcher to the hospital. There was another Nurses' Note dated [DATE] at 1:30 PM by the same nurse indicated the resident's daughter was called due to her current condition. The resident's temp was 94.1 and she had a palpable pulse of 60, the resident was, breathing swallow and slow. The nurse indicated the resident was repositioned and made comfortable. At 2:09 PM the CNA (Certified Nursing Assistant) came and asked the nurse to see the resident. The writer checked the resident's breathing and repositioned her; she noted the resident's breathing was very shallow and low. At 2:09 PM the nurse called the physician and he stated on his way to see the resident, the nurse called the resident's daughter and there was no answer; a message was left to call as soon as she could. The nurse indicated a call was placed to Hospice and she asked for the Hospice Nurse, paged for the Unit Coordinator and called for help. 2:10 PM the resident was reassessed, the resident was not breathing, the writer indicated a code blue was called and CPR was initiated. At 2:20 PM emergency medical services (EMS arrived) and left the facility at 2:26 PM with the resident via stretcher. An interview was conducted with the Risk Manager (RM) on [DATE] at 2:47 PM. The RM confirmed that the writer of the duplicate Nurses ' Notes on [DATE] was the same writer. She stated the nurse rewrote her note because it was messy. She stated that the result of her investigation was the nurse did her assessment and had called the physician and the resident ' s daughter. The nurse assumed the resident was a DNR because she was on Hospice and the other Hospice resident ' s in the building were a DNR. Once the resident stopped breathing, the nurse went to the medical record and verified the resident ' s code status. At that point the nurse realized the resident was a full code, the nurse called a code blue and initiated CPR. The resident expired. The Risk Manager stated that the nurses were provided education because most people believe that if a person is on hospice that means they have a DNR status. She stated that the facility called an all staff meeting and re-educated the staff; they completed codes for all 3 shifts within 24 hours. They also completed another all staff meeting with post-tests. There was also an open conversation with staff to remind that that all Hospice residents do not have a DNR. A review of the facility policy and procedure for Code Status Orders and Response dated [DATE] and revised on [DATE] revealed the Physician's order for Do Not Resuscitate is written based on the wishes of the resident/patient or authorized party. Advanced Directives will be honored during the code process. DNR order is defined as while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Each resident will have the elected code status documented in their medical record within the physician's orders and the state specified Advanced Directives form kept in the advanced directives section of the medical record. Step 3. Once the resident/responsible party elects a DNR option the following measures will be implemented. a. Nursing will place a yellow DNR bracelet on the resident. Resident identification will be verified by two staff members when applying the bracelet, either 2 nurses or a nurse and the social worker. Step 4. Response: a. Upon finding a resident/patient unresponsive, call for help; b. Evaluate for heartbeat, respirations and pulse; c. Check for yellow DNR bracelet-if none is found the Medical Record will be checked for physician's order for code status prior to CPR being initiated; d. If the resident is a full code the respondent for help to the call for help will immediately overhead page a "code blue" and indicate the room number, or the location of the resident/patient and deliver the medical record and emergency cart and AED if applicable to the code blue status; e. If Code status is " DNR " -Do not initiate CPR (notify physician, supervisor and family); f. If code status is a full code, begin CPR; g. If code status is not designated the resident is a full code and CPR will be initiated. An interview with the Director of Nursing (DON) on [DATE] at 11:35 AM revealed that the Quality Assurance Team met on [DATE] following Resident #2's event to determine the reason the nurse did not implement CPR to Resident #2 in a timely manner. The outcome determination was that there had been a system failure, but an individual nurse's failure to realize that not all Hospice residents choose to withhold CPR. Per the DON the decision of the QA committee was to provide facility wide training regarding Hospice residents code status decisions, review the facility's policy and procedure regarding Code Status with all staff, complete a facility wide audit of all residents to ensure the correct information was in the clinical record, ensure all residents that were DNR were wearing a yellow armband, conduct an audit of the Code Blue events over the last 6 months to ensure acceptable practice, and to establish a policy to review the code status of all potential Hospice residents prior to admission. The following Action Plan and Plan of Correction was implemented by the facility on [DATE] and ended on [DATE]. The Corrective Action continues to be monitored through the facility's Quality Assurance Program. 1. An investigation was immediately started [DATE] by the DON and the RM. 2. All staff involved was in-serviced regarding Hospice residents and Code status, and the facility's policy and procedure "Code Status Orders and Response". 3. A facility wide audit of the current code status and advance directives for every resident was completed to ensure accuracy of their code status in the clinical record. 4. There was documentation that staff meetings and education were completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Program content on [DATE] included code blue drills/ Hospice resident/full code. Program content on ,[DATE]-27th included CPR skills test, post-test upon review of Policy 11.1 and 11.2. Objectives. Review of policy/procedure for code status, code cart/supplies, policy # 11.1 and 11.2. Given correct documentation-worksheet. Discussed yellow arm band status, and events that followed. Various departments were involved in the education and training including nursing staff, physical/occupational therapies, the activities department, social services, dietary, housekeeping, laundry, and maintenance. 5. A 6 month audit was completed for all resident deaths and Code Blue events that occurred in the facility from [DATE] to [DATE]. On [DATE] at 1:00 PM an interview with the DON, Nursing Home Administrator (NHA), and the RM there is on-going weekly audits of Advance Directives conducted by the Social Services staff. The audits were requested at the time of the interview and reflected evidence that the audits were on-going on a weekly basis. Per the NHA there is an emphasis placed on the resident's DNR status and Hospice resident's during new employee orientation. A new policy was implemented on [DATE] regarding Code status and training. Per the NHA he advised that he already not accepted 2 admissions in the facility because there was a concern regarding the resident's code status. Per the DON, the 6 month audit on all deaths and codes conducted from [DATE] to [DATE] did not reveal any deficient practice. The DON advised that the nurse that failed to initiate CPR in a timely manner to Resident #2 was terminated and reported to the state licensing board. Interview with staff (CNA #1, LPN #1, CNA #2, LPN #2, and CNA #3) revealed and confirmed that they had been in-serviced, have sufficient knowledge of the need to honor a resident's Advance Directive, where to locate the Advance Directive forms in the clinical record, and have been informed of the facility's Policy and Procedure regarding Code Status. a.) An interview with CNA #1 on [DATE] at 11:05 AM revealed a yellow arm band on the resident meant the resident was a DNR and no CPR would be completed if the resident became unresponsive. She revealed if a resident did not have an arm band, then CPR should be initiated on a resident if they became unresponsive. She indicated that in addition to looking at the resident ' s arm band to verify coded status she could also check the resident chart. b.) Interview with LPN #1 on [DATE] at 12:12 PM revealed that if a resident became unresponsive she would call for help, and the person she called would verify the resident code status in the medical record. She revealed residents with a DNR status had a yellow arm band and if there was no yellow arm band present on the resident CPR would be initiated after looking at the medical record to confirm code status. The LPN revealed she reviewed the resident ' s medical chart upon admission to see what the code status was. An observation of Resident#3 with the LPN#1 revealed he was not wearing a yellow arm band. The nurse was asked who was responsible for placing the arm band on the resident and she stated that she did not know but she would find out. She revealed that periodically the nursing staff would check to ensure the yellow arm band was still present. During the interview the nurse revealed the facility had a crash cart and the entire medical staff was responsible for responding to a code. She indicated the staff had received at least three code drills over the past couple of months. c.) An interview with CNA#2 on [DATE] at 12:26 PM revealed that if the resident had a yellow arm band that meant he was not to be resituated and no CPR would be initiated. She stated that if the resident did not have a yellow arm band then CPR would be initiated. d.) An interview on [DATE] at 1:03 PM with LPN #2 revealed if a resident had a DNR order they would have a yellow arm band on. She revealed that if the resident had an arm band or not the staff was to verify code status prior to initiating CPR because once it was started you could not stop. She indicated that whoever found the resident unresponsive would yell out for help and the staff would verify the code status prior to initiating CPR. The LPN also revealed she had participated in at least 4 code drills since she began employment in January of 2012. The LPN revealed there was one crash cart located on each unit. The crash cart on the Baywood Unit was observed. The door to the room was labeled crash cart, the door to the room was not locked and the equipment inside was clean, organized and in good repair. There was oxygen and suctioning equipment available. The drawers on the crash cart were clearly labeled indicating what supplies it contained. The LPN revealed the medications needed for a code were kept in the locked medication room on each unit. She also revealed the crash carts were checked on the 11p-7a shift. e.) An interview was with CNA #3 on [DATE] at 1:11 PM revealed that she would know if a resident had a DNR status by the presence of a yellow arm band and by checking the patient chart. She revealed that if she found a resident unresponsive she would check for breathing and heart rate, stay with the resident and call out for help, so that someone could get the resident chart to verify if the resident was to have CPR. Review of sampled residents (Resident #1, #3, #4, #5, #6, #7, #8, and #9) revealed clinical records, interview and observations reflected accurate information regarding Advance Directives, and the code status of the residents. a.) A medical record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the resident ' s chart revealed it had a yellow Hospice sticker located inside the front cover and it also had an orange sticker indicting she had a do not resuscitate (DNR) order. A review of the Hospice referral revealed the resident was admitted to Hospice services on [DATE] with the [DIAGNOSES REDACTED]. A review of the resident ' s advance directives revealed the resident had a physician ' s DNR order dated [DATE]. There was a signed State of Florida DNR order dated [DATE] signed by the resident ' s health care surrogate and physician. There was also a certificate of incapacity dated [DATE]. There was documentation of the Power of Attorney for Health Care/Designation of Health Care Surrogate dated [DATE]. A review of the Standards of Care Flowsheet dated [DATE] revealed the resident had a DNR noted. The note was last updated on [DATE]. The current Standards of Care notes dated [DATE] and last updated on [DATE] revealed the resident was on Hospice services. A review of the Collaborative Physician ' s Orders dated [DATE] revealed the resident had a DNR order noted. A review of the Hospice Care Plan dated [DATE] revealed the resident ' s DNR status was noted under the resuscitation code status. A resident interview and observation was completed for Resident #1 on [DATE] at 09:30 AM The resident was alert with confusion, and oriented to person only. The resident was clean, well groomed and no odors were noted. The resident had a yellow arm band on her left forearm in addition to an identification band. The resident revealed the facility was nice and she was treated well b.) A medical record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. There was an orange DNR sticker located on the inside front cover of the chart. A review of the Advanced Directives for the resident revealed he had a DNR order dated [DATE]. There was also a Physician ' s Order for a DNR on [DATE] and an order dated [DATE] for a referral to Hospice to manage pain and symptoms. A review of the History and Physical dated [DATE] revealed the reason the resident was admitted to the facility was for Hospice services. A review of the Standards of Care notes dated [DATE] revealed the resident was noted to be in Hospice services and had a DNR. A review of the Hospice Consultation note dated [DATE] revealed the resident ' s Hospice services were discontinued. A review of the interim care plan for Resident #3 dated [DATE] revealed the resident had a Hospice aide on Tuesday and Thursday. A review of the admission MDS dated [DATE] revealed the resident was coded as receiving hospice services. The care plan meeting was scheduled for [DATE] per the MDS Coordinator. A review of the Care Area Assessments (CAAs) worksheet the revealed the resident was failure to thrive with Hospice supervision. The patient was noted to be a DNR. A family interview was conducted for Resident #3 on [DATE] at 11:00 AM The family member stated that things were going well at the facility and she had no concerns with the resident ' s care. She stated that the facility was honoring her loved one ' s rights and she was enrolled in Hospice services. c.) Review of Resident #4's clinical record revealed the most current admission was [DATE]. The State of Florida DNR was in the record, and signed by the physician on [DATE]. A Progress note dated [DATE] revealed the DNR was verified and yellow arm band placed on the resident. The note was signed by 2 RNs. The resident was also receiving Hospice care in the facility. Observation of the Resident #4 on [DATE] at 12:37 PM revealed she was wearing a yellow arm band. d.) Resident #5's clinical record review on [DATE] revealed a yellow State of Florida Do Not Resuscitate Order dated and signed by the physician on [DATE]. The face sheet revealed that the resident was admitted on [DATE]. On [DATE] at 10:50 AM an observation of Resident #5 revealed the resident lying in bed, her eyes closed and she appeared to be asleep. A yellow arm band was present on her left wrist. e.) Resident #6's clinical record review on [DATE] revealed the most recent admission was on [DATE]. The clinical record revealed a Living Will was in place and dated [DATE]. The clinical record revealed an order determining total incapacity dated on [DATE]. Full code status per MD orders. f.) Resident #7's clinical record review on [DATE] revealed that the most recent admission was [DATE]. The Living Will was present on the clinical record and was dated [DATE]. Physician orders revealed full code effective [DATE]. g.) Resident #8's clinical record review on [DATE] revealed her admitted was [DATE]. Progress note dated [DATE] revealed DNR order verified and yellow arm band was placed on resident ' s wrist. The progress not was signed by 2 RNs. There was a yellow DNR order signed by MD on [DATE] in the clinical record. h.) Resident #9's clinical record review on [DATE] revealed her admitted was [DATE]. The record revealed that the facility was aware the resident did not any Advanced Directive on [DATE]. i.) Resident #10's clinical record review on [DATE] revealed the resident was admitted on [DATE]. A Florida DNR order was in the clinical record dated and signed by the MD on [DATE]. A progress note revealed on [DATE] that the DNR order was verified and a yellow arm band was placed on the resident ' s wrist. The progress note was signed by 2 RNs.